The Inverse Commissioning Law

The Inverse care Law, first suggested in The Lancet in 1971 by Julian Tudor Hart says that those who most need medical care are least likely to receive it. Conversely, those with least need tend to get the best use from health services. As John Appleby, then of the King’s Fund, wrote for Health Service Journal, some minority groups and people in less affluent areas are offered “poor quality services, to which they have relative difficulty securing access and they suffer multiple external disadvantage.” Whereas the affluent, more confident middle classes, whose life expectancies are already longer, are also better at finding and accessing healthcare, and services in the areas they live are often better too. So in “inner cities and deprived areas, there tend to be fewer doctors working with higher caseloads and sicker patients”. This unfairness cuts at the roots of the NHS, designed to be for us all.

The Inverse Care Law was suggested, and has since been well-evidenced, in the context of healthcare, but it’s not hard to see how it applies to every public service. As council-run social care services have come under more pressure, their budgets have been reduced most in the most deprived areas, as central government funding has been cut and councils forced to rely more upon council tax and business rates, which are lower in poorer areas. People with learning disabilities are a group most likely to need social care support, but who may have communication challenges which make it hard to find, demand and specify that support, or to complain and change providers if it goes wrong.

One of the reasons why the inverse care law if self-perpetuating, is because it applies not only to who can access support, but also to who gets to design it. In other words, we could reframe Tudor Hart’s law as, “those who most need to reshape public services, are likely to have the least power to do so”. ‘Coproducing’ public services with those who make use of them and their communities is more talked about than carried out, despite a huge range of tools and guides on how to do so. To be done properly, it requires those used to highly codified decision-making processes, based around reports, proposals and committee meetings, all wrapped up in impenetrable language, to be willing to start afresh with accessible, common-sense questions like, ‘What does a good life look like to the people who use our services?’ and ‘What part can we all play in achieving that?’ That takes time which already feels crammed over-full. It takes humility: for highly-paid professionals to recognise that their frantic and stressful working lives are consistently failing to solve the conundrums at the heart of our public services: how can they be affordable but high quality? Personalised yet universal? It takes trust in the very people planners are used to thinking of as being most needy and vulnerable, and having the least to offer.

A few of the most articulate, confident and brave service users make it onto the decision-making committees, but they are likely to be people who have the education, support networks and resources to be able to contribute ‘appropriately’ to those committees, without being paid to do so. The people who potentially have the most radical changes to offer can be from groups and communities committees find ‘hardest to engage’. I am also frequently in rooms where public service decisions are being made by a group which is entirely or almost entirely white and where the gender mix is the inverse of the predominantly female health and care workforces.

This Inverse Commissioning Law will only be upended when we stop seeing service planning as something which can be done by any one group of people on its own. If the goal of public services is to provide support in proportion to need, and to reach furthest towards those farthest from the centre, then designing our services and systems must be a collective effort. State services invented the inverse care law, but outsourced money-making services profit from it and many not-for-profits have failed to do enough to tackle it.

Re-designing health and social care services to tackle inequalities should be seen as vital work, which makes people who make the most use of the services vital design partners, alongside those voluntary, community and social enterprise groups which have genuine reach into communities: often small, grassroots and user-led organisations are best placed to do so. We will know that this is happening and that it is having an impact on inequality, when more people with recent lived experience progress into paid decision-making roles and those decision-making teams are diverse more  generally.

We talk endlessly about the need for new ideas in public services. Let’s start with involving some new people in coming up with them.

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