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The Finding the five Thousand project
Health inequality audits in Barnet of deaths from coronary heart disease (CHD) (and thus, by implication, also from stroke) show a persisting higher death rate in those aged under 75 years who live in the more deprived parts of the borough. We have also identified that the post code of Barnet GP-registered patients admitted to hospital with heart attacks has no relationship to the treatment they receive. Our hypothesis is thus that higher CHD death rates amongst those living in more deprived areas reflect higher levels of unrecognised and/or unmanaged CHD and stroke risk factors.
We have identified the full post codes of some 13,500 households living in social housing, i.e. in some of the borough’s most deprived areas.
About 85% of Barnet residents living in social housing are registered with Barnet GPs. The majority are registered in 21 out of a total of 72 practices, which are located in or adjacent to some of the most deprived parts of the borough, as shown in Figure 1.
Quality and Outcomes Framework (QoF) data in these practices show that most are achieving above-maximum threshold performance in terms of controlling blood pressure in people known to have high blood pressure, a past history of CHD or stroke, diabetes and/or chronic kidney disease. Put another way, QoF data suggest that these practices are providing good quality care for all those patients with an established disease that increases the risk of heart attack or stroke.
Figure 1: The location of GP practices with the highest proportion of registered patients living in social housing in relation to deprivation levels
Edgware Hale
BurntOak
Colindale
WestHendon
GoldersGreen Childs
Hill
Hendon
GardenSuburb
FinchleyChurch
End
Underhill
Oakley EastBarnet
High Barnet
WestFinchley
EastFinchley
Coppetts
Totteridge
Mill Hill
Woodhouse
BrunswickPark
Edgware Hale
BurntOak
Colindale
WestHendon
GoldersGreen Childs
Hill
Hendon
GardenSuburb
FinchleyChurch
End
Underhill
Oakley EastBarnet
High Barnet
WestFinchley
WestFinchley
EastFinchley
EastFinchley
CoppettsCoppetts
Totteridge
Mill Hill
Woodhouse
BrunswickPark
BrunswickPark
Index of MultipleDeprivation (2007)
Very high
High
Moderate
Low
Very low
Edgware Hale
BurntOak
Colindale
WestHendon
GoldersGreen Childs
Hill
Hendon
GardenSuburb
FinchleyChurch
End
Underhill
Oakley EastBarnet
High Barnet
WestFinchley
EastFinchley
Coppetts
Totteridge
Mill Hill
Woodhouse
BrunswickPark
Edgware Hale
BurntOak
Colindale
WestHendon
GoldersGreen Childs
Hill
Hendon
GardenSuburb
FinchleyChurch
End
Underhill
Oakley EastBarnet
High Barnet
WestFinchley
WestFinchley
EastFinchley
EastFinchley
CoppettsCoppetts
Totteridge
Mill Hill
Woodhouse
BrunswickPark
BrunswickPark
Edgware Hale
BurntOak
Colindale
WestHendon
GoldersGreen Childs
Hill
Hendon
GardenSuburb
FinchleyChurch
End
Underhill
Oakley EastBarnet
High Barnet
WestFinchley
EastFinchley
Coppetts
Totteridge
Mill Hill
Woodhouse
BrunswickPark
Edgware Hale
BurntOak
Colindale
WestHendon
GoldersGreen Childs
Hill
Hendon
GardenSuburb
FinchleyChurch
End
Underhill
Oakley EastBarnet
High Barnet
WestFinchley
WestFinchley
EastFinchley
EastFinchley
CoppettsCoppetts
Totteridge
Mill Hill
Woodhouse
BrunswickPark
BrunswickPark
Index of MultipleDeprivation (2007)
Very high
High
Moderate
Low
Very low
Index of MultipleDeprivation (2007)
Very high
High
Moderate
Low
Very low
With help from Pfizer Ltd, we have obtained Health Acorn data and used this to model various characteristics of the populations in these areas. Modelling with these data suggests that there are many more people in these practices who are smokers and/or who are obese than is currently recognised. Put another way, in these practices there is likely to be a large number of people with unidentified and thus currently unmodified risk factors for CHD and stroke, such as smoking, hyperlipidaemia, pre-diabetes, diabetes and hypertension. This is shown in Figure 2.
The ethnic makeup of the people registered in these practices also differs from the Barnet average. This is shown in Table 1. This is relevant because (i) people in different ethnic groups can have different likelihoods of developing certain conditions, such as diabetes and high blood pressure, and (ii) people in different ethnic groups have different beliefs and cultural values and behaviours that require different approaches if we are to engage them effectively in reducing vascular disease risk factors.
