Aviva's Health of the Nation report

The Aviva Health of the Nation IndexFebruary 2013

Contents

3 Foreword

4 Looking for the perfect practice. Life as a GP in the UK

6 What’s up? Health trends on the increase

9 So how are we feeling today? Health awareness among patients

14 Spotlight on mental health

16 Spotlight on the workplace

18 So do we care, about care? Engaging with the NHS

23 What have we learned? Health of the Nation – a 10-year anniversary

Foreword

Aviva Health of the Nation Index Report 3

We’re always ready to take on board the views of the people who matter most: it’s what helps us focus on providing products and services that people really need. This is the tenth year in which we’ve conducted our Health of the Nation study, canvassing the opinions of GPs right across the UK. This year we’ve extended our research to include the views of 1,000 patients to understand their experiences of healthcare in the UK.

For us, the Health of the Nation study has become an insightful means of examining key health issues over a period of time. It helps us gauge how the environment is evolving and identify stakeholder views that could help influence changes to our products and services.

As in previous years, this time we’re looking at GPs’ lives and their views on the working environment; the trends they’ve been identifying in the patients they’re seeing and, in particular, the continuing impact on their workload of mental health issues and health concerns arising from the workplace.

We’ve canvassed GPs on their views about health education and the information, or lack of it that affects the patient-doctor relationship; we asked for opinions on the quality of both established and potential future clinical pathways, and we questioned GPs about their engagement with the NHS.

Bearing in mind the changes that may happen as a result of Clinical Commissioning Groups (CCGs) coming into effect from April 2013, our study has highlighted some of the situations in which GPs still appear to need more support, and reasons why patients may suffer the consequences of an evolving service.

Patients have also given us their views. We’ve asked them about health matters; how they are, or aren’t able to seek the levels and quality of care they’re expecting, and which steps they’re taking to engage with the medical profession for support and more information about their health and wellbeing.

The result? Another insightful cross-section of opinions on the state of our nation’s health services. We hope you find this Health of the Nation study as useful as we have found it to be revealing.

Mark Noble, Managing Director, Health and Corporate Benefits, UK & Ireland Life

Looking for the perfect practiceLife as a GP in the UKA GP’s practice already shoulders the burden of a diverse range of responsibilities: to individual patients as well as regulating bodies and Primary Care Trusts.

The Royal College of General Practitioners has agreed that effective commissioning will depend on continuous analysis of a community’s needs, and the design, specification and procurement of services to meet those needs. Inevitably, the onus will fall on GPs to collect data that can be analysed to help achieve those aims.

But it is, perhaps, thanks to the diverse nature of their work that the majority of GPs (73%) have told us they’re deriving moderate or high levels of satisfaction from their jobs.

It will be interesting to see if this changes over the next twelve months, as the impact of commissioning takes full effect.

The likelihood is that GPs may feel more obliged to be involved in administrative activities than they are at present. Reassuringly, our study reveals their focus is still clearly on attending to patients’ clinical concerns.

Highlights

• 20%ofGPs’timeisspentdealingwithminorconcernsthat could have been seen to by practice nurses or may not have warranted an appointment at all. As insufficient time with patients is still our GPs’ greatest concern, we believe this clearly emphasises the need for more initiatives (and resources) that could help direct patients to the most appropriate support.

• Withoutcountrywideguidelinestohelpprioritisethemany factors involved, GPs are - on average – giving 78% of patients an open referral through the choose and book system. However, most patients are unable to compare the quality or cost of treatment that’s being recommended, and may be choosing a referral pathway based on convenience alone.

• OlderGPsareconcernedabouttheimpactoftheHealthand Social Care Bill, but also see the appearance of CCGs as an opportunity to procure better services for their patients.

• GPsinNorthernIrelandappeartobehappiest,with50% citing job satisfaction levels as high; in the South West however, over a quarter (26%) said their satisfaction levels were low.

Onaverage GPs spend 67% of their time with patients.

4 Aviva Health of the Nation Index Report

The working day

GPs in the UK offer the complete spectrum of care to people in their local community. From in-surgery appointments that will be dealing with psychological, physical and social concerns through to off-site attendance in clinical centres and, if necessary, their patients’ homes. A broad skill-set is involved that includes an opportunity to prevent illness as well as treat it.

On average, how is a GP’s working day currently divided?

We asked GPs to break down their working day. Responses showed there’s an opportunity to free up more ‘patient time’, by delivering resources that would better inform individuals about medical health matters. Just seven GPs, less than 3%, told us part of their working day was currently spent teaching, training or educating and raising health awareness.

Reassuringly however, a low 3% of GPs’ time was committed to dealing with cases that should have been seen by personnel in an Accident and Emergency unit.

Onaverage:

• 39%oftheworkingdaywasspentdealingwithmedicalissues that required a GP’s attention

• 20%ofthedaywasspentdealingwithsocialcareissuesor the ‘worried well’

• 16%ofthedaywastakenupwithadministrationorpractice issues

Onaverage,afifthofGPs’workingdaysarespenttakingcare of issues that either a practice nurse could deal with (9%),ordealingwithminormedicalconcernsthatdidn’twarrant professional medical attention (11%).

• GPsare,onaverage,contractedtowork36hoursperweek, but most appear to be working 42 hours or more.

• While45%oftheGPswespoketoexpectedthosehours to stay the same, over half (51%) expected to be working longer hours in the future.

Year on year, our studies show we’re making GP appointments for problems that could be dealt with by a practice nurse or that may not need medical attention at all. More awareness of health matters could help address this situation, and free up GP’s time to deal with more important medical cases.

