5 December 2006

`Inverse care law' still evident in Scotland

Deprived areas of Scotland are being poorly served by a new payment system introduced into the NHS to reward doctors’ practices for improving the quality of their services, new research from three of the country’s leading universities shows.

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, according to the researchers from the Universities of Dundee, Aberdeen and Glasgow.

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.

Professor Sutton said "These problems could have been anticipated if more time and attention had been paid to modelling the consequences of the new payment system prior to its implementation. A substantial amount of NHS resources are involved and could have been more accurately targeted."

The links between quality of primary care services and deprivation also show that people in many poorer areas are still either receiving lower quality of care or are not responding to the some of the services offered through GP practices.

"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," said Professor Guthrie.

"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 reasons for this are varied, and may not be easily met by the General Medical Services Contract. There are wider issues that may need to be addressed in how people engage with their health service, but what we can see is that there is still variation either in the care provided or how people respond to it and it is patterned along lines of socio-economic deprivation."

Dr Gary McLean said these findings were not immediately apparent due to the way performance is calculated under the General Medical Services Contract which allows practices to ‘exception report’.

"The exceptions system may succeed in not penalising practices financially for the characteristics of the population they serve. However, it offers little incentive for the delivery of care to deprived populations, and contributes to a continuation of the inverse care law," said Dr McLean.

In conclusion, Professor Guthrie said, "The inverse care law, where more deprived patients with greater health needs tend to get worse healthcare, is still in operation for some important measures of quality. The present payment system does not recognise the extra work that practices in more deprived areas will have to do to improve access and uptake of more complex care, and on average it financially penalises them compared to more affluent practices. As such, the new contract does not support the Scottish Executive’s aim to improve health more rapidly in the most deprived areas."

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

The JECH paper can be viewed in full at:
http://jech.bmj.com/cgi/content/full/60/11/

A pdf. file of the BJGP paper is attached.

FOR FURTHER INFO CONTACT:

Jennifer Phillips,
Communications Officer,
College of Life Sciences and Medicine,
University of Aberdeen,
Aberdeen AB24 3FX
Tel: 01224 273174

Ray McHugh
Press Officer
University of Glasgow
r.mchugh@admin.gla.ac.uk
Tel - 0141 330 3535

For media enquiries contact:

Roddy Isles
Head, Press Office
University of Dundee
Nethergate Dundee, DD1 4HN
TEL: 01382 384910
E-MAIL: r.isles@dundee.ac.uk