GPs at the Deep End
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Transcript of GPs at the Deep End
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
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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
