Primary Care & Health Inequality

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!”