On average, what percentage of time are GPs spending with patients per week?


Wales North East East Anglia Yorkshire & the Humber

Northern Ireland

Scotland South West London South East West Midlands

East Midlands

82%

76% 74%71% 70% 69% 68% 68%

64%

58%56%

69%

North West

For which conditions have GPs noticed an increase in patient numbers over the past year?

What’s up?Health trends on the increase

GPs deal with a wide variety of health concerns. Some are major issues, some are relatively minor, but we’ve looked back at our first Health of the Nation study to remind ourselves about health concerns that appeared to be on the increase a decade ago – and compared those with the trends we’re seeing today.

Topping the list ten years ago were ME and Chronic Fatigue Syndrome; obesity, stress, depression and alcoholism. And in some respects, the landscape has changed relatively little – those issues are still prevalent in the top ten conditions on the increase.

This year however, an alarmingly high proportion of GPs (84%), identified stress and anxiety issues being the greatest upward trend in their practices; 55% cited other mental health issues as being noteworthy. Media campaigns and Government initiatives may be helping to raise awareness of help for mental health issues, and this could, in turn, be having a positive effect and encouraging patients to engage more with their GPs in general. But with so many patient cases being presented more often, the question quickly arises – what could be done to address the underlying causes of that stress and anxiety, both at home and in the workplace?

• Withevidencethatpeoplewithmentalhealthconditions are feeling less stigma, it could be the case that those with symptoms of stress, depression and anxiety are simply more open to asking for help.

• However,our2012HealthoftheWorkplacestudyrevealed many people believe they’re having to work harder as a result of changes in the economic climate in recent years, and that this is having a tangible effect on their overall mental health. Just under a third of the employers we spoke to had introduced initiatives to help manage workplace stress, but the employees we spoke to believed much more could be done.

20% of the GPs we spoke to said they believed Government-backed, patient education could help reduce instances of the conditions they’re dealing with most often.


84%

55% 53%50%

44%40%

36%

26% 25%21%

16%12%

10% 3% 3% 2%

Mental health issues

excluding stress and

anxiety

Dementia and

Alzheimer’s

Stress / Anxiety

Obesity Alcoholism and drug addiction

Musculo- skeletal

conditions

Diabetes Irritable Bowel

Syndrome

ME / Chronic fatigue

syndrome

Cancer Arthritis Migraines Heart Disease

Stroke Other Asthma

Which conditions are GPs expecting to treat more often over the next year?

As they deal with patients who have already made appointments, it’s natural for GPs to have an opinion on the conditions they’re likely to see most in the future, too:

Over the last five years, have GPs seen the working environment have more of an impact – or less – on the following illnesses?

Are work initiatives working?

We work alongside employers to help them promote improvements in health and wellbeing among their employees. Unfortunately, it looks as though the workplace is still having a notable impact on the rise in cases of certain conditions, and one stands out above the rest.With93%ofGPssayingtheyattributeitdirectlytoarise in cases of stress, there’s a compelling case for more mental health services – such as stress counselling, or the support provided by an employee assistance programme – to be made available to employees.

Around a third of the claims we deal with under our corporate healthcare policies are for musculoskeletal injuries, dealing with aches and pains in the back, neck, musclesandjoints.OurBack-Upserviceprovidesprompt

access to a clinician who can offer advice to help manage symptoms, and (without the need for a GP’s appointment or referral) make recommendations for appropriate ongoing treatment.

With such a large proportion of claims being made in this area, it’s not a surprise to see that 50% of GPs believe the working environment is responsible for the cases ofbackpainthattheyareseeing.Obesitycanalsobelinked to musculoskeletal pain: this is one of the reasons we encourage employers to promote improvements in diet and fitness levels to their employees – using a health initiative such as MyHealthCounts, for example.

Most GPs believe the working environment is responsible for increases in mental health problems, back pain, and obesity.


21% 20% 20%

13%12%

3% 2% 2% 2% 2%1%

Stayed the same Fallen Risen

Otherstress/depression /

anxiety

work related stress

Diabetes Obesity Mental health issues

amongst elderly

Drug and alcohol abuse

Cancer Musculo- skeletal injury e.g. back pain

Tobacco related illness

Other Heart conditions

RSI Back pain Stress Depression Alcoholism Headaches Drug abuse Eating disorders

Eye problems ME / CFS Obesity

We asked the GPs taking part in our survey about a number of factors that could have been affecting the health of their patients in general over the last 5 years: had they noticed poor diet, for example, being a greater influence in the cases they were seeing.

Having seen the increases in cases of some conditions being attributed so significantly to the workplace, it was perhaps to be expected that the economic climate is being seen as having a negative impact on the health of patients ingeneral.Andunfortunately,althoughtheOlympicsmayhave stimulated greater interest in sport across the nation, at the moment it looks as though we have yet to take

action: 64% of GPs told us that a lack of exercise was impacting their patients’ health.

However, it does look as though we’re seeing a positive reduction in the effects of nicotine addiction. For 43% of GPs, the effects of smoking have made less impact on the health of their patients over the last year.

Have these factors had more or less impact on patients over the last 5 years?

Three quarter of GPs (75%) believe the economic climate is having a significant impact on the health of their patients.

Poor diet

Emotional home environment

Alcohol

Smoking

Lack of exercise

Drugs

Pollution

Economic climate

Physical working environment

Emotional working environment


58%

8%

33% 26%43%

31%

63%

5%

32% 37%

14%

50%

64%

12%23%

75%

14% 50%

10%25%

64% 71%

10% 19%

43%

15%

42%

71%

5%

25%

More impact Less impact No change

100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%

So how are we feeling today?Health awareness among patientsAnalysis of trends is what helps us plan ahead: our products and services evolve to meet people’s actual health needs. As GPs are seeing more patients presenting with some conditions, it appears that patients are becoming more health-aware in general. What’s interesting is that their propensity to self-diagnose has also increased significantly.

