1.  The College welcomes the opportunity to contribute to the Parliamentary Health Care Committee's inquiry into the contributions of the NHS to reducing health inequalities.

  2.  The Royal College of General Practitioners is the largest membership organisation in the United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of general medical practice and to act as the "voice" of GPs on issues concerned with education, training, research, and clinical standards. Founded in 1952, the RCGP has over 33,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline.

  3.  The RCGP has its own Health Inequalities Standing Group (HISG). The group has contributed to college comment on a number of government White Papers, as well as providing evidence to the Acheson Inquiry into Inequalities in Health. Please find attached as an appendix "Health Inequalities, the NHS and Primary Care", a paper written by one of its members, Dr Gilles de Wildt. The HISG was involved in the production of an RCGP policy statement on matters relating to health inequalities "Hard Lives: Improving the Health of People with Multiple Problems", published in 2003. Material from this document is drawn on throughout our response, and a copy is enclosed.

EXECUTIVE SUMMARY

  4.  The College strongly believes in the aim of reducing health inequalities and delivering better patient care. The NHS next stage review could present an opportunity for this to be done if it is carried out following a full and meaningful consultation, to appropriately improve the structure and delivery of healthcare services in Britain today. We must work in partnership, in particular to improve access to diagnostics, access to urgent care and other services within the community and respond to the challenges of a geographically and culturally diverse and mobile population. Improving the quality of the patient experience and provision of care are key priorities. The RCGP is making a detailed response to Lord Darzi's invitation to submit policy ideas to the Next Stage Review.

  5.  As you will know "The Future Direction of General Practice—A Roadmap"[350] (The Roadmap), has recently been issued by the RCGP. This document has the full support of the BMA, COGPED, NAPC, NASGP, NHS Alliance, SAPC and SPA as well as the College's own Patient Partnership Group. We see this Roadmap as an effective framework within which healthcare reform in primary care can take place and health inequities can be tackled. It focuses on three key areas:

—  Improving the quality of the doctor patient relationship

—  Developing general practices as learning organisations

—  Encouraging practices to form federated entities

  6.  The Roadmap outlines a new model of health and social care that builds on the needs of patients and the strengths and values of general practice. The College anticpates that the good and innovative practice outlined in the document will be systematised in a flexible and appropriate way and rolled out on a wider scale to deliver patient care and reduce health inequalities across the country.

  7.  The RCGP strongly believes that the federated model is the best vision for reform of healthcare, this is outlined in the Roadmap and the enclosed response to the NHS Next Stage Review "Invitation to Submit Policy Ideas" This model involves different practices working together in "federations" or collaborations to deliver a wider range of quality healthcare services where patients want—closer to home—by healthcare professionals they know and trust.

  8.  The NHS has a significant role to play in reducing health inequalities. However the task of reducing health inequalities requires the adoption of a robust multi-agency approach to the problem, involving health and social care, housing and educational organisations.

  9.  Greater interaction and collaborative working between primary and secondary care is necessary to reduce health inequalities. This is outlined in a Joint Statement from the RCGP and the Royal College of Physicians[351]. Doctors must be encouraged enabled to work together across traditional boundaries to meet the needs of patients.

  10.  Integrated working between primary and social care is important to ensure a joined-up and holistic approach is taken to the delivery of care in the community and the effective reduction of health inequalities. This is particularly important in areas such as substance misuse, care of the elderly and mental health services where a high proportion of patients will have co-morbidities requiring non-medical interventions that could be facilitated through the development of an integrated care plan.

  11.  A key value of general practice is a holistic approach to disease management. This is the approach that is most appropriate to its community setting. This is particularly important in tackling health inequalities. Co-morbidity occurs disproportionately within populations that are socio-economically disadvantaged or elderly and particularly within the population which are both[352],[353]. Therefore we believe a holistic approach to medicine in the community that accounts for co-morbidity and for other socio-economic factors is the best one to address patients and particularly to reduce health inequalities. Further, older people, those with significant co-morbidity, and those who are disadvantaged, either socio-economically or by ethnic-group, are often under-represented from clinical research trials.

  12.  We would therefore exercise caution with too strong a reliance on the development of clinical guidelines in primary care that are based on single disease studies using clinical research trials such as Randomised Controlled trials and other techniques. Such approaches are familiar to specialists and often appropriate for the improvement of guidelines management of single disease management in hospital settings but not always for primary care, given the exclusion of patients of certain ages and with co-morbidities. Additionally, for patients with multiple problems, several guidelines may be applicable and it is not always beneficial for patients to be treated according to the requirements of each of the guidelines, as such management could result in polypharmacy and excessive interventions.

