MS and the Inverse Care Law at 50


Barts-MS rose-tinted-odometer: ★

Variation in access to good medical care and better outcomes has never been higher in high-income countries such as the UK. Variation is simply a euphemism for inequality. The MS community in the UK realised this a few years ago, which prompted us to launch our ‘Raising the Bar’ initiative to address inequality in access to healthcare for people with MS living in the UK.

With this as a backdrop, it is worth reflecting on the 50th anniversary of the publication of  Julian Tudor Hart’s paper “The Inverse Care Law”, which was published in The Lancet on the 27th Februrary 1971. The article opens with the following lines: 

“The availability of good medical care tends to vary with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”

The Lancet is celebrating the 50th anniversary of the publication of Hart’s seminal paper with a hard-hitting editorial, which I would urge you to read. 

Editorial. 50 years of the inverse care law. Lancet 27th Feb 2021.


…. Globally, letting market forces dictate health care is still a major contributor to inequity—private health care can only be accessed by those who can afford to pay.

….. In many countries, social care and long-term care are managed by private providers too. 

….. Although health care is widely endorsed as a basic human right, the systems that provide it inequitably embody capitalism at its worst, where the wealthy benefit, leaving behind those most in need.

What are we trying to do with our ‘Raising the Bar’ initiative? We simply want no patient with MS to left behind. Our programme of activities has coalesced around five main workstreams. 

(1) The ‘Data & Audit’ workstream is focusing on measuring the wide variation in MS services in the UK. We hope the data will then be used as a catalyst for change, i.e. new business cases for service development.

(2) The ‘Patients as partners’ workstream is the improve health literacy amongst pwMS;p to help them navigate the NHS. There is compelling data showing that people with chronic disease who are engaged with their disease and its management do better, both in terms of health outcomes and improved quality of life. Similarly, when it comes to self-monitoring, self-management and behavioural interventions, which will be essential to transform MS outcomes we will need pwMS to become true partners in raising the bar.

(3) The ‘Wellness, lifestyle & social determinants of health’ workstream is promoting the holistic management of MS. This workstream focuses on wellness and lifestyle interventions to maximise brain and physical health. This workstream is also working on ways the MS community can address the social determinants that dominate health outcome in other disease areas; we are sure it is no different in MS.

(4) We acknowledge that if we want no patient to be left behind we are going to need a new generation of leaders; people with the vision, energy and drive to make the changes necessary to make our MS services equitable and valuable. This is why we have launched a ‘leadership programme’ to provide HCPs working in MS with the necessary leadership skills. Yes, not everybody is born a leader. Effective leadership skills need to be learnt. 

(5) Finally, we have a workstream that addresses UK infrastructure such as ‘national registers and research’ studies that will provide the evidence base to change or implement new practices across the country. 

So if you are a healthcare professional working in MS you need to please join the MS Academy and become a part of our raising the bar initiative. With the waning of the COVID-19 pandemic the NHS promises to be more responsive to innovation, more inclusive and wants to address both inequality and it causes. I think there is no better time than now to make a difference. 

If you want to hear more about what we are trying to do please log into the MS Trust’s virtual conference. In the Q&A session tomorrow afternoon we will be addressing many of these issues.

The following are my discussion points for my brief 10-minute introduction.

CoI: multiple

Twitter: @gavinGiovannoni                                              Medium: @gavin_24211

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • Number 2. It also seems to be important that patients engage in the NHS itself. To understand the NHS, and the trust more, which might benefit them.

    They can do this in a variety of ways: Becoming a member of an NHS Foundation trust (all NHS trusts are expected to become foundation trusts in the next three to five years). Membership open to staff, patients and service users of a trust.

    Volunteering in NHS patient and public involvement.

  • On point 2; as pwMS, we can engage in research as participants, champions, bloggers, applying to be on ethics committee.
    On point 3; the social determinants of health. Michael Marmot made a powerful case against health inequality. Sadly, even though he is well respected, his work hasn’t really been given the attention it deserves by policy makers. Result? Ongoing inequality on educational , financial and geographical measures.

    • I see the points raised by both ANONYMOUS and KIT as patient empowerment. This can help improve patient health. Something that needs to be promoted.

      This blog helps patient empowerment. I feel more empowered after reading this blog. Thanks to Prof G, Mouse Doctor’s and the rest of the blog team.

  • Somebody pointed out to me that nothing has changed since the publication of the Black Report in 1980. Had the Thatcher government acted on the Report’s finds we would be a very different place today.

    A M Gray. Inequalities in health. The Black Report: a summary and comment. Int J Health Serv. 1982;12(3):349-80. doi: 10.2190/XXMM-JMQU-2A7Y-HX1E.

    In August 1980 the United Kingdom Department of Health and Social Security published the Report of the Working Group on Inequalities in Health, also known as the Black Report (after chairman Sir Douglas Black, President of the Royal College of Physicians). The Report showed in great detail the extent of which ill-health and death are unequally distributed among the population of Britain and suggested that these inequalities have been widening rather than diminishing since the establishment of the National Health Service in 1948. The Report concluded that these inequalities were not mainly attributable to failings in the NHS, but rather to many other social inequalities influencing health: income, education, housing, diet, employment, and conditions of work. In consequence, the Report recommended a wide strategy of social policy measures to combat inequalities in health. These findings and recommendations were virtually disowned by the then Secretary of State for Social Services, very few copies of the Report were printed, and few people had the opportunity to read it. The Black Report is an important document that deserves wide attention and debate. This summary and comment are intended to give greater access to its evidence, arguments, conclusions, and recommendations.

  • Could there be scope for a peer worker role in MS?, (part time paid work). Not sure how it would be funded. Someone who would get training. It’s a role currently usually only working in mental health. It could help pwMS navigate the NHS and MS. A bit different to the MS champion role.

By Prof G



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