With thanks to Professor Graeme Watt, Deep End Project for later slides.

1. GPST Education day
3rd October 2012

2. Plan for the day
1) 9.30-12.00 Community orientation
2) 12.00-13.00 Problem Cases
3) 13.00-14.00 Lunch
4) 14.00 Diabetes
5) 15.30 Family planning

3. Community orientation – outline of
areas for session
1. GP curriculum, look at knowledge and skills
expected
2. Practice profiles and impact on work load
3. How much is the GP part of the community?
4. Inequalities in health and inequalities in healthcare
5. Individual vs community
6. Rationing

4. GP curriculum statement
“GPs have a responsibility for the community in
which they work, which extends beyond the
consultation with an individual patient. The work of
family doctors is determined by the makeup of the
community and therefore they must understand
the potentials and limitations of the community in
which they work and its character in terms of
socio-economic and health features….

5. GP Curriculum statement continued
……The GP is in a position to consider many of
the issues and how they interrelate, and the
importance of this within the community. In all
societies healthcare systems are being rationed,
and doctors are being involved in the rationing
decisions; they have an ethical and moral duty to
influence health policy in the community.”

6. Community Orientation is concerned
with:
l the ability to reconcile the health needs of
●
individual patients
●
the community in which they live,
l Balancing these available resources

7. Practice profiles
l ISD(information services division Scotland)
can provide info on demographics
(age/sex/deprivation) for each practice.

8. Discussion points
l Groups discuss features of own practice
population/community and how this affects the job.
l Urban/suburban/inner city/ rural
l Deprivation / wealth
l Social class
l Age / sex
l Drug use
l Ethnicity

9. Debate:How closely should GPs
be part of the community?
Motions:
l GPs should live in the community they serve.
l GPs should be recruited from the community
they serve.

10. Debate snowball
Whole group splits into 2 groups: For & Against
Within the For, 3 subgroups come up with ideas
Within the Against, 3 subgroups come up with
ideas (15 mins)
“For” groups merge,consider strategy (10 mins)
“Against” groups merge & consider strategy
Elect spokespeople for debate
Debate!

11. l AJ
Inequalities in health and
healthcare

12. Inequalities in health and
healthcare
l Average life expectancy for women born in
Botswana?
l 43 years
l Average life expectancy for women born in Japan?
l 86 years
l Life expectancy for men in poorest parts of
Glasgow?
l 54 years
l Life expectancy for men in most affluent parts of
Glasgow?
l 82 years

13. Inequalities in health and healthcare
l Contributing factors:
●
Poverty/social class
●
Ethnicity
●
Gender
●
Age
●
Mental illness
●
Education
●
Diet and exercise
●
Substance misuse – drugs and alcohol
●
Smoking
●
Housing
●
Pre birth

14. 4) Inequalities in health and
healthcare
l Downstream Causes
l Exposures – e.g. damp housing, hazardous work
l Behaviours – e.g. smoking, diet, exercise, drugs
l Personal strengths or vulnerabilities – e.g. coping
styles, resilience, ability to plan for the future
l Upstream Causes
l Political and economic factors – e.g. education,
taxation, healthcare, crime and policing, etc
l Interventions need a combination of both
downstream and upstream policies

15. Health Inequalities and
Community Orientation
l Recognising the health needs of the individual patient
and the community in which they live and balancing
these with available resources
l Harm reduction
l Try to keep things “in house”
l Knowledge of where to eat free/cheaply
l Awareness of services and organisations that can
provide support to homeless people/those at risk of
homelessness
l E.g. Crisis Centre, hostels, Streetwork, Rock Trust,
SACRO

16. Who has better health?
l solicitor
l drug user
l asylum seeker with no English language
l learning disability
l doctor
l teacher
l lorry driver
l pensioner

17. Who gets the best health care?
l solicitor
l drug user
l asylum seeker with no English language
l learning disability
l doctor
l teacher
l lorry driver
l pensioner

18. Individual vs community
l Autonomy vs justice
l Greatest good for the greatest number
l Patient advocate or need to take into account
wider community

19. Rationing
l Implicit and explicit

20. Implicit
l Postcode
l GP gatekeeper role
l Age
l education

21. Rationing: Explicit
l NICE
l SIGN
l SMC (Scottish medicines consortium)
l LJF (Lothian joint formulary)
l Health Boards eg Fife & IVF
l Age
l Lifestyle
l Disease category

22. Group work
l Examples of inequalities in health or health
care

23. Inequalities in health and healthcare
Inverse care law
Julian Tudor Hart 1971
NMC

24. Inequalities in health and healthcare
"The availability of good medical care tends
to vary inversely with the need for it in the
population served.”
=
Those who need medical care the most are
the least likely to get it.