When, in 2011, the Government launched its Public Health Responsibility Deal to help improve the management of our health services, it said that ‘everyone has a part to play in improving public health’ – including individuals themselves.

With that in mind it’s interesting to see what steps the public takes to inform themselves about health issues and monitor or improve their own wellbeing.

In this study, we placed a particular emphasis on self-diagnosis – asking views on health and the reasons why and how people try to find out the cause of symptoms they’re experiencing.

How do you rate your health?

45%

10%

28%

15%

2%

Ten years ago, the GPs we spoke to estimated that around 15% of their patients looked up information about their condition before visiting the surgery. Two thirds had seen an increase in this trend; almost 70% of those GPs thought those patients’ behaviour had had a positive impact on their subsequent health.

Today, with so much more information readily available online, it’s no surprise that more and more individuals are self-educating in advance of an appointment. Sources of insight vary, but not surprisingly almost half the patients we spoke to (44%) are turning to the Internet for information.

Are there benefits to self-diagnosis?

1%

44%

23%

6%

25%

1% Yes, I look on the internet

Yes, I buy kits from the Pharmacy

Yes, I judge my condition on my previous experience / illness

Yes, I use informative TV programmes

Yes, I read magazines

Yes, I ask my friends and family for advice

No, Never

Do you self-diagnose, if you’re unwell?

• 29%ofpatientswanttobemoreinformed when they see their GP

• 33%self-diagnoseoutofcuriosity,butnotinstead of visiting a GP

• 31%self-diagnosetoavoidseeingaGP

• 7%self-diagnosebecausetheyhadnofaith in their GP

Why do you self-diagnose?


Very good Good Average Not very good Poor

75% of the patients we spoke to told us they were self-diagnosing before seeing a doctor. But although 82% of GPs have seen an upward trend in people looking for information, GPs have a very different perception of how many people are actually researching their symptoms before having a personal consultation.

• Only5%ofGPsbelievedthatasmanyasthree-quartersoftheir patients were self-diagnosing prior to an appointment.

• Only13%wereoftheopinionthathalftheirpatientswere looking for information.

• 67%thoughtaquarteroftheirpatientsorfewerwould self-diagnose in advance.

Ourresearchshowsthatalthoughpatientsarelargelywilling to self-diagnose, they’re also less than likely to share the fact they’ve done some research with their GP.

A quarter of the patients we spoke to told us they never self-diagnose. However, this is not the negative insight it may first appear to be, because 64% of people believed it was simply better to see a GP in person, and 28% believed self-diagnosis would raise concerns rather than lower them.

The whole truth?

28%

8%

I don’t self-diagnose because I think this would cause me to worry more

I don’t self-diagnose because it’s best to just see your doctor in person

I don’t self-diagnose because it’s too time consuming

Do GPs think it’s beneficial for patients to self-diagnose before an appointment?

Without a guarantee of its validity, patients may be sceptical about medical information that’s been sourced somewhere other than through their GP. However, it looks as though some of us are using the data as a benchmark, from which to value or potentially challenge adoctor’sviews.Asignificantpercentage–39%–ofGPs appreciated the efforts that patients made, but saw self-diagnosis as a challenge if patients were unwilling to accept a diagnosis.

2%

21%

23%

15%

39%

Yes, it can be very helpful

Yes, but only if they are then willing to

No, it causes scare mongering

No, I think it serves no benefit at all

It varies from patient to patient


64%

Time to visit the GP

Visiting a GP may not always be convenient, but neither is illness. We asked people to tell us how often on average they visited a GP, and why. The answers were intriguing, not least because they show a marked difference in attitudes between men and women.

• 30%ofmensaidtheyrarelybecomeillcomparedto21% of women. But 35% of men said they’d changed their views on visiting a GP in recent years, primarily as they’d become more aware of how important it is to look after your own health.

• Foralmostafifthofmen(17%),visitstotheGPhadbecomemorefrequent.Only14%ofmenhadn’tvisitedtheir GP in the last three years, compared to 7% of women, and – knowing that routine check-ups are a good idea – 13% of men and 22% of women cited this as the main reason for visiting the doctor.

Different approaches to health

Onthewhole,itappearsthatmenarelesslikelytopayavisit to their GP than women.

We asked ‘what were the reasons for the delay?’

• 51%ofwomensaidtheywouldsufferinsilenceifunwell as there were jobs to be done; compared to this, only 44% of men took the same approach.

• 27%ofmen,however,werelikelytotaketimeoffandgo to bed, instead of going to their GP, compared to just 21% of women.

• Overafifthofoursurvey’srespondents(21%men,20% women) said they’d take medicine ‘to keep going’ rather than go to their GP.

• 29%ofwomenwouldwaittoseeifthesymptomswent away, 16% blamed their inability to get a quick appointmentand9%saiditwouldbeastruggletomake an appointment that suited working hours. Incomparison,21%,14%and9%ofmengavethesame answers respectively

However, we also asked about attitudes to making an appointment – what, if any, would be the reasons to delay. Overaquarterofthewomenwespoketo(28%)saidthey’d never avoided going to see their GP if they were unwell. But although some are visiting their GPs more frequently,overathird(39%)ofthemalerespondentstothis survey had put off going to see their GP.

Happily, only 2% of the men and women we spoke to said they would ‘milk an illness for all it’s worth’.

