Stewart Mercer Plymouth November 3rd, 2017 Key challenges for developing comprehensive primary care in deprived areas Stewart Mercer Plymouth November 3rd, 2017

Things I’ll talk about…. The nature of the challenge Workforce and the inverse care law Data Policy Integration Evidence The Power of the Deep End

The nature of the challenge

Mapping the best and the worst health in Britain. Shaw, M. et al. BMJ 2005;330:1016-1021 Copyright ©2005 BMJ Publishing Group Ltd.

ILL-HEALTH VARIABLES BY DEPRIVATION   5

Healthcare is a social determinant too…. Healthcare is also a social determinant of health, because healthcare improves health If healthcare is delivered inequitably then the NHS will widen rather than narrow health inequalities

HEALTH ISSUES ESPECIALLY PREVALENT IN THE DEPRIVED AREAS Mental health problems Drugs and alcohol Material poverty Vulnerable children and adults Migrants, refugees and asylum seekers Fitness to work Sexual abuse history Homelessness GENERIC ISSUES How to engage with patients who are difficult to engage How to deal with complexity in high volume How to apply evidence DEEP END REPORT 24

Workforce and the inverse care law Workforce now a major problem in primary care and general practice Generally harder to recruit to deprived areas and higher burn-out Underlying key factor is the inverse care law

The Inverse Care Law ‘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 : higher patient need but flat distribution of GP manpower in deprived areas

GENERAL PRACTITIONERS AT THE DEEP END 12 12

Data Good population and primary care data is essential for health and social care planning Do we have good data on the health and social care needs of people in deprived areas? Do we even have good data on healthcare and social care service provision in deprived areas? Without both, unmet need cannot be measured

People living in more deprived areas in Scotland develop multimorbidity 10-15 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

Multiple morbidity and the inverse care law

CONSULTATIONS IN DEPRIVED AREAS Multiple morbidity and social complexity Shortage of time Reduced expectation for shared decision making Lower enablement (especially for complex problems) Poorer outcomes at 1 month Practitioner stress Mercer SM, Watt GCMw : clinical primary care encounters in deprived and affluent areas of Scotland Annals of Family Medicine 2007; 2016

Policy There are no major policies that acknowledge and commit to reversing the inverse care law Focus has moved to the ageing population and to self-management The needs of younger multimorbid patients in deprived areas are very different

Integration Important everywhere not just in deprived areas Harder to achieve in deprived areas when everyone is running fast just to stand still

TOO MANY HUBS INCREASES THE TREATMENT BURDEN

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

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

Evidence

Evidence-based medicine Clinical Guidelines are based on RCTs that exclude patients with multimorbidity There is a dearth of evidence on the management of patients with multimorbidity in primary care There is even less on managing multimorbid primary care patients in deprived areas

Living well with multimorbidity: the CARE Plus Study Stewart Mercer Bruce Guthrie Elizabeth Fenwick Bridie Fotzpatrick Alex McConnachie Rosalind O’Brien Graham Watt Sally Wyke NHS and Deep End General Practices 2009- 2014

System Professional Patient CARE PLUS: a whole-system approach System Professional Patient Resource for more time with continuity System Support meetings and structure for empathic, person-centred consultations (CARE) Practitioner Patient CD and written guide on mindfulness Plus CBT guide Community activities recommended

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

CARE Plus was also very cost-effective Cost < £13,000 per QALY NICE currently supports a cost of £20,000 per QALY Mercer SW, Fitzpatrick B, Guthrie B, Fenwick E, Grieve E, Lawson K, Boyer N, McConnachie A, Lloyd SM, O’Brien R, Watt GCM, Wyke S. The Care Plus study- a whole system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: cluster randomised controlled trial. BMC Medicine 2016, 14:88

The Power of the Deep End

ACHIEVEMENTS A lot, quickly and cheaply Identity Engagement Profile Voice Phase 1 Meetings Phase 2 Publications, Presentations and Profile Phase 3 Opportunities, Influence, Resources Phase 4 Implementation, Lobbying Projects Govan SHIP, LINK Workers , Care Plus, Benefits, Alcohol, Housing

DEEP END REPORTS www.gla.ac.uk/deepend First meeting at Erskine Needs, demands and resources Vulnerable families Keep Well and ASSIGN Single-handed practice Patient encounters GP training Social prescribing Learning Journey Care of the elderly Alcohol problems in young adults Caring for vulnerable children and families The Access Toolkit : views of Deep End GPs Reviewing progress in 2010 and plans for 2011 Palliative care in the Deep End Austerity Report Detecting cancer early Integrated care Access to specialists What can NHS Scotland do to prevent and reduce heath inequalities GP experience of welfare reform in very deprived areas Mental health issues in the Deep End The contribution of general practice to improving the health of vulnerable children and families What are the CPD needs of GPs working in Deep End practices? Strengthening primary care partnership responses to the welfare reforms Generalist and specialist views of mental health issues in very deprived areas lmproving partnership working between general practices and financial advice services in Glasgow : one year on is www.gla.ac.uk/deepend

SIX ESSENTIAL COMPONENTS Extra TIME for consultations (INVERSE CARE LAW) Best use of serial ENCOUNTERS ((PATIENT STORIES) General practices as the NATURAL HUBS of local health systems (LINKING WITH OTHERS) 4. Better CONNECTIONS across the front line (SHARED LEARNING) 5. Better SUPPORT for the front line (INFRASTRUCTURE) 6. LEADERSHIP at different levels (AT EVERY LEVEL)

Summary and Conclusions The challenges facing comprehensive primary care in deprived areas relate to the unmet healthcare needs of the populations served The inverse care law stymies attempts to improve population health through primary care There is a lack of research that focuses on complex needs of multimorbid patients in deprived areas Primary care is a natural hub for the integration of health and social care services Policy needs to change GP in the Deep End can be a powerful voice for advocacy