Medical deprivation, area deprivation and public policy

,I, 6?-xw2/79/0492-0,

MEDICAL

DEPRIVATION, AND PUBLIC PAUL

I I SO2SX)N)

AREA DEPRIVATION POLICY

L. KNOX

Department of Geography. The University. Dundee DDI

4HN, Scotland

Abstract-This paper describes the relationship between the geographical distribution of primary care and the geographical distribution of areas of multiple social deprivation in Britain, and examines the role of public policies in relation to both. The locational behaviour of general practitioners is identified as the basis for regressive geographical variations in primary care. The public policy response to these variations is outlined, and shown to be inadequate: evidence is presented of persistent geographical variations in primary care. Attention is focused on intra-urban variations in the quality and accessibility of primary care facilities. which have largely been neglected in the formulation of public policy. These variations are found to reinforce spatial patterns of social deprivation and medical need in cities, and it is concluded that medical manpower policies need to be integrated more with the comprehensive approaches to compensatory social planning in other fields if the inter-dependent problems of locaiised medical and social deprivation are to be tackled effectively.

Health is central to community well-being as well as to personal welfare. It has a strong influence on people’s earning capacity and productivity; it affects educational performance (and thus determines employment prospects); and it is fundamental to people’s ability to enjoy and appreciate ail other aspects of life. Health has also been shown to explain. in statistical terms at least, a large proportion of the variation between people in their overall happiness or “perceived well-being” [I]; and surveys have shown that in Britain, as in the U.S.A. and other western societies, health and the provision of health care facilities are consistently valued higher than any other aspect of well-being, including housing, money income, social status, education, family life and leisure [2]. Conversely, health is itself directly affected by people’s real (and perceived) personal circumstances, by social conditions and by the physical environment in the workplace and the home neighbourhood. The distribution of health care resources and the formulation of public policies within the health sector thus have an impact upon indi~duals and communities which goes well beyond clinical considerations alone. This is especially important at the lower end of the socio-economic scale, where personal health can be shown to be an important component in localised cycles of poverty and deprivation-cycles which many social scientists believe can be broken only by the application of a coordinated suite of public policy initiatives. It follows from this argument that the allocation of health service resources should be planned and evaluated in as wide a context as possible, with health service policies being co-ordinated, if not directly linked, with other policies specifically aimed at improving the social well-being of depressed regions and deprived neighbourhoods. This, in turn, is the rationale for the present examination of the geographical distribution of primary medical care resources in Britain. About 98% of the population in Birtain are registered as panel patients with family doctors in the National Health Service (NHS), making an average of about four visits per year to their doctor for mediS.S.Y. 13i2w-c

cal advice, treatment, or referral to hospital or other welfare services. General practitioners, together with

the nurses, midwives, health visitors and others who make up the primary medical care team, deal with over 90% of ail illnesses which reach the formal structure of the health service. so that the health of each cominunity clearly depends on the front-line effectiveness of the general medical practioner service. Fortunately, the organisation of primary care into refativeiy small units means that the distributjon of family doctors can-potentialfy-be finely tuned to the priorities of public policy over fairly short time horizons. The central issue here is whether or not existing policies have been successful in matching the distribution of medical manpower to the areas of greatest need. THE LOCATIONAL PREFERENCES OF GENERAL PRACTITIONERS

In a free market, where doctors are not directly constrained in their location decisions by public pohties of any kind, the geographical distribution of GPs tends to be positively infhrenced by concentrations of people (i.e. potential patients) in general and of high income groups (who tend to have an inelastic demand for medical care) in particular. They are also in~uen~d by the pull of local ties generated at home and at medical school, by the regional and neighbourhood preferences of their spouse, by the availability of office space for themselves and hospital beds for their patients; and by the proximity of other doctors, who are not only able to provide the opportunity for professional interaction but are also able to cover periods of absence due to illness, vacations, or in-service training [3]. On the other hand, GPs tend to be repelled by concentrations of low-income groups, especially ethnic and racial minorities, and by areas with an unattractive physical environm~t. As studies of the geography of primary care in Australia and the United States have shown the net result is a gross imbalance between medical needs and resources, with physicians 111

PAUL L. KNOX

112

tending to be over-represented in the most prosperous and physically attractive regions, in affluent white suburbs, and in central-city districts around hospitals and the principal centres of retail and commercial activity [4]. Similar factors governed the location of GPs in Britain before the creation of the NHS. with similar outcomes. A study of the geographical distribution of medical resources in 1938 found the location of GPs to be determined “primarily by the income level.. . of the locality*’ [5]. Doctor-rich areas thus included atBuent and predo~n~tly rural areas like Hamg shire and Sussex, together with a few towns and cities-like Boumemouth, Eastboume and Southport-with a large population of wealthy retired people. At the other extreme were “doctor-poor” industrial areas in the North-East, the Midlands, Lancashire and Yorkshire, the inner-areas of the large conurbations, and some of the rapidly-~x~n~ng areas of the Home Counties and East Midlands When it took over in 1948. the NHS inherited this distribution of manpower, together with its implications for the quality of primary care in the worst-off areas. Under the NHS, each person could elect to join the list of any local general practitioner, whose services woutd be free. This, of course, generated heavy workloads for general practitioners working in the underdoctored areas, whilst their patients inevitably received less care. Thus, despite a fundamental improvement in equality of access to primary care in financial terms, there remained marked inequalities in the quality and relative availability of primary care. The magnitude of these inequalities is reflected in the list sizes of NHS doctors by area in 1955 (Table I). Whereas very few people in rural Wales, Scotland and most retirement resorts found themselves on lists of more than 3000 patients, half or more of the patients in the likes of Bamsley and Gateshead found themselves sharing the services of their family doctor with at least 3000 other people. The practical implications of these data are illustrated by the findings of a survey of GPs in England undertaken shortly after the start of the NHS. It was found that “the working environment of general practitioners in industrial areas was so limiting that their individual capacity

as doctors counted very little. In the circumstances prevailing, the most essential qualification for the industrial is ability as a snap diagnostician-an ability to reach an accurate diagnosis on a minimum of evident . . . the worst elements of general practice are to be found in those places where there is the greatest and most urgent demand for good medical services.. . . Some conditions of general practice are bad enough to change a good doctor into a bad doctor in a very short time. These very bad

