`Inverse care law' still evident in Scotland

Leading academics from the Universities of Dundee, Glasgow and Aberdeen have reported that deprived areas of Scotland are poorly served by a new payment system introduced to the NHS to reward doctors' practices for improving the quality of their services.

The researchers say extreme variations in the amount GPs are paid and inequalities in the quality of care delivered to people in deprived areas are still apparent in Scotland under the General Medical Services Contract.

The research was carried out by Professor Bruce Guthrie, of Tayside Centre for General Practice at the University of Dundee, Dr Gary McLean, of the Department for General Practice and Primary Care at the University of Glasgow, and Matt Sutton, Professor of Health Economics at University of Aberdeen. They examined data on workload and reward for GP practices and also quality of care linked to social and economic deprivation.

They broadly concluded that there is still evidence in Scotland of an `inverse care law', where more deprived patients with greater health needs tend to get worse healthcare, and the practices serving these patients tend to receive fewer resources.

Their findings show major differences in the money earned by some GP practices for delivering the same quality of care to the same number of patients, with practices in deprived areas generally faring more poorly.

The payment system for GP practices utilises a formula called the Adjusted Disease Prevalence Factor (ADPF) to adjust payment for the number of patients with a particular disease.

The researchers warn this produces major differences in the money earned by practices for delivering the same quality to the same number of patients - up to a 44-fold variation at the extremes, although most practices are within a two-fold variation.

The researchers cite two practices each delivering the same quality of care to the 30 patients with Coronary Heart Disease registered with them. One practice is paid £850 for its work with CHD patients, the other £25,063.

The payment system also diverts money from more deprived practices to more affluent practices - on average the 10% most affluent practices receive approximately £6000 more per practice than the 10% most deprived practices, compared to a system where payment is fairly related to workload.

"The bottom line is that the payment system is unfair because payment varies considerably across practices, and because, on average, it pays less to more deprived practices for the same level of quality delivered to the same number of patients," said Professor Guthrie.

"The bald statistics show that practices in more deprived areas are generally struggling more than their more affluent neighbours to deliver some services. They are performing remarkably well in the routine procedures which can be carried out as part of a normal patient visit, with little evidence that this care is any different from that given to affluent patients."

"But what they are less able to do is get people in for more complex care that has to be done in a planned appointment, or which require taking drugs on a long-term basis."

The researchers results are published in two separate papers in the British Journal of General Practice and the Journal of Epidemiology and Community Health.