How often do you visit your GP?

Daily

Once a

week

Once a

month

Ever

y thre

e month

s

Ever

y six

month

s

Once a

year

Never

35%

40%

30%

25%

20%

15%

10%

5%

0%

The ease with which patients can or cannot make a GP’s appointment is still a concern.

In all, 24% of the patients we spoke to said that, in some way, their GP’s unavailability influenced a delay in seeking medical help.

48% are suffering in silence.

Men Women

4%9%

9%

11%

17%

18%

22%

31%

37%

31%

14%

7%


Caring for each other

It was good to see that most people were aware of their partners’ general health. But there was also a slight difference in the way men and women then approached their concerns:

• 43%ofmencouldpersuadetheirpartner to see a GP; a slightly higher percentage of women, 46%, had the same influence.

• 29%ofmenhadnotraisedaconcernabouttheirpartner’s health; only 17% of women reserved opinions in the same way.

• 13%ofmenhaddiscussedsomethingthatwasworrying them about their partner’s health, but seen no result from the conversation; 17% of women had made unsuccessful attempts to raise concerns.

The good news is that 10% of the men and women we spoke to had successfully persuaded partners to make lifestyle changes for the better. Interestingly, 10% of women had exercised those changes (such as diet), while only 5% of men had taken the same action.

Feeling better

Self-examinations involve checking testicles and breasts for physical changes: when you know how your body normally looks and feels, any changes in appearance should be easier to notice. The media has raised awareness about the importance of self-examination, but it appears there’s still some way to go in educating everyone as to its value.

Do you self-check for signs of testicular cancer or breast cancer?

• Only75%ofthewomenwespoketodoany self-examination.

• Alowerpercentage–only60%–ofmenchecks their bodies in the same way.

How often do you check?

These are alarming statistics

•Forthequarterofwomenwho don’t self-check, 32% say they’re too busy and don’t remember and an equal proportion (32%) say they don’t know how.

•Ofthosemenwhodon’tself-check, 37% say they don’t know how to; while 30% don’t think they need to check for signs of breast cancer or testicular cancer


I think I am too young to need to

There are no historical issues in my family and I think these things are hereditary

I don’t think I need to

I don’t know how to

I am too busy and never remember

Daily

Wee

kly

Ever

y tim

e I

show

er /

bath

Ever

y 2-3

wee

ks

Ever

y 3 m

onth

s

Regu

larly

Twice

a ye

ar

Onceo

rtwice

am

onth

Not as

ofte

n as

I sh

ould

Ever

y 2 m

onth

s

Yearly

Other

Don’t

know

3.2%

19.6%

4.5%2%

40.9%

3.9% 4.5% 4.6%1.4%

5.8%

8.6%

0.7% 0.4%

6%

11%

23%

35%

25%

If you don’t check, why not?

It transpires that most people take responsibility for their own care, but we asked some pertinent questions about engagement with health services in general.

• 87%ofthewomenwespoketosaidtheywould be the person to make a decision about which GP to see; only 63% of men we spoke to made the same judgement.

• Whenitcomestobeingresponsibleforresearchinginsurance that could pay for medical care, 53% of those carrying out research themselves were men.

• 48%ofthosecarryingoutthepurchaseofprivatemedical insurance were men – women accounted for 59%oftherespondentswhosaidtheyweremostlikely to be keeping up to date with health news.

• Womenwerealsomorewillingtosaytheywouldbemore likely to follow health fads, but equally, 64% of women considered they took health matters more seriously than men.

• 70%ofthewomenwespoketosaidtheyweremostlikely to carry the responsibility of care if someone in thefamilywasunwell.Only34%ofmenvoicedthesame opinion – that a man would be most likely to play the role of carer.

Differences of opinionAs we’ve seen from their approaches to visiting a GP, our study highlights that men and women have differences in opinions about health matters in general.

The gender division was also noticeable in perceptions of care, as were views across the country. We asked people’s opinions regarding the quality of health treatments being received in their area.

14% of respondents in the North West believed health services in their area were comparatively poor; by contrast, just 1% of the respondents in Scotland shared the same opinion.

38%40%

42%

I think it is good

70%

60%

50%

40%

30%

20%

10%

0%Yorkshire and the Humber

East Midlands

West Midlands

South East

South West

Wales Scotland Nothern Ireland

North East

North West

I think it is sufficient

I think it is poor

It depends on what treatment is required

I have no point of reference


I have no point of reference 4%4%

9%

35%

Women

15%6%

It depends on what treatment is required

I think it is poor

I think it is sufficient

I think it is good

8%

East London

Spotlight on mental health Worrying signs

A great deal of our GPs’ time is spent dealing with mental health issues. It’s still the most prevalent type of illness, with 84% of GPs seeing more patients than ever before suffering from stress and anxiety.

Across the country, opinions vary as to the reasons for this increase. In the North West and South West, GPs believe changes in diagnostic criteria are the cause. Financial pressures could be the reason for more mental health problems, according to GPs practicing in London, the South East, East Anglia and the Midlands, and Yorkshire and the Humber region.

An interesting opinion came from the East Midlands, where GPs blame the increase in mental health issues on the use of social media for friendship and resulting isolation.

Do GPs agree that mental health is one of the most pressing priorities for the NHS?

Are GPs seeing long waiting lists for Talking Therapies in some areas?

Just under half the GPs we spoke to (47%) believe there’s still a stigma associated with mental health issues, which may be preventing people from seeking help.

Butit’sworthnotingthat39%ofGPsthoughtmediacampaigns were having a positive impact on that situation, mostnotablyintheNorthWest,where59%ofGPsshared this view.

