Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
'Poor is just poor'
- Turab Ali (12 May 2004)
-
Primary care treatment of patients with heart failure
- Una Macleod (18 May 2004)
-
Time to reformulate the inverse care law
- Jean Adams, Martin White (20 May 2004)
|
|
|||
|
Turab Ali, Specialist Registrar, Cardiology Leighton Hospital, Crewe, CW1 4QJ
Send response to journal:
|
EDITOR: McAlister et al did not commit to the simple fact that many of our socioeconomically deprived patients are not followed up by the doctors in general practice purely because they are not as pressurised by them as they are by the relatively affluent people because 'poor is just poor'. I come across at times with these patients complaining about their surgery that the doctor would not listen to them. This is so unfortunate and discriminatory. I think just blaming them that they do not adhere to the medical advice and 'do not attend' appointments is not true. They ought to be dealt with fairly anyways but I feel, from the social perspective, taking care of them is even more important as they will put more burden on the social services if not looked after properly. Competing interests: None declared |
|||
|
|
|||
|
Una Macleod, Lecturer General Practice and Primary Care, University of Glasgow, G12 9LX
Send response to journal:
|
Editor – McAlister et al’s work (1) is a useful addition to the literature on socio-economic status and morbidity, demonstrating the burden of ill health especially in socio-economically deprived areas. I was particularly interested in, and surprised by, the finding that deprived patients had less contact with their general practitioner than affluent patients. We studied primary and secondary care with respect to breast cancer and found that there was greater general practitioner contact in deprived areas compared with affluent areas.(2) In addition, we found that deprived women had more hospital admissions for conditions unrelated to their breast cancer than affluent women. It is therefore possible that the deprived patients in McAlister’s study were in hospital more frequently than affluent patients and therefore not available for general practitioner contact. Indeed, heart failure is a clinical condition, which especially when more severe, may result in frequent hospital admission. In the socio-economically deprived area of north-east Glasgow, patient with moderate to severe heart failure are now frequently followed up after admission to hospital or attendance at clinic by cardiac failure liaison nurses, again potentially reducing contact with general practice, although not reducing quality of care. We have also demonstrated greater co-existing morbidity in deprived patients compared with more affluent patients;(3) again it could be speculated that these co -morbidities result in more hospital admissions in this group as was the case in our breast cancer study. Although the Scottish continuous morbidity recording project has advantages in that the data are routinely collected and as such, are readily available for analysis, at the time of this study it was under- represented in relation to general practices situated in deprived areas. These points emphasise the need for high quality primary research in addition to secondary analysis of routinely recorded data in order to understand the mechanisms and experience of deprivation and morbidity. 1. McAlister FA, Murphy NF, Simpson CR, Stewart S, MacIntyre K, Kirkpatrick M, Chalmers J, Redpath A, Capewell S, McMurray JJV. Influence of socioeconomic deprivation on the primary care burden and treatment of patients with a diagnosis of heart failure in general practice in Scotland: population based study. BMJ 2004;328:1110-2. 2. Macleod U, Ross S, Twelves C, George WD, Gillis C, Watt GCM. Primary and secondary care management of women with early breast cancer from affluent and deprived areas: a retrospective review of hospital and general practice records. BMJ 2000; 320:1442-5. 3. Macleod U, Mitchell E, Black M, Spence, G. Co-morbidity and socio -economic deprivation: an observational study of the prevalence of co- morbidity in general practice. European Journal of General Practice 2004; 10:24-26. Competing interests: None declared |
|||
|
|
|||
|
Jean Adams, Research fellow School of Population and Health Sciences, University of Newcastle, UK, NE2 4HH, Martin White
Send response to journal:
|
EDITOR – McAlister et al (2004) report a relationship between deprivation and contact with a general practitioner among Scottish patients with heart failure, such that individuals living in more deprived areas tend to see their general practitioner less than those living in affluent areas.(1) They then go on to state that this is a “novel example of Tudor-Hart’s inverse care relation”. Tudor Hart’s inverse care law states that “the availability of good medical care tends to vary inversely with the need for it in the population served”.(2) Whilst McAlister et al do report a socioeconomic gradient in incidence and prevalence of heart failure – indicating that deprivation is a fair proxy for need in this case – they offer no evidence that general practitioner attendance rates are a good measure of “the availability of good medical care”. Indeed, they find no appreciable relationship between deprivation and prescriptions of digoxin, spiranolactone, beta-blockers or angiotensin converting enzyme inhibitors, suggesting that the provision of secondary prevention – surely one of the important outcomes of “good medical care” – does not vary according to socio-economic position. That Tudor Hart’s paper on the inverse care law is still being cited more than 30 years after publication is an indication that there is widespread belief that the law continues to operate.(3) However, the inverse care law has been widely misinterpreted and there is little good quality evidence that “the availability of good medical care” does “vary with the need for it in the population served”.(4-6) Conversely, there is substantial evidence of socio-economic gradients in many aspects of public health and health care uptake and efficacy.(7-11) We suggest that the time has come to reformulate the increase care law and develop new theory concerning the many inverse socio-economic laws that appear to operate. Yours faithfully Jean Adams and Martin White 1. McAlister F, Murphy N, Simpson C, Stewart S, MacIntyre K, Kirkpatrick M, et al. Influence of socioeconomic deprivation on the primary care burden and treatment of patients with a diagnosis of heart failure in general practice in Scotland: population based study. British Medical Journal 2004;doi:10.1136/bmj.38043.414074.EE. 2. Tudor Hart J. The inverse care law. The Lancet 1971(7696):405-412. 3. Tudor Hart J. Commentary: three decades of the inverse care law. British Medical Journal 2000;320(7226):18-19. 4. Wright C. Who comes to be weighed: an exception to the inverse care law. The Lancet 1997;350(9078):642. 5. Brown S, Lumley J. Antenatal care: a case of the inverse care law? Australian Journal of Public Health 1997;17(2):95-103. 6. Chew-Graham C, Mullin S, May C, Hedley S, Cole H. Managing depression in primary care another example of the inverse care law. Family Practice 2002;19(6):632-637. 7. Townsend J, Roderick P, Cooper J. Cigarette smoking by socioeconomic group, sex, and age: effecs of price, income, and health publicity. British Medical Journal 1994;309(6959):923-927. 8. Reading R, Colver A, Openshaw S, Jarvis S. Do interventions that improve immunisation uptake also reduce social inequalities in uptake? BMJ 1994;308(6937):1142-1144. 9. Schou L, Wight C. Does dental health education affect inequalities in dental health? Community Dental Health 1994;11:97-1000. 10. Kirk T. Appriasal of the effectiveness of nutrition education in the context of infant feeding. Journal of Human Nutrition 1980;34:429-438. 11. Lagerlund M, Maxwell A, Bastani R, Thurfjell E, Ekbom A, Lambe M. Sociodemographic predictors of non-attendance at invitational mammography screening - a population-based register study (Sweden). Cancer Causes and Control 2002;13:73-82. Competing interests: None declared |
|||