Primary Care
Research shows that 3.7 million people in England will have a major illness by 2040, an increase of 700,000 more working-age adults compared to figures in 2019. Most concerningly, 80% of that increase will be in the most deprived parts of the country.
These projections, published by the Health Foundation, serve as a stark reminder that we have yet to find a definitive answer to the question of health inequalities. Substantial variation in outcomes persists between the poorest and most affluent parts of the UK.
Without action, it is expected that people will develop major illnesses 10 years earlier in the next two decades if they are living in an area of poverty. In this article, we examine what’s driving these projections, how health inequalities impact populations and possible action areas.
There are said to be five conditions driving health inequality. These are cardiovascular disease, type 2 diabetes, chronic pain, chronic obstructive pulmonary disease, anxiety and depression.
Prevalence of many of these is anticipated to grow at a faster rate in the 10% most deprived parts of the country compared to the 10% least deprived.
What does this tell us? Firstly, these are conditions that are largely preventable or can be well managed in primary care. And yet, we know that many of the poorest parts of the UK face inequitable access to GP services.
This is where the proverbial catch 22 of inverse care law rears its head with the old adage that ‘those who need healthcare the most are least likely to receive it’. Indeed, in the most deprived areas, there are fewer GPs per patient, with 2,400 patients per fully-qualified doctor, compared with 2,100 patients per doctor in the least deprived.
Compounding this problem is the continued lack of investment in primary care, leaving services stretched and struggling to meet demand in underserved areas.
But let’s rewind for a second and look at some of the risk factors behind these conditions. Alcohol-related harm has been found to be higher in disadvantaged groups while smoking rates are often higher too. Furthermore, where people live in poverty, it can be harder to live healthy lives.
Eating healthy is costly. Research from the Food Foundation found that the most deprived fifth of the population would need to spend 50% of their disposable income on food to meet the cost of the Government recommended healthy diet. This compares to just 11% for the least deprived fifth. The same research also reported that the most deprived fifth of adults eat 37% less fruit and veg, 54% less oily fish and 17% less dietary fibre than the least deprived fifth.
We must also look at what food is readily available in areas of deprivation. In terms of the proportion of food outlets in England, fast food restaurants account for one in three in the most deprived parts compared to one in five in the least deprived. The cost-of-living crisis has also not gone away with people facing a choice of ‘heat or eat’ in the face of rising energy bills.
“It is therefore unsurprising to see a strong relationship between deprivation and poor diet. Given the link between diet and ill health, it is also unsurprising to see a strong relationship between deprivation and a range of diet-related health problems, including cardiovascular disease and diabetes.”
- King’s Fund, Illustrating the relationship between poverty and NHS services
Certainly, taking just hypertension as an example, prevalence of hypertension In England ranges from 23% in the least deprived quintile of indices of multiple deprivation to 40% in the most deprived.
There is also growing complexity in healthcare needs. People on the lowest incomes are four times more likely to be living with multiple long-term conditions. And those from minority ethnic groups and the disadvantaged are at the greatest risk. A study found that people in the most deprived areas developed three or more conditions seven years earlier than those in the least deprived.
In response, more tailored support is required to effectively care for chronic multimorbidity. The National Institute for Health and Care Research writes:
“People with multiple conditions need effective support to manage their conditions. Our previous review found that the health and care system frequently fails to respond to the needs of the whole person, and instead focuses on individual diseases or issues.”
Indeed, a holistic approach that takes into account physical and emotional needs as well as environmental factors is vital. Furthermore, we need to help individuals navigate the system more easily when living with chronic multimorbidity. We know healthcare is often fragmented and managing multiple treatments let alone multiple appointments for each condition can be difficult to say the least.
Services must closely focus on accessibility needs and be tailored to needs of minority ethnic and disadvantaged groups. And to simplify the care experience of living with multimorbidity, holistic reviews can enable all conditions and medications to be reviewed in a single contact.
This also has a dual benefit in helping primary care services to streamline call and recall and create additional capacity. A multidisciplinary approach leveraging prescribing pharmacists specialising in multimorbidity can help develop care plans that support adoption of optimal management strategies and lifestyle behaviors too.
Poverty can lead to a sense of disconnection whereby individuals may be reluctant to engage or have a sense of apathy towards healthcare and community services. Some commentators have referred to this as ‘othering’ where those living in deprived areas can feel excluded and experience a sense of stigma attached to their circumstances.
A by-product of this could be the non-attendance of appointments. The NHS Confederation has highlighted the impact of health inequalities on did not attend (DNA) rates where individuals living in deprived areas are said to be more likely to DNA and have poorer outcomes.
While a Mind report on the connection between mental health and people living in poverty reported distrust in care providers as a recurring theme in its survey findings. One respondent who who had chosen not to seek formal support from their GP for their mental health remarked:
“I don’t want the GP to log me on some database as ‘mad’ and then be denied a credit card in the future.”
Thus, simply providing ‘more access’ will not be ‘the silver bullet’ for individuals who do not want to engage with healthcare or community services either out of fear, stigma, apathy or for other reasons.
And, as we know, when people do not engage with health services, major illnesses go undiagnosed for longer. One need only look at the number of people living with undiagnosed diabetes in areas of deprivation for example. The undiagnosed rate in the bottom quintile of indices of multiple deprivation (IMD) is double the figure in the top IMD quintile.
It’s clear that we must double down on proactive outreach to drive engagement and case-find individuals where poverty is prevalent. Data can be used to risk stratify populations and drive early intervention.
For example, here at Suvera we’ve helped partners identify patients with undiagnosed hypertension by taking a data-driven approach. For South One Newham PCN, part of North East London ICB, Suvera added an additional 223 patients with hypertension to the register, an increase of around 8% of patients who are now receiving appropriate treatment. While our proactive frailty service saw 74% of patients across South Central Ealing PCN engage with Suvera outreach for holistic frailty reviews.
This article points to some core underlying issues related to the socio-economic determinants of ill health.
This includes the need for earlier intervention to prevent and manage conditions identified as driving health inequalities. Additionally, we must also target risk factors, looking at real, daily challenges people face in adopting healthier choices.
Where individuals are living with multiple, complex chronic illnesses, that will mean simplifying the system, both in navigation and helping people to manage their health in a more streamlined way. A proactive approach will be essential to activate and empower individuals in their healthcare where disengagement is prevalent.
Alongside these action areas, we can point to 4 key recommendations:
We are working with practices, primary care networks and integrated care boards to effectively target chronic disease and its risk factors in areas of deprivation.
We analyse data to identify undiagnosed patients and pinpoint overlapping chronic conditions. Suvera takes care of patient outreach, engagement and condition management, optimising care plans and medicines.
If you would like to work with us, contact our team on partnerships@suvera.co.uk.
Read our case studies here.