What interventions have addressed the inverse care law in general practice in Scotland over the last 20 years? A systematic scoping review.

BACKGROUND: Recent evidence demonstrates persistence of the inverse care law (ICL), with fewer GPs and less funding in more deprived areas. AIM: To map out interventions that aimed to address the ICL and the rationale behind them, and to review the impact and sustainability of these interventions - what has worked, for whom, and why? METHOD: The authors searched Embase, Web of Science, MEDLINE, CINAHL, Cochrane, and BASE from 2000 to 2022 for articles describing interventions or policies that aimed to address the ICL in general practice in Scotland. A systematic grey literature search of government, NHS, and third-sector websites was also performed. All articles were double screened for inclusion. Quantitative and qualitative studies were included. Other forms of primary care, such as dental or pharmacy, were not included. RESULTS: There were 77 included articles (35 from the database search and 42 from the grey literature) reporting on 20 interventions. Interventions were categorised as: 1) enhancing financial or social support; 2) targeting specific health conditions; 3) holistic interventions targeting specific populations; and 4) enhancing generalist care. Seven key interventions accounted for over 70% of all included articles. Evidence of impact and sustainability was variable. Key lessons were summarised for each intervention and grouped by category. CONCLUSION: To address the ICL, a key recommendation is for greater investment in general practice as part of the overall NHS spend, with graded additional resources for more deprived areas depending on local population need (a 'proportionate universalism' approach).

Is Scotland's new GP contract addressing the inverse care law?

Scotland, like many countries around the world, has wide health inequalities resulting, in part, from the longstanding 'inverse care law', in which a mismatch between patient needs and provision of care in general practice in deprived areas results in poorer care and worse patient outcomes compared with affluent areas. In early 2018, Scotland embarked on a new GP contract, a stated aim of which was to reduce healthcare inequalities. National data on avoidable mortality showed a 4.8 (2019) and 4.9 (2021)-fold higher rate in the most deprived compared with the most affluent decile of the population. However, the distribution of whole-time equivalent (WTE) general practice clinicians per 10,000 patients, including GPs, and practice-employed practice nurses and other allied healthcare professionals, showed the opposite trend in both 2019 and 2022, with fewer WTE clinicians of all types in GP practices in deprived areas compared with affluent areas. These findings suggest that radical change is needed to reverse the inverse care law in Scotland.

Health inequalities, multimorbidity and primary care in Scotland.

Scotland has an ageing population and the widest health inequalities in Western Europe. Multiple health conditions develop ∼10-15 years earlier in deprived areas than in affluent areas. General practice is central to the effective and safe management of such complex multiple health conditions, but the inverse care law has permeated deprived communities ('Deep End' general practices) for the past 50 years. A new, radical, Scottish GP contract was introduced in April 2018, which has a vision to improve quality of care through cluster working and expansion of the multidisciplinary team (MDT), enabling GPs to deliver 'expert generalism' to patients with complex needs. It states a specific intention to address health inequalities and also to support the integration of health and social care. Here, we discuss recent evidence for whether the ambition of the new GP contract, to reduce health inequalities, is being achieved.