Key points

  • The ‘inverse care law’ was first defined by the GP Julian Tudor Hart 50 years ago, to describe how – perversely – people who most need health care are least likely to receive it. The inverse care law persists in the NHS today. GP practices in more deprived areas of England are relatively underfunded, under-doctored, and perform less well on a range of quality indicators compared with practices in wealthier areas.
  • Past governments have used a mix of approaches to try to make the provision of primary care in England fairer – including changes to GP funding, contracts, buildings, staffing, and other areas. In this report, we analyse national policies to reduce inequities in the supply of GP services in England since 1990, and evidence on their impact.
  • A variety of policies have attempted to boost the number of GPs in deprived areas, such as central controls on GP distribution or financial incentives for GPs. Some appear to have had positive effects. But policy measures in other areas, such as GP funding, have been more limited. Evidence suggests that the formula underpinning general practice funding in England does not adequately adjust for the greater care need associated with deprivation.
  • Policy development has not been linear. In the late 1990s and 2000s, Labour governments introduced several policies to try to improve general practice in deprived areas, as part of a wider strategy to reduce health inequalities. Evidence on their effect is limited, but these policies likely contributed to more equitable distribution of GPs. In contrast, efforts to tackle the inverse care law in general practice since 2010 have been more limited.
  • Overall, policy efforts to reduce inequities in the provision of GP services over the past 30 years have not been enough to overcome them. Policies have often been small in comparison with the scale of the problem – swimming against a strong tide of other factors shaping inequities. Improvements in the distribution of GPs in the late 2000s now appear to have reversed: analysis of data on GP numbers in England from 2015 to 2020 suggest that inequities in the distribution of GPs are growing.
  • General practice in England is under major strain. GP consultation numbers are now higher than before the pandemic but the number of permanent, fully qualified GPs has fallen since 2015. Current policies on general practice risk widening existing inequities.
  • National policymakers can do more to address these problems in general practice. An independent review of general practice funding allocations should be established and its recommendations implemented. Government should also consider stronger central coordination and oversight of GP distribution in England, as part of a new comprehensive workforce strategy for general practice. New integrated care boards should be required to develop plans to reduce inequities in the provision of high-quality GP services.
  • Tackling the inverse care law in general practice aligns with the government’s ‘levelling up’ agenda, and must become a core objective of national policy. Without deliberate policy action, inequities in the availability of high-quality general practice in England are likely to continue growing, holding back efforts to level up the country.
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