G.P.. . .

conditions are to be found chiefly in industrial areas”

[6]

PUBLIC POLJCY VERSUS THE INVERSE CARE LAW The doctors themselves were afforded some compensation for these conditions through the system of remuneration in the NHS, whereby doctors’ incomes are directly related to the size of their list of patients through capitation fees. Their patients, however, had no such compensation. In response to this situation,

a system of controls and incentives to the location of GPs was introduced. Administered by two independent bodies-the Medical Practices Committee for England and Wales and the Medical Practices Co~ittee for Scotland-this system has remained the principal platform of public policy in relation to the distribution of medical manpower in Britain ever since. It is quite simple in operation. Basically, GPs are not permitted to practice in districts already having an average list size of less than 1800 (“restricted areas”) but are actively encouraged through cash incentives, to practice in districts with an average list size of more than 2500 (“designated areas’*). At first, this strategy proved to be very effective in redistributing manpower from over-doctored to under-doctored areas, despite the vigorous opposition of the British Medical Association. This success was undoubtedly due in some measure to the superfluity of newly qualified doctors entering the “market” in the early years of the NHS. Faced with this “buyers’ market”, many doctors had no choice but to enter general practice in under-doctored working class districts [7], thus bringing an immediate improvement in both the quantity and quality of primary care in such areas. By the end of the 195Os, the regional distribution of GPs became static as vacancies everywhere were filled and the overall level of manpower reached the desired professional norm [S]. Although not administratively related to public policies in other spheres, this medical manpower policy was in fact very closely related in spirit and strategy to the whole post-war attempt to eradicate what Disraeli had called the “Two Nations”. Policies designed to tackle the basic problems of unemployment, poverty and out-migration in Britain’s “problem regions” were all based, like the GP policy, on a mixture of “stick” (i.e. negative direction through, for example, Industrial Development Certificates) and *carrot* (i.e. financial incentives through, for example, Development Area subsidies to industry); and were derived from legisiation (the 1975 Distribution of Industry Act and the 1947 Town and Country Planning Act) which was almost as radical in conception as the NHS Act of 1946. The regional focus of much of. this policy was founded on a genuine belief, fostered by the Barlow Report [9J. that the problem of the “Two Nations” was as much a regional as a class problem. Regional policies were seen as essential in making the fullest use of national resources by increasing the effectiveness of relatively immobile local resources. In addition, the utility of regional policies was increased by the need to recognise the increasing strength of the political lobby from disadvantaged regions and by the desire of the central government to gain the maximum political effect from a minimum of public expenditure [lo]. The net effect of regional policies in Britain in the 1950s was dramatic. In addition to the impressive ~is~ibu~on of medical man~wer, industrial employment in the Development Areas increased at 2.5 times the national rate between 1947 and 1949, with a commensurate increase in the quality of the local so&-economic infrastructure. At this stage, then, the policy governing the distribution of manpower in the primary care sector of

4 6 IO I2 I2 I2 I6 I8 I8

I

%

_.__,“.”

.I.rm_

0 0 0 0 0 0 0 0 0 0

0 /0

___

I__I_i.^_._

--

_-_-

Health

Barnsley Gateshead Dudley Coventry Norwich Great Yarmouth St Helens Wolverhampton Southampton East Ham

Worst IO County Boroughs

1956; Department of Health for Scotland, Scottish

Anglesey Argyll Ayr Cardigan Carmarthen Galloway Merioneth Ross and Cromarty Sutherland Westmorland

Best 10 Administrative Counties

Source: Ministry of Health, Annual Report,

Bath

Eastbourne Chester Bournemouth Wakefield Reading Southend Southport West Hartlepool South Shields

Best 10 County Boroughs

-_

Srorisrics, 1956.

61 51 56 55 55 54 53 52 51 48

%

.

Table 1. Percentage of all NHS patients on lists of 3000 or more. by area, 1955

..-.-.

,

.

...”

Ely Peterborough Essex Nottinghamshire Northamptonshire Middlesex Lanarkshire

Stafforshire Derbyshire Durham

.A,^1_

Worst 10 Administrative Counties

._

28 --

34 31 30

37 37 37 35

45 37

%

.-_

;

-Z g

w J 2. 2 =. 0 3 *; 2

R P

E 3. 5 g.

P

g

PAUL L. KNOX

114

the NHS was both successful in itself and complementary to the spirit and purpose of other socio-economic policies. Unfortunatety, neither this nor the more general socio-economic poiicies were able to sustain their success long enough to change the fund~en~l structure of regional deprivation. An inflationary crisis forced a general cut-back in government expenditure, and this retrenchment was soon reinforced by the change of government in 1951, which brought in a Conservative government with more modest ambitions for the welfare of depressed areas. Medical man~wer policy has also failed to cope with events since the 1950s. but for different reasons. In the early 196Os, medical schools decreased their intake of students in response to the Willinck Report’s suggestion in 1957 that the market for doctors in Britain would soon be overloaded [ 113. In the event, however, these cutbacks served only to exacerbate the subsequent drift of doctors from general practice into the hospital service and the drain of doctors to even more lucrative overseas posts [12]. As a result, the supply of GPs failed to match population changes, and many areas once more became underdoctored. The process of redistributing GPs had gone into reverSe by 196 I ; and in the next six years the proportion of people in England and Wales living in “designated areas” doubled, from 17 to 35% [ 131. In 1966 the basic system of controls and incentives was strengthened by the so-called Doctor’s Charter, which introduced higher cash payments for doctors practising in areas officially designated as under-doc-

