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We are heartened to see Liam Smeeth and Iona Heath stress the
centrality of the relationship between power (wealth) and health in their
reply to our letter. Their original editorial, "Tackling inequalities in
primary care" was subtitled "recording socioeconomic data in primary care
is essential". This fact, along with the fact that the only topic
discussed in any depth in their piece was the collection and potential
uses of descriptive data, gave us the impression that the authors believed
this to be the key issue (1,2). We are glad that this impression was
wrong, however we were confused by the rhetorical question they went on to
pose,
"Are those at higher risk simply to be assigned to "usual care"? How
can this possibly be justified."
Though presumably directed at us it appears unrelated to anything in
our letter. Perhaps we should clarify. Those at higher risk of serious
disease for reasons of their lower social position should have needs-based
access to appropriately resourced services that deliver interventions of
demonstrable effectiveness. GPs can work to ensure all of these things. We
also mentioned the importance of advocacy and political lobbying. The
latter includes making the most of any public platform we are given to
convey the central issues.
The evidence for the effectiveness of currently available
interventions to reduce inequalities is hardly inspiring (3) but this
should not lead us to assume primary care cannot make a difference. In one
deprived Welsh community 25 years of the type of approach we are
advocating was associated with an adult mortality below the UK average.
Neighbouring, similarly deprived, communities had mortality rates 50%
above national average. Diligent data collection, incidentally, was a key
part of this model (4).
1. Macleod J, Loudon R. Exploring possible solutions to a problem is
more important than describing the problem BMJ 1999;319:454
2. Smeeth L, Heath I Author's reply BMJ 1999;319:454
3. Arblaster L, Entwistle V, Lambert M, Forster M, Sheldon T, Watt I.
Review of the research on the effectiveness of health service
interventions to reduce variations in health. Part 1. York: NHS Centre
for Reviews and Dissemination,1995.
4. Hart JT, Thomas C, Gibbons B, Edwards C, Hart M, Jones J, Jones M,
Walton P. Twenty five years of case finding and audit in a socially
deprived community. BMJ 1991;302:1509-13.
Competing interests:
No competing interests
19 August 1999
John Macleod
Clinical Research Fellow
Rhian Loudon
Inequalities Research Group, Department of General Practice, University of Birmingham
At the risk of stating the obvious, perhaps Dr. Darvill has come up
with a simple and ideal solution to the gathering, and, more importantly,
targeting of health care. We should spend far more time and resources
targetting precisely those people who return the blank forms if they are
the illiterate and overstressed.
The middle classes will increasingly be looking after themselves, and
paying for, their health interventions anyway. If people don't like it
they should phone their MP, not their GP - a simple letter substitution
could make all the difference in the world to our workload!
Yours Faithfully
Chris Manning
Conflict of Interest: Just retired from the NHS because it was
driving me mad.
Reply to Smeeth and Heath''s comment on our letter
We are heartened to see Liam Smeeth and Iona Heath stress the
centrality of the relationship between power (wealth) and health in their
reply to our letter. Their original editorial, "Tackling inequalities in
primary care" was subtitled "recording socioeconomic data in primary care
is essential". This fact, along with the fact that the only topic
discussed in any depth in their piece was the collection and potential
uses of descriptive data, gave us the impression that the authors believed
this to be the key issue (1,2). We are glad that this impression was
wrong, however we were confused by the rhetorical question they went on to
pose,
"Are those at higher risk simply to be assigned to "usual care"? How
can this possibly be justified."
Though presumably directed at us it appears unrelated to anything in
our letter. Perhaps we should clarify. Those at higher risk of serious
disease for reasons of their lower social position should have needs-based
access to appropriately resourced services that deliver interventions of
demonstrable effectiveness. GPs can work to ensure all of these things. We
also mentioned the importance of advocacy and political lobbying. The
latter includes making the most of any public platform we are given to
convey the central issues.
The evidence for the effectiveness of currently available
interventions to reduce inequalities is hardly inspiring (3) but this
should not lead us to assume primary care cannot make a difference. In one
deprived Welsh community 25 years of the type of approach we are
advocating was associated with an adult mortality below the UK average.
Neighbouring, similarly deprived, communities had mortality rates 50%
above national average. Diligent data collection, incidentally, was a key
part of this model (4).
1. Macleod J, Loudon R. Exploring possible solutions to a problem is
more important than describing the problem BMJ 1999;319:454
2. Smeeth L, Heath I Author's reply BMJ 1999;319:454
3. Arblaster L, Entwistle V, Lambert M, Forster M, Sheldon T, Watt I.
Review of the research on the effectiveness of health service
interventions to reduce variations in health. Part 1. York: NHS Centre
for Reviews and Dissemination,1995.
4. Hart JT, Thomas C, Gibbons B, Edwards C, Hart M, Jones J, Jones M,
Walton P. Twenty five years of case finding and audit in a socially
deprived community. BMJ 1991;302:1509-13.
Competing interests: No competing interests