Does opening up access address the Inverse Care Law? Dr Peter Cairns writes our guest blog


This time last year we faced up to the fact that our access system needed to be improved.

Our practice is one of those known in Scotland as the ‘Deep End’, the 100 practices working with the most deprived populations. Despite our best efforts, we could not meet demand, at least within the confines of a traditional appointment system.

Too much of the “how and what” we were doing as General Practitioners seemed set in stone - for no obvious reason. We were able to apply our powers of critical appraisal to complex research papers, yet still insist that for most patient problems, the preferred solution was an arbitrary 10 minute appointment made via an anonymous receptionist.

Ditching our traditional appointment system and applying common sense to our access problems was liberating. The outcomes are not perfect, but it’s been a good starting point for overhauling how we work.

A Dot Community Health (or similar) approach is not only a logical response to dealing with excessive patient demand. It may also have particular utility in a deprived setting – where we have to deal with a challenging mix of medical and social problems, some trivial, some very serious. We also have to accept that for our population, these problems are mostly perceived as urgent.

Crucially we are now more able to engage the 10 to 20 per cent of our population that simply weren’t able to easily access our service under a traditional appointment.system.

Does a Dot Community Health Approach help address the Inverse Care Law?

The question recently arose as to whether adopting a Dot Community Health Approach could help address health inequalities? Although it is certainly a more sensible and efficient approach for any practice to engage with its population, the answer may be considerably more nuanced than first meets the eye.

Where demand is so excessive that a traditional appointment model cannot come close to meeting to it (the situation in most deprived areas), Dot Community Health systems offer an opportunity to share out clinical resource on a more equal footing. It cannot however magic away the fact that in Scotland in least, General Practice has become a key access point for all kinds of social problems and services, excessive demand for which cripples our ability to deliver actual clinical care.

Switching to Dot Community Health has allowed us for the first time to better gauge the total size of the challenge (patient demand) we face. An unexpected consequence of this is that it encourages further rationalisation of our excessive workload. We are becoming more organised, efficient and business minded – better at spreading the limited resource more equitably, being less disposed to provide key non-medical services to our patients (e.g. letters for Benefits Appeals, housing letters, etc), and arguably taking a less holistic approach.

So the question still stands – will adopting a Dot Community Health Approach improve or exacerbate our inequalities in the long term?

Dr Peter Cairns is at GP at Wester Hailes in Edinburgh

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