1. Breannon Babbel, MPP, MPH
Urban Studies
University of Glasgow
31 May 2016
Tackling health inequalities in
primary care: an exploration of
GPs experience at the frontline
2.
3. Outline
⢠Background context
⢠Scottish healthcare vs. US healthcare
⢠Scotlandâs health inequalities
⢠GPs working in areas of deprivation
⢠Lipskyâs street-level bureaucracy
⢠Methods
⢠Findings
⢠GP role in tackling health inequalities
⢠GP as SLB
⢠GPs and advocacy
⢠Implications for the US
12. Role of Healthcare in Tackling Health
Inequalities
⢠Healthcare can:
â Reduce the severity and delay progression of
disease (Starfield, 2004)
â Mitigate health inequalities via population health
coverage which focuses on socially disadvantaged
and marginalised populations (Gilson et al., 2007)
⢠Universal healthcare can ameliorate the health
damage caused by disadvantage (Macintyre, 2007)
13. Patients in deprived areas
ď§ Multiple morbidity
ď§ Mental Illness
ď§ Addiction
ď§ Unemployment
ď§ Lower Income
GP Challenges Related to Deprivation
Complexity
15. Lipskyâs Street-Level Bureaucrat
SLBs are characterised by
their:
⢠Large caseloads
⢠Inadequate resources
⢠Need to process work
expeditiously
⢠Non-voluntary clients
16. Lipskyâs Street-Level Bureaucrat
SLB âdilemmasâ result from
trying to meet
bureaucratic goals and
patientsâ needs:
⢠Autonomy vs.
bureaucratic control
⢠Responsiveness vs.
standardisation
⢠Demand vs. supply
(Lipsky 1980, 2010)
Professional
Autonomy Organisational
Guidelines
18. * Possilpark Health Centre- 1st, 4th, and 25th most deprived practices in Scotland
24 semi-
structured
interviews
Glasgow
& Lothian
Health Boards
19. Research Agenda
⢠What role (if any) do they see in tackling health
inequalities?
⢠What are their constraints?
⢠How do they negotiate the conflict of professional
autonomy vs organisational control?
⢠How do they view their role
as potential patient advocate?
21. GPs: Social Constructions of Patients
Negative Constructions
⢠Victim blaming
âA lot of it is I think they just basically like to abuse
drugs [rather than change lifestyles]. Itâs the same
with alcohol, they just like to abuse alcohol and
thatâs it.â
22. GPs: Social Constructions of Patients
Positive Constructions
⢠Patient empathy
âThe problems people have, just trying to live their
lives never mind look after their healthâŚI mean
they also are aware that they should be changing
the lifestyles, should try and stop smoking or they
should be drinking less or whatever.â
23. GPs: Health Inequalities
Negative Constructions
⢠Focus on lifestyle and
health behavior
âCultures of smoking and drinkingâŚâ
âMost people actually prefer sweet things and crisps,
and they donât want to have an apple...â
24. GPs: Health Inequalities
Positive Constructions
⢠Wider SDH and
structural determinants
âMany of our patients are on such a low wage I
don't know how they surviveâŚâ
âWhere's the incentives to stop smoking, if your life
is falling apart around you?â
âIf we donât deal with [wider structural inequalities]
weâre stuffed...the real determinants [of health] are
getting worse and worse.â
25. GPs: Health Inequalities
More convergence on individual role:
1. Health improvements via prevention, protection and
promotion strategies
âIf you invest more money in general practice, then
patients will get seen quicker, we should pick up health
problems quicker and cancer survival statistics and
everything else should improve.â
2. Continuity of patient care
âWeâre a constant in their life and weâre always here.â
27. GP as SLB: Workload Constraints
Constraints primarily stemmed
from:
⢠Shortage of time
⢠Complexity of patients
⢠Contractual obligations
28. GP as SLB: Workload Constraints
âLet's say you're very efficient, and you give yourself ...2
minutes to type things up. So it's 8 minutes for an
appointment. If somebody comes in, very typically, with
2 or 3 separate issues, you're then thinking, okay, you're
giving yourself 2.5 minutes per issueâŚthat's just gonna
be, from the patient's side of things, so ridiculously
rushed and haphazard. And from my side, you might
miss things.â
29. GP as SLB: Autonomy vs Control
âItâs about an 89 year old whoâs got a cholesterol of 5.1.
Well, it really doesnât matter whether her cholesterol is
4.9 or 5.1, sheâs 89âŚ
You know clinically I am able to make the
judgement, and I should be able to
âŚI probably shouldnât increase their statin because it will
just make them have nasty side effects. And itâs probably
4.9 when I do it next week anyway.â
30. GP as SLB: Negotiating Dilemmas
For GPs, professional autonomy overrides bureaucratic
guidelines if:
1. They perceive ignoring the guideline to be in the
best interest of the patient and
2. The financial loss is minimal
Independent contractor status viewed as vital for
allowing GPs to determine individual patient and
practice priorities
ď SLB doesnât explain GP role outside of practice
32. GP Advocacy: Clinical Care
⢠Involvement in secondary/specialist care
âAnd they might come in with a plastic bag full of
different letters, all the different services theyâre involved
with. And it might be, âIâve missed these appointmentsâ,
and Iâll pick up the phone and try and deal with
that.â
âWe are advocates in the sense that we just sort
everything out for people.â
33. GP Advocacy: Individual Social Issues
⢠Addressing the ânon-medical side of practicing in a
deprived areaâ
âYou think, right, this person gets chucked out of their
house, their mental health is gonna deteriorate, their
physical health is gonna deteriorate, and Iâm gonna have
a bigger problem on my hands and Iâll have a more sick
patient, so it makes an interest for me to actually
write that letter for free to give them a help.â
34. GP Advocacy: Community
⢠Developing links within the community
âSo most of whatâs making our patients come to the doctors
are those lists of life threatening conditions which are well
understood â social isolation, mental problems, poor
parenting, drug and alcohol issues, unemployment,
deprivation. Now, most of those are not a straight health
issue, so the answer is not going to be a medical practice,
but the answer will be a medical practice linking with
other services.â
35. GP Advocacy: Policy & Politics
⢠Flag where inequalities exist
⢠Bear witness to the damaging effects political
decisions have on patientsâ lives
⢠Advocate for policy change
âWe donât have the resources to give people jobs or give
people better housing, or more money, or deal with child
povertyâthatâs a political and social issue. And we can
only advise what we see and what the effects of that is on
patientsâ health.â
36. Deep End Group
⢠âVery much guided by frontline GPs and their working
experiencesâŚâ
⢠Successful in â[getting] the ear of the governmentâ
GP Advocacy: Policy & Politics
Key Outputs
⢠Advocacy on policy
⢠Pilot projects including:
improving linkages with
community services, connecting
primary care to social work
37. Implications for the US
Importance of GP empathy; ability to identify need
Ability to shape policy through the use of local knowledge
and community engagement:
1. Patient advocacy
2. Improving connections with local services (FQHC)
3. Influencing policy
Value of a practitioner-led, academic supported group,
which has successfully advocated on behalf of the patients
it serves