health inequalities and complexity in general practice gpst teaching 15 th december 2011
TRANSCRIPT
Learning objectives
• “don’t really know what this is about”
• “what constitutes health inequalities in GP”
• “strategies for tackling/dealing with/addressing/bridging the gap in/overcoming health inequalities”
• “monitoring health inequalities in GP”
• “difficulties working in deprived areas (GPs at the Deep End)”
Overview
Morning• Health inequalities – overview• Multimorbidity and complexity in general practice• Health inequalities – “Lessons from the Deep
End”
Afternoon• The role of pharmacy in reducing health
inequalities• Deprivation and health – a GP’s perspective
Curriculum outcomes
• 5. Healthy people: promoting health and preventing disease
“Gaining a better understanding about inequalities in health and strategies to address inequalities in health are important aspects of training to be a general practitioner”
Curriculum outcomes
• “In general terms, provision of health care is more deficient where it is most needed: the inverse care law. GPs are often from a background that is different from their patients who suffer from deprivation. To be an effective doctor, it is important to put in extra effort to understand patients’ beliefs and expectations…”
• Disproportionately affected by co-morbidity
• Under-represented (or excluded) from clinical research
Exposure in Hospital jobs
• Psychiatry• Paediatrics• Obs & Gyn• Accident &
Emergency• General
medicine/DOME• General surgery• Orthopaedics• General Practice
• Depression/Anxiety• Child protection issues• Low birth weight• Unintentional and NAI• Drugs/Alcohol• Multiple morbidity• Polypharmacy• Low expectations• Benefits system
What are health inequalities?
• Socioeconomic status (SES)
• Age• Gender• Ethnicity
• Sexuality• Disability• Religion
• Local– Individual– Household– Neighbourhood
• Regional• “Glasgow effect”
• National• “Scottish effect”
• Global
Life expectancy
1999 to 2001
72.7 - 76.0
76.1 - 77.4
77.5 - 78.5
78.6 - 79.5
79.6 - 81.2
Source: ONS, 2004. Maps by Ben Wheeler
Life expectancy
1999 to 2001
72.7 - 76.0
76.1 - 77.4
77.5 - 78.5
78.6 - 79.5
79.6 - 81.2
Source: ONS, 2004. Maps by Ben Wheeler
Source: Office for National Statistics
Gender differences in life expectancy at birth
Women Men Difference Japan 85.3 78.4 6.9
Iceland 81.8 78.4 3.4
France 83.5 75.9 7.6
Italy 82.5 76.8 5.7
UK 80.5 75.8 4.7
Russia 72.1 58.4 13.7
Sierra Leone 35.7 32.4 3.3
Source: life expectancy at birth, 2002 - WHO
Health determinants are multiple, complex, and interlinked
• “People do not just live in poverty, they may also be a lone parent, may have a long term disability that affects
the work they can do, or live with discrimination that impacts on their mental health. Gender, and masculinity in particular, contributes to problems of violence, to the reluctance of men to seek help for problems and may
make men more likely to resort to alcohol and drugs than to seek help for a mental health problem.”
• Equally Well: Report of the Ministerial Task Force on Health Inequalities, 2008
Health inequalities in Scotland
• Socioeconomic status (SES)– Education– Occupation– Household income
• Poverty and deprivation– Area-based measurements
Occupation
• Social Class
• I Professional occupations
• II Managerial and intermediate occupations
• III Skilled occupations• NM: non-manual
• M: manual
• IV Partly skilled occupations
• V Unskilled occupations
• Examples of occupations
• Doctor, accountant• Teacher, manager
• Secretary, sales rep• Bus driver, electrician• Security guard, assembly worker• Office cleaner, labourer
Smoking prevalence UK men 1948 to 1999 by social class
Source: Lawlor et al. 2003, Am J Public Health 2003;93:266-70
Routine and manual work
• Lower earnings
• Less stable earnings
• Poorer working conditions
• Greater risk of unemployment
• Recurrent and long-term unemployment
Poverty
• What is poverty?– Absolute vs. Relative
• How would you measure it?– ? so many $ a day– ? Minimum standard of living – ? Minimum rights to resources– ? 60% of median household income
Poverty
• “Individuals, families, and groups in the population can be said to be in poverty when they lack resources to obtain the types of diet, participate in the activities, and have the living conditions and amenities which are customary, or at least widely encouraged or approved, in the societies in which they belong.”
– Prof P Townsend (1979), “Poverty in the UK”
Deprivation
• Area-based measures – Take information from individuals and
households and aggregate them at area level.
