In this ground breaking book, the authors propose ways to cut through uncertainty, which is explored as an inevitable (and even desirable) component of clinical practice. A Map of Uncertainty in Medicine (MUM) is used to classify uncertainty and to define the skills that will help find a way though practical difficulties. It is always good to have your MUM with you in a tricky situation!
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Working with Vulnerable Groups
A Clinical Handbook for GPs
By Paramjit Gill, Nat Wright, Iain Brew
Royal College of General PractitionersCopyright © 2014 Royal College of General Practitioners
All rights reserved.
General practice, health inequalities and social exclusion
Una Macleod and Paramjit Gill
Key learning points
Recognise the impact of health inequalities on health and health care.
Understand the term 'social exclusion'.
Describe the role of general practice in addressing health inequalities.
Discuss the ethical issues raised in delivering care to disadvantaged groups.
Since the beginning of the NHS, inequalities in health have existed. Though a number of initiatives to tackle these have been described, health inequalities still remain a challenge. General practice is a core element of the new NHS and its role in tackling these inequalities is likely to increase in the coming years. This chapter provides an overview of the range of health inequalities and the role of general practice in addressing these.
First, we need to understand what the term 'social exclusion' means. For years policymakers have been speaking about health inequalities and disadvantage, and during the past decade social exclusion has become the preferred term. It refers to the inability of an individual, group or community to participate effectively in economic, social, political and cultural life: alienation and distance from the mainstream society. It is a very broad definition and refers to people who are suffering multiple and enduring disadvantage; they do not have the opportunities that the majority of us take for granted. It can therefore include, for example, the homeless, asylum seekers and refugees. Can you think of any more groups?
Box 1.1 (overleaf) lists some further examples but note that this is not an exhaustive list and the groups can overlap with individuals having multiple complex health and social needs. The challenges of caring for some of these groups within general practice are covered in this book but first we provide the background to these.
The essence of general practice
The fundamental element of general practice is the relationship between patient and doctor. This remains true despite the considerable changes to society and to practice that have occurred over previous decades. In the past, this relationship was characterised by the term 'family doctor': GPs occupied a place in communities and in families, and continuity of care for patients by the same family doctor was the norm. Although this model has largely disappeared, the relationship between patient and GP is still key to modern health care. Continuity of care continues to be important, although this may sometimes be informational rather than personal. In some instances the relationship may be one that spans many years, while in others it may be for the duration of an episode of illness. For some patients it is a relationship with one doctor, while for others it is an ongoing engagement with a practice.
Traditionally, the doctor–patient relationship was based on face-to-face engagements lasting around 5–10 minutes (lengthening in more recent decades). More recently, other types of consultation have become more common, such as those via telephone and electronic communication. But regardless of method, at the heart of the process remains the encounter between patient and doctor. However, it is not only the type of consultation that has changed in recent years, but also the encounter itself, which has become increasingly complex. Whereas previously the GP–patient consultation was largely a diagnostic or supportive encounter, the general practice consultation may now also include health improvement and risk assessment, anticipatory care, long-term disease management, and advanced care planning. Similarly, the external pressures on GPs have also changed. Although many in the UK remain independent contractors, they are much more accountable to Primary Care Organisations and to professional bodies, a situation that adds its own weight to the doctor–patient encounter. For example, in many areas of the UK there are explicit pressures on drug and prescription budgets that need to be considered within the context of the individual consultation.
As well as caring for individual patients, GPs also take on a population perspective in managing conditions within the practice. For example, procedures such as cardiovascular screening are initiated within practices to reduce the public health impact on a locality. Another example is working with other practices within a locality to ensure that services such as health visiting are provided.
Whatever the method of consultation, and regardless of internal or external influences, many GPs would describe good general practice as seeking to do the best for the individual patient in the consultation at any given point in time. This book challenges us to consider that all of our patients are not equal in terms of need, and that therefore we may have greater responsibilities to some patients than to others. This creates a tension between considering the wider context and the individual patient – trying to resolve this tension has become everyday work for GPs. This book is designed to provide some guidance in relation to dealing with this.
GP activities and consultations do not take place in a vacuum; rather, they occur in the social context of the time, and in the social context of people's lives. This is clearly more important with respect to some consultations and situations than others, but it is rarely irrelevant. All are not equal – people's needs vary, sometimes throughout their lives, sometimes as a result of inherent disadvantage. And as this book will demonstrate, some are more disadvantaged than others.