It is important to note that the expected prevalences of risk factors are modelled; they do not represent actual data for individual people. However, they tend to corroborate our hypothesis that higher CHD death rates amongst people living in the more deprived parts of the borough are probably due to unrecognised and/or unmanaged CHD and stroke risk factors.
Figure 2: Comparison of practice-recorded and modelled number of patients with obesity and who smoke
We also think it likely that the majority of these people do not visit their GP surgery. We therefore need to find ways to engage them individually in the community, identify those at risk (e.g. by measuring their blood pressure and body mass index and identifying smokers) and encourage and enable them to attend their GP surgery for management.
We further think it likely that many of these people will not yet have identifiable disease, such as diabetes or a history of heart attack or stroke. Targeted work by their GP practices to
0
200
400
600
800
1000
1200
1400
1600
1800
A B C D E F G H I J K L M N O P Q R S T U
Practice-recorded obesity
Modelled number of obese people in practice
Practice-recorded smokers
Modelled number of smokers in practice
Practice
Nu
mb
er o
f p
atie
nts
0
200
400
600
800
1000
1200
1400
1600
1800
A B C D E F G H I J K L M N O P Q R S T U
Practice-recorded obesityPractice-recorded obesity
Modelled number of obese people in practiceModelled number of obese people in practice
Practice-recorded smokersPractice-recorded smokers
Modelled number of smokers in practiceModelled number of smokers in practice
Practice
Nu
mb
er o
f p
atie
nts
manage these risk factors may therefore not be included in remuneration via the QoF or other aspects of the GP contract and thus require a local enhanced service payment. I recommend that any such payment should be based on the achievement of pre-defined blood pressure, lipid and glycosylated haemoglobin levels as well as the identification of those with abnormal metrics such as raised blood cholesterol. Smoking cessation is covered by existing arrangements.
Table 1: Comparisons of ethnic makeup of the 21 practices
White Asian Black
Barnet population 69% 9% 6%
Practice
A 59% 15% 15%
B 88% 6% 2%
C 66% 14% 11%
D 53% 27% 9%
E 70% 12% 9%
F 51% 15% 22%
G 58% 21% 12%
H 75% 10% 7%
I 84% 7% 3%
J 74% 16% 7%
K 49% 30% 11%
L 82% 8% 4%
M 84% 7% 4%
N 78% 10% 5%
O 78% 8% 7%
P 88% 5% 2%
Q 67% 16% 6%
R 64% 13% 13%
S 65% 13% 11%
T 62% 21% 8%
U 64% 18% 8%
Barnet has been selected as a pilot site by the London Social Marketing Group (engaged by NHS London). In collaboration with Pfizer Ltd and Barnet Council, we are currently undertaking a social marketing research exercise with two companies, TNS and thinkpublic.
The TNS work is concentrating on issues such as:
do people recognise heath risks? What is important? What is not? What matters to them in health terms?
what might influence them to see health as an important issue (especially in terms of heart disease and stroke and in relation to smoking and problems like raised blood cholesterol, diabetes and high blood pressure)?
what might influence them to have aspects of their health checked? and
where might they go for such checks?
The thinkpublic work is looking to:
explore the lives of people at risk from vascular problems in relation to accessing support services;
identify the reasons why these people do not access the vascular check service;
aim to identify how people internalise Barnet’s existing messages and the drivers behind the target audiences’ behaviours;
explore different approaches to communicating with the target audience; and
produce a clear set of recommendations for Barnet’s social marketing campaign.
Using Health Acorn data, and to enable better targeted research of the main population segments, we have identified streets in Barnet in these social housing areas where there are much higher proportions of White, Asian or Black people.
The outcomes of this market research will be used to inform pilot work with the London Social Marketing Group and the PCT working collaboratively with Barnet Council. This will probably include activities such as:
leaflet drops in specific streets targeted at the population segments most likely to be living there;
letters to individuals, probably through or on behalf of their GP surgery, inviting them for a health check;
posters at bus stops, on the back of public toilet doors (e.g. in pubs and shopping centres) and elsewhere, targeted at the population segments most likely to be living/working/going there, publicising the issue;
publicity in public places, e.g. supermarkets, shopping malls, targeted at the population segments most likely to be going there, publicising the issue;
posters in GP surgeries and community pharmacies, targeted at the population segments most likely to be attending there, publicising the issue;
publicity in work places, e.g. Barnet PCT, Barnet Council, public transport depots, targeted at the population segments most likely to be working there, publicising the issue; and
advertorial in local papers and, as may be possible, items on local radio, publicising the issue.