Do GPs agree there’s a lack of support for them, regarding these health concerns?

Are GPs prescribing medication (anti-depressants), when they believe Talking Therapies would be more beneficial?

Less than a quarter of the GPs we spoke to (23%) believed that access to Talking Therapies such as cognitive behavioural therapy would improve over the next few years. A telling statistic is the fact that 77% of GPs believed the workplace is one of the biggest causes of stress and anxiety for patients in the UK.

Problems such as anxiety, depression, stress and phobias are very common. Talking Therapies is a Government-sponsored, nation-wide service that offers help to people with those problems.

Yes

59%

36%

4%

Neutral Yes

68%

21%

11%

Neutral

Yes

84%

12%

3%

Neutral Yes

74%

20%

Neutral


6%

No No

No No

Overhalfofourrespondents(52%)toldusthatthey’vesuffered from one mental condition or another during their lifetime; many had experienced symptoms aligned with more than one type of illness – and the majority of people (74%) knew someone else who had suffered or was suffering from mental health problems.

Ofthepeoplewespoketo,22%saidtheywerenowfeelingbetter;9%saidtheywerestillunwelland21%ofour survey said they still experienced symptoms from time to time. It was encouraging to see that 57% of people would not be embarrassed to admit having a mental health problem.

We asked patients to detail which types of mental health issue they’d experienced:

The majority of patients (51%) felt that a period of 2 to 3 weeks was the maximum time they should wait for a referral to counselling or a psychological service, to find out more about and get support for that condition. It’s worth noting that the 18-week maximum waiting period set by the NHS does not apply to non-medical, consultant-led mental health services. Most people (85%) were understandably concerned that a condition could worsen if they had to wait a long time before getting a referral.

What support did you receive for these conditions?

It’s alarming to note that 8% of patients believed they were sent away from their GP having been given no support for one type of mental health issue or another.

Nearly three-quarters of the patients we spoke to (73%) don’t think the Government and / or the NHS do enough to tackle mental health problems.

GPs share those patients’ concerns:

• 50%ofGPsbelievetheirlocaltrustprovidesapoorservice for patients with mental health issues.

• 37%ofGPsbelievetheserviceispoorforpatientswith depression, one of the highest prevalences of mental health issue in our survey.

Wor

k-re

late

d s

tres

s

Dep

ress

ion

SAD

(Se

aso

nal

A

ffec

tive

Dis

ord

er)

Mild

an

xiet

y an

d /

or

dep

ress

ion

rel

ated

to

st

ress

or

trau

ma

Pan

ic a

ttac

ks

Pho

bia

s

Para

no

ia

Dig

esti

ve d

iso

rder

re

late

d t

o s

tres

s /

Freq

uen

t h

ead

ach

es

rela

ted

to

str

ess

/ an

xiet

y

Bi-

po

lar

dis

ord

erOC

D

Ch

ron

ic f

atig

ue

/ ME

40%

35%

30%

25%

20%

15%

10%

5%

0%

I was prescribed drugs such as anti-depressants

58%

32%

29%

24%

14%

14%

8%

6%

I was referred for counselling / cognitive behavioural therapy

I was referred for a specialist consultation

I was told to reduce my hours / signed off work

The GP sent me away with no support

I was told to take more exercise

Other

I was referred for further tests


35%

31%

23% 21%

14% 14%

10%7%

5% 5% 5%1%

anxi

ety

e.g.

IBS

Spotlight on the workplace Working harder

A ‘Fit Note’ is the informal name for the Statement of Fitness for Work; a computer-completed version was introduced in July 2012 with the aim of further smoothing the process for GPs who are helping employees get back to work as soon as possible.

There was reason to believe the formalised Fit Note would provide a useful platform for GPs to open discussions with patients about their health, with a view to helping them reduce long-term sickness absence – a clear benefit to employers, as well as employees. There’s an even opinion on whether or not it’s working:

Is the fit note an effective tool?

Overallhowever,itappearsGPsstillfeeltheonusshouldbe on companies and their staff to take more responsibility for their health in the first place, which would hopefully lead to a reduction in the need for GP appointments.

• 85%ofGPsthoughtemployerscoulddomoretohelptheir staff get back to work

• 75%ofGPsthoughtemployerscoulddomoretohelptheir employees stay healthy

• 71%ofGPsthoughttheNHSwasnotappropriatelyresourced to help employees return to work

Those look like substantial figures. However, it’s vitally important to keep statistics in context.

• WeaskedGPswhetherornottheyhadacloseenoughrelationship with patients to understand their individual needs in terms of making a successful return to the workplace after illness or injury.

Only 50% felt they did.

Yes

32% 32%

36%


NoNeutral

According to the National Joint Register, there were over 84,000 hip and more than 87,000 knee replacements in England alone in 2011/12.

Ofthepeoplewespoketoforthisstudy,9%hadsufferedfrom conditions resulting in the replacement of one or more of the following joints: hips, ankles, knees, elbows or shoulders (over 130 different operations in all). However, a staggering 76% of respondents said they knew someone who had undergone at least one of those operations.

However, joint replacement is not necessarily always linked to the deterioration of health in old age: a quarter of the respondents who’d had an operation themselves were 25 years old or younger at the time; only a third (36 people in all) were older than 60 years of age. We asked everyone in our survey:

How would you cope if you needed a joint replacement, but weren’t able to have one?

• 24%ofrespondentsthoughttheywouldfindawaytocope financially and emotionally

• 22%ofrespondentssaidtheywouldcomplain,14%thought it likely they would get depressed about the situation

• 13%ofrespondentssaidtheywouldchangetheirlifestyle in an attempt to cope

Overaquarterofthepeoplewespoketo(28%)said‘everyday’ things, like driving or getting shopping done, would be their primary concern if a knee joint or hip needed to be replaced.

