2. PUBLIC HEALTH POLICIES
1. No contact with the public
2. Single contacts
3. Serial contacts

3. Geographical denominators
“communities of place”
GP list denominators
“communities of interest”

4. The challenge of universal coverage - 1948 and now

6. NOT ONLY
Evidence-based medicine (QOF, SIGN)
BUT ALSO
Unconditional, personalised, continuity of care

7. WHO NEEDS INTEGRATED CARE ?
Potentially anyone but mostly
the 15% of patients
who account for 50% of general practice workload

9. If we do not change direction
we shall arrive where we are heading
Chinese proverb

10. DIFFERENCES IN LIFE EXPECTANCY
BETWEEN MOST AND LEAST DEPRIVED DECILES
SCOTLAND 2007/08
MEN
Most Least Difference
deprived deprived
Life expectancy 67.6 80.9 13.3
Healthy life expectancy 56.9 75.7 18.8
Years spent in poor health 10.7 5.2 5.5
WOMEN
Most Least Difference
deprived deprived
Life expectancy 75.6 84.2 8.6
Healthy life expectancy 60.8 77.9 17.1
Years spent in poor health 14.8 6.3 8.5
Long-term monitoring of health inequalities. The Scottish Government 2010

11. Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde
Deprivation Decile
250
200
Age-Sex Standardised Ratio
150 sir64
shr64
100 smr74
Linear (WTE
GPs)
50
0
1 2 3 4 5 6 7 8 9 10
Deprivation Decile

13. Multimorbidity is common in Scotland
– 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

14. Most people with any long term condition
have multiple conditions in Scotland
Heart failure 3 9 14 74
Stroke/TIA 6 14 18 62
Atrial fibrillation 7 13 16 65
Coronary heart disease 9 16 19 56
Painful condition 13 21 21 46
Diabetes 14 20 19 47
COPD 18 19 17 47
Hypertension 22 24 19 35
Cancer 23 21 17 39
Epilepsy 31 23 16 29
Asthma 48 20 12 21
Dementia 5 13 18 64
Anxiety 7 17 20 56
Schizophrenia/bipolar 13 21 21 46
Depression 23 22 18 36
0% 20% 40% 60% 80% 100%
Percentage of patients with each condition who have other conditions
This condition only This condition + 1 other + 2 others + 3 or more others

15. There are more people in Scotland with
multimorbidity below 65 years than
above

16. People living in more deprived areas in
Scotland develop multimorbidity 10 years
before those living in the most affluent
areas

17. Mental health problems are strongly
associated with the number of physical
conditions that people have, particularly in
deprived areas in Scotland

18. Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde
Deprivation Decile
250
200
Age-Sex Standardised Ratio
150 sir64
shr64
100 smr74
Linear (WTE
GPs)
50
0
1 2 3 4 5 6 7 8 9 10
Deprivation Decile

19. CHD CASELOAD PER WTE GENERAL PRACTITIONER
Quintile of No of cases WTE CHD cases
Deprivation with at least GP per WTE GP
one CHD diagnosis
1 6543 100.9 65
2 6399 97.9 65
3 9262 121.7 76
4 8455 110.8 76
5 9378 111.2 84 (+29%)
SOURCE : GREATER GLASGOW LES DATA

20. KEY POINTS ABOUT ENCOUNTERS
Multiple morbidity and social complexity
Shortage of time
Reduced expectations
Lower enablement
Health literacy
Practitioner stress
Weak interfaces

21. GP stress by clinical encounter length
in areas of high and low deprivation
5.0
4.7
4.5
4.0
3.9
3.8
3.5
3.4 3.5
3.4
Mean stress
Deprivation group
3.0 3.1
3.0
high
2.5 low
5 min or less 10-14 min
6-9 min 15 min and above
Consultation length

22. GENERAL PRACTITIONERS AT THE DEEP END
Age & Sex Standardised Census Health Measures by Greater Glasgow & Clyde
Deprivation Decile
250
200
Age-Sex Standardised Ratio
150 sir64
shr64
100 smr74
Linear (WTE
GPs)
50
0
1 2 3 4 5 6 7 8 9 10
Deprivation Decile