tored, reduced the relative importance of capitation fees (and so discouraged the assembly of large lists of patients), and subsidised the costs of improvements to practice premises and the costs of employing ancillary staff f143. Nevertheless, inequalities in accessibility to primary care seem to have persisted. Not surprisingly, the areas worst affected by the relative shortage of manpower have been those which are least attractive in their working conditions, cash incentives notwithstanding. Indeed, the belief seems to be widespread in the medicaf profession “that the designated areas are, as it were, a kind of Third World-worthy to receive general medical services, but scarcely fit places in which sensible people would voluntarily choose to live” [153. It is somewhat ironic, therefore, that 97?/ of the 167 new general practitioners who entered practice in under-doctored areas (i.e. designated areas) in 1969 came from overseas [IS]. The net result is that the distribution of family doctors in Britain has again given cause for concern in recent years. In 1970, for instance, the Planning Unit of the British Medical Association expressed some anxiety over the magnitude of regional differences in average list sizes, pointing out that there were over 40 areas where individual doctors were obliged to care for lists in excess of 3200 patients [17]. Moreover, the situation has been seen by many as part of a more general mismatch between needs and resources in the NHS-a mismatch which is compounding most of the long-standing and well-docu-

Table 2. Regional variations in levels of primary care in 1975

% of

principals with lists a2500

Average list size

50

2434 2450 2495 2302

Location quotient*

Engiand (Standard Regions):

North Yorkshire & Humberside East Midlands East Anglia South East South West West Midlands Northwest Scotland {Health Board Areas): Argyll & Ciyde Ayr Borders Dumfries & Galloway Fife Forth Valley Grampian Greater Glasgow Highland Lanarkshire Lothian Orkney Shetland Tayside Western Isles

47 :: 38 26 46 49

-

2188 2424 2454 1825 2112 1677 1730 2113 1974 1833 2015 1440 2268 1896 1122 1209 1879 1435

0:95 0.94 0.93 1.03 I .02 1.10 0.95 0.94 1.05 0.9 I

1.15 I.11 0.91 0.97 1.05 0.95 I .36 0.85 1.02 1.72 1.s9 1.03 1.35

Source: Department of Health and Social Services, Health and Personal Sociul Services Statistics. 1975; Scottish Health Department Scottish Health Statistics, 1975. * The Location Quotient is a measure of localisation, calculated as the ratio of the local incidence of doctors per patient to the national incidence of doctors per patient. Values greater than 1.00 indicate that a region has more than its share of GPs in relation to its share of the national population.

Medical deprivation, area deprivation and public policy social and geographical gradients in mortality, morbidity, and the quality of life in general. The Seebohm Committee, for example, emphasised the regressive variations in the quality of health and weifare services provided by local authorities [ 181, and both Coates and Rawstron [19] and Cooper and Culyer [20] have shown how regressive variations in the incidence of family doctors and hospitii services reinforce the general socioeconomic dominance of the south-east. Others, such as Titmus [21] and Townsend [22]. have emphasised class variations in access to medical care across virtually the whole spectrum of NHS activities. Hart has succinctly summed these trends up in terms of an “inverse care law”, whereby “the avai~~iiity of good medical care tends to vary inversely with the need of the population served” [23]. How true is this of the geographical provision of primary care in relation to areas of need and multiple deprivation? Table 2 shows the evidence of the avaiiable data for 1975. At this rather coarse regional level it is certainly possible to find some support for the idea of an inverse care i,aw, although the data are by no means unequivocal. The prosperous South East of England has a fair (or, at least, proportional) share of medical manpower, in contrast to the economically depressed Yorkshire and Humberside, Northern and North Western regions. On the other hand, the East and West Midlands, where levels of living are amongst the highest in the country [24], have less than their proportional “share” of medical manpower. In Scotland, the least doctored regions are those like Greater Glasgow. Lanarkshire and Fife, which contain large concentrations of “multiply deprived” populations [25], and where levels of mortality and morbidity from all causes are significantly higher than in the more generously doctored rural areas of the Highlands and Islands. There are good reasons, however, why the average list size should be ~~ifi~~y lower in rural regions, the most important .of which is of course the question of distance between surgery and patients. mented

INTRA-URBAN

VARIATIONS

Whilst the evidence for an inverse care law at the regional level remains equivocal, there are increasing grounds to suspect that intru-urban variations in the delivery of primary care should be the focus of concern. Cartwright’s analysis of hospital patients [26] provided some indication of regressive tendencies in the availability of primary care within urban areas over 15 years ago, when she found that relatively more GPs in working-class neighbourhoods had to deal with large lists of patients than did GPs in middle-class areas, that only half as many had higher qualifications, that less than one-fifth as many had access to physiotherapy, fewer had access to contrastmedia X-rays, only half as many held hospital appointments or had access to hospital beds in which they could care for their own patients; and only onethird as many managed’to visit their patients when they were in hospital under specialist care. Until recentty. the controls and incentives applying to the location of GPs rarely operated at a scale below that of whole towns or cities [27]. so that the

