1. Stewart Mercer Plymouth November 3rd, 2017
Key challenges for developing comprehensive primary care in deprived areas
Stewart Mercer
Plymouth November 3rd, 2017

2. Things I’ll talk about….
The nature of the challenge
Workforce and the inverse care law
Data
Policy
Integration
Evidence
The Power of the Deep End

3. The nature of the challenge

4. Mapping the best and the worst health in Britain.
Shaw, M. et al. BMJ 2005;330:
Copyright ©2005 BMJ Publishing Group Ltd.

5. ILL-HEALTH VARIABLES BY DEPRIVATION5

7. Healthcare is a social determinant too….
Healthcare is also a social determinant of health, because healthcare improves health
If healthcare is delivered inequitably then the NHS will widen rather than narrow health inequalities

8. HEALTH ISSUES ESPECIALLY PREVALENT IN THE DEPRIVED AREAS
Mental health problems
Drugs and alcohol
Material poverty
Vulnerable children and adults
Migrants, refugees and asylum seekers
Fitness to work
Sexual abuse history
Homelessness
GENERIC ISSUES
How to engage with patients who are difficult to engage
How to deal with complexity in high volume
How to apply evidence
DEEP END REPORT 24

9. Workforce and the inverse care law
Workforce now a major problem in primary care and general practice
Generally harder to recruit to deprived areas and higher burn-out
Underlying key factor is the inverse care law

10. The Inverse Care Law
‘The provision of good medical care tends to vary inversely with the need for it in the population served.’

11. The Inverse Care Law : higher patient need but flat distribution of GP manpower in deprived areas

12. GENERAL PRACTITIONERS AT THE DEEP END12 12

13. Data
Good population and primary care data is essential for health and social care planning
Do we have good data on the health and social care needs of people in deprived areas?
Do we even have good data on healthcare and social care service provision in deprived areas?
Without both, unmet need cannot be measured

14. People living in more deprived areas in Scotland develop multimorbidity years before those living in the most affluent areas

15. Mental health problems are strongly associated with the number of physical conditions that people have, particularly in deprived areas in Scotland

16. Multiple morbidity and the inverse care law

17. CONSULTATIONS IN DEPRIVED AREAS
Multiple morbidity and social complexity
Shortage of time
Reduced expectation for shared decision making
Lower enablement (especially for complex problems)
Poorer outcomes at 1 month
Practitioner stress
Mercer SM, Watt GCMw : clinical primary care encounters in deprived and affluent areas of Scotland
Annals of Family Medicine 2007; 2016

18. Policy
There are no major policies that acknowledge and commit to reversing the inverse care law
Focus has moved to the ageing population and to self-management
The needs of younger multimorbid patients in deprived areas are very different

19. Integration Important everywhere not just in deprived areas
Harder to achieve in deprived areas when everyone is running fast just to stand still

20. TOO MANY HUBS
INCREASES THE TREATMENT BURDEN

21. I’VE JUST INVENTED A MACHINE THAT DOES THE WORK OF TWO MEN.
UNFORTUNATELY, IT TAKES THREE MEN TO WORK IT
SPIKE MILLIGAN

22. INVENTING THE WHEEL INTEGRATED CARE DEPENDS ON MULTIPLE RELATIONSHIPS
HUB
Contact
Coverage
Continuity
Comprehensive
Coordinated
Flexibility
Relationships
Trust
Leadership
SPOKES + RIMS
Keep Well
Child Health
Elderly
Mental Health
Addictions
Community Care
Secondary Care
Voluntary sector
Local Communities
INTEGRATED CARE DEPENDS ON MULTIPLE RELATIONSHIPS

23. Evidence

24. Evidence-based medicine
Clinical Guidelines are based on RCTs that exclude patients with multimorbidity
There is a dearth of evidence on the management of patients with multimorbidity in primary care
There is even less on managing multimorbid primary care patients in deprived areas

25. Living well with multimorbidity: the CARE Plus Study
Stewart Mercer Bruce Guthrie Elizabeth Fenwick Bridie Fotzpatrick Alex McConnachie Rosalind O’Brien Graham Watt Sally Wyke NHS and Deep End General Practices

26. System Professional Patient
CARE PLUS:
a whole-system approach
System
Professional
Patient
Resource for more time with continuity
System
Support meetings and structure for empathic, person-centred consultations (CARE)
Practitioner
Patient
CD and written guide on mindfulness
Plus CBT guide
Community activities recommended

27. Patients in the CARE Plus group had improvements in quality of life and wellbeing at 12 months
Favours Usual Care
Favours CARE Plus

28. CARE Plus was also very cost-effective
Cost < £13,000 per QALY
NICE currently supports a cost of £20,000 per QALY
Mercer SW, Fitzpatrick B, Guthrie B, Fenwick E, Grieve E, Lawson K, Boyer N, McConnachie A, Lloyd SM, O’Brien R, Watt GCM, Wyke S. The Care Plus study- a whole system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: cluster randomised controlled trial. BMC Medicine 2016, 14:88

29. The Power of the Deep End

31. ACHIEVEMENTS A lot, quickly and cheaply Identity Engagement Profile
Voice
Phase 1 Meetings
Phase 2 Publications, Presentations and Profile
Phase 3 Opportunities, Influence, Resources
Phase 4 Implementation, Lobbying
Projects Govan SHIP, LINK Workers , Care Plus, Benefits, Alcohol, Housing

32. DEEP END REPORTS www.gla.ac.uk/deepend First meeting at Erskine
Needs, demands and resources
Vulnerable families
Keep Well and ASSIGN
Single-handed practice
Patient encounters
GP training
Social prescribing
Learning Journey
Care of the elderly
Alcohol problems in young adults
Caring for vulnerable children and families
The Access Toolkit : views of Deep End GPs
Reviewing progress in 2010 and plans for 2011
Palliative care in the Deep End
Austerity Report
Detecting cancer early
Integrated care
Access to specialists
What can NHS Scotland do to prevent and reduce heath inequalities
GP experience of welfare reform in very deprived areas
Mental health issues in the Deep End
The contribution of general practice to improving the health of vulnerable children and families
What are the CPD needs of GPs working in Deep End practices?
Strengthening primary care partnership responses to the welfare reforms
Generalist and specialist views of mental health issues in very deprived areas
lmproving partnership working between general practices and financial advice services in Glasgow : one year on is

33. SIX ESSENTIAL COMPONENTS
Extra TIME for consultations (INVERSE CARE LAW)
Best use of serial ENCOUNTERS ((PATIENT STORIES)
General practices as the NATURAL HUBS
of local health systems (LINKING WITH OTHERS)
4. Better CONNECTIONS across the front line (SHARED LEARNING)
5. Better SUPPORT for the front line (INFRASTRUCTURE)
6. LEADERSHIP at different levels (AT EVERY LEVEL)

34. Summary and Conclusions
The challenges facing comprehensive primary care in deprived areas relate to the unmet healthcare needs of the populations served
The inverse care law stymies attempts to improve population health through primary care
There is a lack of research that focuses on complex needs of multimorbid patients in deprived areas
Primary care is a natural hub for the integration of health and social care services
Policy needs to change
GP in the Deep End can be a powerful voice for advocacy