Inequalities

Good afternoon; I am surprised that there is no mentions in the report of mental health as well as roles of alcohol and druggs as well as perinatal care and their consequences on areas with deprived population . In our area -Woolwich SE18- these are mains reasons along with some mentionned in the report -BME and underDoctor- identified for poor health outcomes.

This is a timely and useful paper which helps to focus attention on the "role" of General Practice within the health and social care environments. What practitioners think they are there to do may differ from the expectation of the users/commissioners/other providers and merits more consideration.
Although nursing is mentioned in the study it is disappointing that its contribution seems to be largely described as a means to "free up time for GPs". Nursing is uniquely placed to compliment General Practice in that its approach is holistic and person centred, nursing values respect that health is both a process and a state. The report rightly comments that GPs have traditionally not been well prepared in areas of health promotion, whereas nursing always looks beyond the presenting problem towards promotion of independence, choice and wellbeing. I would suggest that GP Practices with nursing partnership and development of services to work alongside people with long term conditions do much to foster self-care, choice and health in their areas. GP commissioning, with nursing partnership and a multidisciplinary approach has the potential to make a significant difference to the expectations of users contracting to use the services of the practice and the customer care they receive as a result which would emphasize education, choice, dignity, independence and responsibility in planning alongside the treatment.

Dear Patrick,
Thanks so much for a thought-provoking paper. I enjoyed it. I was particularly interested in the recommendations of "social prescribing". On the back of your and Marmot's recommendation we are going to try to improve this area in Hackney by getting GP trainees involved. The VTS group have certainly warmed to it as have senior Hackney GPs. The VTS plan to research certain areas and services locally (as they work all over Hackney) and then we plan to pool our knowledge. The need to address the social dimension and determinants are readily recognised by GPs junior and senior alike. I was wondering whether you could expand further on what you felt "social prescribing" and perhaps "social pathways" would look like, how we could establish it systemically and how it might function. You also mention the need to evaluate interventions in this field to judge their impact. How do you or should we plan to do that? The Hackney VTS and I would be most grateful for your insights!

This is a useful and timely contribution to the literature on Health inequalities. Marmot and others have drawn attention to the key importance of social determinants of health, and Wilkinson and Pickett to the grave health consequences of an increasingly unequal society. However a key question is "what is the role of the NHS in ameliorating, or perhaps exacerbating health inequalities?" As this paper demonstrates, general practice is a key player here (I include here the entire PHC team, not just GPs!). I write from Plymouth, UK where there is 14 years difference in average life expectancy across a small city (250,000) with a very homogenous population. The key variable is place. There is a direct correlation between neighbourhood deprivation (as measured by IMD 2007) and average mortality. Half of the difference in mortality is attributable to Cardio-Vascular disease, something that at least theoretically should be preventable. There are 3 possible explanations. 1) the epidemiology of CVD is different (maybe people in the most deprived neighbourhoods just drop down dead with no preceding symptom (so we need better prevention). 2)People in deprived neighbourhoods have antecedent symptoms but they do not present them to GP surgeries or they are missed if they do (so we need better patient and GP education). 3)People in deprived neighbourhoods present to GP surgeries but are less likely to get effectively treated long-term (so we need to look after these patients better which can be challenging).
We are currently engaged in research to find out what is happening by identifying every person in the 4 most and the 4 least deprived neighbourhoods by postcode (in whatever practice they are registered) and directly comparing detection and effective treatment rates between the two cohorts. we hope to publish our results in 2011.
This paper will be very helpful for the next phase - what to do about any differences that we find!