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Opportunity to challenge inequality?

The issue of health inequality is integral to both ongoing talks regarding a new GP contract and the Government’s stated intention to implement Sláintecare.

The Department of Health has also stressed that one of the chief goals of its public health policy, Healthy Ireland, is to “reduce health inequalities”.  That health inequality is a fact, and a serious challenge, is publicly accepted by most working within healthcare and backed up by statistics (see panel), but does this moment of change create a possibility for some serious progress in fighting health inequality?

To some doctors, both the GP contract talks and Sláintecare do indeed provide a unique opportunity to tackle various issues of inequality, but others remain deeply sceptical about Sláintecare in particular.

In terms of the ongoing talks around a new GP contract, participants told this newspaper that inequality is front-and-centre in the discussions, with particular focus on the possibility of the introduction of a weighted payment and resources system to favour doctors working in areas of particular economic deprivation.

Contract

For its part, the IMO said it “constantly” raised the need for a deprivation-weighted system under a new GP contract with Government and that such issues are forming part of the ongoing talks.

“The issue of deprivation-weighting for deprived patients or a deprivation allowance for GPs working in deprived areas is one which the IMO have consistently raised with Government,” an IMO spokesperson told the Medical Independent (MI).

“It remains an issue under the Memorandum of Understanding. Patients in deprived areas often have comorbidities and on average have a significantly lower life expectation. As the GMS is weighted on the basis of age and these patients tend to have significant health problems at a much younger age, it is necessary to weight specifically for such patients.”

The spokesperson added that the issue of how deprivation impacted rural primary care was also forming part of the contract negotiations.

“Rural and remote areas also require supports due to their isolated nature, lack of secondary system supports and the wider geographic spread of such patients,” said the IMO spokesperson.

“In this regard, the removal of distance coding for such patients was a significant blow to rural general practice and one which must be remedied by the provision of additional resources to support such practices and patients.”

NAGP CEO Mr Chris Goodey told MI that the Association also supports the introduction of some weighted payment or resource system in a future contract to reflect the reality of deprivation and inequality. He added that the “issue had been discussed” between NAGP negotiators and the Department at meetings last year. However, Mr Goodey highlighted the NAGP’s serious concerns with the general slowness of talks and the lack of progress towards creating a new contract.

Prof Susan Smith, Associate Professor in the Department of General Practice at the RCSI, and a member of the ‘GPs at the Deep End’ group, is strongly in favour of the introduction of a weighted system under a new contract. The Deep End group is made up of a number of GPs serving populations in deprived areas of the country. It was established in 2012 and has been inspired by the original Deep End group formed in Glasgow in 2009.

“At the moment, the GMS contract is just a payment based on age of the patient and it does not take account at all of the social deprivation or anything like that,” Prof Smith told MI.

“We know from lots of data in Ireland and across the world that socio-economic status has a massive impact on health. People who are in the most disadvantaged communities get conditions much earlier, and yet GPs working in those areas get the same resources to look after people who are essentially far sicker and in need of greater help. They also have less capacity to use out-of-pocket payments, trying to pay our way out of our current waiting list structure — say, for diagnostic tests like x-rays or to try and see a specialist.

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Prof Susan Smith

“They hit problems, because both the public system has such long waiting lists and also because GPs in those areas have less time to manage the individual patient, because people have more complex needs.”

The figures behind inequality

According to the European Commission’s State of Health in the EU — Ireland Country Health Profile 2017, more than 80 per cent of the population in Ireland report being in good health, a higher proportion than in all other EU countries.

But behind this good news there is a more complicated story of inequality and economic deprivation impact on health.

“However, as in other EU countries, there is a gap in self-rated health by socioeconomic status, with more than 90 per cent of people in the highest-income quintile reporting to be in good health, compared with about 70 per cent of people in the lowest income quintile,” reads the Commission’s Health Profile.

It further notes that behavioural risk factors are more prevalent among disadvantaged populations in this country.

“As in other EU countries, many behavioural risk factors to health in Ireland are more common among people from groups with lower socioeconomic status,” reads the profile.

“For example, people living in the most deprived areas of Ireland are more than twice (35 per cent) as likely to smoke than those living in the least deprived areas (16 per cent). The situation is similar for other risk factors, such as binge drinking and obesity.

“This higher prevalence of risk factors among people with lower levels of education or income contributes to health inequalities.”

This conclusion is backed-up by Irish-based studies and figures. The IMO’s Position Paper on Health Inequalities (2012) notes that despite significant improvements in health and life expectancy on the island, health inequalities remain.

“Health inequalities are evident at all stages of life, from birth to old age,” according to the union’s position paper.

“Health inequalities are also reported in populations living in deprived areas and in disadvantaged population groups, such as people living in poverty, the unemployed and Travellers.”