The distribution and quality of GP services and their influence on health inequalities, including how the Quality and Outcomes Framework and Practice-based Commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities

  13.  The development of collaborative practice between those who serve whole populations and those who serve a personal list should be prioritised. There is a risk that services will become fragmented with inappropriate healthcare reforms that shift services without account of local circumstances—partnership working between professions and services must be preserved in order to successfully tackle health inequalities. Resource allocation formulae must take account of the demands that co-morbidity places on the healthcare system and that this affects deprived areas disproportionately.

  14.  Targets for the management of single disease states need to be weighted to reflect the compounding effects of co-morbidity. Without this, practices that serve people with multiple problems will be systematically disadvantaged as is outlined elsewhere in this response.

Practice Based Commissioning

  15.  The RCGP would support practice based commissioning as a means by which GPs can work in collaboration to deliver patient-centred primary care for deprived communities. We would, however, warn against the possibility of short contract cycles (as a result of increased contestability for services) damaging the doctor-patient relationship. The involvement of the private sector could also, in theory, lead to a situation where the most "high risk" patients are marginalised in favour of "low risk" healthier patients for the purpose of profit. Appropriate systems and incentives must be developed to ensure this does not happen. The most disadvantaged in society fall disproportionately into the first category.

  16.  We support the use of creative use of PBC, for example to provide resources to enable practices to provide enhanced services within schools, appropriately co-located services and better delivery of mental health and substance misuse services.

Quality and Outcomes Framework

  17.  We recognise that the Quality and Outcomes Framework has increased the accountability and transparency of primary care. We do, however, believe that there are a number of problems associated with a framework which measures GP performance against a limited number of easily measurable clinical activities. These are:

—  The indicators used in the QOF measurements do not take account of many of the illnesses which prevalent in areas of high deprivation eg alcohol and illicit drug dependence.

—  The system encourages unitary care pathways ie the GPs success in identifying and treating a single disease. The system does not take co-morbidity into account, which is most prevalent in deprived areas.

—  Many of the QOF trials focus on younger people and so give a distorted picture of the efficacy of treatment.

—  It can be argued that a system which aims to standardise treatment is inherently reductionist and ignores the complexity and variation of disease between individuals. If taken to its logical extreme this can lead to a blanket, mechanistic approaches to healthcare.[354]

—  The system is based on inducements, and so if a GP has to work harder in a deprived area to reach the same targets, they may be inclined to practise elsewhere leading to skills shortages in the most deprived areas.

  18.  We would advise that policy makers work on the basis that poverty is multi-dimensional. This should encourage greater multi-agency working and a review of the indicators used in the QOF measurements.

The effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities; and which interventions are most cost-effective

  19.  Whilst the RCGP does recognise the potential of interventions designed to improve modifiable determinants of health we feel that the success of these interventions depends on a change in attitudes amongst health care professionals and a more rigorous training to deliver them. Furthermore, the specific targeting of key causes of health inequalities should be done in an appropriate way that preserves the principles of a holistic approach in primary care to ensure that other services are not compromised.

Smoking

  20.  The most disadvantaged sectors of society have benefitted the least from the downward trend in smoking prevalence that has occurred over recent decades in the UK. There are currently about 10 million smokers in the UK, and international experience indicates that it is unlikely that this figure can even be halved within the next 10-20 years. Smoking cessation is clearly an area where the NHS has a remit and it should be involved in the following:

—  Systematic identification of smokers in all health consultations

—  Individual promotion of smoking cessation to all smokers

—  Provision of the most intensive cessation support with which smokers are likely to comply, to all who express a desire to attempt to quit (the more intensive the support used, the more likely the smoker is to succeed)

—  Routine follow up and repeat intervention where appropriate

  The following areas, however, are not within the remit of the NHS, and the government should take a lead on these:

—  Price—increasing the price of tobacco products decreases consumption, provided that alternative (ie smuggled or other illicit) sources of tobacco products are also closed off

—  Mass media health promotion—high impact and varied advertising campaigns and other promotional activities that encourage smokers to quit, and young people to avoid starting

—  Smoke-free policies—preventing smoking in public and in the workplace has a substantial impact on smoking prevalence.

—  Banning all advertising and promotion of tobacco products

  21.  Whilst the proportion of smokers accessing cessation services and using cessation therapies has increased progressively in recent years, these proportions are still very small. We would like to see all healthcare professionals embrace smoking cessation to the extent it deserves. Doctors, nurses and other health professionals are still not trained to deliver smoking cessation interventions, and some do not see it as their job to do so.

