35
PUBLIC HEALTH POLICIES 1. No contact with the public 2. Single contacts 3. Serial contacts
PUBLIC HEALTH POLICIES
1. No contact with the public
2. Single contacts
3. Serial contacts
WHO NEEDS INTEGRATED CARE ?
POTENTIALLY ANYONE BUT MOSTLY
THE 15% OF PATIENTS
WHO ACCOUNT FOR 50% OF NHS WORKLOAD
Multimorbidity in Scotland
The Scottish School of Primary Care 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
Most people with any long term condition have multiple conditions in Scotland
23
13
7
5
48
31
23
22
18
14
13
9
7
6
3
22
21
17
13
20
23
21
24
19
20
21
16
13
14
9
18
21
20
18
12
16
17
19
17
19
21
19
16
18
14
36
46
56
64
21
29
39
35
47
47
46
56
65
62
74
0% 20% 40% 60% 80% 100%
Depression
Schizophrenia/bipolar
Anxiety
Dementia
Asthma
Epilepsy
Cancer
Hypertension
COPD
Diabetes
Painful condition
Coronary heart disease
Atrial fibrillation
Stroke/TIA
Heart failure
Percentage of patients with each condition who have other conditionsThis condition only This condition + 1 other + 2 others + 3 or more others
Most people with any long term condition have multiple conditions in Scotland
There are more people in Scotland with multimorbidity below 65 years than above
ACHIEVEMENTS
A lot, quickly and cheaply
• Identity• Engagement• Profile• Voice
Phase 1 2010 MeetingsPhase 2 2011 Publications, Presentations and ProfilePhase 3 2012 Opportunities, Influence, Resources
Projects LINKS , Care Plus, Bridge, 17c, Austerity
Glasgow Deprivation Interest Group, following Lothian
2nd National Meeting
QUESTION
WHY DO YOU ROB BANKS ?
ANSWER
BECAUSE THAT’S WHERE THE MONEY IS
WILLIE SUTTON
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
WHERE ARE THE 100 PRACTICES?CHP No of top 100
practicesIMD 2009
Glasgow East CHCP 27 )Glasgow North CHCP 18 )Glasgow West CHCP 14 ) 76Glasgow South-West CHCP 13 )Glasgow South-East CHCP 4 )Inverclyde 7Edinburgh 4Tayside 4Ayrshire 5Renfrewshire 1Fife 1Grampian 1Lanarkshire 1
TOTAL 100
ASPECTS OF THE 100 MOST DEPRIVED PRACTICES
43% of male deaths and 24% of female deaths occur under 70(compared with 25% of male and 14% of female deaths in the most affluent 100 practices)
A large majority of practices are in Glasgow
20 practices are single-handed
60% have three or fewer WTE general practitioners
Average list size is 4300
QOF POINTS 2007
TOTAL CLINICAL NON-CLINICAL
Most affluent practices 984 645 339
Mixed practices 979 643 336
Most deprived practices 977 641 335
ADDITIONAL ACTIVITIES
Undergraduate teaching 45
Postgraduate teaching 27
Research (SPCRN) 66
Primary Care Collaborative (SPCC) 67
WHAT DO DEEP END
GENERAL PRACTITIONERS
AND COUNT DRACULA
HAVE IN COMMON ?
