Dr Julian Tudor Hart – an appreciation
Dr Julian Tudor Hart (Image: Wikimedia Commons)
Julian Tudor Hart was a visionary leader who combined advocacy for equitable primary care and social justice, trenchant critiques of market influences in health care and innovative research showing how whole population approaches to improving health could transform primary care. Amongst his seminal works his paper ‘The Inverse Care Law’ published in The Lancet in 1971 is perhaps the best known and still widely quoted. It documented how those who most need high quality health care are least likely to receive it and how privately funded and delivered health care undermined high quality universal coverage. He observed that the removal of market forces from the provision of primary care with the advent of the NHS had resulted in improved access for disadvantaged populations, concluding that ‘a national health service can run quite well without the profit motive, and that the motivation of the work itself can be more powerful in a de-commercialised setting’.
At a time when the sources of funding for the NHS are being reviewed it is instructive to see that such debates have been an enduring feature of the political landscape. In his paper Julian noted that even at that time some politicians believed that the ceiling for tax-based funding of health services had been reached and that additional funds should be raised by out-of-pocket payments. This perception proved incorrect and expenditure on health care from taxation subsequently increased, thus avoiding the regressive effects of charging for health care at the point of use.
Unusually, Julian Tudor Hart combined authorship of classic papers with many years of clinical practice in primary care focusing on disadvantaged populations, driven by his political commitment to socialism. Following a period as a general practitioner in a practice caring for a deprived community in Notting Hill, West London he worked for 30 years as a general practitioner in Glyncorrwg, a former mining village in the Afan Valley, South Wales. Influenced by luminaries such as Archie Cochrane and Richard Doll, he was a pioneering exponent of combining an epidemiological population approach with clinical practice. He articulated a whole population approach to the control of high blood pressure using the opportunity presented by patient contacts with primary care services to measure blood pressure and other key cardiovascular risk factors and showing that, through such ‘anticipatory care’, virtually 100% coverage could be achieved. His practice was the first to be designed as a research practice by the Medical Research Council and undertook a range innovative studies, mostly based on Julian Tudor Hart’s own work. He provided an unparalleled opportunity for young researchers and general practitioners in training (including myself) to learn from his unstinting commitment to rigorous research and high quality clinical care in a well-defined but socially disadvantaged community.
A paper in the BMJ with many of his research fellows in 1993 described more than 20 years follow up of screen-detected hypertension in people under 40 years of age. Several important papers on salt intake and hypertension contributed substantially to understanding of the relationship, including providing evidence against the hypothesis that people with a family history of high blood pressure show greater sensitivity in their blood pressure response to dietary sodium compared to those without a family history (Lancet 1983). He also had the courage to put his own clinical practice under the spotlight in a paper describing the results of an audit of 500 consecutive deaths (BMJ 1987).
Julian Tudor Hart also had strong views about medical education and the prerequisites for effective practice in primary care. He was an early advocate for departments of academic general practice in medical schools – an aim which still remains unfulfilled in many countries . His visionary book ’ A New Kind of Doctor’ was written for ‘students, doctors, other health workers, and non-medical people interested in the National Health Service (NHS), regardless of their political affiliations’. In it he examines the social context in which health care is delivered and articulates a vision for professionalism which encompasses working with patients as active partners to co-create health, addressing health and disease in many cases as a continuum requiring whole population approaches, and widening the recruitment of doctors so that they become more representative of the population they serve. Although his own commitment to Socialism was made clear and exemplified by his Presidency of the Socialist Health Association, his outstanding communication skills and clarity of thought meant that his ideas were often well received by those from a range of political perspectives. The 40th anniversary of the Alma Ata declaration in 2018 reminds us that the central message from ‘The Inverse Care Law’ and his outstanding body of writing and research about the central importance of universal primary health care to a civilised society is as relevant as ever.
Written by Prof Sir Andy Haines