This document discusses the role of primary care in reducing health inequalities. It shows that areas with high deprivation have greater health needs, poorer access to primary care, and less effective consultations. Consultations in deprived areas are shorter, more stressful for GPs, and less enabling for patients. However, an evaluation of a practice that implemented extended consultations for complex patients found it enhanced patient enablement and reduced GP stress. The extra time in long consultations was used for issues like mental health, communication, chronic disease management, and care coordination.

1. The Role of Primary Care in Reducing
Health Inequalities
Stewart W Mercer
Professor of Primary Care Research

2. ILL-HEALTH VARIABLES BY DEPRIVATION
180
160
140
120
100 Mortality <75
Limiting long-term illness
80 Not good' general health
60
40
20
0
1 2 3 4 5 6 7 8 9 10
Deprivation decile

3. Distribution of deprivation in
Scotland

6. The Importance of General Practice and
Primary Care

7. STARFIELD
Lancet 1994;344:1129-33

8. PRIMARY CARE
MAKES A DIFFERENCE
Does health care improve health?
Craig, Wright, Hanlon and Galbraith
Journal of Health Services Research and Policy 2006;11:1-2
Medicine matters after all
Bunker
Nuffield Trust, 2001
Does health care save lives? Avoidable mortality revisited
Nolte and McKee
Nuffield Trust, 2004

9. 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

10. STRENGTHS OF GENERAL PRACTICE
CONTACT
COVERAGE
CONTINUITY
COMPREHENSIVENESS
COORDINATION
RELATIONSHIPS

11. 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

13. 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

14. Data
• Demographic and socio-economic factors,
health variables and a range of measures
relating to access, reason for consultation,
and quality of consultation

15. Results

16. Need
High Dep Low Dep P value
GHQ-12 41% 29% <0.001
caseness
Long-term 54% 42% <0.001
illness
3 or more 31% 24% 0.008
LTCs
Health 27% 14% <0.001
(Bad)
Unemployed 32% 14% <0.001

17. Need: Relationship between psychological distress
and co-morbidity in high and low deprivation areas
60
50
50
48
40
40
37
30 32
% GHQ caseness
28
24 Deprivation group
20
19
High
10 Low
none one tw o three or more
Co-morbidity: No. of long-standing conditions

18. Access and expectations
High Dep Low Dep P value
Access (> 3 66% 52% <0.001
days)
Rating (poor/v. 21% 10% <0.001
poor)
No. of probs 52% 40% <0.001
(>1)
Both new and 38% 32% <0.093
old prob
Psycho-social 30% 19% <0.001

19. Response: Distribution of clinical encounter length
in areas of high and low deprivation
50
40
39
30
29
26 26
23 23
20 22
13 Deprivation group
10
Percent
High
0 Low
5 min or less 10-14 min
6-9 min 15 min and above
Consultation Length

20. Outcome: GP stress by clinical encounter length in
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

21. Effect: Patient enablement by consultation length
in psychosocial consultations in areas of high and
low deprivation
4.6
4.4
4.2
4.0
Mean Patient Enablement
3.8
3.6
3.4 Deprivation group
3.2 high
3.0 low
5 min or less 6-9 min 10-14 min 15 min and above
Consultation length

22. 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 life
2) Able to understand your illness
3) Able to cope with your illness
4) Able to keep yourself healthy
5)Confident about your health
6) Able to help yourself
Scored as ‘much better’ (2), ‘better’ (1), ‘same or less’ (0),

23. 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

24. 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)

25. High versus low deprivation GP
consultations
• Worse health • Less patient centred
• More chronic disease care (videos)
• More multimorbidity • Lower GP empathy
• More mental illness • Lower satisfaction
• More symptoms to • Poorer outcomes at 1
discuss month
• More re-attendances
and referrals over 2
months

26. Multiple morbidity and the inverse
care law

27. WHAT IS REQUIRED FOR GENERAL
PRACTICE AND PRIMARY CARE TO
IMPROVE HEATH AND REDUCE
INEQUALITIES ?

28. Q. WHAT CAN GENERAL PRACTICES DO TO IMPROVE HEATH
AND REDUCE INEQUALITIES ?
D. Increase the
VOLUME
QUALITY
COVERAGE
and EFFECTIVENESS
of what it does

29. Quality of care
1. Access
2 . E f f e c t iv e n e s s
T e c h n ic a l In te rp e rs o n a l
e f f e c t iv e n e s s E f f e c t iv e n e s s

30. The “clinical”
narrative
The “human”
narrative

31. How?

33. 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

34. Participants
• 300 adult patients at baseline
• 324 at follow-up, more than 1 year after the
introduction of longer consultations

35. S u m m a ry
E x t e n d e d c o n s u lt a t io n s
P a t ie n t e n a b le m e n t G P S tre s s
enhanced re d u c e d

36. 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’)

37. IS TIME ENOUGH?
Patient expectations
Patient-centredness
Pro-active rather than reactive care
Enabling and Encouraging self-care

38. 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

39. 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

40. WHAT ELSE?

41. 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 AND
LOCAL COMMUNITIES
BETTER LINKS WITH THE REST OF THE NHS, INCLUDING
OUT OF HOURS, ELECTIVE REFERRALS AND HOSPITAL SERVICES

42. THE INVERSE CARE LAW

43. 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

45. 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:

46. 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

47. 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 Sigerist
Professor of Medical History
Johns Hopkins University

48. 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.”

49. “Thank you!”