The success of NHS organisations at co-ordinating activities with other organisations, for example local authorities, education and housing providers, to tackle inequalities; and what incentives can be provided to ensure these organisations improve care

  22.  The RCGP believes that PCTs should encourage and support multi-agency participation in planning and service delivery, including schools and local authorities. We would also recommend that public health specialists who have a dual role of practicing in primary care, or general practitioners with a special interest in public health have a critical part to play in such co-ordination as they possess an overview of both clinical care and organisational structure. For innovative projects to be successful we require all parts of the system (ie the care pathway) to be involved at every stage in the planning. Such projects could be supported by whole system research, and participatory and action approaches to research. We believe the NHS has a duty to ensure that all health and social care pathways for mental health, addiction and physical health needs allow for these needs to be addressed in ways that are culturally sensitive by services that are fully integrated into the patient's community setting.

  23.  Resource incentives could be provided for the co-location of different agencies such as mental health, children and elderly services, where this appropriate. Incentives could also for the provision of enhanced public health services such smoking cessation, dietetic and podiatry within practices. This should also include cost of premises. The provision should be implemented in a way that will help combat health inequalities and deliver better services the most socio-economically and health disadvantaged areas.

The effectiveness of the Department of Health in co-ordinating policy with other government department, in order to meet its PSA targets for reducing inequalities

  24.  Cross governmental working and communication is essential. DH must work better particularly with the DfES and the Home Office and other relevant Departments to ensure the effective addressing of health inequalities and its multi-dimensional causes. The improved delivery of programmes for disadvantaged children, reducing the harms of smoking and tackling substance misuse all require a joined-up Governmental approach.

OTHER POINTS AND RECOMMENDATIONS

Interpreting Services

  25.  Effective interpreting services are important for appropriately delivering healthcare in some communities, often those that suffer from health disadvantaged. There are currently half a million individuals amongst four established communities (Indian, Pakistani, Bangladeshi and Chinese) whose functional English is poor. This does not include refugees, asylum seekers and recent migrants from Eastern Europe.

Defining Poverty

  26.  We should adopt a wider definition of poverty to include access to psychological and relational support. To overcome the problem of intense groupings of social exclusion and associated ill health, we would advocate a multi-disciplinary family case management model whereby family doctors, in collaboration with public health nurses and community outreach/development workers, focus on areas such as shopping, cooking and motivational interviewing with the aim of emphasising choice and empowerment.

Research to manage co-morbidity

  27.  There is an urgent need to know much more about the optimal management of co-morbidity. The evidence base of clinical practice is derived almost entirely from research into single disease states. Older people, those with significant co-morbidity, and those who are disadvantaged, either socio-economically or by ethnic group, are usually under-represented and often excluded fro m clinical research trials.

Continuity of Care and Personal Care

  28.  High quality care of multiple and compounding health problems depends on the ability of the clinician to deliver personal and continuing care over time. Such care also needs longer consultations. Where patients from disadvantaged ethnic groups also require interpretation and advocacy, consultation times need to be at least doubled.

  29.  I acknowledge the contributions of Dr Paramjit Gill, Dr Nat Wright, Dr Arti Maini, Dr Dave Tomson, Dr Richard Byng, Dr Angela Jones, Dr Tim Coleman and Dr Gilles de Wildt towards the above comments. While contributing to this response, it cannot be assumed that those named all necessarily agree with all of the above comments.

Dr Maureen Baker

Honorary Secretary of Council

January 2008

351   "Making the best use of doctors' skills-a balanced partnership-a Joint Statement from the Royal College of General Practitioners and the Royal College of Physicians on how specialists and generalists can work together for the benefit of patients in the NHS", April 2006 http://www.rcplondon.ac.uk/news/statements/jointRCPGP.pdf Back

352   Watt G. The inverse law today. Lancet 2002; 360: 252-254. Back

353   Menotti A, Mulder Nissinen A, et al. Prevalence of morbidity and multi-morbidity in elderly male populations and their impact on 10-year all cause mortality: The FINE study (Finland, Italy, Netherlands, Elderly). J Clin Epidemial 2001; 54: : 680-686. Back

354   Iona Heath, Julia Hippisley-Cox, Liam Smeeth. Measuring performance and missing the point?. BMJ (British Medical Journal), Volume 335, Number 7629 (November 2007), pp. 1075-1076. Back