Using figures from the CSO, the IMO’s paper also highlights that life expectancy at birth for males living in the most deprived areas is 4.3 years less (73.7 years vs 78 years) than that for males living in most affluent areas, while life expectancy for females living in the most deprived areas is 2.7 years less (80 years vs 82.7 years) than that for females living in the most affluent areas.

“Furthermore, life expectancy at birth is 6.1 years higher for male professionals and five years higher for female professionals than their unskilled counterparts.”

The HSE and Department of Health do not deny the significant challenges raised by health inequality, with the Department stating that one of the chief goals of its public health policy Healthy Ireland is to “reduce health inequalities”.

Deprivation

Prof Smith said that such a payment would help rural “as well as urban GPs”.

“I think if the deprivation payment was based on individual patients, any GP looking after those patients would get the additional resources and that would apply to rural GPs also, because rural deprivation is quite serious as well,” she stated.

“It’s just because the numbers are smaller, it is not often as obvious as urban deprivation.”

But Prof Smith said this was not just about money: “You don’t just need the weighted capitation payments, you also need other things being put in place.

“Things which may be more relevant for practices that deal with what’s called ‘blanket deprivation’, so where the majority of patients are living in deprived communities, which is less common in rural areas because there is more of a social mix.”

Prof Smith said these aspects would include “primary care teams and infrastructure” in deprived areas.

“They should be prioritised. We already have a model with the DEIS [Department of Education and Skills] schools; we acknowledge that those schools need extra resources they need capital and staff. We would say the same applies to general practices. So perhaps you would get additional practice nurse support.

“In some of these areas, GPs are still being asked to make huge financial commitments and being asked to rent, so that is going to put off young GPs from going into those areas. The work is harder, therefore the policy-makers need to try and make sure people are not penalised for trying to work in those areas.”

In terms of the ongoing contract talks, Prof Smith said the Deep End GP group does not have any particular insight into progress, however “we know that people are very aware of the issue”.

“We are not a political organisation and we are not aligned with any GP group; we have specifically stayed independent from the unions and the College [ICGP].

“But we obviously liaise and we try to meet everybody. We have met the College — they are very supportive — the unions, Department and HSE officials; we are trying to meet the Minister [for Health Simon Harris] again.

“People are generally supportive. But there will be lots of competing demands [within the talks].”

For doctors working every day with the challenges of poverty and inequality, the need for more GPs is clear.

Dr Austin O’Carroll works in a medical practice on Mountjoy Street in Dublin’s inner city. He is also a founder of Safetynet, a network for health professionals and organisations working to improve healthcare access for homeless people.

When asked what is the most crucial issue in this country in terms of health inequality and the provision of healthcare, Dr O’Carroll told MI it is the iniquitous nature of the primary care provision system.

“Despite people in areas of deprivation having a lower life span and spending twice as long with multimorbidity than people from affluent areas, the distribution of GPs is unevenly distributed towards affluent areas,” according to Dr O’Carroll.

When asked  what is the most important reform Government could initiate in this area, he said it should be to “increase the number of GPs working in areas of deprivation” and “introduce health liaison workers in areas of deprivation”.

Distressing

The issues currently discussed in the contract talks are not merely theoretical and will have real life impacts on the work of GPs such as Dr Edel McGinnity, who works in the Riverside Medical Centre in Mulhuddart, Dublin 15, an area of significant economic disadvantage.

“The most crucial issue is that mortality in the poorest areas is up to three times higher than the most affluent,” Dr McGinnity told this newspaper.

“Obviously, a lot of this is due to social and economic factors, but it is greatly aggravated by the fact that access to health services is much worse. This is because of the persistence in distributing resources according to numbers with no regard for need,” she said.

“This issue is very severe in general practice. Multimorbidity [in patients] is more common, approximately 40 per cent higher for GPs in disadvantaged areas, and occurs at a much younger age, typically 10-to-15 years earlier.

“In addition, they are more than twice as likely to have a combination of physical and mental health problems.

“The only way GPs in such areas can deal with increased need is to have shorter consultation times, which means that care is suboptimal. This is especially problematic in relation to chronic disease management, cancer screening and early detection, which often have to take a back seat to acute health and psychosocial issues.

“The level of lost opportunity to improve health that we witness daily is very distressing, all because we don’t have time.”

But the Mulhuddart-based GP believes there are significant reforms that could be made, echoing some of the points made by Prof Smith.

 “The most urgent reform necessary is to distribute resources according to need, as already happens in the education service (DEIS schools),” she said.

“This is needed across all services, but especially general practice, mental health services (especially for children) and diagnostics. Another useful policy would be to introduce ‘link-working’, which has been trialled with success in Scotland, where link workers based in practices can make a huge difference to health by assisting patients and their GPs to navigate social issues affecting their health.”