• SIMD – Scottish Index of Multiple Deprivation
• ScotPHO – Scottish Public Health Observatory
SIMD – Scottish Index of Multiple Deprivation
• Developed in response to 2003 report “Measuring Deprivation in Scotland : Developing a Long-Term Strategy”
• Combines 38 indicators across 7 domains:– current income (28%)– employment (28%)– health (14%)– education (14%)– geographic access (9%)– crime (5%) – housing (2%)
6505 datazones(populations of between 500 and 1000 residents)
ScotPHO – Public Health Observatory
• 59 indicators across 10 domains:– Life expectancy & mortality– Behaviours– Ill health and injury– Mental Health– Social care & housing– Education– Economy– Crime– Environment– Women & Children’s Health
38 comparator areas (most based on CHPs) cf. 32 local authorities/councils
Age specific contribution to inequalities of specific causes of death across SIMD income quintiles. Men, Scotland
2000-02.
SES Health inequalities
• “Downstream causes”– Specific exposures (e.g. damp housing, hazardous
work or neighbourhood settings) – Behaviours (e.g. smoking, diet, exercise, alcohol) – Personal strengths or vulnerabilities (e.g. coping
styles, resilience, ability to plan for the future).
• “Upstream causes”– Pathways that put members of different SES groups at
lower or higher risk of such exposures and vulnerabilities (e.g. the education, taxation, and health care systems, the labour and housing markets, planning regulations, crime and policing etc).
Inequalities in health in Scotland:what are they and what can we do about them?
• Key messages:– Changes over time (infectious disease then; chronic disease
now)– Different axes of variation (SES, gender, ethnicity, geography)– Specific exposures, behaviours, strengths and vulnerabilities– “downstream” vs. “upstream” causes– Earlier and later life risks can be cumulative (lifecourse
approach)– Social gradient in most diseases, but not all– Education, Employment and Income are key entry points– Most health determinants lie outside the NHS– Policy matters…
Strengths of general practice
• Coverage
• Continuity
• Co-ordination
• Flexibility
• Trust
• Effective
• Equitable
• Sustainable
What can GPs do?
• Advocacy• Social prescribing • Supporting Self management
– Assets-based approach• QOF/ASSIGN• Anticipatory care (Keep Well?)• GPs at the Deep End
– “all that GPs can do to reduce health inequalities is via the sum of care they provide for all their patients”
– increase volume and quality of care in deprived areas.
– ?importance of continuity and good relationships
Patient Advocacy
• Speaking or writing on behalf of patients
• Patient welfare and benefits advice
• Referrals– Discuss challenges to access/attending
appointments
• Lower uptake of screening– DNA Letters discussed, not just filed?
Social prescribing
• Use of non-medical community resources
• Availability of resources (housing, benefits) often rationed by medical need– From dependency to self-efficacy
• Information Leaflets, Websites
• Voluntary services
• Exercise, Art, Books, Learning, Laughter-on prescription?
Social prescribingCommunity Health Shop
Womens’ AidCash for Kids
Quarriers
Community Addiction Team
Maggie Centre
Weight loss groups CRUSE
Narcotics Anonymous AA/ Al Anon
Stress Centre
Council on Alcohol
Community Law Centre
Princess Trust for Carers
Counselling services eg COPE
Citizens advice
School nurseWelfare Rights
Parent and Child Team Breathing Space
Relate Scotland
Volunteer Scotland
Victim Support
QOF – Quality and Outcomes Framework
• Major national pay-for-performance scheme, introduced as part of GP contract in 2004
• Quality targets in chronic disease/risk factors• Reductions in inequalities in chronic disease
management in affluent vs deprived areas• But… limitations of data• Higher ‘exception reporting’ rates in practices with
higher deprivation levels. Also, low thresholds• ?Move from process to prescribing/intermediate outcomes
Source: Alshamsan R, et al. (2010) Impact of pay for performance on inequalities in health care: systematic review. Journal of Health Services Research & Policy Vol 15 No 3: 178-184
ASSIGN
• Developed in Dundee University in 2006, in collaboration with SIGN
• Based on Scottish data
• Includes socioeconomic status and family history
• Framingham underestimates risk in deprived populations
Anticipatory Care
• “Better health, better care”– Ageing population– Persistent health inequalities– More Long-term conditions– More multiple morbidity/complex needs
• National Anticipatory Care programme:– Keep Well– Well North
Keep Well
• Targets 45-64 year-olds in areas of greatest need
• Early intervention for those at high risk of CHD and diabetes
• Initial Health check
• Intervention/Referral
• Follow-up
Inverse Care Law
• “The availability of good medical care tends to vary inversely with the need for it in the population served” [Julian Tudor Hart]
• 39% of practices in the most affluent 20% of Scotland are involved in GP training, but this drops to 24% of practices in the most deprived 20%.
General practice in deprived areas
• Multimorbidity, esp. psychological distress• Poor material circumstances (housing,
transport, job insecurity)• Poor family circumstances (illness in
relations, alcohol and drug misuse)• Poor knowledge of health and resources• Low expectations• Lifestyles characterised by day-to-day
living