The document discusses how to move from social injustice in healthcare to fairer systems and healthier places. It notes that people living in deprived areas have worse health outcomes and shorter life expectancies. The inverse care law holds that availability of good medical care varies inversely with need of the population served. Creating healthier, more sustainable communities through access to green spaces, social connections, and fair employment can help address these inequities. Love and courage from healthcare workers are essential to improving systems and individual health.

1. Reversing the Inverse Care
Law
How we move from
social injustice in healthcare
to
fairer systems and healthier places
Dr Liliana Risi
NHS GP Tower Hamlets
Fellow (FRCGP) and Emeritus Provost
RCGP North East London Faculty
LRISI@nhs.net
@LilianaRisi

2. PLACE MATTERS
( Syndemic = Synergy Covid-19 with pre-existing conditions)
• People can expect to spend more of their lives in poor health
(Ella Kissi-Debrah)
• Improvements to life expectancy have stalled, and declined for the
poorest 10% of women
• The health gap has grown between wealthy and deprived areas
• Living in a deprived area of the North East of England is worse for your
health than living in a similarly deprived area in London, to the extent
that life expectancy is nearly five years less
• Deprivation domains: Income, Employment, Education, Health, Crime,
Barriers to Housing and Services, Living Environment
CLIMATE HEALTH CREATION MATTERS
(Blue /Green/Social prescribing =
Clean air, Access to green space, social connectedness)
• Giving every child the best start in life
• Enabling all people to maximise their capabilities
and have control over their lives
• Ensuring a healthy standard of living for all
• Creating fair employment and good work for all
• Creating and developing healthy and sustainable
places and communities
WE MATTER AS THE WORKFORCE
(Love and Courage)
LONDON DEEP END
HEALTH EQUITY
Fairer systems and healthier places
2010 - 2020
INVERSE CARE LAW
Julian Tudor Hart 1971
Patients in deprived areas with complex
problems consult more often, feel less
enabled and their doctors feel more
stressed, after consultations
PAIR OF ACES
COPING
Kenneth 36y
I have come for my repeat anti-depressant script
and my tramadol, it sometimes helps but I have not
been able to get a repeat in time, I often forget to
take it. The pain is really bad at night. I am on
Universal Credit but it is a very small amount of
money and I am struggling to buy food. I am due to
be evicted as I am in arrears and there is a court
meeting in December. I am having dental work and
will have all my teeth removed. I missed my
appointment with the substance misuse counsellor
last week. I felt low a few months ago when my 6-
year-old son was taken into care but lifted more
recently when my 16-year-old daughter who lives
with me, had her baby. I had a difficult childhood
with a lot of violence and both my parents are now
dead. I have no other family. I also need a referral to
the foodbank.
November 2019

3. Kenneth 36y
I have come for my repeat anti-depressant script
and my tramadol, it sometimes helps but I have not
been able to get a repeat in time, I often
forget to take it. The pain is really bad at night.
I am on Universal Credit but it is a very small
amount of money and I am struggling to buy food. I
am due to be evicted as I am in arrears and there is
a court meeting in December. I am having dental
work and will have all my teeth removed. I missed
my appointment with the substance misuse
counsellor last week. I felt low a few months ago
when my 6-year-old son was taken into care but
lifted more recently when my 16-year-old daughter
who lives with me, had her baby. I had a difficult
childhood with a lot of violence and both my
parents are now dead. I have no other family. I also
need a referral to the foodbank.
November 2019

4. LONDON DEEP END
HEALTH EQUITY
2010 - 2020
Patients in deprived areas with complex
problems consult more often, feel less
enabled and their doctors feel more
stressed, after consultations
PAIR OF ACES
Kenneth 36y
I have come for my repeat anti-depressant script
and my tramadol, it sometimes helps but I have not
been able to get a repeat in time, I often forget to
take it. The pain is really bad at night. I am on
Universal Credit but it is a very small amount of
money and I am struggling to buy food. I am due to
be evicted as I am in arrears and there is a court
meeting in December. I am having dental work and
will have all my teeth removed. I missed my
appointment with the substance misuse counsellor
last week. I felt low a few months ago when my 6-
year-old son was taken into care but lifted more
recently when my 16-year-old daughter who lives
with me, had her baby. I had a difficult childhood
with a lot of violence and both my parents are now
dead. I have no other family. I also need a referral to
the foodbank.
November 2019

