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PUBLIC HEALTH POLICIES1. No contact with the public2. Single contacts3. Serial contacts
Geographical denominators     “communities of place”GP list denominators     “communities of interest”
The challenge of universal coverage - 1948 and now
NOT ONLYEvidence-based medicine (QOF, SIGN)BUT ALSOUnconditional, personalised, continuity of care
WHO NEEDS INTEGRATED CARE ?Potentially anyone but mostlythe 15% of patientswho account for 50% of general practice workload
If we do not change directionwe shall arrive where we are heading                                       Chinese proverb
DIFFERENCES IN LIFE EXPECTANCYBETWEEN MOST AND LEAST DEPRIVED DECILESSCOTLAND 2007/08                                     ...
Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde                                                  ...
Multimorbidity is common in Scotland– The majority of over-65s have 2 or more conditions, and  the majority of over-75s ha...
Most people with any long term condition  have multiple conditions in Scotland          Heart failure          3          ...
There are more people in Scotland with  multimorbidity below 65 years than                above
People living in more deprived areas inScotland develop multimorbidity 10 years before those living in the most affluent  ...
Mental health problems are strongly associated with the number of physicalconditions that people have, particularly in    ...
Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde                                                  ...
CHD CASELOAD PER WTE GENERAL PRACTITIONERQuintile of   No of cases         WTE         CHD casesDeprivation   with at leas...
KEY POINTS ABOUT ENCOUNTERSMultiple morbidity and social complexityShortage of timeReduced expectationsLower enablementHea...
GP stress by clinical encounter lengthin areas of high and low deprivation                 5.0                            ...
GENERAL PRACTITIONERS AT THE DEEP END                                                                          Age & Sex S...
A WORKFORCE LACKING COVERAGE, RELATIONSHIPS AND CONTINUITY
DECORATORS   BUILDERS
4 PROBLEMS WITH TARGETINGProportionate universalism(“We are all responsible for all”)Unsustained, ineffective intervention...
WRITING A REPORT ON HEALTH INEQUALITIES AND GENERAL PRACTICE1. Not another report that sits on the shelf, and makes no dif...
Listen to the patientHe is telling you the diagnosis                                  SIR WILLIAM OSLER
QUESTIONWHY DO YOU ROB BANKS ?ANSWERBECAUSE THAT’S WHERE THE MONEY IS                   WILLIE SUTTON
WHERE ARE THE MOST DEPRIVED POPULATIONS ?The problem of concentration (BLANKET DEPRIVATION)50% are registered with the 100...
WHERE ARE THE 100 PRACTICES?CHP                       No of top 100                          practices                    ...
QOF POINTS 2007                          TOTAL   CLINICAL   NON-CLINICALMost affluent practices   984     645        339Mi...
ADDITIONAL ACTIVITIESUndergraduate teaching              45Postgraduate teaching               27Research (SPCRN)         ...
INVERSE CARE LAW“The availability of good medical care tends to vary inverselywith the need for it in the population serve...
WHAT DO DEEP ENDGENERAL PRACTITIONERS AND COUNT DRACULA  HAVE IN COMMON ?
1. First meeting at Erskine2. Needs, demands and resources3. Vulnerable families4. Keep Well and ASSIGN5. Single-handed pr...
TIME
SERIAL            ENCOUNTERBRIEFENCOUNTER
LINKS
INTRINSIC FEATURES OF GENERAL PRACTICEContactCoverageContinuityCoordinationFlexibilityRelationshipsTrust
CONSULTATIONS ARE NOT ENOUGHStrengthening local health systems by :-BETTER LINKS WITH PATIENTSBETTER LINKS WITH HEALTH IMP...
INVENTING THE WHEELHUB                                             SPOKES + RIMSContact                                   ...
POLICYRECOGNITION
HOW TO AVOID F R A G M E N T A T I O N ?
FRAGMENTATIONDysfunctional consultationsDiscontinuityPoor coordinationGaps in coverage
TOO MANY BITSI’VE JUST INVENTED A MACHINE THAT DOES THE WORK OF TWO MEN.UNFORTUNATELY, IT TAKES THREE MEN TO WORK IT      ...
Health practitioners need to asknot only “What do I do?”but also “What am I part of?”                                   Do...
MUTUALITY    Relationships based on            Recognition            Joint work            Effective communication       ...
RELATIONSHIPS WITH PATIENTSInitially face to face, eventually side by side                                         Julian ...
