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. 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. 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. GP Curriculum statement continuedThe 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. 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. Practice profilesl ISD(information services division
Scotland) can provide info on demographics (age/sex/deprivation)
for each practice.
8. Discussion pointsl Groups discuss features of own
practicepopulation/community and how this affects the job.l
Urban/suburban/inner city/ rurall Deprivation / wealthl Social
classl Age / sexl Drug usel Ethnicity
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 communitythey serve.
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. l AJInequalities in health andhealthcare
12. Inequalities in health andhealthcarel Average life
expectancy for women born inBotswana?l 43 yearsl Average life
expectancy for women born in Japan?l 86 yearsl Life expectancy for
men in poorest parts ofGlasgow?l 54 yearsl Life expectancy for men
in most affluent parts ofGlasgow?l 82 years
13. Inequalities in health and healthcarel Contributing
factors:Poverty/social classEthnicityGenderAgeMental
illnessEducationDiet and exerciseSubstance misuse drugs and
alcoholSmokingHousingPre birth
14. 4) Inequalities in health andhealthcarel Downstream Causesl
Exposures e.g. damp housing, hazardous workl Behaviours e.g.
smoking, diet, exercise, drugsl Personal strengths or
vulnerabilities e.g. copingstyles, resilience, ability to plan for
the futurel Upstream Causesl Political and economic factors e.g.
education,taxation, healthcare, crime and policing, etcl
Interventions need a combination of bothdownstream and upstream
policies
15. Health Inequalities andCommunity Orientationl Recognising
the health needs of the individual patientand the community in
which they live and balancingthese with available resourcesl Harm
reductionl Try to keep things in housel Knowledge of where to eat
free/cheaplyl Awareness of services and organisations that
canprovide support to homeless people/those at risk ofhomelessnessl
E.g. Crisis Centre, hostels, Streetwork, Rock Trust, SACRO
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. 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. Individual vs communityl Autonomy vs justicel Greatest good
for the greatest numberl Patient advocate or need to take into
accountwider community
19. Rationingl Implicit and explicit
20. Implicitl Postcodel GP gatekeeper rolel Agel education
22. Group workl Examples of inequalities in health or health
care
23. Inequalities in health and healthcareInverse care lawJulian
Tudor Hart 1971NMC
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. 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 acrossall classes during the first 35 years
of the NHS but therewas still a correlation between social class
and infantmortality rates, life expectancy and inequalities of
theuse of health care servicesl The government changed and when
released in May1980 the press release drew attention away from
manyof the findings due to the implications for expenditure
26. The Acheson Reportl IndependentInquiry into Inequalities
inHealth Report 1998l Chaired by Sir Donald Acheson (formerCMO)l
Demonstrated that despite a downward trendin mortality from
1970-1990 the lower socialclasses experienced a much less
rapidmortality decline
27. WHO Commission on SocialDeterminants of Health 2008l
CommissiononSocial Determinantsof Health. Closingthe gap in
ageneration.WHO, 2008l
www.who.int/social_determinants/thecommission/finalreport/
28. WHO Commission on SocialDeterminants of Health 2008l
Improve daily living conditionsl Tackle the inequitable
distribution of power, money, and resources
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. 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. 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. 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. TIME TO CAREHealth Inequalities, Deprivation and General
Practice in Scotland RCGP Scotland Health Inequalities Short Life
Working Group Report December 2010
34. Age & Sex Standardised Census Health Measures by
Greater Glasgow & ClydeDeprivation Decile 250 200Age-Sex
Standardised Ratio 150sir64shr64 100smr74Linear (WTEGPs)5001 2 3 4
5 67 8 910 Deprivation Decile
35. People living in more deprived areas in Scotland develop
multimorbidity 10 years before those living in the most affluent
areas
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. INVENTING THE WHEELHUB SPOKES + RIMSContact Keep
WellCoverageChild HealthContinuityElderlyComprehensive Mental
HealthCoordinated AddictionsFlexibility Community CareRelationships
Secondary CareTrust Voluntary sectorLeadershipLocal
CommunitiesINTEGRATED CARE DEPENDS ON MULTIPLE
RELATIONSHIPSINVESTMENT IN RELATIONSHIPS BUILDS SOCIAL CAPITAL
38. Conclusions Practitioners lack time in consultations to
address the multiple,morbidity, social complexity and reduced
expectations that aretypical of patients living in severe
socio-economic deprivation. Opportunities for anticipatory care are
often fleeting and may be lostif there is not the opportunity to
connect quickly with otherdisciplines and services that are closely
linked to the practice. Practices provide contact, coverage,
continuity, flexibility andcoordination, and need to be recognised
and supported as the hubsaround which other services operate.
39. Summary1. GP curriculum2. Practice profiles3. GP
involvement in community4. Inequalities in health and inequalities
in healthcare5. Individual vs community6. Rationing
40. Conclusions The only route by which practices in severely
deprived areas canimprove patients health and narrow health
inequalities is byincreasing the volume and quality of the care
they provide. When public funding is under severe pressure it is
especiallyimportant that NHS resources are targeted where they are
mostneeded. NHS support services should be audited in terms of the
support theyprovide for practices working in the front line.
Further work with GPs and practice teams outwith the deep
endpractices and in remote and rural areas is required to establish
theimpact of deprivation on patients and primary health care
workers inthese areas
41. Case work
42. 2 case historiesl Small groups
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. Mrs Campbell What sort of issues do you wish to address
with the couple? What practical ways could you go about gathering
the informationyou require? What services might be available in
your area that are appropriatefor them? Medical? Allied Health
Professionals? Social? Charitable?
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. Mr Robertson What service may be Longer term, who else
chouldappropriate here for further get involved to help
Mrassessment of Mr Robertsons Robertson continue to
livepresentation? Do you knowindependently at home orhow to refer
and what is facilitate moving to moreinvolved?appropriate
accommodation? What services are you aware ofthat could/should be
put inplace to ensure his immediatesafety? (Again, do you knowhow
to refer and what isinvolved?)