24. A WORKFORCE LACKING COVERAGE, RELATIONSHIPS AND CONTINUITY

26. DECORATORS BUILDERS

27. 4 PROBLEMS WITH TARGETING
Proportionate universalism
(“We are all responsible for all”)
Unsustained, ineffective interventions
Denial of the inverse care law
Professionalisation of Health Inequalities

29. WRITING A REPORT ON HEALTH INEQUALITIES AND GENERAL PRACTICE
1. Not another report that sits on the shelf, and makes no difference
2. No tool kit, telling GPs what to do
3. Start by listening to GPs in the front line
TIME TO CARE
Health Inequalities, Deprivation and General Practice in Scotland
RCGP Scotland Health Inequalities
Short Life Working Group Report
December 2010
“Practitioners lack time in consultations to address the multiple,
morbidity, social complexity and reduced expectations that are
typical of patients living in severe socio-economic deprivation.”

30. Listen to the patient
He is telling you the diagnosis
SIR WILLIAM OSLER

32. QUESTION
WHY DO YOU ROB BANKS ?
ANSWER
BECAUSE THAT’S WHERE THE MONEY IS
WILLIE SUTTON

33. WHERE ARE THE MOST DEPRIVED POPULATIONS ?
The problem of concentration (BLANKET DEPRIVATION)
50% are registered with the 100 “most deprived” practice populations
(from 50-90% of patients in the most deprived 15% of postcodes)
The problem of dilution (POCKET DEPRIVATION)
50% are registered with 700 other practices in Scotland
(less than 50% in the most deprived 15% of postcodes)
The problem of non-involvement (HIDDEN DEPRIVATION)
200 practices have no patients in the most deprived 15% of postcodes

34. WHERE ARE THE 100 PRACTICES?
CHP No of top 100
practices
SIMD 2006 SIMD 2009
Glasgow East CHCP 28 ) 27 )
Glasgow North CHCP 18 ) 18 )
Glasgow West CHCP 16 ) 85 14 ) 76
Glasgow South-West CHCP 14 ) 13 )
Glasgow South-East CHCP 9 ) 4 )
Inverclyde 5 7
Edinburgh 5 4
Tayside 2 4
Ayrshire 2 5
Renfrewshire 1 1
Fife 1
Grampian 1
Lanarkshire 1
TOTAL 100 100

35. QOF POINTS 2007
TOTAL CLINICAL NON-CLINICAL
Most affluent practices 984 645 339
Mixed practices 979 643 336
Most deprived practices 977 641 335

36. ADDITIONAL ACTIVITIES
Undergraduate teaching 45
Postgraduate teaching 27
Research (SPCRN) 66
Primary Care Collaborative (SPCC) 67
Keep Well (phase 1) 24
Keep Well (phase 2) 13

37. INVERSE CARE LAW
“The availability of good medical care tends to vary inversely
with the need for it in the population served”.
The inverse care law is a policy of NHS Scotland which restricts
care in relation to need.
Not the difference between good and bad care, but between what
general practices can do and could do with resources based on need.

38. WHAT DO DEEP END
GENERAL PRACTITIONERS
AND COUNT DRACULA
HAVE IN COMMON ?

39. 1. First meeting at Erskine
2. Needs, demands and resources
3. Vulnerable families
4. Keep Well and ASSIGN
5. Single-handed practice
6. Patient encounters
7. GP training
8. Social prescribing
9. Learning Journey
10.Care of the elderly
11.Alcohol problems in young adults
12.Caring for vulnerable children and families
13.The Access Toolkit : views of Deep End GPs
14.Reviewing progress in 2010 and plans for 2011
15.Palliative care in the Deep End
www.gla.ac.uk/departments/generalpracticeprimarycare/deepend

41. TIME

42. SERIAL
ENCOUNTER
BRIEF
ENCOUNTER

44. LINKS

45. INTRINSIC FEATURES OF GENERAL PRACTICE
Contact
Coverage
Continuity
Coordination
Flexibility
Relationships
Trust

46. CONSULTATIONS ARE NOT ENOUGH
Strengthening local health systems by :-
BETTER LINKS WITH PATIENTS
BETTER LINKS WITH HEALTH IMPROVEMENT
BETTER LINKS WITH OTHER NHS PRIMARY CARE SERVICES
BETTER LINKS WITH THE REST OF THE NHS, INCLUDING
OUT OF HOURS, ELECTIVE REFERRALS AND HOSPITAL SERVICES
BETTER COLLABORATION WITH LOCAL AUTHORITY SERVICES
BETTER COLLABORATION WITH VOLUNTARY SERVICES AND
LOCAL COMMUNITIES

