Equitable choices for Health

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  • Thanks Aims: To present findings of ippr’s research on The role of primary care in delivering equitable choice in health care
  • Three key messages of our report We want to deliver a strong message that at present choice policy risks increasing inequities. Wider benefits – could contribute to tackling health inequalities. Most of the solutions to inequity lie in primary care. Apply lessons from choice in secondary care to develop choice in primary care and for people with long term conditions
  • Choice moved from being primarily mechanism to reduce waiting lists to being seen as key mechanism to drive up quality. Although talked about has engaging groups communities and individuals – bit of a leap from 1 and 2. We want to see move from 1 and 2 to 3. partly seeing it – but until recently Brown talked about ‘contestability’ mainly as way of improving quality, although yesterday
  • Eg gap between those born in dorset and those in Glasgow is 8-11 years (for boys) – and this has widened under labour. Although everyone is living longer. Also years spent in health – gap widening. Relate to all sorts of things – lifestyle, living conditions, work, income, expectations and crucially and perhaps not looked at enough is also relates to access to health services
  • Equity is core principle of NHS – but hard to achieve Preventative Elective Life saving More GPs in wealthier areas - but mainly an issue in London o “Affluent achievers” had 40% higher CABG and angioplasty rates than the ‘have-nots’, despite far higher mortality from CHD in the deprived group. o o. A one-point move down a seven-point deprivation scale resulted in GPs spending 3.4% less time with time with the individual concerned Despite attempts to weight finances – seemingly intractible NHS compounding health inequalities that already mean if you live in a poor area you are likely to die 7 years earlier than wealthy area.
  • Ippr Commission for Social Justice, 1994 Deputy Chair: Patricia Hewitt
  • Debate about causes Inverse care law More care you need, the less you receive. One-size-fits-all – means less specialisation in particular groups, health needs etc. Voice
  • More deprived areas, fewer GPs, less time with GP. GPs struggle to manage. A one-point move down a seven-point deprivation scale resulted in GPs spending 3.4% less time with time with the individual concerned people from minority ethnic groups are more likely than whites to: find physical access to their general practitioner (GP) difficult; have longer waiting times in the surgery; feel that the time spent with them was inadequate; and be less satisfied with the outcome of the consultation 441 , 457 . They may also be less likely to be referred to secondary and tertiary care Social classes IV and V had 10% fewer preventive consultations than social classes I and II Hip replacements were 20% lower among lower SEGs despite roughly 30% higher need
  • Can’t get to see GPs – for those in worst areas, GPs in commuter centres, walk in cetnres etc – not really crack it – although definitely are of benefit to most Participation in decisions about health leads to better outcomes better concordance with treatment Ownership of goals Independence Well-being – autonomy -> health How can choice contribute to tackling these? Will not be a panacea but could contribute rather than exacerbate. Equity of choice would contribute to equity of outcomes How can choice contribute to tackling these?
  • Due to a range of factors E.g. LPCP – survey found inequity in stated desire for choice. Therefore put in place incentives, PCAs, transport – nearly all the inequities disappeared Choice at referral is a different prospect, especially when waiting time decreases. Having piloted choice support mechanisms with extra funding, rolling out without. Choice needs support but also to be more meaningful than choice @ 6 months
  • Quantity Radical options on the supply side – new providers parachuted in Ippr have also argued that need to encourage GPs to move into deprived areas by paying them more Address underlying causes of under-doctoring: financial system penalises doctors in poor areas Quality How much switching of doctors will there be? Conflict between WP’s support of continuity and reliance on pressure of consumers. How much money will follow the patient – and how will it be weighted to their health needs? Lack of incentives to specialise. Likely to continue one-size-fits-all? More to do – review of nGMS formula that was abandoned – money follows the doctor Transport
  • But eligibility and accessibility to transport? But success of out-of-hours? Review of information and possible support to navigate – later in the year Emphasis on practices and commissioner choice, rather than patient choice
  • Access Need more than just commuter centres etc – need Drs to be apid more I ndeprived areas – culturally sensitive. Help with transport Information revolution in primary care Information, support and advocacy Voluntary and community sector Choice will need to be informed choice if going to improve allocation and help people to make healthy choices Beyond performance indicators Health-related quality of life outcomes Wider factors of patient experience for personalisation All providers subject to same information for choice requirements Accessible information – languages, abilities, formats Not just mortality data – doesn’t measure most healthcare Challenge for primary care will be to develop this kind of information Need much more support and advocacy – support people to make choices and access right care and receive right care. Use of CVS and advocacy – support prescriptions Professional attitudes – culturally sensitive – aware of needs – patient needs and link with deprivation.
  • When you start looking into choice – people talk about it in different ways We want to see empowerment – where everybody – including the most disadvantaged and excluded are able to take advantages of supported choice – long term advantages include – better access, better consultations, improved health literacy, better health – reduction in health inequalities. There but requires investment – including support, information, support prescriptions, improved access to GPs Challenging medical paternalism Health care – a process of production, not (just) an item of consumption However consumerism – active involvement in decision making – and market – incentives for providers to meet needs and preferences of patients – can bring benefits, through participation and engagement in the decision, creating a dialogue However need to bring patient back in to patient choice so that empowerment and engagement are the drivers
  • Three key messages of our report We want to deliver a message that at present choice policy risks increasing inequities. Wider benefits – could contribute to tackling health inequalities. Most of the solutions to inequity lie in primary care. Apply lessons from choice in secondary care to develop choice in primary care and for people with long term conditions
  • Equitable choices for Health