34% said that not being able to work, becoming a burden, or not being able to support a family would worry them most.

How long would you be prepared to wait for this type of operation?

Waiting times for joint replacements vary across the country. We also asked respondents to indicate how long they’d be prepared to wait for treatment – what did they consider to be a reasonable amount of time – if they were struggling to walk, and needed a hip or knee joint to be replaced.

Onaverage,mostpeoplethoughtthatawaitingtimeofbetween one and three months would be acceptable – which is roughly in line with the NHS’s 18-week maximum waiting period guidelines.

Spotlight on joint replacementsHips and knees

This year we looked at ‘replacements’, putting a focus on the experiences of respondents who’d had operations to replace hip or knee joints in particular.

43% of people know someone who has had a hip replacement. 28% know someone who has had a knee replacement.

2 weeks

15%

34%

4%

33%

12%

2%

3 months Six monthsto a year

More thana year


1 Month 6 Months

So do we care about care? Patients’ views on funding care

Whether or not it’s to do with absence from work, it’s important to be confident in the person from whom we’re seeking help.

The NHS provides varying levels of support across the country, and our survey showed that patients have firm opinions about their relationships with GPs and ‘the system’ in general. We asked, “If there were long waiting times would you consider ‘going private’ for treatment?”

• 55%saidtheywouldn’tbeabletoself-fundtreatment

• 13%felttheycouldclaimonaprivatemedicalinsurance policy

• 23%wouldfindfundsthemselvestopayfortreatment

• 9%saidtheywouldsuffer,andwaituntil treatment was available from the NHS

The views on what was an acceptable price for improved health varied. We asked how much people felt they could afford, if they chose to self-fund treatment – almost half

(47%) said they would find money from their personal savings. However:

• 58%couldafford£1,000orless

• 27%couldaffordbetween£1,000and£5,000

• Only5%couldaffordbetween£5,000and£10,000

So how would you pay for treatment?

Overaquarter(27%)oftherespondentstooursurveysaid they’d be prepared to borrow from friends or family, takeoutaloanorincurcreditcarddebttoself-fund;19%were prepared to re-mortgage their property. We believe these figures highlight the fact that many people are aware of costs, but – without private medical insurance – they would be ill prepared to pay for treatment if they opted for private care.

For many people, private medical insurance negates the need to worry about access to care irrespective of where they live. We asked respondents:

What do you think of the postcode lottery system, in which some areas of the country offer better access to care for some conditions than others?

7%

3%

9%

3%

13%

65%

It depends on the condition - I wouldn’t want my taxes spent on

conditions that aren’t essential

I think people should ensure they have health insurance to protect

themselves from this

I think it is very unfair

I was not aware of this

5%

7%

7%

36%

27%

8%

Very concerned, I have no confidence in the leadership

of the DOH & NHS

Very concerned - I can’t see a future for the NHS

Concerned - I expect patient care and the breadth of services to

decline in the future

Neutral - I feel that changes in the NHS will have little

impact on patients

Optimistic - I have confidence in the leadership

of the DOH & NHS

Optimistic - I feel that the direction the NHS is going in will

deliver better care for patients

I don’t have an opinion on this

Probing further into their opinions as patients, we then asked:

“As a patient, what’s your outlook for the NHS?”


It’s an unavoidable fact, treatment quality cannot be

consistent across the country

I think people should be able to select where they get treated

10%

Engaging with the NHS GPs’ views, patients’ opinions

We asked patients what they thought about the quality of care provided by the National Health Service (NHS) today.

Opinionsvaried,butthere’sanindicationthatthegeneralpublic is concerned that some areas of the NHS are coming under undue pressure.

• 13%ofpeoplethoughttheNHShaddeclinedinitsquality of services over the last decade

• Just15%felttheUK’sNationalHealthServicewasoneof the best state-provided health services in the world

Very few people – 3% – declined to share an opinion on this.

For which services do GPs feel the NHS provides a good service? Where does the NHS not deliver an adequate service to its customers?

Opinion highlights

In general, GPs feel the NHS doesn’t provide adequate services to help patients with eating disorders; obesity is also poorly addressed. In contrast, cancer, cataracts and diabetes are conditions for which individuals are catered relatively well.

This is interesting, because 20% of GPs cited diabetes as being one of the conditions most likely to increase over the coming year – and diabetes can be linked with obesity. Sadly, irrespective of being due to general budget cuts, redistribution of funds, or allocation of funds or ‘more life-threatening conditions’, 16% of GPs expect their local NHS to stop offering treatment for eating disorders in the next 5 years.

Alcoholism and drug addiction

Alzheimer’s and dementia

Arthritis Asthma Cancer Cataracts Diabetes Eating disorders

Heart disease Hip / knee replacements

Depression Mental health issues (excluding stress / anxiety)

Stress / anxiety

Musculo- skeletal conditions needing physiotherapy

People wanting health advice

Strokes Obesity

80%

70%

60%

50%

40%

30%

20%

10%

0%

Poor Adequate Good


I don’t have an opinion on this

I believe the NHS varies across the country

I think the NHS has declined in quality over the past decade

I think some areas of the NHS are under a lot of pressure: care of

the elderly for example

I think generally speaking the NHS is very good, but some areas

are stronger than others

I think our health service is one of the best in the world

3%

5%

13%

26%

37%

15%

According to GPs, who owns the referral process?

