Reappraisal of the Inverse Care Law – Discussion

Results Summary

Socioeconomic Status and Age

The data showed that in relation to age and socioeconomic status (age left full-time education) there were significant relationships for all six indicators of health care service, however these patterns were the opposite to expected for all:

  1. ‘How long waited for an appointment’:
    1. There was a weak relationship with age left education: those that left aged 16 or less were less likely to have waited more than 2 working days.
    2. There appeared to be no clear pattern with age group, though significant.
  2. ‘Whether given enough time to discuss medical problem’:
    1. There was a weak relationship, with age left education: those that left school aged 16 or less were more likely to have been given enough time to discuss their problem.
    2. There was a strong relationship with age group: older age groups were more likely to have been given enough time to discuss their problem.
  3. ‘Whether treated with respect and dignity’:
    1. There was a weak relationship with age left education: those that left aged 16 or less were more likely to have been treated with respect and dignity ‘all of the time’.
    2. There was a strong relationship with age group: those aged 51 and over were more likely to have been treated with respect and dignity ‘all of the time’.
  4. ‘Whether been referred to specialist in last 12 months’:
    1. There was a weak relationship with age left education: those that left school at 16 or less were more likely to have been referred to a specialist.
    2. There was a strong relationship with age group: those aged 65 or over were more likely to have been referred to a specialist.
  5. ‘Main reason dealt with to satisfaction’:
    1. There was a weak relationship with age left education: those that left school at 16 or less were more likely to have had their problem dealt with ‘completely’ to their satisfaction.
    2. There was a strong relationship with age group: those aged 51 and over were more likely to have had their problem dealt with ‘completely’ to their satisfaction.
  6. ‘Whether put off going to GP due to inconvenient opening times’:
    1. There was a strong relationship with age left education: those that left school at 16 or less were less likely to have been put off due to inconvenient opening times.
    2. There was a very strong relationship with age group: those aged 51 or over were less likely to be put off by inconvenient opening times.

High and Low Deprivation PCT Groups

There was a slight difference between the high and low deprivation groups and this was in line with expectations for all indicators except for whether they had been referred to a specialist, which had a slight difference in the opposite direction.

  1. ‘How long waited for appointment’: the high deprivation group was both more likely to have been seen without an appointment and more likely to have waited more than 2 working days, though the greatest difference was only 10%.
  2. ‘Whether given enough time to discuss problem’: high deprivation groups were less likely to have ‘definitely’ been given enough time to discuss their problem; the difference was 12%.
  3. ‘Whether treated with respect and dignity’: there was very little difference, but the high deprivation group was 2% less likely to have been treated with respect and dignity ‘all of the time’.
  4. ‘Whether been referred to a specialist’: the high deprivation group were 3% more likely to have been referred to a specialist.
  5. ‘Whether main reason dealt with to satisfaction’: there was a slight difference between the groups: the high deprivation group were 7% more likely not to have had their problem dealt with to their satisfaction.
  6. ‘Whether put off going to GP due to inconvenient opening times’: the low deprivation group were 10% less likely to be put off due to inconvenient opening times.

Results in Relation to Literature Review

The three significant findings from these results are:

  1. Older age groups and those that left school younger tended to rate the services more positively, contrary to expectations.
  2. Respondents from more deprived PCT areas tended to rate services more negatively than those from less deprived areas (the Inverse Care Law persists despite finding 1.)
  3. Age appears to be a more significant factor in relation to satisfaction with healthcare received.

The results contradict the theory of this project as well as the findings discussed in the literature review, that a patient’s experience of health care is more likely to be affected by their socioeconomic class, (those from a lower socioeconomic class receiving care of a lower quality), and therefore stems from the GP-patient relationship, rather than wider structural economic causes.

Whilst the results appear to undermine the findings in the literature review there are two possible explanations for this. It could be the case that those of a lower socioeconomic class and those who are older have in fact received better health care, suggesting that recent policies have worked and the Inverse Care Law has been overcome. However this conclusion is contradicted by a vast collection of other studies as stated in the literature review and evident from results a pattern remains in relation to deprivation of PCT areas.

