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. 2001 Jun;51(467):478-80, 483-5.

Unequal to the task: deprivation, health and UK general practice at the millennium.

N Beale
PMCID: PMC1314031  PMID: 11407055

Abstract

The NHS is over 50 years old, but health inequalities remain prevalent in the United Kingdom (UK). Material deprivation may be less apparent; however, social deprivation is becoming worse while the markers of socioeconomic disadvantage remain unsatisfactory. Health is an even more elusive concept; nevertheless, the evidence for an increasing association between deprivation, poor health, and early death is overwhelming. Equally unavoidable is the impact of this social degradation on UK primary care. Service industries have deserted deprived communities but, on the whole, GPs struggle on. Denied the supplementary resources they deserve they become disenchanted, too exhausted to convert incentives into rewards. Clear-headed strategic thinking from the top brass is overdue.

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Selected References

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  1. Alment A. To coin a phrase. BMJ. 2000 Jul 29;321(7256):272–272. doi: 10.1136/bmj.321.7256.272. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Auvinen A., Karjalainen S., Pukkala E. Social class and cancer patient survival in Finland. Am J Epidemiol. 1995 Nov 15;142(10):1089–1102. doi: 10.1093/oxfordjournals.aje.a117562. [DOI] [PubMed] [Google Scholar]
  3. Balarajan R., Yuen P., Machin D. Deprivation and general practitioner workload. BMJ. 1992 Feb 29;304(6826):529–534. doi: 10.1136/bmj.304.6826.529. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bartley M. Health costs of social injustice. BMJ. 1994 Nov 5;309(6963):1177–1178. doi: 10.1136/bmj.309.6963.1177. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Ben-Shlomo Y., White I., McKeigue P. M. Prediction of general practice workload from census based social deprivation scores. J Epidemiol Community Health. 1992 Oct;46(5):532–536. doi: 10.1136/jech.46.5.532. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Bennett S. Socioeconomic inequalities in coronary heart disease and stroke mortality among Australian men, 1979-1993. Int J Epidemiol. 1996 Apr;25(2):266–275. doi: 10.1093/ije/25.2.266. [DOI] [PubMed] [Google Scholar]
  7. Borrell C., Arias A. Socioeconomic factors and mortality in urban settings: the case of Barcelona, Spain. J Epidemiol Community Health. 1995 Oct;49(5):460–465. doi: 10.1136/jech.49.5.460. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Bruijnzeels M. A., van der Wouden J. C., Foets M. General practice consultation in childhood in The Netherlands: sociodemographic variation. J Epidemiol Community Health. 1995 Oct;49(5):532–533. doi: 10.1136/jech.49.5.532. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Campbell D. A., Radford J. M., Burton P. Unemployment rates: an alternative to the Jarman index? BMJ. 1991 Sep 28;303(6805):750–755. doi: 10.1136/bmj.303.6805.750. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Carlisle R., Groom L. M., Avery A. J., Boot D., Earwicker S. Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey. BMJ. 1998 Feb 14;316(7130):520–523. doi: 10.1136/bmj.316.7130.520. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Carr-Hill R. A., Sheldon T. Designing a deprivation payment for general practitioners: the UPA(8) wonderland. BMJ. 1991 Feb 16;302(6773):393–396. doi: 10.1136/bmj.302.6773.393. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Chard J., Lilford R., Gardiner D. Looking beyond the next patient: sociology and modern health care. Lancet. 1999 Feb 6;353(9151):486–489. doi: 10.1016/S0140-6736(98)07304-8. [DOI] [PubMed] [Google Scholar]
  13. Charlton B. G. Is inequality bad for the national health? Lancet. 1994 Jan 22;343(8891):221–222. doi: 10.1016/s0140-6736(94)90996-2. [DOI] [PubMed] [Google Scholar]
  14. Chase H. D., Davies P. R. Calculation of the underprivileged area score for a practice in inner London. Br J Gen Pract. 1991 Feb;41(343):63–66. [PMC free article] [PubMed] [Google Scholar]
  15. Chaturvedi N., Ben-Shlomo Y. From the surgery to the surgeon: does deprivation influence consultation and operation rates? Br J Gen Pract. 1995 Mar;45(392):127–131. [PMC free article] [PubMed] [Google Scholar]