Referrals From patient, to GP, and others

Overthelast10years,medicaladvancesmeanthatrecommendationsfortreatmentmay have changed. However, the referral process – from a patient’s initial concerns through to the first appointment with a specialist who can make a detailed diagnosis – has altered very little.

In the patient’s journey, the role of a GP extends from counsellor, confidante and assessor, to both communicator and facilitator. It’s the GPs’ role to make appropriate referrals for more investigation of a condition or symptoms, but data to inform their decision is not readily available.

There’s a great deal of variation in the way GPs make referrals, and relatively few patients would query their recommendation.

However, as part of the Competition Commission’s investigation into the supply and acquisition of private healthcare services in this country, the referral process is undergoing close scrutiny.

Aviva is contributing to this investigation, assisting the Competition Commission as they look at factors that could be affecting GPs referral choices:

• Arepotentialclinicaloutcomestakenintoconsiderationenough by GPs?

• Isthereenoughtransparencyregardingthecost,quality and availability of one specific treatment – in comparison to others?

• Perhapsmostimportantly,arepatients’viewsbeingconsidered enough during the referral process that’s supposed to afford them the best possible treatment and recovery?

Only15%ofGPsbelievetheirpatients ‘own’ the referral process. We believe there’s an urgent need for patients to see more information, and be more involved in the decision-making processes that affect their treatment and care.

61%15%

9%

14%

The majority of GPs - 62% - believed they were completely in control of the referral process. Given the emphasis on transparency in recent years, and the desire that patients should have an opportunity to become more involved in the decisions surrounding their treatment, a surprisingly low number - 15% - believed that, ultimately, their patients were the decision-makers at the point of referral.


GP

Patient

Specialist

Insurer

Other(combination)

How do GPs decide which specialist a patient sees, or where they’re treated?

Whenever it’s practical, GPs are likely to give patients an option to choose their specialist and place of treatment. We believe the decision a patient takes, at that point, is more likely to be based on geographical convenience than data available about quality of care or cost of treatment.

The referral options provided by GPs may be based on previous experience or reputation rather than a quantified measurement of clinical outcomes.

For private treatment, which factors do GPs consider in their referrals?

When referring patients for private treatment that will be either self-funded or covered by an insurance policy, there are many factors that have to be considered in addition to the individual’s immediate clinical needs.

However, one of the challenges faced by the Competition Commission (and patients) is the lack of consistency or guidelines informing the way in which GPs should prioritise those factors, one over the other. Clinicians take a very ‘individual’ approach to making a recommendation.

We believe that greater transparency regarding the comparative quality and costs of a treatment – from facility to facility, or even among specialists and/or anaesthetists for example – could help.

Onaverage,GPsaregiving78%of patients an open referral. However, most patients are unable to compare the quality or cost of a treatment – and may be selecting a referral pathway based on convenience alone.

48%

22%

6%

24%

30%

29%

35%

1%

3%

2%


I gave them a choice of specialists and hospitals to choose from

I select the specialist I feel is best for them

I ask the patient which specialist they’d like to see and refer them to the one they choose

I give the patient an open referral

Quality of care / outcomes

Quality of facilities

Waiting times for NHS treatments

Financial penalty of premium increase when an insurer does not cover the full cost of treatment

Choice of specialist / consultant

Availability of advanced treatments / technologies

Which conditions do GPs find most challenging to refer for specialist attention?

Consistent with our previous Health of the Nation reports. We asked which referrals GPs were finding most challenging.

It’s worth noting that, in comparison with the results of our first Health of the Nation study ten years ago, the referral landscape has changed very little – although fewer GPs are finding the process quite such a challenge, overall.

Tired of dealing with ME and CFS?

As with last year’s survey, GPs told us that they were still struggling to refer patients on for more specialistinsightstoMyalgicEncephalomyelitis(ME)andChronicFatigueSyndrome(CFS).Overaperiod of ten years, these are still the number one conditions that GPs find most challenging to refer on for specialist attention. What’s most alarming however, is that 42% of GPs thought the NHS would no longer provide services for ME and CFS by 2015.

2012: top 10 conditions and % of GPs who find these referrals challenging

ME / Chronic fatigue syndrome Obesity Drug / alcohol

abuseMental health (exc. stress)

40%

35%

30%

25%

20%

15%

10%

5%

0%Stress (work related)

Depression Stress (non work related)

Back pain Headaches Irritable Bowel Syndrome

45%39%

24%

20%17% 17%

16% 16% 15% 14%12%

ME / Chronic fatigue syndrome

Food allergies

Fibromyalgia Eating disorders

70%

60%

50%

40%

30%

20%

10%

0%Learning difficulties in children

Alcoholism Drug abuse Headaches Musculo- skeletal

ObsessiveCompulsive Disorder

80% 76%72%

59%

44% 43%

34%

55%

37%31%

44%

2003: top 10 conditions and % of GPs who found those referrals challenging

ME / Chronic fatigue syndrome

Food allergies

Eating disorders

Stress (work related)

70%

60%

50%

40%

30%

20%

10%

0%Learning difficulties in children

Stress (not work related)

Drug abuse Obesity Musculo- skeletal

Mental health issues

60%56%

53%

45% 44%40%

36%

53%

40%

35%

2011: top 10 conditions and % of GPs who found those referrals challenging


What have we learned? Health of the Nation – a 10-year anniversary

OurHealthoftheNationstudywasfirstpublishedin2003.Webelievethismakesit the longest-running private medical insurer’s study of GPs’ views in the UK. Now, 10 years on, we’re about to see some of the most radical reforms in the 63-year history of the National Health Service (NHS) take place – so this study holds even greater significance for anyone seeking insights to the views of the GPs and patients it serves.