RELATIONSHIPS REQUIRING MUTUALITY AND TRUST1. Patients and Practitioners (SERIAL ENCOUNTERS)2. Practices and other Service...
SIX ESSENTIAL COMPONENTS1. Extra TIME for consultations2. Best use of SERIAL ENCOUNTERS3. General practices as the NATURAL...
THE QUESTIONCan we imagine, develop, and supporta plurality of local health systems based on general practices,providing r...
ACHIEVEMENTSA lot, quickly and cheaplyIdentity, Engagement, Morale, Voice, RecognitionPhase 1           2010     15 Meetin...
ADVOCACYThe social causes of illness are just as important as the physical ones.The practitioners of a distressed area are...
60          Those of the world’s 25                                                                                       ...
THE CULTURE OF POWERorTHE POWER OF CULTURE
GPs at the Deep End
GPs at the Deep End
GPs at the Deep End
GPs at the Deep End
GPs at the Deep End
GPs at the Deep End
GPs at the Deep End
GPs at the Deep End
GPs at the Deep End
GPs at the Deep End
GPs at the Deep End
GPs at the Deep End
GPs at the Deep End
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GPs at the Deep End

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GPs at the Deep End

  1. 1. PUBLIC HEALTH POLICIES1. No contact with the public2. Single contacts3. Serial contacts
  2. 2. Geographical denominators “communities of place”GP list denominators “communities of interest”
  3. 3. The challenge of universal coverage - 1948 and now
  4. 4. NOT ONLYEvidence-based medicine (QOF, SIGN)BUT ALSOUnconditional, personalised, continuity of care
  5. 5. WHO NEEDS INTEGRATED CARE ?Potentially anyone but mostlythe 15% of patientswho account for 50% of general practice workload
  6. 6. If we do not change directionwe shall arrive where we are heading Chinese proverb
  7. 7. DIFFERENCES IN LIFE EXPECTANCYBETWEEN MOST AND LEAST DEPRIVED DECILESSCOTLAND 2007/08 MEN Most Least Difference deprived deprivedLife expectancy 67.6 80.9 13.3Healthy life expectancy 56.9 75.7 18.8Years spent in poor health 10.7 5.2 5.5 WOMEN Most Least Difference deprived deprivedLife expectancy 75.6 84.2 8.6Healthy life expectancy 60.8 77.9 17.1Years spent in poor health 14.8 6.3 8.5Long-term monitoring of health inequalities. The Scottish Government 2010
  8. 8. Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde Deprivation Decile 250 200Age-Sex Standardised Ratio 150 sir64 shr64 100 smr74 Linear (WTE GPs) 50 0 1 2 3 4 5 6 7 8 9 10 Deprivation Decile
  9. 9. Multimorbidity is common in Scotland– The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions– More people have 2 or more conditions than only have 1
  10. 10. Most people with any long term condition have multiple conditions in Scotland Heart failure 3 9 14 74 Stroke/TIA 6 14 18 62 Atrial fibrillation 7 13 16 65Coronary heart disease 9 16 19 56 Painful condition 13 21 21 46 Diabetes 14 20 19 47 COPD 18 19 17 47 Hypertension 22 24 19 35 Cancer 23 21 17 39 Epilepsy 31 23 16 29 Asthma 48 20 12 21 Dementia 5 13 18 64 Anxiety 7 17 20 56 Schizophrenia/bipolar 13 21 21 46 Depression 23 22 18 36 0% 20% 40% 60% 80% 100% Percentage of patients with each condition who have other conditions This condition only This condition + 1 other + 2 others + 3 or more others
  11. 11. There are more people in Scotland with multimorbidity below 65 years than above
  12. 12. People living in more deprived areas inScotland develop multimorbidity 10 years before those living in the most affluent areas
  13. 13. Mental health problems are strongly associated with the number of physicalconditions that people have, particularly in deprived areas in Scotland