    1. 1. Equitable choices for Health Jessica Allen Institute for Public Policy Research www.ippr.org
    2. 2. Key messages• Choice could increase inequities if it is not geared towards disadvantaged• Equitable, progressive vision of choice could reduce inequities and achieve wider benefits• White Paper makes progress, but more needs to be done
    3. 3. One of Main Drivers of Health Service Reform• Choice – reduce waiting lists• Choice – drive up quality• Choice – inform engage and hand power to groups, communities and individuals.
    4. 4. • Think of the responsible parent, the informed patient, the active citizen and the dedicated teacher, nurse or local public servant who - with an extension of choice and voice, individual and collective - are taking control and driving change forward.Gordon Brown Feb 27 06
    5. 5. Inequalities in Health• Very varied life expectancy, years spent in good health• Depend partly on access to health services – inequities in health care.
    6. 6. Healthcare inequities• Equity founding principle of NHS but…• Health care inequity within the NHS• Social classes IV and V had 10% fewer preventive consultations than social classes I and II• Hip replacements were 20% lower among lower SEGs despite roughly 30% higher need• Intervention rates of CABG or angiography following heart attack were 30% lower in lowest SEG than the highest.
    7. 7. ‘People in poorer families and some minority ethnic groups get less satisfactory treatment. ‘Well-informed, middle class people are often better at getting what they need. ‘Every health authority should be under a statutory duty to reduce inequities in health care provision.’
    8. 8. Unequal access in primary care
    9. 9. Causes of inequity: supply• Under-doctored areas• Distance, registration• Relative quality• Professional beliefs and attitudes• One-size-fits-all
    10. 10. Unequal quality• Time with GP• Satisfaction and benefit per consultation• Treatment and referral rates
    11. 11. Causes of inequity: demand• Unequal resourcesTransport, work and personal commitments• Unequal ‘Choosability’Capabilities, beliefs, knowledgeInverse information lawParticipation in decision-making
    12. 12. Equity and choosability• Patients currently inequitably involved in decisions• Pilots show equitable choosing is possible in acute sector• …but limited applicability to wider health and care choices…• …and lessons not being rolled out
    13. 13. Choice and Equity in White PaperSupply Quantity: – Under-doctored areas – Resource shift to primary care and prevention Quality – Commissioning and regulation
    14. 14. Choice and equity in White PaperDemand:Work and personal commitmentsTransport to primary care‘Choosability’ Health beliefs, capabilities, knowledge? Professional beliefs and attitudes?
    15. 15. Equity and choosabilityAccessInformationSupport and advocacyProfessional attitudes
    16. 16. Theory of Choice• Choice as citizen empowerment• Choice as consumerism• Choice as market• Choice as co-production
    17. 17. Key messages• Choice could increase inequities if it is not geared towards disadvantaged• Equitable, progressive vision of choice could reduce inequities and achieve wider benefits• White Paper makes progress, but more needs to be done

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