I came into work on my morning off last week to drain an abscess on Nigel’s back. It was the third abscess I’d drained on him in the last three months. His body is covered with skin sores, testament to poorly controlled diabetes resulting in chronically raised blood sugar levels and a severely compromised immune system. The history of the last decade of his life is etched into his skin. If you study his post-septic scars, like the criss-crossed forearms of my patients who self harm, you will see that there are times of rapid growth; concentrations of old scars, faded over the years, are unmistakeably periods of intense suffering and loss of control. A human dendrochronology, like the rings of an old tree, the tightest concentrations correlate with the hardest years.
If my patients had better housing, employment, education and financial security I’m sure I would see a lot less of them. According to their hierarchy of needs, health maintenance comes a few levels above financial security. When they come to see me, relief of the acute symptoms of distress such as headaches, tiredness, dizziness, aches and pains as well as more overt anxiety and depression takes precedence over the business side of healthcare which is measured, coded and paid for, such as blood pressure or blood sugar control or an asthma or medication review. It is impossible to discuss diabetic control or smoking cessation with someone whose housing depends on her benefits which have just been cut. The diseases that will take years from someone’s life are not the ones they can take of control of when they have lost control of their finances, nor are the problems patients present with the ones that are measured when we talk about healthcare productivity. This is why the recent General Practice at the Deep End research is so important. Information from general practitioners working in the 100 most deprived general practices in Scotland has been gathered to show the impact of austerity on their patients and they share my experience in London,
I observe this again and again that I cannot address medical issues as I have to deal with the patient’s agenda first, which is getting money to feed and heat.
These problems are nation-wide. Health professionals working in general practice and mental health services report significant increases in patients presenting with deteriorating mental health problems because of distress due to the withdrawal of welfare.
The demand for appointments so that I can help patients appeal their assessment or write a letter to facilitate rehousing means the time I have to manage chronic disease or diagnose serious illness is severely pressured. We are seeing increasingly that patients are failing to attend for routine reviews but coming instead for urgent and unplanned appointments; regular prescriptions are not collected because of disorganisation bought on by stress, or insufficient money to pay for them. People who had given up smoking are starting again, and diets and other healthy behaviours abandoned. A report last week on the impact of the economy and policy on heath inequalities in London confirms that poverty has significant detrimental effects on mental health and personal relationships and that there is a vicious cycle of mental illness and debt. Women and children are at particular risk. The British Medical Association last week condemed the government’s Welfare Reform Act because of the impact it was having on patients, as reported by GPs.
Poverty and social exclusion are vital social determinants of health which have serious impacts on life expectancy; there is a difference in life expectancy of 17 years between the richest and poorest inhabitants of the London borough of Westminster. They are also an important driver of demand of health services, in part because of the impact they have on multimorbidity. This is the situation where two or more conditions co-exist in the same patient, hence they are also known as co-morbidities; for example, heart disease and diabetes or cancer and depression. By the age of 65 most of the population have at least 2 morbidities, but young and middle aged people in the most deprived areas have rates of multimorbidity equivalent to those of people 10 to 15 years older in the most affluent areas. And yet despite considerable interest in multiborbidity, there is little or no recognition that social factors are multimorbidities.
Adverse social factors need to be treated as comorbidities, so that we think about how for example colitis, arthritis and poor health literacy interact. One danger of failing to include them is that their impact on the efficiency and productivity of care is ignored. Not only are GPs overwhelmed by patients presenting in distress, but hospitals beds are blocked by patients who lack the sufficient social support for them to be cared for elsewhere and A&E departments, like GP surgeries are full of people who don’t know where else to go. A&E staff report readmitting the same patients week after week because they cannot cope at home, just as GPs report seeing the same patients week after week because they cannot cope without employment or benefits.
The NHS is expected to make unprecedented efficiency and productivity savings of at least 5% a year for the next 8 years, the equivalent of up to £50bn by 2019-20, ‘a productivity challenge too far’ according to Professor John Appleby of the Kings Fund. But already services designed to provide healthcare are being forced to provide social care, because the NHS is the place of last resort when people are most desperate. Productivity and efficiency will go into reverse as our efforts to contain our patients distress takes precedence over management of their chronic diseases.
We urgently need Deep End research throughout the country. In addition, all medical professionals, in particular GPs, district nurses, health visitors and mental health workers who meet with the most vulnerable people in society need training in advocacy. We also need health economists to help measure the impact of welfare cuts on the NHS and the wider economy.
If the BMA is to regain some of the respect lost over its failure to halt the dreadful NHS reforms and its poorly managed response to the pensions debacle, it should make this work its priority.
Without this, we’ll be left with little more than our human dendrochronology.
References:
Deprivation:
Health inequalities ONS 2014: Males in the most advantaged areas can expect to live 19.3 years longer in ‘Good’ health than those in the least advantaged areas as measured by the slope index of inequality (SII). For females this was 20.1 years.
