Urban health and health services inequalities and Julian Tudor Hart’s inverse case law: a role for community placements


Western Sydney made the national news this weekend.

The Sunday Telegraph, Sydney Herald and ABC News all ran stories based around a report published by the Western Sydney Region Organisation of Councils (WSROC)[i] that contains findings of research demonstrating significant inequalities in health service provision between the 10 Council areas represented in the organisation and the rest of the City. The report linked the western suburbs relative social and economical disadvantage when compared to the rest of the City to the higher incidence of risk factors, rates of preventable disease and worse health outcomes and demonstrated that these inequalities are compounded by the provision of poorer quality healthcare.

Picking over the report, the media noted that there are around 10% fewer hospital beds per 100,000 people in western suburbs when compared to north, south and east, that staff to patient ratios are worse, with an average of one GP per 1049 people compared to one per 754 for the rest of the City and the waiting times for a range of operations were markedly worse – in some case nearly a year for a hip or knee replacement versus 20 days. Some reports chose to highlight concerns that the situation will worsen as the population in the west grows more rapidly than elsewhere in the City.


Buried among the partisan political point scoring which constituted a considerable proportion of the commentary on the report, there was a high degree of consensus with the suggestion from a representative of WSROC that the report implied a need for new and additional investment in health services in Western Sydney. The idea of offering a financial incentive akin to that offered to doctors to incentivise them to work in rural communities was mooted.


Tudor Hart: alive and kicking

This seems like another example of Julian Tudor Hart’s inverse case law in action. Put simply, that the availability of good medical care tends to vary inversely with the need for it in the population served (Hart, 1971).  The situation might be worse still if Graham Watt’s assertions about the way that the inverse law shapes the kinds of public health measures adopted to address the underlying causes of ill-health are borne out; namely that given the same resources, primary health-care teams in deprived areas, initiating programmes to prevent disease complications and to reverse risks, will achieve less (Watt, 2002).


The role of the community placement in reversing the inverse case law

Is there a role for non-clinical community-based education in addressing these inverse laws: in increasing the numbers of doctors who are attracted to working in tougher, poorer health and social environments, in enabling them to make better use of resources and to formulate more appropriate and effective public health interventions?


With regard to the first part of the question, there is the encouragement of evidence suggesting that exposure to and engagement of medical students with under-served communities can influence their career intentions. The work is perhaps most far progressed in evaluation of initiatives to improve provision and doctor recruitment to practice in rural and remote areas of Australia. There is evidence to suggest that placements in these contexts can lead to urban students considering taking up rural practice and rural students staying in their communities (Critchley et al, 2007; Stagg et al, 2009) A recent UK review suggests the same outcomes can be found among students who take up placement experience in urban areas of need (Littlewood et al, 2005).

And what of the questions around whether non-clinical community-placements can lead to better understanding among medics of community needs and more efficient use of resources to do better public health work?  We just don’t know yet. I would be positive at least so far as to suggest that community-placements have the capacity to make future doctors aware of the challenges around reaching into deprived communities and to equip them with some skills to do so. Where they devise and implement health promotion activities as a part of their community placements, they are already, perhaps, making a difference. We should pay more attention to finding out.

A note of caution

But let’s not be too ambitious for community placements. As the media coverage here in Australia implies, money might be a bigger and more potent incentive to doctors to provide the services that communities need where they need them than a desire to address social and health inequality.

We should also heed Julian Tudor Hart’s recent reflections on his law (Hart, 2004). He thinks that incentives and interventions directed at individual doctors may be relatively underpowered to alter the flow towards greater inequality in health and health services.  It is, he says because, ‘The Inverse Care Law is created and sustained by market forces in the economy at large, by direct economic incentives and disincentives, and by an originally dominant professional culture accumulated around those incentives and disincentives.’

In other words, it is social polarization and the culture of medical practice that are the problems that need addressing, not a lack of encouragement to doctors to work where they are needed.

It is perhaps salutary to be reminded that community-based non-clinical placements will not alone create a brave new world of health equity, but we should not distracted from asking if they can help to bridge to gap and seeking to measure if they do.



Critchley, J., DeWitt, D. E., Khan, M. A. and  Liaw, S.  (2007) A required rural health module increases students’ interest in rural health careers. Rural and Remote Health 7: 688.

Hart, J. T. (1971) The inverse care law, The Lancet, 1(7696):405–412.

Hart, J. T. (2004) Inverse and Positive Care Laws, British Journal of General Practice, 54(509): 890.

Watt, G (2002) The inverse care law today, The Lancet, 360:252–54

Littlewood, S., Ypinazar, V. Margolis, S., Scherpbier, A. Spencer, J. and Dornan, T. (2005) Early practical experience and the social responsiveness of clinical education: systematic review, British Medical Journal, 331:387

Stagg, P., Greenhill, J. and Worley, P.S. (2009)  A new model to understand the career choice and practice location decisions of medical graduates. Rural and Remote Health 9: 1245.

ABC News, Sydney’s west loses out in health lottery, ABC News, Sunday 19th August 2012, available here.

Yamine, E. (2012) Sick heath system is failing western Sydney, The Sunday Telegraph, 19th August 2012, available here.

WSROC (2012) Critical Condition: A comparative study of health services in Western Sydney, available here.




[i] WSROC represents 10 local councils in Western Sydney. The organization describes itself as occupying a strategic role in identifying regional issues and proposing policy solutions.  It advocates on behalf of the communities served by the Councils with both Federal and State government. WSROC works with local community and commercial partners including the University of Western Sydney.








About learningtodoctor

Simon is Senior Teaching Fellow at Durham University.
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1 Response to Urban health and health services inequalities and Julian Tudor Hart’s inverse case law: a role for community placements

  1. Jeni Harden says:

    I have just read a whole load of 1st year medical students’ resit exams answering the question on health inequalities and feel very depressed by the use of the term ‘these people’ usually followed closely by ‘poorly educated’. For most of our students, this kind of othering is understandable as the life of, for example, a mother of 4 living on benefits in a housing scheme in Edinburgh, is entirely alien to them. They may have never been to an area like that far less ever have spoken to someone who lives there. We need to find ways to address their general ignorance and community placements can serve a purpose with that challenge. Thanks for keeping us updated and hope you are having a great time – very jealous!!

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