115

contrast between working-class and middle-class neighbourhoods has been reinforced by the natural tendency of family doctors to live and work in weliestablished high-status areas, where there often exists the possibility of earning extra income with fees from private patients. Moreover, the structure and ideology of the medical profession in Britain also discourages progressive change in the provision of primary care at this level, since not only is working in blue-collar neighbourhoods held to be unglamorous and unsatis fying [28]. but time spent in general practice in such areas is seen as almost certain disqualification for any further career advancement [29J. The locational behaviour of family doctors at this scale is also in~uen~d by structural, ‘or “fabric” effects which tend to reinforce the relative advantages enjoyed by older middle-class neighbourhoods. There is, for instance, an almost complete lack of accommodation suitable for use as doctors’ surgeries in the large housing estates-both public and specuiativelybuilt-which have encircled most British cities since 1945. Purpose-built Health Centres, housing the offices of six or more GPs, together with nursing staff, ancillary workers, and sometimes a dentist, have been established in some of the suburban neighbourhoods of some cities in recent years. But the rationalisation of practices involved in setting up Health Centres inevitably means that (unless they are staffed by extra manpower) the net effect will mean more patients having to travel further between home and GP than before (30). In short, Health Centres provide the benefits of economies of scale only at the expense of equity in patients’ accessibility to GP services. The crucial issue here, of course, is the extent to which distance acts as a barrier to primary care. In British cities, where large sectors of the population are still without private transport, the actual distance from home to surgery is critical. Half a mii~“pr~-pushing distance”-is often regarded as the upper limit for mothers with pre-school children and for the elderly [31]; and travelling much more than this by public transport may involve a long wait or a change of bus unless both home and surgery he conveniently near a bus route. In this context, the disuti~ty of traveihng to the surgery can act as a substantial barrier to proper care, influencing “therapeutic behaviour” just as educational, religious and classrelated barriers do [32]. Patients living further away will tend to make light of symptoms or put up with discomfort and uncertainty, gambling that their symptoms are not related to any serious condition rather than making the effort to travel to their doctor. There is already convincing evidence that distanceperceived distance as well as real distance-has a marked negative effect on consultation rates [33]. It seems reasonable to suppose that this will eventually exercise a direct effect on local patterns of morbidity and mortality. It is also worth noting that blue-collar workers are, in general, less inclined to consult family doctors and much less concerned than white-collar workers with preventive medicine, with the result that distance itself affects the delivery of medical care differentially by social class [34], notwithstanding class differences in car ownership. Moreover, such effects do not appear to be attenuated by increased requests for home visits: Hopkins et al., for example, found

II6

PAUL

that patients living further away from the surgery not only had lower utilisation rates than others. but were also more reluctant to call out their doctor for home visits [35]. Because of this, the relative lack of accessibility to family doctors in economically depressed and socially deprived neighbourhoods must be seen as an important component in sustaining the localised cycle of poverty in which the inter-dependence of unskilled work. low incomes, poor living conditions, and poor educational opportunities produces successive generations of residents equipped with only limited occupational skills and generates high rates of morbidity and mortality from infectious diseases, high rates of infant mortality and suicide. and high rates of psychological stress. mental ill-health and social malaise in general. At a broader level, the relative accessibility of family doctors between neighbourhoods can also be seen as a significant determinant of people’s real income, part of the “social wage” whose magnitude depends to a large extent on the redistributive effects of the externalities associated with the siting of the various public and semi-public facilities within cities.

ACCES!GlBlLlTY TO PRIMARY CARE IN GLASGOW

The question thus arises as to the actual degree of disparity in accessibility to primary care between different kinds of neighbourhood. An analysis of the distribution of doctors’ surgeries in relation to potential patients in Glasgow in 1974 suggests that such disparities are in fact considerable. An index of accessibility to family doctors has been calculated for neighbourhoods [36] within Glasgow on the basis of a gravity model which incorporates the two major determinants of patient behaviour in British cities: freedom of choice of doctor and the frictional effects of distance. The basic index of accessibility is computed [37] as:

where Ai = accessibility in neighbourhood Sj = total GP surgery consultation in neighbourhood j.

L.

KNOX present distribution of population and its differential local use of private and public transport [39]. Table 3 shows the distribution of these index values, according to the six principal kinds of neighbourhood type [40] in Glasgow. Because of the localisation of doctors in the older central areas of the city [41], the three inner-city neighbourhood types emerge with the highest average levels of accessibility to the city’s 597 GPs. The most favoured communities are the relatively small and compact zones of tenement housing occupied by New Commonwealth immigrants-mainly Asians. Their particularly high scores are attributable quite simply to the proximity of the large Health Centre at Woodside. At the other extreme are the neighbourhoods based on public housing estates which. between them, house over twothirds of the city’s population. These neighbourhoods. especially the likes of Drumchapel, Barmulloch. Garthamlock and Easterhouse on the periphery of the city which contain many of the city’s most notorious “problem estates”, have very few local surgeries at all. Moreover. levels of car ownership are low (typically. over 75% of the households in these areas do not have a car). and bus services to other parts of the city are infrequent and expensive; so that large numbers of people must face return journeys of over four miles in order to see their GP. The problem is particularly acute for families rehoused from substandard tenement dwellings in the inner city, since the shortage of doctor’s surgeries in peripheral suburban estates means that they often have no choice but to remain on the list of their inner-city GP, thus facing return journeys of up to eight miles. Overall, then. the degree of disparity in accessibility to GPs between different parts of the city can be shown to be considerable, although the pattern of variation is not one which would conform closely with Hart’s inverse care law: the two areas of extreme socio-economic deprivation-the inner city and the peripheral zone of public housing+merge as bestand worst-off respectively in terms of accessibility to primary care. whilst the higher-status owner-occupied zones collectively emerge with intermediate scores.

OTHER ASPECTS OF MEDICAL i.

time available

and K = an exponent representing the deterrent effect of the costs of travel: set at 1.52 on the basis of an analysis of a regression analysis of the actual fall-off in patient registration with distance from surgeries[38]. This index has been computed for the nodal centre of I I7 neighbourhoods in Glasgow. and then weighted according to local levels of car ownership and the potential number of patients living in and travelling to each neighbourhood to receive primary care. Finally, the index was scaled to give a measure of accessibility for which values greater than 100 indicate a relative over-provision of GPs. given the

DEPRIVATION

Physical inaccessibility to GPs, however, is only one aspect of medical deprivation in urban areas. Other aspects of the geography of primary care lend more support to Hart’s idea of an inverse care law. with inner-city areas emerging as the worst-off in terms of the qualify. if not the availability, of primary care facilities. In Glasgow’s East End. for example. a more detailed examination of the 84 GPs, their organisation and their surgeries reveals an unhappy situation which is belied by the high levels of physical accessibility to GPs in the area. The East End is one of the harshest and most brutalised urban environments in Britain. with a population of over 150.000 and where the extent and intensity of unemployment. housing stress. environmental deprivation and social pathology is practically unrivalled in north-western Europe. It is an area with a large and increasing elderly population. with high proportions of one-parent families. vagrants, in-migrants. students and other

