The Role of Primary Care in Reducing Health Inequalities
Stewart W MercerProfessor of Primary Care Research
ILL-HEALTH VARIABLES BY DEPRIVATION
0
20
40
60
80
100
120
140
160
180
1 2 3 4 5 6 7 8 9 10
Deprivation decile
Mortality <75
Limiting long-term illness
Not good' general health
Distribution of deprivation in Scotland
The Importance of General Practice and Primary Care
STARFIELDLancet 1994;344:1129-33
PRIMARY CARE
MAKES A DIFFERENCE
Does health care improve health?Craig, Wright, Hanlon and GalbraithJournal of Health Services Research and Policy 2006;11:1-2
Medicine matters after allBunkerNuffield Trust, 2001
Does health care save lives? Avoidable mortality revisitedNolte and McKeeNuffield Trust, 2004
The role of primary care in population health
• Primary care can contribute to health improvement of the population:
– Preventative activities– Risk reversal in the ‘well’– Screening
– Prevention of disease complications
– Enabling living well with illness and disability– Reduction of distress and disability– Palliative care for end-stage disease
STRENGTHS OF GENERAL PRACTICE
CONTACT
COVERAGE
CONTINUITY
COMPREHENSIVENESS
COORDINATION
RELATIONSHIPS
The Inverse Care Law
• ‘The provision of good medical care tends to vary inversely with the need for it in the population served.’
• www.juliantudorhart.org
Methods
• Cross-sectional questionnaire study• > 3,000 patients attending 26 GPs/26
Practices• High Deprivation or Low deprivation• 70% response rate in both types of areas
Data
• Demographic and socio-economic factors, health variables and a range of measures relating to access, reason for consultation, and quality of consultation
Results
Need
<0.00114%32%Unemployed
<0.00114%27%Health
(Bad)
0.00824%31%3 or more LTCs
<0.00142%54%Long-term illness
<0.00129%41%GHQ-12 caseness
P valueLow DepHigh Dep
Need: Relationship between psychological distress and co-morbidity in high and low deprivation areas
Co-morbidity: No. of long-standing conditions
three or moretw oonenone
% G
HQ
ca
sen
ess
60
50
40
30
20
10
Deprivation group
High
Low
40
32
24
19
5048
37
28
Access and expectations
<0.00119%30%Psycho-social
<0.09332%38%Both new and old prob
<0.00140%52%No. of probs (>1)
<0.00110%21%Rating (poor/v. poor)
<0.00152%66%Access (> 3 days)
P valueLow DepHigh Dep
Response: Distribution of clinical encounter length in areas of high and low deprivation
Consultation Length
15 min and above
10-14 min
6-9 min
5 min or less
Pe
rce
nt
50
40
30
20
10
0
Deprivation group
High
Low
2223
29
26
13
23
39
26
Outcome: GP stress by clinical encounter length in
areas of high and low deprivation
Consultation length
15 min and above
10-14 min
6-9 min
5 min or less
Me
an
str
ess
5.0
4.5
4.0
3.5
3.0
2.5
Deprivation group
high
low
3.0
3.43.5
3.1
4.7
3.93.8
3.4
Effect: Patient enablement by consultation length in psychosocial consultations in areas of high and
low deprivation
Consultation length
15 min and above10-14 min6-9 min5 min or less
Me
an
Pa
tien
t E
na
ble
me
nt
4.6
4.4
4.2
4.0
3.8
3.6
3.4
3.2
3.0
Deprivation group
high
low
Patient Enablement Instrument (Howie et al 1998,1999)
As a results of your visit to the doctor today, do you feel you are;
1) Able to cope with life2) Able to understand your illness3) Able to cope with your illness4) Able to keep yourself healthy5)Confident about your health6) Able to help yourself
Scored as ‘much better’ (2), ‘better’ (1), ‘same or less’ (0),
The GP coal-face in deprived areas of Scotland; how the inverse care law operates
• …increased need…higher demand…more complex problems
• …poorer access…..less time.…lower patient enablement…higher GP stress
What about objective measures and outcomes?
• Prospective study of 700 videoed GPs consultations in areas of high and low deprivation – Objective ratings of videos
– Patient ratings of consultation (empathy, enablement)
– Outcomes at 1 (MYMOP) and 2 months (use of services)
High versus low deprivation GP consultations
• Worse health• More chronic disease• More multimorbidity
• More mental illness• More symptoms to
discuss
• Less patient centred care (videos)
• Lower GP empathy• Lower satisfaction
• Poorer outcomes at 1 month
• More re-attendances and referrals over 2 months
Multiple morbidity and the inverse care law
WHAT IS REQUIRED FOR GENERAL PRACTICE AND PRIMARY CARE TO IMPROVE HEATH AND REDUCE INEQUALITIES ?
