The inverse care law today
The inverse care law today
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DOI：
10.1016/s0140-6736(02)09466-7
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发表时间：
2002-07-20
期刊：
影响因子：
168.9
通讯作者：
Watt, G
中科院分区：
文献类型：
--
作者：
Watt, G
其次，政策制定过程缺乏来自常规数据和研究的重要信息。 Fair Shares for All 提供了这种限制的一个典型例子，5 该组织试图建立一个公式，根据需要重新分配苏格兰的 NHS 资源。根据持续发病率记录项目中涉及的约 50 个一般实践所记录的卫生服务活动来确定需求。该计划中的实践很少来自贫困地区，也没有关于未满足需求的数据。报告的结论是，受社会经济贫困影响最严重的两个卫生委员会（占苏格兰人口的 29%，但包括卡斯泰尔贫困类别 6 和 7 的 65% 地区）应获得一般医疗服务（全科医疗）预算的 29%。尽管有最好的意图以及最好的统计和经济分析方法，但这项工作很大程度上未能在初级保健内重新分配资源。第三，人们对已经尝试过的做法知之甚少。波莉·汤因比（Polly Toynbee）在最近出版的《事情变得更好了吗？》一书中回顾了本届政府第一届任期的成就时评论道，“几十年来，国民医疗服务体系（NHS）从富裕地区向健康状况较差的地区分配资金，健康差距不断扩大，这表明国民医疗服务体系（NHS）所带来的真正改变是多么微乎其微”。 11 一位领先的社会评论员竟然在这个问题上犯了如此严重的错误，这是对当前正统观念的衡量。 NHS 之所以没有造成什么影响，是因为资金没有得到重新分配。剥夺支付，即使是新的改进形式，也不会将资金从富裕地区转移到健康状况较差的地区，至少不会以人们普遍认为的方式转移。它们的主要作用是根据家庭医生的收入创造一个公平的竞争环境，以便贫困地区更有可能招募和留住全科医生。比运动场更好的类比是游泳池。每个能看见的人都把头露出水面。富裕地区的家庭医生是站在浅水区，脚踩在底层，而贫困地区的家庭医生却是踩在深水区，靠吃苦吃苦。这个比喻并不是说富裕地区的家庭医生不忙，或者说他们没有要求很高的病人。每个人都很忙，但都忙着不同的问题。在整个英国，为卡斯泰尔贫困类别 6 和 7 地区提供服务的 70 岁以下死亡人数是为贫困类别 1 和 2 富裕地区提供服务的两倍。
Second, the policy-making process lacks essential information from routine data and from research. A classic example of this limitation was provided by Fair Shares for All, 5 which attempted to establish a formula to redistribute NHS resources in Scotland according to need. Need was identified on the basis of health-service activity, as recorded by about 50 general practices involved in a continuous morbidity recording project. Few practices in the scheme came from deprived areas and no data were available for unmet need. The report concluded that the two health boards most affected by socioeconomic deprivation, comprising 29% of the Scottish population, but including 65% of areas in Carstair’s deprivation categories 6 and 7, should receive 29% of the budget for general medical services (general practice). Despite the best of intentions and the best methods of statistical and economical analysis, the exercise largely failed to redistribute resources within primary care.Third, there are poorly informed views of what has been tried. In a recent book, Did Things Get Better?, reviewing the achievements of the present Government’s first term, Polly Toynbee commented that,“during decades when the NHS had distributed money to bad health areas from rich ones, the health gap widened, showing how little real difference the NHS makes”. 11 That a leading social commentator should get this issue so hopelessly wrong is a measure of current orthodoxy. The reason the NHS makes little difference is that money has not been redistributed. Deprivation payments, even in their new improved form, do not shift money from rich areas to bad health areas, at least not in the way that is generally perceived. Their main effect is to create a level playing field, based on the incomes of family doctors, so that there is more likelihood of recruiting and retaining general practitioners in deprived areas. A better analogy than the playing field is a swimming pool. Everyone who can be seen has their head above water. Family doctors in affluent areas are standing in the shallow end with their feet on the bottom, whereas those in deprived areas are treading water in the deep end, receiving deprivation payments for their trouble. This analogy is not to suggest that family doctors in affluent areas are not busy, or that they do not have demanding patients. Everyone is busy, but busy with different problems. In the UK as a whole, practices serving areas in Carstair’s deprivation categories 6 and 7 have twice as many deaths under age 70 years as practices that serve affluent areas in deprivation categories 1 and 2.