miércoles, 15 de enero de 2014

Hay leyes muy duras: Ley de cuidados inversos












Los ciudadanos deben conocer la ley de cuidados inversos. Es la única forma de que los políticos también la conozcan, y actúen en consecuencia. Es una ley sencilla, no escrita en ningún tratado penal ni civil que Julian Tudor Hart, médico de familia británico, describió con sencillez en un magistral artículo en la revista JAMA el año 1971. La ley expone que la disponibilidad de buena asistencia sanitaria tiende a variar inversamente con las necesidades de salud de la población atendida. Los que más necesitan asistencia sanitaria reciben menos, los que necesitan menos reciben más. 

La ley de cuidados inversos es más patente en zonas donde la sanidad sigue las normas del libre mercado, zonas con poca asistencia pública y mucha privada. El ejemplo de Estados Unidos es el más evidente, con millones de personas sin derecho a recibir asistencia sanitaria y otros tantos que solo reciben beneficencia.

Nuestra situación en España, con un sistema sanitario público, no es ajena a la ley de cuidados inversos. Los médicos de zonas rurales tienen menos recursos tanto en los centros de salud como en los hospitales. En ocasiones las diferencias son tremendas. Esta asimetría rompe el principio de justicia e igualdad, uno de los pilares de nuestro ordenamiento jurídico y del propio sistema sanitario.

Imagínense qué pasaría si se privatizara parte de la sanidad como se empeñan en hacer desde la Consejería de Sanidad de Madrid. Las diferencias aumentarían y se cumpliría de nuevo la ley de cuidados inversos. Los ancianos, enfermos complejos, los que padezcan problemas sociales o psiquiátricos recibirían menos recursos sanitarios.

Les dejo unas ideas extraidas del artículo del doctor Tudor Hart y el link al texto completo. Es uno de los textos que todo profesional sanitario debería saberse de memoria. Incluyo aquí a todos los gestores, técnicos y políticos del ramo.



  1. La disponibilidad de una buena atención médica tiende a variar inversamente con la necesidad de la población atendida . Esta ley de atención inversa funciona de forma más completa donde la atención médica está más expuesta a las fuerzas del mercado, y en menor medida en que dicha exposición se reduce. La distribución de libre mercado de la atención médica es una forma social primitiva e históricamente obsoleta, su retorno implicaría  exagerar aún más la mala distribución de los recursos sanitarios.
  2. "Cualquier afirmación de que el N.H.S. ha logrado su objetivo de ofrecer la igualdad en la atención médica es una ilusión. De hecho, la igualdad absoluta nunca se podría lograr en cualquier sistema de atención médica, educación u otros servicios esenciales para la comunidad. Los motivos para sugerir lo contrario son políticos e ignoran los factores humanos."
  3. En las zonas con más enfermedad y mortalidad los médicos generales tienen más trabajo, las listas de espera son más largas, hay menos apoyo del hospital, y heredan procesos clíncios mas ineficaces que en las áreas más saludables, a su vez los médicos de hospitales cargan sobre sus hombros pesadas cargas con casos complejos que enfrentan con menos personal y equipo, edificios más obsoletos, y crisis recurrentes en la disponibilidad de camas y personal de reemplazo. Estas tendencias se pueden resumir como la ley de cuidados inversos: la disponibilidad de una buena atención médica tiende a variar inversamente con la necesidad de la población atendida.





Hard laws: The inverse care law


Citizens should know the inverse care law. It is the only way politicians also know it, and act accordingly. It is a simple law, not written in any criminal or civil treaty. Julian Tudor Hart, a retired  general practitioner, described it in a masterful article in JAMA in 1971. The law states that the availability of good medical care tends to vary inversely with the health needs of the population served. Those most in need receive less health care, which need less get more.The inverse care law is most evident in areas where health care follows the rules of the free market, areas with little public assistance and private facilities. The example of the United States is  obvious, with millions of people without the right to receive health care and others who only receive charities.Our situation in Spain, with a public health system, follows also the law of inverse care. Doctors in rural areas have fewer resources both in primary care clinics and hospitals. Sometimes the differences are tremendous. This asymmetry breaks the principle of justice and equality, one of the pillars of our legal system and the healthcare system.Imagine what would happen if privatized as part of health are determined to do from the Ministry of Health of Madrid. The differences increase fullfilling again the inverse care law. The elderly, the complex sick, those suffering social or psychiatric problems receive less health care resources.I copy some ideas from Dr Tudor Hart's article and the link to full text. It is one of the texts that every clinician should know by heart. I do the recomendation extensive to all managers, technicians and politicians from the health field.





The availability of good medical care tends to vary inversely with the need for 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 market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.


The only sacrifice that would have to be made would be the concept of equality within the National Health Service . . . any claim that the N.H.S. has achieved its aim of providing equality in medical care is an illusion.  In fact, absolute equality could never be achieved under any system of medical care, education or other essential service to the community.  The motives for suggesting otherwise are political and ignore human factors.

The pursuit of the very best for each patient who needs it remains an important force in the progress of care; a young person in renal failure may need a doctor who will fight for dialysis, or a grossly handicapped child one who will find the way to exactly the right department, and steer past the defeatists in the wrong ones.  But this pursuit must pay some regard to humane priorities, as it may not if the patient is a purchaser of medical care as a commodity.  The idealised, isolated doctor/patient relationship, that ignores the needs of other people and their claims on the doctor’s time and other scarce resources, is incom­plete and distorts our view of medicine.  During the formative period of modern medicine this ideal situa­tion could be realised only among the wealthy, or, in the special conditions of teaching hospitals, among those of the unprivileged with “interesting” diseases.  The ambition to practise this ideal medicine under ideal conditions still makes doctors all over the world leave those who need them most, and go to those who need them least, and it retards the development of national schools of thought and practice in medicine, genuinely based on the local content of medical care.  The ideal isolated doctor/patient relation has the same root as the 19th-century preoccupation with Robinson Crusoe as an economic elementary particle; both arise from a view of society that can perceive only a con­tractual relation between independent individuals.  The new and hopeful dimension in general practice is the recognition that the primary-care doctor interacts with individual members of a defined community.  Such a community-oriented doctor is not likely to encourage expensive excursions into the 21st century, since his position makes him aware, as few specialists can be, of the scale of demand at its point of origin, and will therefore be receptive to common-sense priorities.  It is this primary-care doctor who in our country initiates nearly every train of causation in the use of sophisticated medical care, and has some degree of control over what is done or not done at every point.  The commitment is a great deal less open-ended than many believe; we really do not prolong useless, painful, or demented lives on the scale sometimes imagined.  We tend to be more interested in the people who have diseases than in the diseases themselves, and that is the first requirement of reasonable economy and a humane scale of priorities.

In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support, and inherit more clinically ineffective traditions of consultation, than in the healthiest areas; and hospital doctors shoulder heavier case-loads with less staff and equipment, more obsolete buildings, and suffer recurrent crises in the availability of beds and replacement staff.  These trends can be summed up as the inverse care law: that the availability of good medical care tends to vary inversely with the need of  the population served.