  16. Davey Smith G., Egger M. Socioeconomic differentials in wealth and health. BMJ. 1993 Oct 30;307(6912):1085–1086. doi: 10.1136/bmj.307.6912.1085. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Duncan B. B., Rumel D., Zelmanowicz A., Mengue S. S., dos Santos S., Dalmáz A. Social inequality in mortality in São Paulo State, Brazil. Int J Epidemiol. 1995 Apr;24(2):359–365. doi: 10.1093/ije/24.2.359. [DOI] [PubMed] [Google Scholar]
  18. Eachus J., Chan P., Pearson N., Propper C., Davey Smith G. An additional dimension to health inequalities: disease severity and socioeconomic position. J Epidemiol Community Health. 1999 Oct;53(10):603–611. doi: 10.1136/jech.53.10.603. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Fein O. The influence of social class on health status: American and British research on health inequalities. J Gen Intern Med. 1995 Oct;10(10):577–586. doi: 10.1007/BF02640369. [DOI] [PubMed] [Google Scholar]
  20. Foley E., Willmott F., Rowen D., Patel R., Low J. L. Are there excess Sharons in genitourinary clinics? BMJ. 1999 Dec 18;319(7225):1615–1615. doi: 10.1136/bmj.319.7225.1615. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Foy C., Hutchinson A., Smyth J. Providing census data for general practice. 2. Usefulness. J R Coll Gen Pract. 1987 Oct;37(303):451–454. [PMC free article] [PubMed] [Google Scholar]
  22. Haines A., Heath I., Smith R. Joining together to combat poverty. Everybody welcome and needed. BMJ. 2000 Jan 1;320(7226):1–2. doi: 10.1136/bmj.320.7226.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Hart J. T. The inverse care law. Lancet. 1971 Feb 27;1(7696):405–412. doi: 10.1016/s0140-6736(71)92410-x. [DOI] [PubMed] [Google Scholar]
  24. Hastings A., Rashid A. General practice in deprived areas: problems and solutions. Br J Gen Pract. 1993 Feb;43(367):47-8, 51. [PMC free article] [PubMed] [Google Scholar]
  25. Hippisley-Cox J., Hardy C., Pringle M., Fielding K., Carlisle R., Chilvers C. The effect of deprivation on variations in general practitioners' referral rates: a cross sectional study of computerised data on new medical and surgical outpatient referrals in Nottinghamshire. BMJ. 1997 May 17;314(7092):1458–1461. doi: 10.1136/bmj.314.7092.1458. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Hobbs R., Cole T. Deprivation payments revisited (again) BMJ. 1996 Sep 14;313(7058):641–642. doi: 10.1136/bmj.313.7058.641. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Hutchinson A., Foy C., Sandhu B. Comparison of two scores for allocating resources to doctors in deprived areas. BMJ. 1989 Nov 4;299(6708):1142–1144. doi: 10.1136/bmj.299.6708.1142. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Hutchinson A., Foy C., Smyth J. Providing census data for general practice. 1. Feasibility. J R Coll Gen Pract. 1987 Oct;37(303):448–450. [PMC free article] [PubMed] [Google Scholar]
  29. Jacobson B., Yen L. Health action zones. BMJ. 1998 Jan 17;316(7126):164–164. doi: 10.1136/bmj.316.7126.164. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Jarman B. Identification of underprivileged areas. Br Med J (Clin Res Ed) 1983 May 28;286(6379):1705–1709. doi: 10.1136/bmj.286.6379.1705. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Jarman B. Underprivileged areas: validation and distribution of scores. Br Med J (Clin Res Ed) 1984 Dec 8;289(6458):1587–1592. doi: 10.1136/bmj.289.6458.1587. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Jenkins C., Campbell J. Catchment areas in general practice and their relation to size and quality of practice and deprivation: a descriptive study in one London borough. BMJ. 1996 Nov 9;313(7066):1189–1192. doi: 10.1136/bmj.313.7066.1189. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Jessop E. G. Deprivation and mortality in non-metropolitan areas of England and Wales. J Epidemiol Community Health. 1996 Oct;50(5):524–526. doi: 10.1136/jech.50.5.524. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Judge K., Mays N. A new approach to weighted capitation. BMJ. 1994 Oct 22;309(6961):1031–1032. doi: 10.1136/bmj.309.6961.1031. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Kaprio J., Sarna S., Fogelholm M., Koskenvuo M. Total and occupationally active life expectancies in relation to social class and marital status in men classified as healthy at 20 in Finland. J Epidemiol Community Health. 1996 Dec;50(6):653–660. doi: 10.1136/jech.50.6.653. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Kee F., Wilson R., Currie S., Sloan J., Houston R., Rowlands B., Moorehead J. Socioeconomic circumstances and the risk of bowel cancer in Northern Ireland. J Epidemiol Community Health. 1996 Dec;50(6):640–644. doi: 10.1136/jech.50.6.640. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Lang T., Ducimetière P. Premature cardiovascular mortality in France: divergent evolution between social categories from 1970 to 1990. Int J Epidemiol. 1995 Apr;24(2):331–339. doi: 10.1093/ije/24.2.331. [DOI] [PubMed] [Google Scholar]