5. 2010 - 2020
Patients in deprived areas with complex
problems consult more often, feel less
enabled and their doctors feel more
stressed, after consultations
PAIR OF ACES
Kenneth 36y
I have come for my repeat anti-depressant script
and my tramadol, it sometimes helps but I have not
been able to get a repeat in time, I often forget to
take it. The pain is really bad at night. I am on
Universal Credit but it is a very small amount of
money and I am struggling to buy food. I am due to
be evicted as I am in arrears and there is a court
meeting in December. I am having dental work and
will have all my teeth removed. I missed my
appointment with the substance misuse counsellor
last week. I felt low a few months ago when my 6-
year-old son was taken into care but lifted more
recently when my 16-year-old daughter who lives
with me, had her baby. I had a difficult childhood
with a lot of violence and both my parents are now
dead. I have no other family. I also need a referral to
the foodbank.
November 2019
PLACE MATTERS
• People can expect to spend more of their lives
in poor health
• Improvements to life expectancy have
stalled, and declined for the poorest 10% of
women
• The health gap has grown between wealthy
and deprived areas
• Living in a deprived area of the North East of
England is worse for your health than living in
a similarly deprived area in London, to the
extent that life expectancy is nearly five years
less
• Deprivation domains: Income, Employment,
Education, Health, Crime, Barriers to Housing
and Services, Living Environment
(Covid-19 Pandemic or Syndemic?
Syndemic = Synergy Covid-19 with pre-existing conditions)

6. Every Breath Matters Ella Kissi Debra (b.2004 d.2013)

7. Patients in deprived areas with complex
problems consult more often, feel less
enabled and their doctors feel more
stressed, after consultations
INVERSE CARE LAW
Julian Tudor Hart 1971
Patients in deprived areas
with complex problems
consult more often,
feel less enabled after
consultations and
their doctors feel more
stressed after consultations
(Allostatic load = cumulative stress)
The drowning pool
“unworried unwell”
2013
“The inverse care law is the principle that the availability of good medical or social care tends to vary inversely with the need of the population served”

8. 2010 - 2020
CLIMATE HEALTH CREATION
MATTERS
• Giving every child the best start in life
• Enabling all people to maximise their
capabilities and have control over their lives
• Ensuring a healthy standard of living for all
• Creating fair employment and good work
for all
• Creating and developing healthy and
sustainable places and communities
(Blue /Green/Social prescribing =
Clean air, Access to green space, social
connectedness)
HEALTH EQUITY

9. PLACE MATTERS
( Syndemic = Synergy Covid-19 with pre-existing conditions)
• People can expect to spend more of their lives in poor health
(Ella Kissi-Debrah)
• Improvements to life expectancy have stalled, and declined
for the poorest 10% of women
• The health gap has grown between wealthy and deprived areas
• Living in a deprived area of the North East of England is worse for your
health than living in a similarly deprived area in London, to the extent
that life expectancy is nearly five years less
• Deprivation domains: Income, Employment, Education, Health, Crime,
Barriers to Housing and Services, Living Environment
CLIMATE HEALTH CREATION MATTERS
(Blue /Green/Social prescribing =
Clean air, Access to green space, social connectedness)
• Giving every child the best start in life
• Enabling all people to maximise their capabilities
and have control over their lives
• Ensuring a healthy standard of living for all
• Creating fair employment and good work for all
• Creating and developing healthy and sustainable
places and communities
LONDON DEEP END
HEALTH EQUITY
Fairer systems and healthier places
2010 - 2020
INVERSE CARE LAW
Julian Tudor Hart 1971
Patients in deprived areas with complex
problems consult more often, feel less
enabled and their doctors feel more
stressed, after consultations
PAIR OF ACES
Kenneth 36y
I have come for my repeat anti-depressant script
and my tramadol, it sometimes helps but I have not
been able to get a repeat in time, I often forget to
take it. The pain is really bad at night. I am on
Universal Credit but it is a very small amount of
money and I am struggling to buy food. I am due to
be evicted as I am in arrears and there is a court
meeting in December. I am having dental work and
will have all my teeth removed. I missed my
appointment with the substance misuse counsellor
last week. I felt low a few months ago when my 6-
year-old son was taken into care but lifted more
recently when my 16-year-old daughter who lives
with me, had her baby. I had a difficult childhood
with a lot of violence and both my parents are now
dead. I have no other family. I also need a referral to
the foodbank.
November 2019