Medical deprivation.

area deprivation

Table 3. Accessibility of GPs in Glasgow, by neighbourhood

Ne~ghbourh~d

type

New Commonwealth Immigrant areas “Very deprived” inner city “Deprived” inner city Mixed owner-occupied, privately rented and public housing Older public housing estates Newer peripheral public housing estates

and vulnerable groups with special medical needs. It is not, however, an area which has attracted medical manpower in proportion to its needs. Almost three-quarters of the area’s GPs are now over 45, and 17% are over 65 years old [42], compared to the national figures of 5@/, and 7”/, respectively [43). This reflects the persistent unattractiveness of the area to GPs since the late 194Os, when the post-war glut of young doctors forced many GPs to take jobs in depressed areas like the East End. Moreover, the organisation of the area’s doctors has remained static, despite changes in the area itself and in contemporary patterns of health care delivery elsewhere. Over W/, of E;lst End practices are single-handed (run entirely by one practitioner) for instance, reflecting the lack of progress in developing team work and group practices. And the conditions of many of the poorly equipped lockup surgeries (consulting rooms occupied only during office hours; in inner city areas they often consist of a small converted retail shop set in the ground floor of a tenement block) used by these doctors has deteriorated at a rate which matches that of the East End as a whole. Apart from the damage to the morale of both doctors and patients, these damp, grubby and crowded premises often pose a real threat in themselves to health-to the extent that conventional wisdom holds that “you go in with the ‘flu and come out with pneumonia”. It is not surprising that many patients prefer to seek treatment at the city’s hospital outpatient departments, thus transferring the problem to another branch of the Health Service. Other large cities evidentiy experience the same problems in inner-city districts. Phillips, for example, describes the reality of primary care in the Vauxhall area of Liverpool as follows: indigent

“There are no chairs (in the waiting room). From the ceiling a large piece of wallpaper hangs down limply. Unshaded light bulbs, coated in grime, hang among drooping coils of lighting flex. Nearby. three GPs hold their surgeries in a converted pair of shops. The windows are boarded up and one ol’ the few panes of glass is smashed. The waiting area smells damp. It contains chairs-red. plush, former cinema seats, torn and losing their stuffing, and wooden benches arrayed around the walls.” [44]

Complaints by patients of cursory and unsympathetic treatment by doctors are rife. In such ‘areas it is the conditions in which primary care is presentedwhat Dutton [45] describes as a “dehumanising ambience”-which constitute the major barrier to therapeutic behaviour, and not distance between home and surgery. Nevertheless, there are many

117

and public policy type

Mean accessibility score

Standard deviation

86.7 79.6 75.1 13.4 61.7 54.1

4.1 6.4 13.6 11.1 7.5 11.1

patients who are subject to both deterrents. As in Glasgow, patients who move out-or are moved-to suburbs such as Speke and Netherley as part of urban renewal schemes are often forced to remain on the list of the GP in the area from which they were rehoused. As a result, many patients must face journeys of over 30 minutes by car each way; or a total of at least four bus journeys. taking much longer and costing well over fl. In London, a more detailed survey of primary care in Thornhill provides an equally disturbing case study of an inner city neighbourhood [46-j. Tbomhili lies between Kings Cross and Barnsbury, and is an area which suffers from all of the problems of inner-area deprivation. It emerged in the worst category in a city-wide survey of “multiple deprivation” [473 and has above-average levels of infant mortality, malnutrition and tuberculosis in a population which is heavily weighted at top and bottom. It has a high proportion (15%) of pensioners, many of whom (over one-third) live alone. It also contains above-average numbers of young children, members of ethnic minority groups, vagrants, alcoholics, and physically and mentally handicapped people. The health needs of the area are swollen by the area’s work force, many of whom prefer to register with a Thomhili GP even though they live outside the area. At a superficial level, though, Thomhiii does not suffer from medical deprivation, even though it is clearly an area of acute deprivation in other respects. Physical accessibility to primary care is high: there are 21 GPs practising from 13 surgeries in the 1.5 square mile area; and the average number of patients per doctor in this part of London is 2162. Indeed, the local executive council of the Medical Practices Committee has adjusted this figure downwards, to 1739, in order to take into account probable changes in the area’s population. This means that Thomhill is in fact “restricted” to all new practitioners on the grounds of overdoctoring. Thomhill is, however, medically deprived. Like their counterparts in Liverpool and Glasgow, Thornhill people receive primary care in poorly-equipped surgeries from doctors who are mostly operating singlehandedly and who therefore find it difficult to employ a nurse or receptionist, to attend in-service courses, and to find a deputy famiiar with their patients and their needs. Astonishingly, one-third of the doctors in Thomhiii are over 70; and this includes two doctors of more than 80 years of age, whose training took place 10 years before the discovery of penicillin. Despite the value of experience, it must be doubtful whether practitioners of this age can effectively tackle a full workload in an area. whose medical needs are as intense

PAUL L. KNOX

118

and specialised as Thornhill’s. Most of the older GPs. in fact, do not attempt to do so, and have deliberately restricted both the size of their lists and their catchment areas. Thus. what appears to be a local abundance of manpower turns out to be a rather depleted group of GPs working in an unto-ordinated way from under-capitalised surgeries. MEDICAL

DEPRIVATION.