  38. Latour J., López V., Rodriguez M., Nolasco A., Alvarez-Dardet C. Inequalities in health in intensive care patients. J Clin Epidemiol. 1991;44(9):889–894. doi: 10.1016/0895-4356(91)90051-a. [DOI] [PubMed] [Google Scholar]
  39. Leese B., Bosanquet N. Change in general practice and its effects on service provision in areas with different socioeconomic characteristics. BMJ. 1995 Aug 26;311(7004):546–550. doi: 10.1136/bmj.311.7004.546. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Leese B., Bosanquet N. High and low incomes in general practice. BMJ. 1989 Apr 8;298(6678):932–934. doi: 10.1136/bmj.298.6678.932. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Lloyd D. C., Harris C. M., Clucas D. W. Low income scheme index: a new deprivation scale based on prescribing in general practice. BMJ. 1995 Jan 21;310(6973):165–169. doi: 10.1136/bmj.310.6973.165. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Macleod U., Ross S., Twelves C., George W. D., Gillis C., Watt G. C. Primary and secondary care management of women with early breast cancer from affluent and deprived areas: retrospective review of hospital and general practice records. BMJ. 2000 May 27;320(7247):1442–1445. doi: 10.1136/bmj.320.7247.1442. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Majeed F. A., Cook D. G., Poloniecki J., Martin D. Using data from the 1991 census. BMJ. 1995 Jun 10;310(6993):1511–1514. doi: 10.1136/bmj.310.6993.1511. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Majeed F. A., Martin D., Crayford T. Deprivation payments to general practitioners: limitations of census data. BMJ. 1996 Sep 14;313(7058):669–670. doi: 10.1136/bmj.313.7058.669. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Manson-Siddle C. J., Robinson M. B. Does increased investment in coronary angiography and revascularisation reduce socioeconomic inequalities in utilisation? J Epidemiol Community Health. 1999 Sep;53(9):572–577. doi: 10.1136/jech.53.9.572. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Marsh P., Carlisle R., Avery A. J. How much does self-reported health status, measured by the SF-36, vary between electoral wards with different Jarman and Townsend scores? Br J Gen Pract. 2000 Aug;50(457):630–634. [PMC free article] [PubMed] [Google Scholar]
  47. Marshall S. F., Hardy R. J., Kuh D. Socioeconomic variation in hysterectomy up to age 52: national, population based, prospective cohort study. BMJ. 2000 Jun 10;320(7249):1579–1579. doi: 10.1136/bmj.320.7249.1579. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Morris J. N., Blane D. B., White I. R. Levels of mortality, education, and social conditions in the 107 local education authority areas of England. J Epidemiol Community Health. 1996 Feb;50(1):15–17. doi: 10.1136/jech.50.1.15. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Murray S. A., Graham L. J., Dlugolecka M. J. How many general practitioners for 1433 patients? BMJ. 1995 Jan 14;310(6972):100–100. doi: 10.1136/bmj.310.6972.100. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Murray S. A., Graham L. J. Practice based health needs assessment: use of four methods in a small neighbourhood. BMJ. 1995 Jun 3;310(6992):1443–1448. doi: 10.1136/bmj.310.6992.1443. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Ness G. J., House A., Ness A. R. Aggression and violent behaviour in general practice: population based survey in the north of England. BMJ. 2000 May 27;320(7247):1447–1448. doi: 10.1136/bmj.320.7247.1447. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. O'Donnell C. A., McConnachie A., Moffat K., Drummond N., Wilson P., Ross S. Cross sectional study of social variation in use of an out of hours patient transport service. BMJ. 1999 Feb 27;318(7183):566–567. doi: 10.1136/bmj.318.7183.566. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Reijneveld S. A. Predicting the workload in urban general practice in The Netherlands from Jarman's indicators of deprivation at patient level. J Epidemiol Community Health. 1996 Oct;50(5):541–544. doi: 10.1136/jech.50.5.541. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Rosso S., Faggiano F., Zanetti R., Costa G. Social class and cancer survival in Turin, Italy. J Epidemiol Community Health. 1997 Feb;51(1):30–34. doi: 10.1136/jech.51.1.30. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Saxena S., Majeed A., Jones M. Socioeconomic differences in childhood consultation rates in general practice in England and Wales: prospective cohort study. BMJ. 1999 Mar 6;318(7184):642–646. doi: 10.1136/bmj.318.7184.642. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Scott A., Shiell A., King M. Is general practitioner decision making associated with patient socio-economic status? Soc Sci Med. 1996 Jan;42(1):35–46. doi: 10.1016/0277-9536(95)00063-1. [DOI] [PubMed] [Google Scholar]