10. W. Edwards Deming (b.1900 d.1993)
Lens of profound knowledge
Kenneth
Improvement Science in Action Quality Improvement
Avedis Donabedian (b.1919 d.2000)
“Systems awareness and systems design are important
for health professionals, but are not enough
They are enabling mechanisms only
It is the ethical dimension of individuals that is essential
to a system’s success
Ultimately, the secret of quality is love
You have to love your patient, you have to love your
profession, you have to love your World
If you have love, you can then work backward to monitor
and improve the system”

11. Where is the future we want already happening ?
With love we need to appreciate our system, the human side of change, understand variation and build knowledge
CONCRETE

12. WE MATTER AS THE WORKFORCE
Love and Courage

13. PLACE MATTERS
( Syndemic = Synergy Covid-19 with pre-existing conditions)
• People can expect to spend more of their lives in poor health
(Ella Kissi-Debrah)
• Improvements to life expectancy have stalled, and declined for the
poorest 10% of women
• The health gap has grown between wealthy and deprived areas
• Living in a deprived area of the North East of England is worse for your
health than living in a similarly deprived area in London, to the extent
that life expectancy is nearly five years less
• Deprivation domains: Income, Employment, Education, Health, Crime,
Barriers to Housing and Services, Living Environment
CLIMATE HEALTH CREATION MATTERS
(Blue /Green/Social prescribing =
Clean air, Access to green space, social connectedness)
• Giving every child the best start in life
• Enabling all people to maximise their capabilities
and have control over their lives
• Ensuring a healthy standard of living for all
• Creating fair employment and good work for all
• Creating and developing healthy and sustainable
places and communities
WE MATTER AS THE WORKFORCE
(Love and Courage)
2010 - 2020
INVERSE CARE LAW
Julian Tudor Hart 1971
Patients in deprived areas with complex
problems consult more often, feel less
enabled and their doctors feel more
stressed, after consultations
PAIR OF ACES
COPING
Kenneth 36y
I have come for my repeat anti-depressant script
and my tramadol, it sometimes helps but I have not
been able to get a repeat in time, I often forget to
take it. The pain is really bad at night. I am on
Universal Credit but it is a very small amount of
money and I am struggling to buy food. I am due to
be evicted as I am in arrears and there is a court
meeting in December. I am having dental work and
will have all my teeth removed. I missed my
appointment with the substance misuse counsellor
last week. I felt low a few months ago when my 6-
year-old son was taken into care but lifted more
recently when my 16-year-old daughter who lives
with me, had her baby. I had a difficult childhood
with a lot of violence and both my parents are now
dead. I have no other family. I also need a referral to
the foodbank.
November 2019

14. LONDON DEEP END HEALTH EQUITY
Fairer systems and healthier places
The ‘London Deep End Health Equity’ logo
captures the shades of green, which is climate
health creation, the curve of the Thames
from West to East, from pocket to blanket
deprivation
The leaf of the plane tree which is all over
London potentially bringing the most benefits
for air quality and shade
The logo name also includes the starting point
‘Deep End’ i.e., areas of deprivation and the
destination ‘Health Equity’
It is also a broader movement than General
Practice to capture population rather than
provider driven health