DEPRIVATION

AREA

AND PUBLIC

POLICY

There is no need here to document more evidence of medical deprivation, whether by neighbourhood or region. Recent policies. formulated largely on the rather simplistic criterion of list size, have clearly been ineffective in combating the various facets of primary medical deprivation in Britain; nor have they taken into account the critical problem posed by the mutual reinforcement of medical deprivation and area deprivation. Nevertheless. concern over the distribution of medical manpower has prompted a reevaluation of public policy at several levels. As a result of the Todd Commission on Medical Education [48], the annual intake of students was significantly increased in an attempt to reverse the persistent trend of increasing list sizes. A recent report by the Department of Health and Social Security [49] has confirmed the need for continuing high levels of recruitment, concluding that 2000 more physicians will be needed by the year 2000 simply to eradicate regional disparities. Another recent discussion paper. however, has emphasised the financial implications of the increased production’of medical graduates. calling for a more rfictioe use of existing resources: partly through redistributing manpower between regions and professional specialities [SO]. The urgency for reform is recognised by the Secretary for Social Services. who has invoked Disraeli’s notion of Two Nations in relation to contemporary patterns of health care [Sl]. The policies which might be used to narrow the gap between the Two Nations. however. have yet to be formulated. The broad strategy may emerge from the Royal Commission on Health. which is still sitting. Specific strategies relating to primary care are the objective of the Joint Working Party set up by the Department of Health and Social Security and the Scottish Home and Health Department in conjunction with the General Medical Services Committee of the British Medical Association: “To consider in respect of Great Britain what characteristics determine whether there are sufficient general practitinners in an area and to look at all the factors. financial and nonfinancial. affecting the recruitment and retention of general medical practitioners in under-doctored areas: and to suggest (a) criteria by which under-doctored areas might be identified and (b) measures which might be taken IO help achieve an adequate number of doctors in such areas.”

In the meantime. both central and local governments have gained a considerable amount of experience in formulating area-based initiatives with which to tackle the economic and social deprivation of cities and regions. These have neighbourhoods, moved away from the earlier strategy of “stick and

carrot” towards the idea of compensatory planning or “positive discrimination”, whereby resources are focused on particular geographic areas in an attempt to ameliorate the effects of multiple deprivation. Many of the early area-based strategies were rather uncoordinated attempts to upgrade the physical environment. These include the clearance area and comprehensive development area programmes. the introduction of smoke control areas, noise abatement areas and pedestrianised neighbourhoods, and the designation of General Improvement Areas and conservation areas [SZ]. The experience of more recent policies. however, provides some important general lessons relevant to the formulation of medical manpower policies. The first area-based strategy to apply the principle of positive discrimination to social objectives was the Educational Priority Area programme, set up in 1967 as a result of the Plowden Report [53]. This was also the first programme to attempt to identify small areas for priority treatment by means of “social indicators”. Subsequently, social indicators have become a standard part of the technics and mechanics of areabased planning, and have played a principal role in identifying areas of need in relation to the several comprehensive approaches to social policy which have emerged over the last few years as the most effective short-term means of tackling urban deprivation [54]. These include the Housing Action Area and Priority Neighbourhood scheme. the Urban Aid Programme, the Comprehensive Development Project. and the Comprehensive Community Programme. Several of these have involved the setting up of special administrative arrangements between different local and functional authorities. Indeed. the need for such co-operation in mounting effective area-based policies within local authority jurisdictions has led to the concept of “area-management”. in which vertical bureaucratic divisions within an authority are scrapped in an attempt to adapt local government organisation “more sensitively and effectively to the needs of particular areas” [55]. One key omission from these policies, of course. has been the provision and organisation of primary medical care. Thanks largely to the conservatism of the medical profession itself. and in particular its resistance. until recently, to the idea of Health Centres [56], the provision and organisation of primary care has remained effectively beyond the control of local planning authorities. Thus, despite the obvious importance of primary care in areas of socio-economic deprivation. medical deprivation has often persisted. reinforcing the local cycle of poverty. A good example is provided by the Glasgow Eastern Area Renewal scheme (GEAR), for which the central government has provided over f200.000.000, together with the necessary legislation to enable a partnership of local public bodies to tackle the problems of the East End of the city. Tenements have been reconditioned, derelict land has been cleared and social amenities have been provided. and yet, because they are beyond the remit of the public bodies involved. doctors practising in the GEAR area must continue to operate from substandard and ill-equipped surgeries, and so continue to play their own particular role in area deprivation.

Medical deprivation, area deprivation and public policy

The current reviews of medical manpower policy provide an opportunity to remedy such situations by seeking some sort of active association with planning authorities so that medical policies can be integrated, or, at least, co-ordinated, with the kind of comprehensive, area-based strategies outlined above. It also seems desirable for indicators of medical deprivation to be developed and used in conjunction with other social indicators in identifying areas of need, whatever the degree of administrative interaction. For example, the various parameters of list size could be supplemented by indicators of physical accessibility to GPs, perhaps weighted by measures of medical need, which could in turn include indices of demographic structure as well as local rates of morbidity and mortality. Both the data and the techniques already exist to institute area-wide monitoring systems along these lines, although the most efficient and sensitive use of resources would probably involve the re-organi~ti~ of local medical practice areas around a more convenient data base than the present medical practice areas [57]. The question then arises as to the kind of positive discrimination which might be applied to areas identified as being under~~tored, or medically deprived. The least disruptive strategy would be to reinforce the existing policies based on initial practice allowances and designated area allowances, which are clearly oriented towards the medical profession’s finely-tuned sense of status and financial reward. The $ze of financial incentives could be increased, as could the subsidies towards employing ancillary staff in under-doctored areas, and towards refurbishing and equipping surgeries. And experience in socially and medically deprived areas could be made to count in computing seniority allowances and sabbatical study leave [SS]. These are short term, cosmetic policies, however. In the longer term, such incentives would be cancelled out as conditions improved; and in any case, doctors must realise that the move to,an unattractive and demanding area would be for only a marginal and short-lived increase in income. Butler and Knight, following a detailed survey of medical practice areas in 1974, concluded that the incentive effects of the designated allowance are small, and suggested that they should be withdrawn rather than increased, retaining a larger allowance for doctors in a few areas of severe medical deprivation and introducing a new component of compensatory payments for living in “unattractive” areas, regardless of list sizes [59]. Such a system would. of course, fit in well with “comprehensive” approaches to area deprivation. More radical approaches to the problems of local medical deprivation involve the reorganisation of primary care. the restructuring of its administrative framework, and the re-orientation of the medical profession itself. The inefficient single-handed practices which are characteristic of inner-city areas, for ’ example, could be reorganised in favour of team work. group practices and Health Centres by employing mildly coercive tactics based on an exte‘nsion of the power of local faniily practitioner committees: after all. a society which is committed to an egalitarian health service should not flinch from actually assigning medical personnel to specific tasks or areas. The rationalisation of practices on this scale-