  14. 14. Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde Deprivation Decile 250 200Age-Sex Standardised Ratio 150 sir64 shr64 100 smr74 Linear (WTE GPs) 50 0 1 2 3 4 5 6 7 8 9 10 Deprivation Decile
  15. 15. CHD CASELOAD PER WTE GENERAL PRACTITIONERQuintile of No of cases WTE CHD casesDeprivation with at least GP per WTE GP one CHD diagnosis1 6543 100.9 652 6399 97.9 653 9262 121.7 764 8455 110.8 765 9378 111.2 84 (+29%) SOURCE : GREATER GLASGOW LES DATA
  16. 16. KEY POINTS ABOUT ENCOUNTERSMultiple morbidity and social complexityShortage of timeReduced expectationsLower enablementHealth literacyPractitioner stressWeak interfaces
  17. 17. GP stress by clinical encounter lengthin areas of high and low deprivation 5.0 4.7 4.5 4.0 3.9 3.8 3.5 3.4 3.5 3.4 Mean stress Deprivation group 3.0 3.1 3.0 high 2.5 low 5 min or less 10-14 min 6-9 min 15 min and above Consultation length
  18. 18. GENERAL PRACTITIONERS AT THE DEEP END Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde Deprivation Decile 250 200 Age-Sex Standardised Ratio 150 sir64 shr64 100 smr74 Linear (WTE GPs) 50 0 1 2 3 4 5 6 7 8 9 10 Deprivation Decile
  19. 19. A WORKFORCE LACKING COVERAGE, RELATIONSHIPS AND CONTINUITY
  20. 20. DECORATORS BUILDERS
  21. 21. 4 PROBLEMS WITH TARGETINGProportionate universalism(“We are all responsible for all”)Unsustained, ineffective interventionsDenial of the inverse care lawProfessionalisation of Health Inequalities
  22. 22. WRITING A REPORT ON HEALTH INEQUALITIES AND GENERAL PRACTICE1. Not another report that sits on the shelf, and makes no difference2. No tool kit, telling GPs what to do3. Start by listening to GPs in the front lineTIME TO CAREHealth Inequalities, Deprivation and General Practice in ScotlandRCGP Scotland Health InequalitiesShort Life Working Group ReportDecember 2010“Practitioners lack time in consultations to address the multiple,morbidity, social complexity and reduced expectations that aretypical of patients living in severe socio-economic deprivation.”
  23. 23. Listen to the patientHe is telling you the diagnosis SIR WILLIAM OSLER
  24. 24. QUESTIONWHY DO YOU ROB BANKS ?ANSWERBECAUSE THAT’S WHERE THE MONEY IS WILLIE SUTTON
  25. 25. WHERE ARE THE MOST DEPRIVED POPULATIONS ?The problem of concentration (BLANKET DEPRIVATION)50% are registered with the 100 “most deprived” practice populations(from 50-90% of patients in the most deprived 15% of postcodes)The problem of dilution (POCKET DEPRIVATION)50% are registered with 700 other practices in Scotland(less than 50% in the most deprived 15% of postcodes)The problem of non-involvement (HIDDEN DEPRIVATION)200 practices have no patients in the most deprived 15% of postcodes
  26. 26. WHERE ARE THE 100 PRACTICES?CHP No of top 100 practices SIMD 2006 SIMD 2009Glasgow East CHCP 28 ) 27 )Glasgow North CHCP 18 ) 18 )Glasgow West CHCP 16 ) 85 14 ) 76Glasgow South-West CHCP 14 ) 13 )Glasgow South-East CHCP 9 ) 4 )Inverclyde 5 7Edinburgh 5 4Tayside 2 4Ayrshire 2 5Renfrewshire 1 1Fife 1Grampian 1Lanarkshire 1TOTAL 100 100
  27. 27. QOF POINTS 2007 TOTAL CLINICAL NON-CLINICALMost affluent practices 984 645 339Mixed practices 979 643 336Most deprived practices 977 641 335
  28. 28. ADDITIONAL ACTIVITIESUndergraduate teaching 45Postgraduate teaching 27Research (SPCRN) 66Primary Care Collaborative (SPCC) 67Keep Well (phase 1) 24Keep Well (phase 2) 13
  29. 29. INVERSE CARE LAW“The availability of good medical care tends to vary inverselywith the need for it in the population served”.The inverse care law is a policy of NHS Scotland which restrictscare in relation to need.Not the difference between good and bad care, but between whatgeneral practices can do and could do with resources based on need.
  30. 30. WHAT DO DEEP ENDGENERAL PRACTITIONERS AND COUNT DRACULA HAVE IN COMMON ?
