PUBLIC HEALTH POLICIES

1. No contact with the public

2. Single contacts

3. Serial contacts

Geographical denominators

“communities of place”

GP list denominators

“communities of interest”

The challenge of universal coverage - 1948 and now

NOT ONLY

Evidence-based medicine (QOF, SIGN)

BUT ALSO

Unconditional, personalised, continuity of care

WHO NEEDS INTEGRATED CARE ?

Potentially anyone but mostly

the 15% of patients

who account for 50% of general practice workload

If we do not change direction

we shall arrive where we are heading

Chinese proverb

DIFFERENCES IN LIFE EXPECTANCY

BETWEEN MOST AND LEAST DEPRIVED DECILES

SCOTLAND 2007/08

MEN

Most Least Difference

deprived deprived

Life expectancy 67.6 80.9 13.3

Healthy life expectancy 56.9 75.7 18.8

Years spent in poor health 10.7 5.2 5.5

WOMEN

Most Least Difference

deprived deprived

Life expectancy 75.6 84.2 8.6

Healthy life expectancy 60.8 77.9 17.1

Years spent in poor health 14.8 6.3 8.5

Long-term monitoring of health inequalities. The Scottish Government 2010

Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde

Deprivation Decile

0

50

100

150

200

250

1 2 3 4 5 6 7 8 9 10

Deprivation Decile

Ag

e-S

ex S

tan

dard

ised

Rati

o

sir64

shr64

smr74

Linear (WTE

GPs)

– 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

Multimorbidity is common in Scotland

Most people with any long term condition

have multiple conditions in Scotland

23

13

7

5

48

31

23

22

18

14

13

9

7

6

3

22

21

17

13

20

23

21

24

19

20

21

16

13

14

9

18

21

20

18

12

16

17

19

17

19

21

19

16

18

14

36

46

56

64

21

29

39

35

47

47

46

56

65

62

74

0% 20% 40% 60% 80% 100%

Depression

Schizophrenia/bipolar

Anxiety

Dementia

Asthma

Epilepsy

Cancer

Hypertension

COPD

Diabetes

Painful condition

Coronary heart disease

Atrial fibrillation

Stroke/TIA

Heart failure

Percentage of patients with each condition who have other conditions

This condition only This condition + 1 other + 2 others + 3 or more others

There are more people in Scotland with

multimorbidity below 65 years than

above

People living in more deprived areas in

Scotland develop multimorbidity 10 years

before those living in the most affluent

areas

Mental health problems are strongly

associated with the number of physical

conditions that people have, particularly in

deprived areas in Scotland

Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde

Deprivation Decile

0

50

100

150

200

250

1 2 3 4 5 6 7 8 9 10

Deprivation Decile

Ag

e-S

ex S

tan

dard

ised

Rati

o

sir64

shr64

smr74

Linear (WTE

GPs)

CHD CASELOAD PER WTE GENERAL PRACTITIONER

Quintile of No of cases WTE CHD cases

Deprivation with at least GP per WTE GP

one CHD diagnosis

1 6543 100.9 65

2 6399 97.9 65

3 9262 121.7 76

4 8455 110.8 76

5 9378 111.2 84 (+29%)

SOURCE : GREATER GLASGOW LES DATA

KEY POINTS ABOUT ENCOUNTERS

Multiple morbidity and social complexity

Shortage of time

Reduced expectations

Lower enablement

Health literacy

Practitioner stress

Weak interfaces

GP stress by clinical encounter length

in areas of high and low deprivation

Consultation length

15 min and above

10-14 min

6-9 min

5 min or less

Me

an

str

ess

5.0

4.5

4.0

3.5

3.0

2.5

Deprivation group

high

low

3.0

3.43.5

3.1

4.7

3.93.8

3.4

GENERAL PRACTITIONERS AT THE DEEP END

Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde

Deprivation Decile

0

50

100

150

200

250

1 2 3 4 5 6 7 8 9 10

Deprivation Decile

Ag

e-S

ex S

tan

dard

ised

Rati

o

sir64

shr64

smr74

Linear (WTE

GPs)

A WORKFORCE LACKING COVERAGE, RELATIONSHIPS AND CONTINUITY

DECORATORS BUILDERS

4 PROBLEMS WITH TARGETING

Proportionate universalism

(“We are all responsible for all”)

Unsustained, ineffective interventions

Denial of the inverse care law

Professionalisation of Health Inequalities

WRITING A REPORT ON HEALTH INEQUALITIES AND GENERAL PRACTICE

1. Not another report that sits on the shelf, and makes no difference

2. No tool kit, telling GPs what to do

3. Start by listening to GPs in the front line

TIME TO CARE

Health Inequalities, Deprivation and General Practice in Scotland

RCGP Scotland Health Inequalities

Short Life Working Group Report

December 2010

“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.”

Listen to the patient

He is telling you the diagnosis

SIR WILLIAM OSLER

QUESTION

WHY DO YOU ROB BANKS ?

ANSWER

BECAUSE 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 “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

WHERE ARE THE 100 PRACTICES?