15. C
O
N
S
E
N
T
Every decision about me, with me

16. PLACE MATTERS
( Syndemic = Synergy Covid-19 with pre-existing conditions)
• People can expect to spend more of their lives in poor health
(Ella Kissi-Debrah)
• Improvements to life expectancy have stalled, and declined for the
poorest 10% of women
• The health gap has grown between wealthy and deprived areas
• Living in a deprived area of the North East of England is worse for your
health than living in a similarly deprived area in London, to the extent
that life expectancy is nearly five years less
• Deprivation domains: Income, Employment, Education, Health, Crime,
Barriers to Housing and Services, Living Environment
CLIMATE HEALTH CREATION MATTERS
(Blue /Green/Social prescribing =
Clean air, Access to green space, social connectedness)
• Giving every child the best start in life
• Enabling all people to maximise their capabilities
and have control over their lives
• Ensuring a healthy standard of living for all
• Creating fair employment and good work for all
• Creating and developing healthy and sustainable
places and communities
WE MATTER AS THE WORKFORCE
(Love and Courage)
LONDON DEEP END
HEALTH EQUITY
Fairer systems and healthier places
2010 - 2020
INVERSE CARE LAW
Julian Tudor Hart 1971
Patients in deprived areas with complex
problems consult more often, feel less
enabled and their doctors feel more
stressed, after consultations
PAIR OF ACES
COPING
Kenneth 36y
I have come for my repeat anti-depressant script
and my tramadol, it sometimes helps but I have not
been able to get a repeat in time, I often forget to
take it. The pain is really bad at night. I am on
Universal Credit but it is a very small amount of
money and I am struggling to buy food. I am due to
be evicted as I am in arrears and there is a court
meeting in December. I am having dental work and
will have all my teeth removed. I missed my
appointment with the substance misuse counsellor
last week. I felt low a few months ago when my 6-
year-old son was taken into care but lifted more
recently when my 16-year-old daughter who lives
with me, had her baby. I had a difficult childhood
with a lot of violence and both my parents are now
dead. I have no other family. I also need a referral to
the foodbank.
November 2019

17. Laughing singing
moving
Such connection
in the room
This is health
creation changing
our world
Thank you

18. References
• Woven Gold https://wovengoldchoir.com/
• Adverse Childhood Experiences, Resilience and Trauma Informed Care: A Public Health Approach to Understanding and Responding to
Adversity https://www.nhshighland.scot.nhs.uk/media/q1ep0mqj/dph_annual_report_2018.pdf
• London Aces Hub https://www.londonaceshub.org/
• Institute of Health Equity https://www.instituteofhealthequity.org/home
• Covid is not a Pandemic https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32000-6/fulltext
• Inverse Care Law https://www.health.org.uk/publications/reports/tackling-the-inverse-care-law
• Scottish Deep End https://www.gla.ac.uk/schools/healthwellbeing/research/generalpractice/deepend/
• Epidemiology of multi-morbidity and implications for health care, research, and medical education: a cross-sectional study
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60240-2/fulltext
• Every Breath Matters Ella Kissi Debra (b.2004 d.2013) https://www.youtube.com/watch?v=bM-ADxNkJr0
• Lens of Profound Knowledge Deming https://www.england.nhs.uk/wp-content/uploads/2021/03/qsir-lens-profound-knowledge.pdf
• Avedis Donabedian https://qualitysafety.bmj.com/content/qhc/13/6/472.full.pdf?frame=header
• Poor - Caleb Femi Poetry https://www.calebfemi.com/
• Health Creation Alliance https://thehealthcreationalliance.org/
• Altogether Better https://www.altogetherbetter.org.uk/
• Greener Practice https://www.greenerpractice.co.uk/
• Trauma-informed care: recognizing and resisting re-traumatization in health care https://pubmed.ncbi.nlm.nih.gov/34993351/
• Trauma Transformed Care https://traumatransformed.org/
• Fairhealth https://www.fairhealth.org.uk/
• London Deep End Health Equity https://handyapproachtocare.com/2023/02/03/leading-for-fairer-sytems-and-healthier-places/
• Handy Approach to Care https://handyapproachtocare.com/
• Singing for breathing https://www.youtube.com/watch?v=q4Oo8Tk0Gio