Doubts about the future

It seems a long while since the Government introduced its health white paper in July 2010, entitled Liberating the NHS. Since then, plans have emerged to reform the service (in England at least), that have proved hugely controversial over the last twelve months.

Political differences and the challenges inherent in such a substantial programme of change resulted in us seeing a new Health Minister take the helm; there are major implications for the NHS’s workforce that are still stimulating vigorous debate; as the Clinical Commissioning Groups (CCGs) come into effect from April 2013, GPs will have their hands full – adapting to change – and need our support, and patience, as they get to grips with the evolving landscape.

What’s clear is that, if these revolutionary changes are to work in the way in which they are intended – reducing costs while improving patient choice, transparency and quality of care – then the Government will need to listen closely not only to GPs but also to the patients whose health they are trying to improve.

This year, our study highlighted the fact that 13% of the patients we spoke to felt the quality of services being provided has declined over the last ten years. 36% believed that trend will continue over the next five years, and 14% felt there was either no future for the NHS or they had very little confidence in its current leadership in the form of the Department of Health. This is not a healthy opinion.

GPs taking the helm

By 1st April 2013, the NHS Commissioning Board (NHSCB) is likely to have tasked over 200 new organisations – clinical commissioning groups (CCGs) – with responsibility forupto£65bnofthe£95bnNHSCBbudget.Thismeansthat 8,000-plus GP practices in England will be members of a CCG, so the bulk of the NHS budget will be in the control of GPs for the first time.

Those CCGs will need to be robust: this Health of the Nation study made certain aspects of our nation’s health focus very clear. 13% of men and 22% of women are now visiting a GP for routine check-ups, and almost one fifth (17%) of us have started seeing our GP more frequently. To be successful, the CCGs will have to decrease levels of disengagement among member practices and work hard at not only improving the services currently being delivered but also at increasing general health awareness among the population, to help reduce instances of poor health in the future.

More pressure, less time

This year, responses have also shown that many of those GPs who’ve experienced difficulties referring patients on to high quality care previously are now looking forward to the possibilities those CCGs may bring. In general though, GPs are still voicing concerns they’ll have more to do (51% envisage their hours increasing in the future) … but will feel less in control after CCGs come into effect.


Uncertain focus

Whether or not increasing trends are due to more instances of a particular condition – or presentation of that problem as a result of greater awareness among its sufferers – is a subject that’s worthy of much debate: it certainly links the importance of education to the cost of treatment and better health in general.

Withthatinmind,itwasinterestingtonotethat29%ofrespondents to this survey believed high-profile ‘celebrity’ illnesses (such as Ruby Wax’s mental health challenges) helped highlight symptoms of concern. 10% of the people we spoke to believed that media attention could actually save lives.

GPs agree: 76% of the practitioners we spoke to had experienced more patients seeking treatment or guidance for a specific condition as a result of a ‘celebrity’ or high-profile personality publicising their own health concerns – so education and awareness should still be a highly significant, contributing factor to the way our health service reform takes place.

Looking to the future

Not everything looks gloomy. We are learning the value of being more informed; GPs as a whole, still feel in control of the referral process and 83% of GPs told us they were experiencing either moderate or high levels of job satisfaction.

In summary, however, this study points once again towards an ever-increasing need for patient education; more commitment to higher quality clinical pathways, and a requirement for greater transparency that will help us all benchmark the quality of service we’re able to access and entitled to expect.

We believe this, Health of the Nation study is another incisive commentary on the nation’s healthcare landscape – and we hope you’ll find it useful.


Notes

Methodology

Aviva canvassed the opinions of 202 GPs across the UK, asking the same questions of an equal number of men and women. To make sure this was a broadly even data sample, we also took population density into account: using the opinions of 46 individuals in the Greater London area for example, while taking on board the views of 12 in Northern Ireland.

AlloftheseGPswereinterviewedduringOctober2012,inanonlinesurveyconductedonourbehalfbytheindependent research company Watermelon.

We also spoke to 1,001 individuals, to canvas their views on a wide range of subjects concerning health matters and their engagement with care across the country. Again, population density was taken into account; 55% of respondents were female, 45% male.

About Aviva

Aviva UK Health is one of the largest providers of private medical insurance, and Group Risk products and services in the UK. We offer everything from individual, personal policies through to corporate cover benefiting 1000s of employees.

We were recently voted Health Insurance Company of the Year at the 2012 Health Insurance awards – for the third year running and Aviva also came first in four other categories including Best Group PMI Health Provider (again, for the third year running) and Best Customer Service.

We believe high quality healthcare should be available to all, and that healthcare itself is a very personal matter. In delivering our products and services, we try to make sure our customers always get the right treatment at the right time and to do that, we have to keep our customers at the heart of everything we do.

For us, the Health of the Nation study has always been a means of visiting key issues over a period of time. It helps us gauge how the environment is changing and identify GPs’ and patients’ thoughts to help influence improvements in our products and services.

Aviva Health UK Limited. Registered in England Number 2464270.

RegisteredOffice8SurreyStreetNorwichNR13NG.

ThisinsuranceisunderwrittenbyAvivaInsuranceUKLimited.RegisteredinEnglandNumber99122,

RegisteredOffice8SurreyStreetNorwichNR13NG.

Authorised and regulated by the Financial Services Authority.

AvivaHealthUKLimited,HeadOffice:ChilworthHouseHampshireCorporateParkTemplarsWay

EastleighHampshireSO533RY.

aviva.co.uk/health

GEN4805 01.2013 © Aviva plc

Documents

Aviva's Health of the Nation report