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whether or not by coercion-inevitably raises the problem of balancing decreased equity (in terms of the accessibility of the surgery to people) against the increased efficiency of medical personnel. Here again, however, indicators developed in other spheres could be used to guide policy: Robertson, for example, has shown how the Tomqvist location-allocation algorithm can be used to decide upon the optimal locations for a specified number of Health Centres in Glasgow [60-J. In a wider context, the problem of making the most effective use of limited resources could be alleviated through a limited degree of substitution of GPs with more of the relatively cheap manpower represented by nurse practitioners and paramedics. Such a programme might be restricted, in the first instance, to specific areas of medical deprivation and linked to a closer functional integration of the general medical services with local authority health and welfare services. This leads to the even more complex issue of restructuring the administration of the general medical services. At present, the different elements of public policy pertaining to GPs are dispersed among several groups. The nature of local incentives and restrictions is decided by negotiation between the British Medical Association and the Department of Health and Social Security/Scottish Home and Health Department; their value is decided upon by the Review Body on Doctors’ and Dentists’ Renumeration; and the areas designated for priority treatment are fixed by the Medical Practices Committees. in addition to the problems of co-ordination caused by this fragmentation, such a framework, with its associated series of narrowly defined objectives, precludes the integration of medical manpower policies with the more comprehensive local initiatives operated by local and central governments and stifles the development of more radical initiatives. Moreover, it seems unlikely that public bodies presently responsible for medical manpower policy will voluntarily surrender their autonomy. They are dominated by medical practitioners and their various professional representatives who, as Townsend has observed, tend to propound dogmas of omniscience, omnipotence and infallibility, to deflect outside criticism, to resist change, and to use power to secure excessively privileged conditions of remuneration and work [61]. These are not quaiities which lend themselves to the creation of a more equitable health care delivery system. The re-orientation of the ideology of the medical profession and the demystification of medicine thus become important longterm objectives, which can only be tackled in medical schools, where the ethos of the profession is created and perpetuated. As a start, more emphasis could be given in medical education to the medical and social value of working in deprived areas. In the mean time, hopes for a more effective strategy for primary care in depressed areas must rest on the hope for more informed and more enlightened decision-making on the part of the established ad hoc machinery. REFERENCES 1. Campbell A.. Converse P. and

Rodgers W. The Qualit) of American Lifi: Perceptions. Ewiuurions und Satisfuctions. Russell Sage. New York. 1976.

120

PAUL

L.

KNOX

McKniff T. P. A Health Cenrre Survey. Department 2. See, for example, Abrams M. Subjective social indiof Public Health. Oidham. undated. cators. Sot. Trends 4. 35-40, 1976. 32. Mechanic D. and Voikhart E. H. Illness behaviour and 3. Shannon G. W. and Dever G. E. Heulrh Cure Delivery medical diagnosis. J. Hirh hum. Behav. I, 86-92. 1962. Spur&i Ferspecrives. McGraw-Hill, New York. 1974. 4. See, for examole. de Vise P. misused atrd ~~tis~~u~~,d 33. Townsend. op. cit. 34. Weiss J. and Greenlick M. Determinants of medical ~ospitais und dacfors: a locational analysis of fhe‘urhan care utiiisation. Med. Care 8 45&62. 1970. he&h care crisis. Association of American Geo35. Hopkins E. J. et al. The relation of patients’ age. sex graphers Commission on College Geography, and distance from surgery to the demand on the family Resource Paper 22, Washington DC.. 1973; and doctor. Jt R. Coil. Gen. Pratt. 16. 368-78. 1968. Stimpson R. J. The spatial characteristics of health 36. The “neighbourhoods” used in the analysis were the care services provision and utiiisation in Australia. 117 groups of contiguous Enumeration Districts with Popuiatio~ and Medicul sy~fposiat~, Institute of British relatively homogenous socio-economic characteristics. Geographers, Hull. 1978. These were identified by the Scottish Development 5. Political and economic planning. Pfanning. BroadDepartment’s Central Research Unit as the basis for sheet 222, Political and Economic Planning. London, their studies of multiple deprivation in Scottish cities. 1944. 6. Coiiings J. S. Luncet i. 555. 1950. See Four cities change study, SDD. CRU, mimeo7. Cartwright A. Purienrs und their doctors. Routledge and graphed report. 1976. Kegan Paul. Henley-on-Thames. 1967. 37. Symons J. Some comments on equity and efficiency 8. Report of the Coftltf~iftee to consider the ~arure in public facility location models. Antipode 3, 54-67. Numbers of Medical Practitioners and the Appropriate 1971. intake of Medical Students (Wiiiinck Report). 38. Data for this analysis were derived from Hopkins et H.M.S.O., London. 1957. al., op. cit. 9. Report qj’ the Royal Commission on the Distrihutiorf oJ 39. The derivation of the final index from the basic index Industrial Populatiorr (Barlow Report). H.M.S.O.. Lonof accessibility is as follows: don, 1940. IO. For a full account of British regional policy. see McCrone G. Regio~ru/ Policy in Britain. George AIien and Unwin. London. 1969. ii. Wiliinck Report. op. cit. where Ai,,, is a time-based index of accessibility for 12. Seaie .I. Medical Emigration from Britain 1930-1961. neighbourhood i. Ci is the percentage of car-owning Br. Med. J. 1. 782-6. 1962. households in neighbourhood i, and 7-c and Tp tire 13. Office of Health Economics. Gerferal Practice Today. the average times taken to travel a given distance by Occasional Paper 28. Office of Health Economics. car and by public transport respectively. The latter London, 1968. were calculated from a sample of actual journey times 14. Office of Health Economics. Thp Work of Prirnatr between r~domly-~iected points. Medical Care. Office of Health Economics: London. This weighted measure is then adjusted to account 1974. for the potential demand for primary care at a given 15. Butler J.. Bevan J. and Taylor R. Family Doctors affd point. This potential has been calculated simply as a Public Policy. Routledge and Kegan Paul, London. function of distance and population densities: 1973. 16. Department of Health and Social Security, Ann& (2) Report 1969. H.M.S.O.. London. 1970. Care. 17. British Medical Association, Primary Medical Planning Unit Report. No. 4. London. 1970. where M, is the potential “market” for primary care 18. Report of the Committee on Local Authority and Allied in neighbourhood i, and Pj is the population of neighPersonal Social Services (Seebohm Report). H.M.S.O.. bourhood j. Scaling the values of both Ai,,, and Mi London, 1968. to percentages of the highest computed value for each 19. Coates B. and Rawstron E. Regional Variations in Briprovides a standard&d basis for the final index. which tain. Batsford. London. 1971. is simply the ratio of the standardised Ai,,, values to 20* Cooper M. M. and Cuiyer A. An economic assessment the Mi value. of some aspects of the operation of the National 40. These six “types” of neighbourhood were derived from Health Service. a cluster analysis of the ii 7 neighbourhoods based on 21. Titmus R. M. Commitment to Welfare. Allen and Un19 socio-economic variables. reported in Scottish Dewin, London, 1968. velopment Department. op. cit. The principal charac22. Townsend P. Inequality and the Health Service. Lancer teristics of each type of area are as follows: i, 1179-90. 1974. New Commonwealth immigrant zones: tenement areas It Hart J. T. The inverse care law. Lancer i. 405-12. 1971. __. distin~ished by high proportions of immigrants from 24. Knox P. L. Spatial variations in level of living in Engthe New Commonw~ith. land and Wales in 1961. Tracts. lnsrir. Br. Grog. 62. Very deprived inner city zones: areas of substandard i-24. 1974. tenement housing. high unemployment. low car ownership and overcrowded households. 25. Hoitermann S. Censtts Indicators of trrhan deprirutiorl. Working Note 6. Great Britairl. Department of the EnDeprived inner city zones: areas characterised by high vironment. London. 1975. levels of unemployment and overcrowding, and high 26. Cartwright A. Huntut? Relations aad Hospifai Care. proportions of males in Socio-Economic Group II. Routledge and Kegan Paul. London. 1964. Mixed zo,~es: includes the tenemental areas of the inner city and most owner-occupied districts: together, they 27. Butler et at, op. cit. constitute the most affluent zones of the city. 28. Cartwright. op. cit., 1967. Older local authority estates: character&d more than 29. Hart, op. cit., p. 408. anything else by high proportions of the elderly. 30. Sumner G. Trends in the location of primary medical care in Britain. Antipode 3, 46-53. 1971. Peripheral local authority estates: newer and inter-war local authority estates tiith above-average proportions 3 1. See, for example. Hiilman M. Persoftal Mohiliry. Poiiticai and Economic Planning. London. 1973: and of children aged S-14. above-average proportions of