  58. Scrivener G., Lloyd D. C. Allocating census data to general practice populations: implications for study of prescribing variation at practice level. BMJ. 1995 Jul 15;311(6998):163–165. doi: 10.1136/bmj.311.6998.163. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Scrivener G., Lloyd D. Effect of deprivation on general practitioners referral rates. Jarman score measures workload not deprivation. BMJ. 1997 Oct 4;315(7112):883–884. [PMC free article] [PubMed] [Google Scholar]
  60. Shanks J., Kheraj S., Fish S. Better ways of assessing health needs in primary care. BMJ. 1995 Feb 25;310(6978):480–481. doi: 10.1136/bmj.310.6978.480. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Sheldon T. A. Formula fever: allocating resources in the NHS. BMJ. 1997 Oct 18;315(7114):964–964. doi: 10.1136/bmj.315.7114.964. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Sheldon T. A., Smith P., Borowitz M., Martin S., Hill R. C. Attempt at deriving a formula for setting general practitioner fundholding budgets. BMJ. 1994 Oct 22;309(6961):1059–1064. doi: 10.1136/bmj.309.6961.1059. [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. Sloggett A., Joshi H. Higher mortality in deprived areas: community or personal disadvantage? BMJ. 1994 Dec 3;309(6967):1470–1474. doi: 10.1136/bmj.309.6967.1470. [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Smith G. D., Dorling D. "I'm all right, John": voting patterns and mortality in England and Wales, 1981-92. BMJ. 1996 Dec 21;313(7072):1573–1577. doi: 10.1136/bmj.313.7072.1573. [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Smith G. D., Hart C., Blane D., Gillis C., Hawthorne V. Lifetime socioeconomic position and mortality: prospective observational study. BMJ. 1997 Feb 22;314(7080):547–552. doi: 10.1136/bmj.314.7080.547. [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. Smith G. D. Second thoughts on the Jarman index. BMJ. 1991 Feb 16;302(6773):359–360. doi: 10.1136/bmj.302.6773.359. [DOI] [PMC free article] [PubMed] [Google Scholar]
  67. Spencer N., Logan S., Scholey S., Gentle S. Deprivation and bronchiolitis. Arch Dis Child. 1996 Jan;74(1):50–52. doi: 10.1136/adc.74.1.50. [DOI] [PMC free article] [PubMed] [Google Scholar]
  68. Talbot R. J. Underprivileged areas and health care planning: implications of use of Jarman indicators of urban deprivation. BMJ. 1991 Feb 16;302(6773):383–386. doi: 10.1136/bmj.302.6773.383. [DOI] [PMC free article] [PubMed] [Google Scholar]
  69. Tudor Hart J. Commentary: three decades of the inverse care law. BMJ. 2000 Jan 1;320(7226):18–19. [PubMed] [Google Scholar]
  70. Vâgerö D. Health inequalities in women and men. BMJ. 2000 May 13;320(7245):1286–1287. doi: 10.1136/bmj.320.7245.1286. [DOI] [PMC free article] [PubMed] [Google Scholar]
  71. Wagstaff A., Paci P., van Doorslaer E. On the measurement of inequalities in health. Soc Sci Med. 1991;33(5):545–557. doi: 10.1016/0277-9536(91)90212-u. [DOI] [PubMed] [Google Scholar]
  72. Wannamethee S. G., Shaper A. G. Socioeconomic status within social class and mortality: a prospective study in middle-aged British men. Int J Epidemiol. 1997 Jun;26(3):532–541. doi: 10.1093/ije/26.3.532. [DOI] [PubMed] [Google Scholar]
  73. Wilkinson R. G. Divided we fall. BMJ. 1994 Apr 30;308(6937):1113–1114. doi: 10.1136/bmj.308.6937.1113. [DOI] [PMC free article] [PubMed] [Google Scholar]
  74. Wilkinson R. G. Income distribution and life expectancy. BMJ. 1992 Jan 18;304(6820):165–168. doi: 10.1136/bmj.304.6820.165. [DOI] [PMC free article] [PubMed] [Google Scholar]
  75. Worrall A., Rea J. N., Ben-Shlomo Y. Counting the cost of social disadvantage in primary care: retrospective analysis of patient data. BMJ. 1997 Jan 4;314(7073):38–42. doi: 10.1136/bmj.314.7073.38. [DOI] [PMC free article] [PubMed] [Google Scholar]

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