Health inequalities and complexity in general practice GPST teaching 15 th 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 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 – a global view Source: WHO Health Report

Source: Office for National Statistics

The Jubilee line of health inequalities

Gender differences in life expectancy at birth Source: life expectancy at birth, WHO

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 IProfessional occupations IIManagerial and intermediate occupations IIISkilled occupations NM: non-manual M: manual IVPartly 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

G77 5 – Broom; Newton Mearns ‘Better’ ‘Worse’

G40 4- Dalmarnock ‘Better’ ‘Worse’

Age specific contribution to inequalities of specific causes of death across SIMD income quintiles. Men, Scotland

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, Laughter- on prescription?

Social prescribing Community Health Shop Womens’ Aid Cash 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 nurse Welfare Rights Parent and Child Team Breathing Space Relate Scotland Volunteer Scotland 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:

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 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