Transcript Health inequalities - General Practice Specialty Training

Health inequalities and
complexity in general practice
GPST teaching
15th December 2011
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
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Psychiatry
Paediatrics
Obs & Gyn
Accident &
Emergency
General
medicine/DOME
General surgery
Orthopaedics
General Practice
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Depression/Anxiety
Child protection issues
Low birth weight
Unintentional and NAI
Drugs/Alcohol
Multiple morbidity
Polypharmacy
Low expectations
Benefits system
What are health inequalities?
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 – a global view
Source: WHO Health Report
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
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: Office for National Statistics
The Jubilee line of health inequalities
Gender differences in life expectancy at birth
Women
Men
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
Difference
Why do health inequalities exist?
What are the determinants of
health?
Dahlgren, G. and Whitehead,
M. (1991) Rainbow model of Health
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
• Examples of occupations
• I
• II
Professional occupations
Managerial and
intermediate occupations
Skilled occupations
• Doctor, accountant
• Teacher, manager
• NM: non-manual
• M: manual
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• III
• IV
• V
Partly skilled occupations
Unskilled occupations
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
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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:
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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
G77 5 – Broom; Newton Mearns
-7 0
-6 0
-5 0
-4 0
-3 0
‘Better’
-2 0
-1 0
0
10
20
30
40
‘Worse’
50
60
70
G40 4- Dalmarnock
-7 0
-6 0
-5 0
-4 0
-3 0
‘Better’
-2 0
-1 0
0
10
20
30
40
‘Worse’
50
60
70
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).
Influences on health from conception to adulthood
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…
What is the role of general practice
in reducing health inequalities?
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, Laughteron prescription?
Social prescribing
Volunteer Scotland
Community Health Shop
Community Addiction Team
Counselling services eg COPE
Womens’ Aid
Stress Centre
Cash for Kids
Citizens advice
Parent and Child Team
School nurse
Breathing Space
Welfare Rights
Princess Trust for Carers
Council on Alcohol
Quarriers
Maggie Centre
Narcotics Anonymous
AA/ Al Anon
Relate Scotland
Weight loss groups
CRUSE
Community Law Centre
Victim Support
Supporting self-management
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
GPs at the Deep End
Source: Watt (2006)
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
Policy
• Targeting the worst off
• Reducing the gap between groups
• Reducing inequalities across the
population
• Health inequalities are not immutable:
policies can and do make a difference