Julian Tudor-Hart has devoted his life to demonstrating and exposing the inverse care law1–3 and the rule of halves.4 There is a part of me that shares his anger that such inequitable distributions exist and persist.
However, I wonder whether what Tudor-Hart has described in the medical context is actually another example of the Pareto principle of asymmetric rewards, popularly known as the 80/20 principle. We see multiple examples of this principle in action. For example:
A university department that is doing well gets a better research assessment evaluation, and so more money with which to do better still.
An author who has been published once is much more likely to be published again, even if new and better authors are emerging.
Twenty per cent of patients will take up 80% of available appointments.
A surgery with many settled and loyal doctors is more likely to be attractive and so recruit and keep more and better staff.
About 80% of NHS resources are spent on patients in their last 6 months of life.
A very good football player will aim for the reserves at Arsenal, Chelsea, or Manchester United sooner than accept first team regularity at Norwich or Portsmouth.
To those that have, more shall be given. No organisation seems to be immune to the workings of this principle. We can protest against it, but those using it will carry on powering ahead anyway. The question comes as to how we start to use it to improve the lives of everyone in our society. The concepts of tipping points and critical masses need to be understood. The recent attention to the concept of lifetime trajectory observation is a hopeful sign of this developing in our thinking.
There seems to be no political will, or available mechanism, to counteract the workings of the 80/20 principle. Perhaps instead it is time that we learnt to go with this rule?
- © British Journal of General Practice, 2005.
