Reducing health inequalities
John Patterson, RCGP Clinical Champion for Health Inequalities
The NHS should be at it’s best where it is needed the most. Across our communities, especially where deprivation is prevalent, there exists a myriad of individuals who have an established disease yet suffer primary or secondary non-diagnosis. The quantity of these cases, coupled with their severity, is the reason all previous ‘industrial size’ health interventions fail.
The first decade of the new millennium saw the most comprehensive programme ever seen in this country to address health inequalities. The programme was established to achieve the national target for 2010 “to reduce inequalities in health outcomes by 10 per cent as measured by infant mortality and life expectancy at birth.”1
The House of Commons select committee report in 2009 concluded that although much admirable work had been undertaken, and evidence of the improvement of the health of all groups in England was apparent, the main targets had been missed.2 The gap in health inequalities between the social classes had widened - by 4% amongst men and by 11% amongst women.
The HINST work,3 established weighted values for conditions contributing to inequity and effective interventions which, they calculated, would reduce this gap by at least 10% if delivered by good primary care. The main learning point from this venture was:
“Focused secondary prevention in primary care is the fastest way to reduce health inequalities”4
Long term condition (LTC) management within primary care by any measure is generally effective and of a high standard across social advantage.5 However, not everyone eligible for treatment receives it.
In the first incidence many people with an established disease are unknown to the health system. This phenomenon has become known as the ‘missing thousands’.6
PHE data indicates that the existence of prevalence gaps - varied between local practices, unexplained by simple epidemiology, generally wider in areas of deprivation - still exist across LTC’s in all areas of the country.7 Some estimates cite 500,000 potentially missed diabetics and up to 5 million people untreated with hypertension.9
The second issue is of secondary non-diagnosis. This is when a problem is identified to the system but that patient then makes themselves, or is made, invisible. We call this the ‘exception locker’.
Whilst the QoF includes the concept of exception reporting (for a variety of good reasons) it is plain that the scale of current exception levels influences national and regional health outcomes. QoF indicators are ranked by their impact and studies show that exception rates increase towards the more significant of these.10 12% of patients registered with DM are exceptioned from DM007.11
When we add the patients on registers who do not obtain clinical targets to these undiagnosed patients and exceptioned patients we start to see a pattern emerge:
R =Pts on QoF register
M=pts on Reg who miss target
E=Pts on Reg who are exceptioned
U= Pts with condition unknown to QoF Reg.
For Diabetes 1 million patients are thought to exist in this unmanaged bubble. For hypertension it is 7.5 million.
Emergent data from the Well North programme suggests that this proportionate pattern is replicated across all clinical areas including mental health and also within many non-clinical proxy measures of health (housing, worklessness etc).12
Since 2004 GP teams now report and/or achieve on 82 million QoF indicators. These same teams deliver 40 million more consultations than five years ago. Many commentators believe primary care capacity to be saturated. I believe this unmanaged bubble is the most important area for focused investment and novel models of care if we are to achieve maximal reductions in health inequalities.
Without addressing this bubble we will forever miss our national/regional health targets.
1http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4019362.pdf accessed August 2015
2http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/286/286.pdf accessed July 2015
3Health Inequalities National Support Teams- disbanded 2011
4http://www.kingsfund.org.uk/topics/public-health/how-healthy-are-we David Buck, Slide 58, accessed July 2015
5http://www.hscic.gov.uk/qof accessed July 2015
6http://www.institute.nhs.uk/commissioning/general/health_inequalities_national_support_team_resources.html accessed July 2015
7http://fingertips.phe.org.uk/profile/general-practice/data accessed July 2015
10www.dhsspsni.gov.uk/qof_exception_reporting_bulletin_2012_13.pdf accessed July 2015
11http://www.hscic.gov.uk/catalogue/PUB15751 accessed July 2015
12https://www.gov.uk/government/publications/duncan-selbies-friday-message-18-july-2014 accessed July 2015