25. The Black Report
l Report on Inequalities in Healthcare
l Commissioned by Health Minister David Ennals in 1977
l Chaired by Sir Douglas Black, former RCP President
l Demonstrated continued improvement in health across
all classes during the first 35 years of the NHS but there
was still a correlation between social class and infant
mortality rates, life expectancy and inequalities of the
use of health care services
l The government changed and when released in May
1980 the press release drew attention away from many
of the findings due to the implications for expenditure

26. The Acheson Report
l Independent Inquiry into Inequalities in
Health Report 1998
l Chaired by Sir Donald Acheson (former
CMO)
l Demonstrated that despite a downward trend
in mortality from 1970-1990 the lower social
classes experienced a much less rapid
mortality decline

27. WHO Commission on Social
Determinants of Health 2008
l Commission on
Social Determinants
of Health. Closing
the gap in a
generation.
WHO, 2008
l www.who.int/social_determinants/thecommission/finalreport/

28. WHO Commission on Social
Determinants of Health 2008
l Improve daily living conditions
l Tackle
the inequitable distribution of power,
money, and resources

29. WHO Commission on Social
Determinants of Health 2008
l Measure the problem, evaluate action,
expand the knowledge base, develop a
workforce that is trained in the social
determinants of health and raise public
awareness about the social determinants of
health

30. Marmot Report
l ProfM Marmot
Strategic review of
health inequalities in
England post-2010.
Marmot review final
report.
University College
London.
www.ucl.ac.uk/gheg/marmotreview/Documents

31. Six policy recommendations to reduce health
inequalities
1. Give every child the best start in life: increase
the proportion of overall expenditure allocated to the
early years and ensure it is focused progressively
across the gradient
2. Enable all children, young people, and adults to
maximise their capabilities and have control over
their lives: reduce the social gradient in skills and
qualifications
3. Create fair employment and good work for all:
improve quality of jobs across the social gradient

32. Six policy recommendations to reduce health
inequalities
4. Ensure a healthy standard of living for all:
reduce the social gradient through progressive
taxation and other fiscal policies
5. Create and develop healthy and sustainable
places and communities
6. Strengthen the role and effect of the prevention
of ill health: prioritise investment across
government to reduce the social gradient

33. TIME TO CARE
Health Inequalities, Deprivation and
General Practice in Scotland
RCGP Scotland Health Inequalities
Short Life Working Group Report
December 2010

35. 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

36. People living in more deprived areas in Scotland
develop multimorbidity 10 years before those
living in the most affluent areas

37. CONSULTATIONS ARE NOT ENOUGH
Strengthening local health systems by :-
BETTER LINKS WITH PATIENTS
BETTER LINKS WITH HEALTH IMPROVEMENT
BETTER LINKS WITH OTHER NHS PRIMARY CARE SERVICES
BETTER LINKS WITH THE REST OF THE NHS, INCLUDING
OUT OF HOURS, ELECTIVE REFERRALS AND HOSPITAL SERVICES
BETTER COLLABORATION WITH LOCAL AUTHORITY SERVICES
BETTER COLLABORATION WITH VOLUNTARY SERVICES AND
LOCAL COMMUNITIES

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

39. Conclusions
Ø Practitioners lack time in consultations to address the multiple,
morbidity, social complexity and reduced expectations that are
typical of patients living in severe socio-economic deprivation.
Ø Opportunities for anticipatory care are often fleeting and may be lost
if there is not the opportunity to connect quickly with other
disciplines and services that are closely linked to the practice.
Ø Practices provide contact, coverage, continuity, flexibility and
coordination, and need to be recognised and supported as the hubs
around which other services operate.

41. Summary
1. GP curriculum
2. Practice profiles
3. GP involvement in community
4. Inequalities in health and inequalities in
healthcare
5. Individual vs community
6. Rationing

42. Conclusions
Ø The only route by which practices in severely deprived areas can
improve patient's health and narrow health inequalities is by
increasing the volume and quality of the care they provide.
Ø When public funding is under severe pressure it is especially
important that NHS resources are targeted where they are most
needed.
Ø NHS support services should be audited in terms of the support they
provide for practices working in the front line.
Ø Further work with GPs and practice teams outwith the ‘deep end’
practices and in remote and rural areas is required to establish the
impact of deprivation on patients and primary health care workers in
these areas

43. Case work

44. 2 case histories
l Small groups

45. Mrs Campbell
Mr and Mrs Campbell have moved to your practice area to be
closer to their relatives. Their daughter, Jane, and her teenage
children are patients at your practice and so the couple have
registered with you. Jane has written a brief note to reception
explaining that she's worried her Dad's not coping.
From the previous medical notes, it appears Mrs Smith has
significant memory impairment, but hasn't been formally
diagnosed with dementia. There are some references to
husband's struggling to adapt to changes in wife's health.
Mrs Smith has never had a psychogeriatric assessment and
notes state has previously “refused” to attend.

46. Mrs Campbell
● What sort of issues do you wish to address with the couple?
● What practical ways could you go about gathering the information
you require?
● What services might be available in your area that are appropriate
for them?
● Medical?
● Allied Health Professionals?
● Social?
● Charitable?

47. Mr Robertson
James Robertson is an elderly gentleman known to your practice
for many years due to his multimorbid complex history IHD, PMR
and COPD. He is normally able to attend the practice for his
routine appointments but requests a home visit as his “walking's
off”. He doesn't have any family nearby and has no help at home.
On further assessment during the home visit, he is very reluctant
to even consider an admission to look into this deterioration. He
says he has lost many friends in the last few years as they As his
recent bloods were normal and there has been a gradual
deterioration according to Mr Robertson, you agree to try and
investigate things with him in the community.

48. Mr Robertson
● What service may be ● Longer term, who else chould
appropriate here for further get involved to help Mr
assessment of Mr Robertson's Robertson continue to live
presentation? Do you know independently at home or
how to refer and what is facilitate moving to more
involved? appropriate accommodation?
● What services are you aware of
that could/should be put in
place to ensure his immediate
safety? (Again, do you know
how to refer and what is
involved?)

49. Thank you!