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The role of PBC in closing the health inequalities gap

Practical Commissioning asked NHS Alliance president Professor Chris Drinkwater about the opportunities for PBC in closing the health gap – and what might hold it back

Practical Commissioning asked NHS Alliance president Professor Chris Drinkwater about the opportunities for PBC in closing the health gap – and what might hold it back

What are the biggest health inequality challenges for the UK?

Smoking, alcohol and obesity – and I put all three under the heading of mental health, which is different to mental illness. By mental health I mean people's outlook on life. How people see themselves will affect whether they choose to smoke, drink or exercise.

Is there a rural-urban divide?

In broad terms, young people are moving into the cities leaving an older population moving into rural areas, and each trend has its own challenges. Birmingham, for example, has the highest infant mortality rate in the country, and the increase in concentrations of elderly people in rural areas is creating difficulties with access and transport.

Why have health inequalities widened when NHS funding has increased over the past decade?

What's actually happened is everyone's life expectancy has improved but there has been a greater improvement for the better-off than for the worse-off, hence the gulf.

The NHS, post-Wanless report, has begun to move from being a hospital service to a health service. But it's much harder to improve the health of a nation than it is to bring down waiting lists. For the former, the investment needs to be long-term and NHS financial structures and political timescales do not favour this sort of investment.

There have been major improvements in cardiovascular and cancer services but another reason the gap has got wider is that the better-off have taken more advantage of the increased investment for the screening of such diseases than communities in disadvantaged areas.

A sense of fatalism has developed among patients in deprived areas. These patients feel their health is a result of external events beyond their control.

This means patients tend to put off getting their health sorted out – and the later they come to you, the less can be done.

How is the Government doing in terms of tackling health inequalities?

The research suggests progress is being made in the right direction but it is slow. The smoking ban has been a big help. Scotland, which introduced the ban a year before us, is already seeing CVD levels declining.

The loss of tax revenue (short-term) meant there was a lot of questioning about this policy within Government before it was introduced and we are seeing the same thing now with alcohol. In terms of take-home pay the cost of alcohol has gone down over the past 20 years, but for tax reasons the Government is fearful of restrictions.

How can PBC change things?

The 2002 Wanless report set out the need for full engagement by patients with the NHS and the need to improve the health of the nation.

Without these two factors the NHS is doomed because costs will continue to escalate and it will become unsustainable as a publicly funded service.

It estimated the cost difference between a slow uptake model and a fully engaged model of health improvement will be £30bn by 2022. We need to move to a situation where public health is everyone's responsibility – and that includes practice-based commissioners.

Exhortation doesn't work. We need to engage patients to improve their health. Practice-based commissioners are in a strong position to work with social services and the local authority so that we have a joined up approach to tackling the wider determinants of health.

Long term the greatest potential for reducing costs and producing savings from commissioning is through investing in public health interventions in disadvantaged communities. Unplanned admissions and use of out-of-hours services are much higher in disadvantaged areas.

GPs are great advocates for their community and know the local issues, so a logical step is that they should work with the local community to help decide what actions can bring about change. Savings should come back to PBC and the local community to decide how they should be reinvested.

PBC is making slow progress in addressing inequalities, partly because PCTs are reluctant to devolve responsibility to PBC. Money follows data – there is good data on hospital admissions, referrals and use of A&E.

If you reduce activities in these areas you can make savings but if you prescribe drugs for obesity and run lifestyle schemes you are increasing expenditure – but are you saving money in the long term?

What first steps would you advise a PBC consortium wanting to tackle health inequalities to take?

I think there are a couple of key areas they could focus on. The first is mental health promotion. Many GP consultations have a mental health component.

Depression is as much a social as a clinical condition but NICE guidelines and QOF favour a clinical model where you measure the problem with a questionnaire and end up prescribing yet more antidepressants.

Some GPs are already linking up with voluntary and community groups through models such as social prescribing of exercise or arts-based activities and if this results in people taking more responsibility for their health, then this is a route PBC may wish to explore.

The other big area PBC could focus on is type 2 diabetes, where there is a good evidence to show that the onset of type 2 diabetes can be prevented or delayed by a combination of increased activity, improved diet and weight loss.

GPs are in a good position to identify those most at risk. PBC forums should be thinking about commissioning systematic programmes that will provide effective support, perhaps along the lines of smoking cessation programmes, to people at risk so that they can change their lifestyles.

But isn't it sometimes years before the benefits from investments in lifestyle start to be seen?

With prevention of type 2 diabetes I don't think it is that hard to show potential benefits in a business case.

Type 2 diabetes reduces life expectancy, and the annual cost to the NHS of a patient with type 2 diabetes can also be calculated.

We need to start developing models that can demonstrate the impact that weight loss and increased levels of physical activity can have on preventing or delaying the onset of type 2 diabetes. We would then be in a position to predict future savings.

There has long been talk from the Government about health and social services working in a more joined up fashion to tackle inequalities – what evidence is there that this is happening?

Directors of public health jointly appointed by PCTs and coterminous local authorities should make this easier. Local strategic partnerships and local area agreements also help by providing an infrastructure within which this can happen.

The other driver is demographic change with an ageing population. Older people not surprisingly generate the greatest proportion of NHS costs.

The challenge for both health and social care is to ensure we maintain a fit and healthy population, and this is where schemes such as the Mid-life LifeCheck (an assessment of 45- to 60-year-olds' lifestyle that highlights their risk factors and facilitates behavioural change by goal-setting – due to be rolled out nationally next year) are coming from because if people aren't thinking by age 50 about keeping fit, and maintaining social networks, then this will put increasing demands on social care budgets and lead to increasing admissions.

A simple example is that there is good research evidence that 15 minutes of physical activity three times a week for the over-65s reduces the chances of getting Alzheimer's disease by 40%, with the greatest benefit shown by the most frail.

Health and social care commissioners need to work together to put effective programmes into place that can begin to deliver this sort of intervention.

Professor Chris Drinkwater is president of the NHS Alliance, a former GP and emeritus professor of primary care development at Northumbria University

Challenge is to overcome the sense of fatalism about health seen among patients in deprived areas

Everybody's life expectancy has improved but improvement has been greater for the better off.

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