Can GPs eradicate health inequalities?

Many believe general practice is ideally placed to help tackle the UK's deep health inequalities, but the profession can't do it alone. David Millett reports on what needs to change

People in deprived areas face worse health outcomes (Photo: iStock)
People in deprived areas face worse health outcomes (Photo: iStock)

The World Health Organisation (WHO) describes health inequalities as ‘avoidable inequalities in health between groups of people’.

But the UK is a long way from avoiding them, and gaps in health outcomes have not been narrowed in recent years.

The RCGP is convinced that GPs – as ‘expert medical generalists at the heart of the community’ – have a pivotal role to play in tackling the problem.

GP funding crisis

Reducing inequalities is tied inextricably to addressing underfunding of general practice, but also depends on cultural change across the public sector, the college says.

In its Health Inequalities report, launched last month, the RCGP argues that the NHS needs to break free from being a ‘reactionary’ service and stop channelling resources towards providing individual episodes of care in ‘silos’.

Underinvestment in general practice over the last 10 years has had a particular impact on health inequalities."

Dr Maureen Baker, RCGP chairwoman

Enabling GPs to commit to a more ‘whole person’ care approach could help address health inequalities, it says.

RCGP chairwoman Dr Maureen Baker says: ‘Underinvestment in general practice over the last 10 years has had a particular impact on health inequalities. We need to get the service in better shape to tackle this.’

In addition to ‘a wider rebalancing of resources towards general practice’, the RCGP has called for incentives to attract more GPs to under-doctored areas and pilots to investigate new models of care.

The scale of the health inequality challenge is vast, with deprivation, public health issues and multimorbidity thought to be among the biggest contributors.

The 2010 Marmot review revealed that people living in the poorest neighbourhoods in England will on average die seven years earlier than those in the richest. People in these areas will spend around 17 years more than their richer counterparts living with disability.

Health inequality

Some health inequalities – such as the differences in outcomes between smokers and non-smokers – seem to present an obvious solution.

But the factors underlying even this difference are complex and finding a fix is far from simple.

For real change to happen, general practice improvements must coincide with a major shift in other public services, health leaders say.

At the launch of the RCGP report, NHS England equality and health inequalities lead Ray Avery said: ‘We need to be more people-focused.’

A more proactive approach to reducing health inequality requires intervention to tackle underlying factors that may not all be directly health-related.

Central GP role

‘We need to order the challenges,’ Mr Avery argued. ‘For example, sometimes a patient’s biggest concern may not be their smoking habit, but their financial worries – and you could tackle their smoking a lot more effectively once you sort out those other problems.’

GPs have a ‘central role’, he said, but could tackle these problems more effectively through a whole system solution involving healthcare services, local government and other public services.

Barriers to information sharing between NHS services, local government and public services can make it difficult for GPs to take the ‘whole person’ view.

Dr Baker says: ‘A huge section of the GP workload is non-medical, including giving patients advice on their benefits – that is part of whole person care and I can talk to them about that. But it could be better for them to go to a benefits advisor.’

GPC deputy chairman Dr Richard Vautrey believes that other parts of the public sector must get their house in order before GPs can be expected to tackle inequality.

GP practice role

‘It is vitally important to make greater efforts to narrow health inequalities, but the best way to do this is through actively tackling the social determinants of care – such as access to good early years education, better employment opportunities and improvements in housing,’ he says.

‘While GPs have some role to play it is these other areas that government and local authorities are best placed to tackle that must be focused on with greater urgency.’

Emma Scowcroft, policy manager at the Department for Communities and Local Government, said at the Health Inequalities launch: ‘The public sector system is not seamless and someone has to deal with the gaps. People go to their GP because they just don’t know where else to turn.’

She said local government is ‘really keen’ to improve communication with CCGs so it is easier for GPs to send and receive information on patients, ultimately improving the care they can provide.

The RCGP has committed to building a learning ‘portal’ alongside NHS England, Public Health England (PHE) and local governments to ‘improve communications and build up networks’ between these services.

The portal would allow CCGs in different areas to learn from successful schemes in other parts of the country.

Different areas face different challenges. Inner city areas, often associated with high levels of deprivation, are well-known to struggle with health inequalities as a result.

But these areas must not be tackled to the exclusion of others. Dr Baker says it can be difficult to decide where finite resources should be invested.

‘We make assumptions about the most in need communities, and tend to focus on inner city areas when talking about health inequalities – but I would flag up remote and coastal areas as well. We need to be more active in addressing assumptions.’

GPs are most likely to settle in the area in which they train – which can be problematic for remote areas with poor links to training schemes.

GP workforce shortage

Low GP numbers in remote areas increase the chance of burnout, and can force those who remain into a more reactive style of care.

Dr John Patterson, the RCGP’s health inequalities clinical champion, says: ‘GPs are the most cost-effective people to activate patients, and they are the cheapest person to help them. My passion is to resource GPs so they can be more proactive, and not stuck in the surgery seeing the 50 patients who have been booked in.’

RCGP would like to see GPs actively monitoring their patient lists and proactively helping those they judge to be at risk of ill health.

But Dr Vautrey warned GPs could not do this alone. ‘We should not allow local and national politicians and policy makers off the hook by trying to shift the work primarily to others to do.’

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