Q. WHAT CAN GENERAL PRACTICES DO TO IMPROVE HEATH AND REDUCE INEQUALITIES ?
D. Increase the
VOLUMEQUALITYCOVERAGEand EFFECTIVENESS
of what it does
Quality of care
T e c h n i c a le f f e c t i v e n e s s
I n t e r p e r s o n a lE f f e c t i v e n e s s
1 . A c c e s s2 . E f f e c t i v e n e s s
The “clinical” narrative
The “human” narrative
How?
Keppoch Practice evaluation
• Consecutive adult patients (16 years and over)• Routine clinics• Cross-sectional study of consultations (complex/
non-complex) at two time points:
– Baseline - before introduction of extended consultations
– Follow-up - after extended consultations for complex cases were imbedded in the system
Participants
• 300 adult patients at baseline
• 324 at follow-up, more than 1 year after the introduction of longer consultations
S u m m a r y
P a t i e n t e n a b l e m e n te n h a n c e d
G P S t r e s sr e d u c e d
E x t e n d e d c o n s u l t a t i o n s
What was the extra time being used for?
• GPs accounts;
– mental-health and psychosocial problems
– communicating (e.g., risk, implications of disease, etc)
– chronic disease management
– opportunistic health screening
– liasing with other agencies/services (‘sorting things out’)
IS TIME ENOUGH?
Patient expectationsPatient-centrednessPro-active rather than reactive careEnabling and Encouraging self-care
LIVING WELL WITH MULTIPLE MORBIDITY:The development and evaluation of a primary
care-based complex intervention to support
patients with multiple morbidities in high deprivation areas
Stewart Mercer, Graham Watt, Sally Wyke, Elisabeth Fenwick, Bruce Guthrie, Terry Findlay
CSO NHS Applied Research Award £830K
Whole-System Intervention within General Practice
• System Level– Longer consultations– Relational continuity
• Practitioner Level– Training and support
• Patient Level– Appropriate self-management support and
education
WHAT ELSE?
WHAT COULD EACH GENERAL PRACTICE DO DIFFERENTLY ?
MORE TIME WITH PATIENTS
BETTER USE OF EXISTING RESOURCE
BETTER LINKS WITH HEALTH IMPROVEMENT
BETTER LINKS WITH OTHER NHS PRIMARY CARE SERVICES
BETTER COLLABORATION WITH LOCAL AUTHORITY SERVICES
BETTER COLLABORATION WITH VOLUNTARY SERVICES ANDLOCAL COMMUNITIES
BETTER LINKS WITH THE REST OF THE NHS, INCLUDING OUT OF HOURS, ELECTIVE REFERRALS AND HOSPITAL SERVICES
THE INVERSE CARE LAW
Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde Deprivation Decile
0
50
100
150
200
250
1 2 3 4 5 6 7 8 9 10
Deprivation Decile
Age
-Sex
Sta
ndar
dise
d R
atio
sir64
shr64
smr74
Linear (WTEGPs)
Summary and Conclusion
• General practice and primary care is important for health and vital for the NHS
• As long as the inverse care law persists, health inequalities will persist
• Human aspects of care are as important as the technical
• Finally, some quotes:
The Essence of General Practice
• “It is open-ended, inclusive rather than exclusive, dealing in wholes not parts. It is personal, it is continuing, …it is about respect, trust, independence and personal integrity. It is founded on science, and yes, yes, evidence, but it also involves the reconciliation of incompatibles, irrationalities and impossible expectations. It rejects the inhuman and the formulaic. It involves privileged access to other people’s deepest secrets, their bodies, and their homes. Will future doctors leave this natural niche unfilled?”
Professor James Willis, November 2006
The social causes of illness are just as important as the physical ones.
The medical officer of health and the practitioners of a distressed area are the natural advocates of the people.
They well know the factors that paralyse all their efforts.
They are not only scientists but also responsible citizens, and if they did not raise their voices, who else should?
Henry SigeristProfessor of Medical HistoryJohns Hopkins University
Hart, Julian Tudor; Dieppe Paul: Lancet 1996
• “Caring has been central to medical practice in all cultures throughout history, and still motivates most health workers. The trade-offs between caring and technical expertise are not rational, necessary, or inevitable, provided that health services pursue human rather than commercial goals.”
“Thank you!”
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