GPST Education day3rd October 2012
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   ...
Community orientation – outline ofareas for session1.   GP curriculum, look at knowledge and skills     expected2.   Pract...
GP curriculum statement “GPs have a responsibility for the community inwhich they work, which extends beyond theconsultati...
GP Curriculum statement continued……The GP is in a position to consider many ofthe issues and how they interrelate, and the...
Community Orientation is concernedwith:l the   ability to reconcile the health needs of   ●       individual patients   ● ...
Practice profilesl ISD(information services division Scotland) can provide info on demographics (age/sex/deprivation) for ...
Discussion pointsl   Groups discuss features of own practice    population/community and how this affects the job.      l ...
Debate:How closely should GPsbe part of the community?Motions:l GPs should live in the community they serve.l GPs should b...
Debate snowballWhole group splits into 2 groups: For & AgainstWithin the For, 3 subgroups come up with ideasWithin the Aga...
l   AJInequalities in health andhealthcare
Inequalities in health andhealthcarel   Average life expectancy for women born in    Botswana?l   43 yearsl   Average life...
Inequalities in health and healthcarel   Contributing factors:    ●        Poverty/social class    ●        Ethnicity    ●...
4) Inequalities in health andhealthcarel   Downstream Causes    l Exposures – e.g. damp housing, hazardous work    l Behav...
Health Inequalities andCommunity Orientationl   Recognising the health needs of the individual patient    and the communit...
Who has better health? l   solicitor l   drug user l   asylum seeker with no English language l   learning disability l   ...
Who gets the best health care? l   solicitor l   drug user l   asylum seeker with no English language l   learning disabil...
Individual vs communityl Autonomy   vs justicel Greatest good for the greatest numberl Patient advocate or need to take in...
Rationingl Implicit   and explicit
Implicitl Postcodel GP gatekeeper rolel Agel education
Rationing: Explicitl NICEl SIGNl SMC   (Scottish medicines consortium)l LJF (Lothian joint formulary)l Health Boards eg Fi...
Group workl Examples   of inequalities in health or health care
Inequalities in health and healthcare          Inverse care law          Julian Tudor Hart 1971                  NMC
Inequalities in health and healthcare"The availability of good medical care tendsto vary inversely with the need for it in...
The Black Reportl   Report on Inequalities in Healthcarel   Commissioned by Health Minister David Ennals in 1977l   Chaire...
The Acheson Reportl Independent    Inquiry into Inequalities in  Health Report 1998l Chaired by Sir Donald Acheson (former...
WHO Commission on SocialDeterminants of Health 2008                  l Commission      on                      Social Dete...
WHO Commission on SocialDeterminants of Health 2008l Improve   daily living conditionsl Tackle       the inequitable distr...
WHO Commission on SocialDeterminants of Health 2008l Measure the problem, evaluate action, expand the knowledge base, deve...
Marmot Reportl ProfM Marmot Strategic review of health inequalities in England post-2010. Marmot review final report. Univ...
Six policy recommendations to reduce healthinequalities1.      Give every child the best start in life: increase     the p...
Six policy recommendations to reduce healthinequalities4.      Ensure a healthy standard of living for all:     reduce the...
TIME TO CAREHealth Inequalities, Deprivation and   General Practice in Scotland     RCGP Scotland Health Inequalities     ...
Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde                                                  ...
People living in more deprived areas in Scotland develop multimorbidity 10 years before those         living in the most a...
CONSULTATIONS ARE NOT ENOUGHStrengthening local health systems by :-BETTER LINKS WITH PATIENTSBETTER LINKS WITH HEALTH IMP...
INVENTING THE WHEELHUB                                             SPOKES + RIMSContact                                   ...
ConclusionsØ   Practitioners lack time in consultations to address the multiple,    morbidity, social complexity and reduc...
Summary1.   GP curriculum2.   Practice profiles3.   GP involvement in community4.   Inequalities in health and inequalitie...
ConclusionsØ   The only route by which practices in severely deprived areas can    improve patients health and narrow heal...
Case work
2 case historiesl Small   groups
Mrs CampbellMr and Mrs Campbell have moved to your practice area to becloser to their relatives. Their daughter, Jane, and...
Mrs Campbell●   What sort of issues do you wish to address with the couple?●   What practical ways could you go about gath...
Mr RobertsonJames Robertson is an elderly gentleman known to your practicefor many years due to his multimorbid complex hi...
Mr Robertson●   What service may be              ●   Longer term, who else chould    appropriate here for further         ...
Thank you!
GPST1 ERP comm orientn health ineq  03102012 nmc DE and cases
GPST1 ERP comm orientn health ineq  03102012 nmc DE and cases
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GPST1 ERP comm orientn health ineq 03102012 nmc DE and cases

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GPST1 ERP comm orientn health ineq 03102012 nmc DE and cases

