Research into primary care and health inequalities Stewart Mercer - - PowerPoint PPT Presentation

Research into primary care and health inequalities

Stewart Mercer Professor of Primary Care Research Director of the Scottish School of primary care

ILL-HEALTH and Health inequalities in Scotland Dehealth ineqPRIVATION

20 40 60 80 100 120 140 160 180 1 2 3 4 5 6 7 8 9 10 Deprivation decile Mortality <75 Limiting long-term illness Not good' general health

Multimorbidity in Scotland

The Scottish School of Primary Care’s Multimorbidity Research Programme

– 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

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

The Inverse Care Law

Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde Deprivation Decile

50 100 150 200 250 1 2 3 4 5 6 7 8 9 10

Deprivation Decile Age-Sex Standardised Ratio

sir64 shr64 smr74 Linear (WTE GPs)

• ‘The provision of good

medical care tends to vary inversely with the need for it in the population served.’

• www.juliantudorhart.org

The Inverse Care Law

Patients in deprived areas of Scotland do not feel enabled by GP encounters

In a study of over 3,000 GP consultations in the West of Scotland, patients in deprived areas (compared to patients in more affluent areas) had :

• More problems to discuss, which were more often

complex (a mix of physical, psychological, and social); Yet….

• Consultations were shorter
• Patients with complex problems were less enabled
• GPs were more stressed

Mercer SW, Watt GCM. Ann Fam Med 2007;5:503-510.

“Exhausting” “Demoralising” “I feel like a wrung-out rag at the end of consultations” “If you’re too caring ... you’ll crack up in a place like this. Our boundaries lie where they are because they have to at the moment” General practitioners and practice nurses in deprived areas struggle to support people with multimorbidity

O'Brien R et al. Chronic Illness 2011;7(1):45-59.

Whole person

Patient- centred

Understand Patients’ Context

Relationship Making patients feel valued

Empowerment

Developing – whole system, whole person approach

• Time
• Continuity
• Support and

training for professionals

• Self-management

support for patients

CARE PLUS: a whole-system approach

Time, continuity, person centredness and self-management support

Patient Practitioner System

System Professional Patient

Longer consultation time with continuity Support meetings and structure for long person-centred consultations CD and written guide

• n mindfulness

Plus CBT guide Community activities recommended

Would GPs and patients participate in a RCT?

Practices from areas of high deprivation NP = 8

CARE Plus NP = 4 N = 76 Baseline N = 76 6 Months N = 68 (89%) 12 Months N = 67 (88%) Usual Care NP = 4 N = 76 Baseline N = 76 6 Months N = 69 (91%) 12 Months N = 67 (88%)

Patient Completed Questionnaires

5 10 15 20 25 30 35 40 care + consulation first usual consultation minutes

Time spent in first index consultation

10 20 30 40 50 60 care + consulation first usual consultation % satisfied

Satisfied with time spent in first index consultation

P<0.0001 P<0.0005

Are consultations ‘better’?

5 10 15 20 25 30 35 40 45 50 care + consulation usual consulation

care measure (% max score)

5 10 15 20 25 30 35 care + consulation usual consulation

PEI (% 'enabled') ns ns

Patients in the CARE Plus group had improvements in quality of life and wellbeing at 12 months

Favours Usual Care Favours CARE Plus

W-BQ12 Positive Well-being W-BQ12 Energy W-BQ12 Negative Well-being* W-BQ12 General Well-being EQ5D-5L AUC EQ5D-5L Effect Size (95% Confidence Interval)

• 0.4
• 0.2

0.0 0.2 0.4 0.6 0.8 1.0 Favours Usual Care Favours CARE Plus

CARE Plus prevents decline in QOL (EQ5-DL)

0.1 0.2 0.3 0.4 0.5 0.6 care+ usual care baseline 6-month

Effect size = 0.35

CARE Plus is also very cost-effective

• Cost-effective:

– Cost < £13,000 per QALY – NICE currently supports a cost of £20,000 per QALY

Summary

• Health inequalities continue to widen
• Multimorbidity is a major challenge
• It is socially patterned, occuring earlier in

deprived areas

• Because of the inverse care law, GPs struggle to

meet patients complex needs in deprived areas

• ‘Reversing’ the inverse care law experimentally

appears to improve outcomes in a very cost- effective way