Is Sláintecare the solution?

While the GP talks rumble on slowly behind closed doors, the progress on the Sláintecare Report has become very public and noisy in recent months. In July, Minister for Health Simon Harris unveiled Ms Laura Magahy as the first Sláintecare Executive Director and  Dr Tom Keane as Chair of the Sláintecare Advisory Council, while the Government published the Sláintecare Implementation Strategy the following month.

Despite some strong criticism from medical representative bodies (such as the IMO and IHCA) regarding Sláintecare, Prof Susan Smith is convinced that the plan, if implemented, will have a positive impact on health inequality.

“I suppose this is where Sláintecare comes in; it really is the first plan that really sought to address universal healthcare access based on need, and we would be strongly supportive of that,” she told MI.

“I am aware that there is controversy around the GP funding element of it. There are GPs who are very strongly critical of the data that was used. The reality is — I know this from my own academic work — we don’t have any good data around GP visitation rates. We are trying to work towards getting that. The truth is, Sláintecare implementation will take a number of years. The budgets were just projected budgets; things can be modified over time, depending on research and what data emerges.”

Prof Smith thinks that it is best not to “knock it and proceed and implement it as best you can”.

But she has sympathy with criticism from the IMO and other organisations with what they regard as Sláintecare’s failure to address resource issues and the recruitment and retention crisis in respect of GPs and consultants. 

“They are right,” she said. “There is an absolute crisis of manpower, [but] it’s kind of separate to Sláintecare. Sláintecare won’t operate without [the manpower crisis being] addressed.

“There will be so many different groups trying to block Sláintecare, because change can be difficult. But I don’t think GPs are trying to block it; most aren’t. They are pointing out the obvious —  that it can’t work unless we have enough GPs.”

In terms of the Government’s progress on Sláintecare, Prof Smith complains that it has been  “incredibly slow”.

“But I am really glad that they’ve moved ahead and appointed someone who seems to be dynamic and focused [new Sláintecare Executive Director]. It’s more positive in the last month or two than it has ever been.”

Dr Mark Murphy, a GP in Dublin, tweets often on issues of health inequality. He also sees Sláintecare as playing a potentially significant roll in dealing with some of these challenges.

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Dr Mark Murphy

“I think there are two broad inequalities in the provision of Irish healthcare,” Dr Murphy told MI.

“The first relates to primary care — with an inverse inequality for persons who do not meet eligibility for GP or primary care services. Fifty-five per cent of the Irish population have to pay the full cost of GP care — this is a barrier to care for many persons who are just above means-threshold eligibility and Ireland is alone in the OECD with this policy.

“It has also limited the ability of general practice to develop nationally, in conjunction with international evidence, guidelines and processes of care.

“Similarly, many persons do not have access to primary care services (ie, public health nurses for dressings, physiotherapy, occupational therapy, etc). Forty years on from the Alma-Ata Declaration and 17 years since the Primary Care Strategy, this represents a sorrowful epitaph of a failure to implement healthcare policy in Ireland.”

For Dr Murphy, the second inequality relates to “unequal access to secondary care services, which includes access to certain primary care investigations affecting those persons who cannot afford  private health insurance.”

Public-funded

Dr Murphy said that Sláintecare may be important in this regard.

“Sláintecare has specifically named one of the main drivers of this problem; a malfunctioning intertwining of public and private sector provision within Irish public hospitals,” he said.

 “We need to implement Sláintecare and increase Government-funded provision of primary care services and public hospital funded services, removing private care from public hospitals.”

“I say Government funding, as I believe we must resist for-profit insurance coverage in the Irish system. As an example, as [then] Minister of Health Leo Varadkar pushed tens of thousands of working families into taking out health insurance packages before persons reached the age of 35; this policy has reduced the ability of working families to save financially and transferred significant monies to private insurance companies, with limited gains for families.”

 However, Dr Murphy also thinks there is a wider lesson that must be learned.

“We need to be cognisant of some unpopular truths — namely, that over-medicalisation is a major threat to every individual’s health, but also the sustainability of modern healthcare systems,” said Dr Murphy.

“This is also coupled with the fact that advancement of life expectancy has halted in the Western world, in conjunction with hype around untested innovations and the role of technology in healthcare.

“As a profession, we need to be honest about the limitations of medicine, our treatments and our tests. As a society, we need to be prudent, funding only policies which have an evidence base and a proven cost-effectiveness.

“But we must also realise that housing, education, social protection and other social determinants of healthcare are arguably more important than the provision of healthcare. As but one example, the health of one asylum-seeker under direct provision would probably [benefit more] from access to the Irish labour market, rather than access to healthcare services.”

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