CHP No of top 100

practices

SIMD 2006 SIMD 2009

Glasgow East CHCP 28 ) 27 )

Glasgow North CHCP 18 ) 18 )

Glasgow West CHCP 16 ) 85 14 ) 76

Glasgow South-West CHCP 14 ) 13 )

Glasgow South-East CHCP 9 ) 4 )

Inverclyde 5 7

Edinburgh 5 4

Tayside 2 4

Ayrshire 2 5

Renfrewshire 1 1

Fife 1

Grampian 1

Lanarkshire 1

TOTAL 100 100

QOF POINTS 2007

TOTAL CLINICAL NON-CLINICAL

Most affluent practices 984 645 339

Mixed practices 979 643 336

Most deprived practices 977 641 335

ADDITIONAL ACTIVITIES

Undergraduate teaching 45

Postgraduate teaching 27

Research (SPCRN) 66

Primary Care Collaborative (SPCC) 67

Keep Well (phase 1) 24

Keep Well (phase 2) 13

INVERSE CARE LAW

“The availability of good medical care tends to vary inversely

with the need for it in the population served”.

The inverse care law is a policy of NHS Scotland which restricts

care in relation to need.

Not the difference between good and bad care, but between what

general practices can do and could do with resources based on need.

WHAT DO DEEP END

GENERAL PRACTITIONERS

AND COUNT DRACULA

HAVE IN COMMON ?

1. First meeting at Erskine

2. Needs, demands and resources

3. Vulnerable families

4. Keep Well and ASSIGN

5. Single-handed practice

6. Patient encounters

7. GP training

8. Social prescribing

9. Learning Journey

10.Care of the elderly

11.Alcohol problems in young adults

12.Caring for vulnerable children and families

13.The Access Toolkit : views of Deep End GPs

14.Reviewing progress in 2010 and plans for 2011

15.Palliative care in the Deep Endwww.gla.ac.uk/departments/generalpracticeprimarycare/deepend

TIME

BRIEF

ENCOUNTER

SERIAL

ENCOUNTER

LINKS

INTRINSIC FEATURES OF GENERAL PRACTICE

Contact

Coverage

Continuity

Coordination

Flexibility

Relationships

Trust

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

HUB

Contact

Coverage

Continuity

Comprehensive

Coordinated

Flexibility

Relationships

Trust

Leadership

SPOKES + RIMS

Keep Well

Child Health

Elderly

Mental Health

Addictions

Community Care

Secondary Care

Voluntary sector

Local Communities

INVENTING THE WHEEL

INTEGRATED CARE DEPENDS ON MULTIPLE RELATIONSHIPS

INVESTMENT IN RELATIONSHIPS BUILDS SOCIAL CAPITAL

POLICY

RECOGNITION

HOW TO AVOID F R A G M E N T A T I O N ?

FRAGMENTATION

Dysfunctional consultations

Discontinuity

Poor coordination

Gaps in coverage

I’VE JUST INVENTED A MACHINE THAT DOES THE WORK OF TWO MEN.

UNFORTUNATELY, IT TAKES THREE MEN TO WORK IT

SPIKE MILLIGAN

TOO MANY BITS

Health practitioners need to ask

not only “What do I do?”

but also “What am I part of?”

Don Berwick

Head of US Medicare and Medicaid

MUTUALITY

Relationships based on

Recognition

Joint work

Effective communication

Understanding and respect

Positive experiences

Confidence in the future

TRUST

RELATIONSHIPS WITH PATIENTS

Initially face to face, eventually side by side

Julian Tudor Hart

A NEW KIND OF DOCTOR

RELATIONSHIPS REQUIRING MUTUALITY AND TRUST

1. 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)

SIX ESSENTIAL COMPONENTS

1. Extra TIME for consultations

2. Best use of SERIAL ENCOUNTERS

3. General practices as the NATURAL HUBS

of local health systems

4. Better CONNECTIONS across the front line

5. Better SUPPORT for the front line

6. LEADERSHIP at different levels

THE QUESTION

Can we imagine, develop, and support

a 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 change

and to shared learning on the way (a learning organisation) ?

ACHIEVEMENTS

A lot, quickly and cheaply

Identity, Engagement, Morale, Voice, Recognition

Phase 1 2010 15 Meetings

Phase 2 2011 Publications, Presentations and Profile

12 BJGP articles

RCGP Occasional Paper

Phase 3 2012 Opportunities

CARE Plus Study

LINKSand BRIDGE projects

Glasgow Deprivation Interest Group, following Lothian

Austerity Survey

2nd National Meeting

Piloting contractual changes

ADVOCACY

The 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

Those of the world’s 25

richest large countries

which are in Europe + USA

Public Expenditure (%GDP) International Monetary Fund (IMF), World Economic

Outlook Databasefor October, Washington, DC, IMF, 2010

http://www.imf.org/external/pubs/ft/weo/2010/02/weodata/index.aspx

30

35

40

45

50

55

60

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

United Kingdom

United States

Greece

Slovenia

Germany

Spain

Ireland

Norway

Portugal

Italy

Netherlands

Finland

Austria

Sweden

France

Denmark

Belgium

Denmark

THE CULTURE OF POWER

or

THE POWER OF CULTURE