Reversing the inverse care law

Dr Sarit Ghosh, Pulse PCN editorial board member and clinical director of Enfield Unity PCN in north London, says the inverse care law worsens when the NHS is under pressure. But there are ways that PCNs can address it.  

Winter is here and with its onset we are likely to see the inevitable surges in infections and hospitals hitting OPEL 4 black alerts.

Last year, systems had to commission acute respiratory infection hubs to cope and extra capacity will be key to getting us through again. However, staffing and workforce continue to be a challenge, especially with the increased sickness rates and attrition during this period.

Primary care has to manage this sharp increase in same-day urgent care. In addition, GPs take on more and more responsibility for patients who do not attend or leave A&E due to the long waits, or have been discharged from hospital prematurely. Some of these patients are at high risk for serious illness, and incidents appear to be happening much more frequently than in the past, with patients falling through the gaps.

Inverse care law

And, of course, ‘urgent’ outpatient referrals no longer mean patients are seen in any reasonable time frame, while some of the more routine concerns are batted back to primary care to deal with. Consequently, practices are holding much more risk than in the past and are more likely to shift this to A&E than traditional referral routes, which compounds the problem.

Earlier this month, I was speaking to one of my colleagues who was expressing burnout, upset that despite the best efforts of those in general practice, patients were being failed more regularly. The pressures on the system, especially the front and back ends of hospitals, means that patients are let down, and those who need the most care are often the ones who receive the least.

This inverse care law has been recognised for over 50 years since Dr Julian Tudor Hart published his seminal paper in The Lancet (1971). And it was, of course, highlighted during the pandemic when health inequalities were exposed. Clearly, there is a long way to go to improve the inequity of provision to more deprived populations. But perhaps we can do something within PCNs to help our more vulnerable cohorts.

With this in mind, our team has been working on some searches to identify the patients most in need of continuity. This is part of our capacity and access plans and builds upon the principles shared by Dr Claire Fuller in her Stocktake for Integrating Primary Care and the example of the Foundry PCN. We believe that the patients in greatest need should be prioritised for care within their practices, while generally well patients looking for more transactional care can be seen in other settings.

Addressing the inverse care law

To facilitate this, we plan to roll the searches out with a front-end booking protocol for our receptionists and a training programme to progress staff towards more formal care navigation. The protocol is designed to capture some of our new and follow-up activity and presentations that could safely move to same-day urgent care hubs during winter and beyond if funding can be found.

As part of this work, clinical directors have visited most of our practices over the past six months to get their detailed feedback, which will shape the PCN plans. We’re also trying to get some quick wins around online consultation rates, GPAD appointment mapping and optimisation of patient routing in our cloud telephony systems.

Clearly, the NHS England strategy appears to be avoiding significant investment into baseline core contracts and instead managing capacity and demand at scale in an integrated way.

In the future, we plan to build upon our proposed model by working more closely with 111, ambulance and community services, and local urgent treatment centres. We hope this will alleviate pressure on our practices, maybe even enough to give them longer appointments with complex patients and some time to focus on deprived populations.

And if we were to be successful in reversing this inverse care law? Now, that would be something to make a real song and dance about.