1. First meeting at Erskine2. Needs, demands and resources3. Vulnerable families4. Keep Well and ASSIGN5. Single-handed practice6. Patient encounters7. GP training8. Social prescribing9. Learning Journey10.Care of the elderly11.Alcohol problems in young adults12.Caring for vulnerable children and families13.The Access Toolkit : views of Deep End GPs14.Reviewing progress in 2010 and plans for 201115.Palliative care in the Deep Endwww.gla.ac.uk/departments/generalpracticeprimarycare/deepend
PRACTICE PARTICIPATION IN DEEP END ACTIVITIES
Number of meetings Number of practicesattended attending
0 271 262 173 124 115 46 07 28 1
TOTAL 100
1. First meeting at Erskine2. Needs, demands and resources3. Vulnerable families4. Keep Well and ASSIGN5. Single-handed practice6. Patient encounters7. GP training8. Social prescribing9. Learning Journey10.Care of the elderly11.Alcohol problems in young adults12.Caring for vulnerable children and families
www.gla.ac.uk/departments/generalpracticeprimarycare/deepend
KEY POINTS ABOUT ENCOUNTERS
Multiple morbidity and social complexity
Shortage of time
Reduced expectations
Lower enablement
Health literacy
Practitioner stress
Weak interfaces
GP stress by clinical encounter length in areas of high and low deprivation
Consultation length
15 min and above
10-14 min
6-9 min
5 min or less
Mea
n st
ress
5.0
4.5
4.0
3.5
3.0
2.5
Deprivation group
high
low
3.0
3.43.5
3.1
4.7
3.93.8
3.4
1. First meeting at Erskine2. Needs, demands and resources3. Vulnerable families4. Keep Well and ASSIGN5. Single-handed practice6. Patient encounters7. GP training8. Social prescribing9. Learning Journey10.Care of the elderly11.Alcohol problems in young adults12.Caring for vulnerable children and families
www.gla.ac.uk/departments/generalpracticeprimarycare/deepend
KEY POINTS
Dealing with vulnerable families is an everyday task
The frustration is knowing where help is needed but not being able to provide help
Practices acquire a lot of knowledge about vulnerable familiesbut this is being undermined
Whether working with patients or with colleagues, the essential ingredientis a long term relationship based on communication, mutuality and trust
Current resources are inadequate to address the problem
Practices need to be resourced (commensurately with need) to be the hub for multi-disciplinary review meetings, linked to other services Concentrating resource on the most severe cases may be counter-productive
1. First meeting at Erskine2. Needs, demands and resources3. Vulnerable families4. Keep Well and ASSIGN5. Single-handed practice6. Patient encounters7. GP training8. Social prescribing9. Learning Journey10.Care of the elderly11.Alcohol problems in young adults12.Caring for vulnerable childen and families
www.gla.ac.uk/departments/generalpracticeprimarycare/deepend
KEY POINTS
Old age starts earlier in deprived areas
Acute hospitals now focus on processing problems quickly
SPARRA has a very low profile
GPs are keen to take an anticipatory approach, but are reluctantto “jump in”.
1. First meeting at Erskine2. Needs, demands and resources3. Vulnerable families4. Keep Well and ASSIGN5. Single-handed practice6. Patient encounters7. GP training8. Social prescribing9. Learning Journey10.Care of the elderly11.Alcohol problems in young adults12.Caring for vulnerable childen and families
www.gla.ac.uk/departments/generalpracticeprimarycare/deepend
LINKS PROJECT
Practices keen to make use of non-medical community resources,but don’t know what is available
Providing relevant, up to date, local information is a huge challenge
Practices can’t extend their activities, when core activities are under pressure
The LINKS project explored the way forward
17C
A WAY OF WORKING WITH PRACTICES
Based on the SPCC model
Groups of 5-6 practices
Protected time to meet together
GP lead
Co-designCentral support
1. First meeting at Erskine2. Needs, demands and resources3. Vulnerable families4. Keep Well and ASSIGN5. Single-handed practice6. Patient encounters7. GP training8. Social prescribing9. Learning Journey10.Care of the elderly11.Alcohol problems in young adults12.Caring for vulnerable childen and families
www.gla.ac.uk/departments/generalpracticeprimarycare/deepend
ADVOCACY
The social causes of illness are just as important as the physical ones.
The medical officer of health and the practitioners of a distressed area are the natural advocates of 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, John Hopkins University
13 September 2010 The Editor The Herald Glasgow
Dear Sir
We write as general practitioners working in the most deprived areas of Scotland, with special experience of the problems of alcohol. Our interest is not through choice, but because of the huge, recent and increasing importance of excessive alcohol consumption as a cause of premature death, physical illness and social harm affecting our young patients.
Research studies show the social patterning of alcohol problems, not only the higher levels of consumption in poor areas, but also the higher levels of harm for a given level of consumption. Death rates from alcohol liver disease are five times more common in poor areas compared with the most affluent areas.
Scotland’s statistics are shocking, but “statistics are people with the tears wiped off”. The current debate about alcohol pricing can lose sight of the misery and devastation that affects our patients and their families, especially the lasting effects on children. Drunken disorder is only the most obvious problem. Every one of us knows of tragic cases of young adults whose lives, and whose family lives, have been ruined by alcohol. Women are particularly vulnerable. No one should die young and yellow from chronic alcohol poisoning.
This is not an issue that can be left to personal responsibility or the massed efforts of health practitioners trying hard to stem the tide. Any measure, such as minimal alcohol pricing, which makes it more difficult for people to consume regular excessive amounts of alcohol should be seized, as a public health measure of the highest importance. Cross party support is the least we should expect from our politicians, especially those representing the most deprived constituencies, in confronting this very real and lethal epidemic.
Signed by the following NHS general practitioners