  31. 31. 1. First meeting at Erskine2. Needs, demands and resources3. Vulnerable families4. Keep Well and ASSIGN5. Single-handed practice6. Patient encounters7. GP training8. Social prescribing9. Learning Journey10.Care of the elderly11.Alcohol problems in young adults12.Caring for vulnerable children and families13.The Access Toolkit : views of Deep End GPs14.Reviewing progress in 2010 and plans for 201115.Palliative care in the Deep Endwww.gla.ac.uk/departments/generalpracticeprimarycare/deepend
  32. 32. TIME
  33. 33. SERIAL ENCOUNTERBRIEFENCOUNTER
  34. 34. LINKS
  35. 35. INTRINSIC FEATURES OF GENERAL PRACTICEContactCoverageContinuityCoordinationFlexibilityRelationshipsTrust
  36. 36. CONSULTATIONS ARE NOT ENOUGHStrengthening local health systems by :-BETTER LINKS WITH PATIENTSBETTER LINKS WITH HEALTH IMPROVEMENTBETTER LINKS WITH OTHER NHS PRIMARY CARE SERVICESBETTER LINKS WITH THE REST OF THE NHS, INCLUDINGOUT OF HOURS, ELECTIVE REFERRALS AND HOSPITAL SERVICESBETTER COLLABORATION WITH LOCAL AUTHORITY SERVICESBETTER COLLABORATION WITH VOLUNTARY SERVICES ANDLOCAL COMMUNITIES
  37. 37. INVENTING THE WHEELHUB SPOKES + RIMSContact Keep WellCoverage Child HealthContinuity ElderlyComprehensive Mental HealthCoordinated AddictionsFlexibility Community CareRelationships Secondary CareTrust Voluntary sectorLeadership Local Communities INTEGRATED CARE DEPENDS ON MULTIPLE RELATIONSHIPS INVESTMENT IN RELATIONSHIPS BUILDS SOCIAL CAPITAL
  38. 38. POLICYRECOGNITION
  39. 39. HOW TO AVOID F R A G M E N T A T I O N ?
  40. 40. FRAGMENTATIONDysfunctional consultationsDiscontinuityPoor coordinationGaps in coverage
  41. 41. TOO MANY BITSI’VE JUST INVENTED A MACHINE THAT DOES THE WORK OF TWO MEN.UNFORTUNATELY, IT TAKES THREE MEN TO WORK IT SPIKE MILLIGAN
  42. 42. Health practitioners need to asknot only “What do I do?”but also “What am I part of?” Don Berwick Head of US Medicare and Medicaid
  43. 43. MUTUALITY Relationships based on Recognition Joint work Effective communication Understanding and respect Positive experiences Confidence in the future TRUST
  44. 44. RELATIONSHIPS WITH PATIENTSInitially face to face, eventually side by side Julian Tudor Hart A NEW KIND OF DOCTOR
  45. 45. RELATIONSHIPS REQUIRING MUTUALITY AND TRUST1. Patients and Practitioners (SERIAL ENCOUNTERS)2. Practices and other Services (SOCIAL CAPITAL)3. Networks of Practices (DEEP END)4. Practices and NHS Management (TWO CULTURES)
  46. 46. SIX ESSENTIAL COMPONENTS1. Extra TIME for consultations2. Best use of SERIAL ENCOUNTERS3. General practices as the NATURAL HUBS of local health systems4. Better CONNECTIONS across the front line5. Better SUPPORT for the front line6. LEADERSHIP at different levels
  47. 47. THE QUESTIONCan we imagine, develop, and supporta plurality of local health systems based on general practices,providing resources according to need (proportionate universalism),combining the strengths of area-based and list-based services,recognising leadership roles at both levels,committed to long term changeand to shared learning on the way (a learning organisation) ?
  48. 48. ACHIEVEMENTSA lot, quickly and cheaplyIdentity, Engagement, Morale, Voice, RecognitionPhase 1 2010 15 MeetingsPhase 2 2011 Publications, Presentations and Profile 12 BJGP articles RCGP Occasional PaperPhase 3 2012 Opportunities CARE Plus Study LINKSand BRIDGE projects Glasgow Deprivation Interest Group, following Lothian Austerity Survey 2nd National Meeting Piloting contractual changes
  49. 49. ADVOCACYThe social causes of illness are just as important as the physical ones.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 Sigerist
  50. 50. 60 Those of the world’s 25 United Kingdom richest large countries Denmark which are in Europe + USA United States Greece55 Slovenia Germany50 Spain Ireland Norway45 Portugal Italy40 Netherlands Finland Austria35 Public Expenditure (%GDP) Sweden International Monetary Fund (IMF), World Economic Outlook Databasefor October, Washington, DC, IMF, 2010 France http://www.imf.org/external/pubs/ft/weo/2010/02/weodata/index.aspx30 Denmark 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Belgium
  51. 51. THE CULTURE OF POWERorTHE POWER OF CULTURE

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