GPs more than any other group of medical professionals see first hand the impact and effects of disadvantage. For example, the occurrence of a sudden and unexpected myocardial infarction requiring urgent stenting or bypass grafting is a significant, potentially life-changing event in anyone's life. It is however experienced differently by the 50-year-old man whose critical illness policy pays off his mortgage, takes care of immediate financial concerns, and whose employer will allow a graduated return to his desk job, than it is by the man of the same age who is considered unfit to return to his job as a publicly employed gardener and whose wife is unable to visit him in hospital because she is caring for their grandchild, the child of their drug-misusing daughter who visits occasionally and only to ask for money. The eventual impact on these two families of the same event will be very different.
The purpose of highlighting these differences is not to deny or lessen the impact of the illness on the first man and his family. Such an event is significant, and will be associated with significant anxieties that may need to be worked through with help from primary care professionals. However, the anxiety and stress surrounding a new diagnosis like this cannot be dealt with appropriately by a GP unless he or she has a good understanding of the patient's social circumstances, and, further, what that social context is likely to mean for the health and wellbeing of his or her patient. Good GPs understand social context, and are aware that the sociology of medicine is as important as the pathology. So while providing care equally to all at the point of need is the aim of the NHS, it is evident that in fact we are not all equal. Even within the same patho-clinical situation, the social context may make similar clinical scenarios work out differently in practice. It is therefore necessary to take account of the differences that exist between patients or families in order to treat them appropriately.
Individual general practices differ in how they witness disadvantage at first hand. Some practices are situated in areas of multiple socioeconomic deprivation, where disadvantage is the rule rather than the exception, and which presents its own organisational and workload challenges. Other practices care for large numbers of specific groups of patients who suffer from a particular type of disadvantage (and may indeed have been established to take account of such a disadvantage), for example practices that serve the homeless or prison populations. For most GPs, however, they will see particular patients with disadvantage among other patients, who are, by comparison, relatively advantaged. All practices will encounter patients who are more disadvantaged than others (for example those with learning disabilities or physical disabilities etc.). For all of us, therefore, understanding the challenges and issues presented by these patients is extremely important.
There are significant differences in health and health outcomes depending on social position. These are well documented but need to be remembered in the context of a book considering social disadvantage. We know that health outcomes, both in relation to morbidity and mortality, are socially patterned, and are influenced by social determinants. The health of individuals largely depends on the social conditions in which they live and work, and in turn their health may determine where they live and work.
There is a considerable body of work documenting the evidence relating to the social determinants of health. As social factors vary between societies, communities and individuals, so too do health outcomes. Consequently, when considering individuals and their lives, these factors need to be taken into account. A number of models exist to describe and explain the interaction between processes resulting in health inequalities, including the well-known model devised by Dahlgren and Whitehead in the early 1990s (Figure 1.1). All of these models recognise the complexity of the issues involved and acknowledge that social factors combine positively or negatively to impact on health outcomes. Although these models consider health inequalities in different ways, all accept that important social factors and processes include:
1 Individual factors such as age, gender, ethnicity and class (sometimes referred to as social position)
2 General socioeconomic, cultural and environmental factors such as employment, living conditions, education, housing and health care
3 Social networks such as family and community
4 Specific exposure or lifestyle factors such as smoking, diet, physical activity and alcohol consumption.
Social processes make the coexistence of several of these factors more likely where one or two of them are present. For example, people living in poor housing who are unemployed may be less likely to exercise and more likely to smoke than those who are employed and living in good housing. The motivation and social support necessary to exercise or to stop smoking are also likely to be lower in those from more disadvantaged situations. Similarly, those with chronic ill health are more likely to be unemployed, outcomes that are both influenced by original social position.
In addition to the impact of social processes and structures, many social scientists argue the importance of life course on health and health outcomes. A life course perspective on health and its social determinants considers an individual's biological status as a marker of his or her past social position, and, as a result of the structured nature of social processes, as being liable to result in the accumulation of future advantage or disadvantage. So, disadvantage early in life is likely to accumulate additional disadvantage throughout life. Therefore, when GPs see patients in middle or old age, many of these processes will already be established. This life course approach can be applied to the study of health inequalities. This approach is an attempt to understand health inequalities from the accumulation and interaction of factors acting both early and later in life.
Life course factors begin before birth and will impact on child health. So, for example, poor nutrient supply to the fetus is likely to affect fetal development. This is a complex process, but it is likely that in well-nourished populations the interaction of diet with the mothers' pre-pregnancy nutritional status, metabolism and physiology will work to produce the best start in life. During infancy, the major risk factors are malnutrition and infection. Both are associated with poor social circumstances, and both can threaten survival as well as development. Childhood circumstances have particularly powerful effects on health outcomes, with some studies demonstrating long-term adverse health consequences. Disadvantage in childhood has been shown to impact not only on physical health, but also on cognitive and emotional development. More recent theories stress the role of the interaction between environmental factors and genetic predisposition, arguing that the physical, psychological and social environment may determine the way in which genes are expressed.
