1. 1. GPST Education day3rd October 2012
2. 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. 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. 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. 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. 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. 7. Practice profilesl ISD(information services division Scotland) can provide info on demographics (age/sex/deprivation) for each practice.
8. 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. 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. 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. 11. l AJInequalities in health andhealthcare
12. 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. 13. Inequalities in health and healthcarel Contributing factors:Poverty/social classEthnicityGenderAgeMental illnessEducationDiet and exerciseSubstance misuse drugs and alcoholSmokingHousingPre birth
14. 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. 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. 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. 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. 18. Individual vs communityl Autonomy vs justicel Greatest good for the greatest numberl Patient advocate or need to take into accountwider community
19. 19. Rationingl Implicit and explicit
20. 20. Implicitl Postcodel GP gatekeeper rolel Agel education
21. 21. Rationing: Explicitl NICEl SIGNl SMC (Scottish medicines consortium)l LJF (Lothian joint formulary)l Health Boards eg Fife & IVFl Agel Lifestylel Disease category
22. 22. Group workl Examples of inequalities in health or health care
23. 23. Inequalities in health and healthcareInverse care lawJulian Tudor Hart 1971NMC
24. 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. 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. 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. 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. 28. WHO Commission on SocialDeterminants of Health 2008l Improve daily living conditionsl Tackle the inequitable distribution of power, money, and resources
29. 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. 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. 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. 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. 33. TIME TO CAREHealth Inequalities, Deprivation and General Practice in Scotland RCGP Scotland Health Inequalities Short Life Working Group Report December 2010
34. 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. 35. People living in more deprived areas in Scotland develop multimorbidity 10 years before those living in the most affluent areas
36. 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. 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. 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. 39. Summary1. GP curriculum2. Practice profiles3. GP involvement in community4. Inequalities in health and inequalities in healthcare5. Individual vs community6. Rationing
40. 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. 41. Case work
42. 42. 2 case historiesl Small groups
43. 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. 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. 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. 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?)
47. 47. Thank you!