  1. 1. GPST Education day3rd October 2012
  2. 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. 3. Community orientation – outline ofareas for session1. GP curriculum, look at knowledge and skills expected2. Practice profiles and impact on work load3. How much is the GP part of the community?4. Inequalities in health and inequalities in healthcare5. Individual vs community6. Rationing
  4. 4. GP curriculum statement “GPs have a responsibility for the community inwhich they work, which extends beyond theconsultation with an individual patient. The work offamily doctors is determined by the makeup of thecommunity and therefore they must understandthe potentials and limitations of the community inwhich they work and its character in terms ofsocio-economic and health features….
  5. 5. GP Curriculum statement continued……The GP is in a position to consider many ofthe issues and how they interrelate, and theimportance of this within the community. In allsocieties healthcare systems are being rationed,and doctors are being involved in the rationingdecisions; they have an ethical and moral duty toinfluence health policy in the community.”
  6. 6. Community Orientation is concernedwith:l the ability to reconcile the health needs of ● individual patients ● the community in which they live,l Balancing these available resources
  7. 7. Practice profilesl ISD(information services division Scotland) can provide info on demographics (age/sex/deprivation) for each practice.
  8. 8. Discussion pointsl 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. 9. Debate:How closely should GPsbe 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. 10. Debate snowballWhole group splits into 2 groups: For & AgainstWithin the For, 3 subgroups come up with ideasWithin the Against, 3 subgroups come up withideas (15 mins)“For” groups merge,consider strategy (10 mins)“Against” groups merge & consider strategyElect spokespeople for debateDebate!
  11. 11. l AJInequalities in health andhealthcare
  12. 12. Inequalities in health andhealthcarel Average life expectancy for women born in Botswana?l 43 yearsl Average life expectancy for women born in Japan?l 86 yearsl Life expectancy for men in poorest parts of Glasgow?l 54 yearsl Life expectancy for men in most affluent parts of Glasgow?l 82 years
  13. 13. Inequalities in health and healthcarel Contributing factors: ● Poverty/social class ● Ethnicity ● Gender ● Age ● Mental illness ● Education ● Diet and exercise ● Substance misuse – drugs and alcohol ● Smoking ● Housing ● Pre birth
  14. 14. 4) Inequalities in health andhealthcarel 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 futurel Upstream Causes l Political and economic factors – e.g. education, taxation, healthcare, crime and policing, etcl Interventions need a combination of both downstream and upstream policies
  15. 15. Health Inequalities andCommunity Orientationl Recognising the health needs of the individual patient and the community in which they live and balancing these with available resourcesl Harm reductionl Try to keep things “in house”l Knowledge of where to eat free/cheaplyl 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. 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. 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. 18. Individual vs communityl Autonomy vs justicel Greatest good for the greatest numberl Patient advocate or need to take into account wider community
  19. 19. Rationingl Implicit and explicit
  20. 20. Implicitl Postcodel GP gatekeeper rolel Agel education
  21. 21. Rationing: Explicitl NICEl SIGNl SMC (Scottish medicines consortium)l LJF (Lothian joint formulary)l Health Boards eg Fife & IVFl Agel Lifestylel Disease category
  22. 22. Group workl Examples of inequalities in health or health care
  23. 23. Inequalities in health and healthcare Inverse care law Julian Tudor Hart 1971 NMC
  24. 24. Inequalities in health and healthcare"The availability of good medical care tendsto vary inversely with the need for it in thepopulation served.” =Those who need medical care the most arethe least likely to get it.
  25. 25. The Black Reportl Report on Inequalities in Healthcarel Commissioned by Health Minister David Ennals in 1977l Chaired by Sir Douglas Black, former RCP Presidentl 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 servicesl 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. 26. The Acheson Reportl Independent Inquiry into Inequalities in Health Report 1998l 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. 27. WHO Commission on SocialDeterminants 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. 28. WHO Commission on SocialDeterminants of Health 2008l Improve daily living conditionsl Tackle the inequitable distribution of power, money, and resources
  29. 29. WHO Commission on SocialDeterminants of Health 2008l 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. 30. Marmot Reportl 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. 31. Six policy recommendations to reduce healthinequalities1. 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 gradient2. Enable all children, young people, and adults to maximise their capabilities and have control over their lives: reduce the social gradient in skills and qualifications3. Create fair employment and good work for all: improve quality of jobs across the social gradient
  32. 32. Six policy recommendations to reduce healthinequalities4. Ensure a healthy standard of living for all: reduce the social gradient through progressive taxation and other fiscal policies5. Create and develop healthy and sustainable places and communities6. Strengthen the role and effect of the prevention of ill health: prioritise investment across government to reduce the social gradient
  33. 33. TIME TO CAREHealth Inequalities, Deprivation and General Practice in Scotland RCGP Scotland Health Inequalities Short Life Working Group Report December 2010
  34. 34. 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
  35. 35. People living in more deprived areas in Scotland develop multimorbidity 10 years before those living in the most affluent areas
  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. ConclusionsØ 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.
  39. 39. Summary1. GP curriculum2. Practice profiles3. GP involvement in community4. Inequalities in health and inequalities in healthcare5. Individual vs community6. Rationing
  40. 40. ConclusionsØ The only route by which practices in severely deprived areas can improve patients 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
  41. 41. Case work
  42. 42. 2 case historiesl Small groups
  43. 43. Mrs CampbellMr and Mrs Campbell have moved to your practice area to becloser to their relatives. Their daughter, Jane, and her teenagechildren are patients at your practice and so the couple haveregistered with you. Jane has written a brief note to receptionexplaining that shes worried her Dads not coping.From the previous medical notes, it appears Mrs Smith hassignificant memory impairment, but hasnt been formallydiagnosed with dementia. There are some references tohusbands struggling to adapt to changes in wifes health.Mrs Smith has never had a psychogeriatric assessment andnotes state has previously “refused” to attend.
  44. 44. 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?
  45. 45. Mr RobertsonJames Robertson is an elderly gentleman known to your practicefor many years due to his multimorbid complex history IHD, PMRand COPD. He is normally able to attend the practice for hisroutine appointments but requests a home visit as his “walkingsoff”. He doesnt have any family nearby and has no help at home.On further assessment during the home visit, he is very reluctantto even consider an admission to look into this deterioration. Hesays he has lost many friends in the last few years as they As hisrecent bloods were normal and there has been a gradualdeterioration according to Mr Robertson, you agree to try andinvestigate things with him in the community.
  46. 46. Mr Robertson● What service may be ● Longer term, who else chould appropriate here for further get involved to help Mr assessment of Mr Robertsons 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?)
  47. 47. Thank you!

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