Thus, individuals enter adulthood with a health advantage or disadvantage relative to the rest of the population. There is evidence that where individuals can better their life experiences, for example by education and/or occupation, they improve their health outcomes. The worst health outcomes are seen in those whose social disadvantage continues into adulthood. Similar patterns are seen in ageing, with those from more disadvantaged groups experiencing ill health at an earlier age, and a more rapid decline in physical ability.
In summary therefore, the physical, psychological and social aspects of an individual are linked together very closely and need to be taken account of when we consider determinants of health, and when we consider the implications of disadvantage.
The implications of disadvantage for general practice
How then is disadvantage encountered in general practice, and what are the implications of this for GPs and for primary care teams?
Disadvantage may have many different implications, some of which are highlighted in the chapters of this book. However, the general implications of disadvantage for primary care are three-fold: 1) how disadvantage may impact on the way in which patients engage with practice, and on the particular expectations that they may have; 2) how disadvantage may create or impact on the actual problems that a patient presents with; and 3) how disadvantage may impact on the way that the practice has to conduct its interaction with that individual, group or patient population. Therefore general practices that find themselves situated in areas of multiple disadvantage are under unique and particular pressures. These have been documented particularly well in General Practitioners at the Deep End.
In order for GPs to understand the implications of disadvantage, perhaps for an individual patient, they first of all need to understand difference, and the particular way or ways in which one patient might differ from others. This book gives help with this for a number of different groups that experience disadvantage. This will involve understanding the disadvantage itself as well as the particular impacts of that on health and the requirements for health care.
The effects of disadvantage, or, as we have already considered, multiple layers of disadvantage, are clearly seen in general practice in many ways. Some aspects of disadvantage relate to life course (for example older people) and some to personal characteristics, such as gender or ethnicity. Others still relate to the health implications of belonging to a particular group, such as the homeless. Within each of the core areas of general practice activity, differences between individuals can be relevant. Some areas where disadvantage may impact are considered below. We mention the relevance of literacy several times; primary care practitioners also need to be aware of the rather more complex idea of 'health literacy'. These overlap, and it is clear that disadvantage is associated with poorer health literacy.
Access to services
Accessing general practice is important for all patients, and obtaining an appointment with the preferred practitioner on a given day may be fraught with challenges. First, a patient needs to understand the system in his or her practice, which may differ from other practices. This may be explained in the practice leaflet, but it may not be readily accessible to all as it assumes a certain level of literacy. In most practices, a negotiation then needs to takes place with the practice receptionist. Even if these seemingly straightforward barriers are overcome, there may be additional physical barriers, for example for wheelchair users.
Self-limiting illness forms a considerable part of the workload of general practice. As models of working and options for reducing pressures within the NHS are considered in the context of an ageing population, this is one area in which more self-care by patients is regarded as easing the burden on the health service. However, patients need to have the capacity to take this burden on themselves, they require appropriate literacy in order to read self-care materials, and they need to have the awareness and ability to access services when an assumed self-limiting illness continues. Such abilities include fairly complex emotional and cognitive processes. For some people, such as those described in this book, this may pose significant challenges.
Excerpted from Working with Vulnerable Groups by Paramjit Gill, Nat Wright, Iain Brew. Copyright © 2014 Royal College of General Practitioners. Excerpted by permission of Royal College of General Practitioners.
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Table of Contents
Foreword Iona Heath,
Preface Paramjit Gill, Nat Wright and Iain Brew,
List of contributors,
1 General practice, health inequalities and social exclusion Una Macleod and Paramjit Gill,
2 Sexual orientation and the health of transgendered people Rafik Taibjee,
3 Caring for people experiencing homelessness in primary care Angela Jones,
4 Caring for Travelling communities in primary care Nwakuru Nwaogwugwu, Joseph O'Neill and Paramjit Gill,
5 Refugees and asylum seekers in primary care: from looking after to working together Gervase Vernon and Rayah Feldman,
6 Prisoner health issues Iain Brew,
7 Caring for older people in primary care Louise Robinson,
8 HIV and other blood-borne viruses Surinder Singh and Paul Shire,
9 Caring for patients with intellectual disabilities Graham Martin,
10 Adolescent health Dick Churchill,
11 Clinical care of disadvantaged groups in remote and rural areas A. Gordon Baird,
12 Intersectoral action as a strategy for primary health care to reduce health inequity Sara Willems and Jan De Maeseneer,
13 The future of general practice: challenges and opportunities Gilles de Wildt and Paramjit Gill,