An alternative explanation is that those of a lower socioeconomic status or older age do not receive better healthcare but are likely to have lower expectations of the service in the first place and are therefore less likely to be critical. Many of the questions asked in the survey required respondents to give a subjective judgement of the care they received and their relative satisfaction. As suggested from the literature review middle class patients are typically more demanding and therefore likely to be less satisfied with the service they do receive.

The Role of Expectations

There is evidence to support the latter explanation that the difference in patient satisfaction actually lies in the differences in patients’ expectations. Thompson and Sunol (1995) reviewed the literature for different theories of the relationship between expectations and satisfaction, and then applied this to the ‘special nature of health care’ (p127). They referred to the work of Cleary and McNeil who ‘found that evaluation of technical care explains little of satisfaction’ despite being the main determinant of health outcome and conclude that expectations are in fact one of the key factors of patient satisfaction (Thompson and Sunol, 1995: 129/30).

A more comprehensive study of expectations can be found in Duffy (2000), who begins from the premise that ‘Expectations of services play a role in how they are rated. Clearly people with low expectations are likely to be less critical of the same service than those with high expectations’; ratings of services then can be said to amount to ‘the difference between actual experience of service delivery and expectations of service delivery’ (p28). Duffy found that the two major factors that impact on expectations are age and level of resources (Duffy, 2000:28); this may explain why the relationship was found to be the opposite to expected for both level of education and age group. Duffy found that in all areas (both deprived and affluent) older people had lower expectations of services and a general ‘lower propensity to complain’, findings reinforced by attitudinal research (Duffy, 2000:p29). Similarly it was found that ‘higher income and social class groups tend to be among the most critical’, but in contrast to age group this relationship was more apparent in deprived areas (Duffy, 2000:31). This appears to fit with the results of this dissertation, as it could explain why despite the findings that people from a lower socioeconomic class were more likely to be satisfied with health care services, the most deprived PCTs still reflect worse health care experience: ‘those in higher social classes and those on higher incomes in deprived areas are much more likely than other groups in deprived areas to say public services fall short of their expectations’ (Duffy, 2000:31). One of the reasons for this difference in expectations is said to be the experience of private sector services, which is of course related to the amount of resources one commands; ‘those who remain reliant on public services will have more limited and less demanding benchmarks’ (Duffy, 2000: 42). Therefore despite these unexpected results, it still may be the case that ‘public services meet need less well in deprived areas, but that the population of deprived areas taken as a whole expect less’ (Duffy, 2000: 5).

The same study also brings to light some interesting implications for the effect of the type of data used in assessing the quality of services: using a qualitative study by Wilson as an example it was found that despite ‘frightening examples of poor service in hospitals, these same patients“would have said they were satisfied with the health services if the question had been asked directly”’ (Duffy, 2000: 42).  This highlights the effect of the data type itself on the answers that are produced, which is particularly relevant to this dissertation given that all data used was quantitative from closed survey questions. Duffy suggests that whilst structured surveys are likely to cause people to understate any criticisms, qualitative methods are likely to cause people to exaggerate problems ‘by encouraging residents to recall instances of poor service’  (Duffy, 2000: 42). If this is true then perhaps these results present a more positive picture of the healthcare services than is actually the case.

Implications for Research and Policy

Considering that expectations may be a significant factor in explaining these unexpected results, and there is some evidence to support that this is a reasonable explanation to give, other research methods are necessary when investigating whether the Inverse Care Law stems from the structural factors that Hart first identified, as in the economic context of the health services, or whether it stems from the interpersonal relations between patients and doctors when an individual’s socioeconomic class is a factor. Observations may be more useful in obtaining a more objective representation of the quality of service received by individuals, rather than self-reported data. Though the Research Ethics Committee may mean that access to GP consultations may be difficult and timely, and there are of course ethical issues with privacy of the patients, anonymity and confidentiality, this would allow a much clearer representation of any discrepancies between the type of service received by different demographic groups and in different areas. This further research is necessary before any solutions or policy suggestions to reduce or eradicate the effects of the Inverse Care Law can be formulated. The results for different PCT groups suggest that the Inverse Care Law is still an area of research worthy of consideration and indicates that policies introduced so far have not been enough.