Medical deprivation,

41. 42.

43. 44.

45.

46.

47. 48. 49.

area deprivation

unemployment. persons in so&-economic Group II. and households without a car. Knox P. L. The intra-urban ecology of primary medical care: patterns of accessibility and their policy implications. Enoiron. Plunn. AlO, 415-35, 1978. The age distribution of doctors in the East End is an estimate, based on the assumption that all doctors quatitied at the age of 25; relevant dates of qualitications were drawn from the ~edicffl Register. Cartwright op. cit., t967. Phillips M. Health gap in a class of its own. The Guurdian 20th October. p. 3, 1978. Dutton D. Explaining the low use of health services by the poor: costs, attitudes. or delivery systems? Am. social. Rev. 43, 348-68, t978. Thornhill Neighbourhood Project. Health Core in Thornhill: A Case of Inner City Deprivation. Thornhill Neighbourhood Project. London, 1978. Greater London Council, Greater London Develop ment Plan, G.L.C.. London, 1969. Report of the Royal Commission on Medicaf ~ducff~io~, 1965-1968 (Todd Renortf. H.M.S.O.. London. 1968. Department of Health and Social Security. Medical Manpower: The Next 20 years. H.M.S.O.. London.

1978. 50. Maynard

A. and Walker A. Doctor Manpower H.M.S.O., 1978. 51. Department of Health and Social Security. op cir.. 1978. 52. Hambleton R. Policies for areas. Local Government Studies. pp. 13-29. April 1977. f975-2g~.

53. 54.

55. 56. 57.

and public policy

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Schools. Report of the Central Advisory Council for Education ~Eng~nd~ (Plowden Report). H.M.S.O.. London, 1967. Knox P. t Territorial social indicators and area profiles: some cautionary observations. Town PI. Rev. 49. 75-83. 1978. Area Management. consultation paper from the Department of the En~ron~nt, November. 1974. Ryan M. Health Centre Policy in EngIand and Wales. Er. J. Social. 19, 3-6, 1968. At present, the boundaries of medical practice areas do not coincide either with census enumeration districts or with postal code zones, the other major source of contemporary social, economic and medica data. Moreover, as Butler and Knight have shown, medical practice areas also suffer from inconsistencies in their size. They also tend to straddle the family practitioner committee areas which were set up as the basic unit of local administration under the 1974 reorganisation of the NHS. See Butler J. and Knight R. 7%~ DesigChildren und Their Primary

nated Areas

Prqject

Study of Medical

Pructice

Areas.

Health Services Research Unit, University of Kent. Canterbury, 1974. 58. Butler et a/., op. cit. 59. Butler and Knight, op. cit. 60. Robertson I. M. L. L.ocution of Sociul Facilities: A Computer Assisted Approach. Central Research Unit Paper, Scottish Development Department, Edinburgh. 1977. 61. Townsend. op. cir.