47. INVENTING THE WHEEL
HUB SPOKES + RIMS
Contact Keep Well
Coverage Child Health
Continuity Elderly
Comprehensive Mental Health
Coordinated Addictions
Flexibility Community Care
Relationships Secondary Care
Trust Voluntary sector
Leadership Local Communities
INTEGRATED CARE DEPENDS ON MULTIPLE RELATIONSHIPS
INVESTMENT IN RELATIONSHIPS BUILDS SOCIAL CAPITAL

48. POLICY
RECOGNITION

49. HOW TO AVOID F R A G M E N T A T I O N ?

50. FRAGMENTATION
Dysfunctional consultations
Discontinuity
Poor coordination
Gaps in coverage

51. TOO MANY BITS
I’VE JUST INVENTED A MACHINE THAT DOES THE WORK OF TWO MEN.
UNFORTUNATELY, IT TAKES THREE MEN TO WORK IT
SPIKE MILLIGAN

52. Health practitioners need to ask
not only “What do I do?”
but also “What am I part of?”
Don Berwick
Head of US Medicare and Medicaid

53. MUTUALITY
Relationships based on
Recognition
Joint work
Effective communication
Understanding and respect
Positive experiences
Confidence in the future
TRUST

54. RELATIONSHIPS WITH PATIENTS
Initially face to face, eventually side by side
Julian Tudor Hart
A NEW KIND OF DOCTOR

55. RELATIONSHIPS REQUIRING MUTUALITY AND TRUST
1. Patients and Practitioners (SERIAL ENCOUNTERS)
2. Practices and other Services (SOCIAL CAPITAL)
3. Networks of Practices (DEEP END)
4. Practices and NHS Management (TWO CULTURES)

56. SIX ESSENTIAL COMPONENTS
1. Extra TIME for consultations
2. Best use of SERIAL ENCOUNTERS
3. General practices as the NATURAL HUBS
of local health systems
4. Better CONNECTIONS across the front line
5. Better SUPPORT for the front line
6. LEADERSHIP at different levels

57. THE QUESTION
Can we imagine, develop, and support
a plurality of local health systems based on general practices,
providing resources according to need (proportionate universalism),
combining the strengths of area-based and list-based services,
recognising leadership roles at both levels,
committed to long term change
and to shared learning on the way (a learning organisation) ?

58. ACHIEVEMENTS
A lot, quickly and cheaply
Identity, Engagement, Morale, Voice, Recognition
Phase 1 2010 15 Meetings
Phase 2 2011 Publications, Presentations and Profile
12 BJGP articles
RCGP Occasional Paper
Phase 3 2012 Opportunities
CARE Plus Study
LINKSand BRIDGE projects
Glasgow Deprivation Interest Group, following Lothian
Austerity Survey
2nd National Meeting
Piloting contractual changes

60. ADVOCACY
The social causes of illness are just as important as the physical ones.
The practitioners of a distressed area are the natural advocates of the people.
They well know the factors that paralyse all their efforts.
They are not only scientists but also responsible citizens,
and if they did not raise their voices, who else should?
Henry Sigerist

61. 60 Those of the world’s 25
United Kingdom
richest large countries Denmark
which are in Europe + USA United States
Greece
55
Slovenia
Germany
50 Spain
Ireland
Norway
45
Portugal
Italy
40 Netherlands
Finland
Austria
35 Public Expenditure (%GDP) Sweden
International Monetary Fund (IMF), World Economic
Outlook Databasefor October, Washington, DC, IMF, 2010 France
http://www.imf.org/external/pubs/ft/weo/2010/02/weodata/index.aspx
30 Denmark
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Belgium

64. THE CULTURE OF POWER
or
THE POWER OF CULTURE