General Practice at the Deep End http://www.gla.ac.uk/researchinstitutes/healthwellbeing/research/generalpractice/deepend/
Royal College of General Practitioners. Deep End progress to date. http://www.rcgp.org.uk/college_locations/rcgp_scotland/initiatives/health_inequalities/deep_end_reports.aspx
Report on ‘The Impact of the Economic Downturn and Policy Changes on Health Inequalities in London” http://www.edf.org.uk/blog/?p=19361
Truth and Lies about Poverty. Joint Public Issues. March 2013
Deprivation, demography, and the distribution of general practice: challenging the conventional wisdom of inverse care: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2553532/
GP access according to deprivation: http://www.patient-access.org.uk/userfiles/file/Demand%20to%20for%20GP%20related%20to%20deprivation.pdf
The Hidden Inequity in Healthcare. B. Starfield. http://www.equityhealthj.com/content/10/1/15
The concept of prevention: a good idea gone astray? http://jech.bmj.com/content/62/7/580.full.pdf
Welfare reform: Pain but no gain. BMA report.
Social Conditions as Fundamental Causes of Disease. Link and Phelan. Seminal Paper from 1995
Impact assessing the abolition of working age Disability Living Allowance. Disability rights.
Health, employment, and economic change, 1973-2009: repeated cross sectional study. BMJ
Association between low functional health literacy and mortality in older adults: longitudinal cohort study. BMJ March 2012
The increased burden of ill health and multimorbidity in poor communities results in high demands on clinical encounters in primary care. http://www.ncbi.nlm.nih.gov/pubmed/18025487
Resilience among doctors who work in challenging areas: a qualitative study http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3123503/
Mental Health Resilience and Inequalities. Mental Health Foundation.
Cameron announces Tory plan to slash benefits. Guardian. 27.06.2012
An average of 23 people are chasing every new job in Britain as the fight to find work intensifies, a new report has warned. Telegraph 27.06.2012
No one seems to be concerned that hugely profitable private firms are forcing thousands into borderline destitution Guardian 02.07.2012
The human cost of welfare reform. 10 min. video Guardian
Financial austerity is being used to dismantle the state. Gabriel Scally Guardian. 03.07.12
A Health Literacy Crisis. Blog.
How the stigma of low literacy can impair patient-professional spoken interactions and affect health: insights from a qualitative investigation BMC Health Service Research August 10th 2013
Multimorbidity:
Psychosocial complexity in multimorbidity: the legacy of adverse childhood experiences Family Practice 2015
Moving beyond single and dual diagnosis in general practice. BMJ 2003
Epidemiology of multimorbidity and implications for health
care, research, and medical education: a cross-sectional study. Lancet
Better Management of Patients with Multimorbidity. The importance of continuity of care in managing patients with multimorbidity BMJ May 2013 M. Rowland
Disease-based care pathways for older patients were found to be neither feasible nor sustainable in primary care. BMC Open Access March 2012 Development of a patient-centred care pathway across healthcare providers: a qualitative study
Literature review from January to April 2012 International Research Community on Multimorbidity.
Multimorbidity and the Inverse Care Law in Primary Care. BMJ June 2012
Beyond diagnosis: Rising to the ultimorbidity Challenge. BMJ June 2012
Better training is needed to deal with multimorbidity. BMJ June 2012
How Can We Treat Multiple Chronic Conditions? BMJ Feb. 2012
Guthrie B et al. The epidemiology of multimorbidity in a large cross-sectional dataset: implications for health care, research and medical education. Lancet Early Online Publication, 10 May 2012 doi:10.1016/S0140-6736(08)61345-8 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960240-2/fulltext
Townsend A, Hunt K, Wyke S. Managing multiple morbidity in mid-life: a qualitative study of attitudes to drug use. BMJ 2003;327:837. http://www.bmj.com/content/327/7419/837
Fortin M, Soubhi H, Hudon C, Bayliss, EA, van den Akker M. Multimorbidity’s many challenges. BMJ 2007;334:1016 http://www.bmj.com/content/334/7602/1016.full
Smith SM, O’Dowd T. Chronic diseases: what happens when they come in multiples? Brit J Gen Pract 2007;57(537):268-70 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2043326/
Towards a more cogent approach to the challenges of multimorbidity. http://www.annfammed.org/content/10/2/100.short?rss=1
Simplifying Care for Complex Patients. http://www.annfammed.org/content/10/1/3.full
Role of depressive symptoms on health related quality of life J psychosom research 2008 http://www.ncbi.nlm.nih.gov/pubmed/19154855
Patients with complex chronic diseases. Perspectives on supporting self-management J Int Med 2007 http://www.ncbi.nlm.nih.gov/pubmed/18026814
Epidemiology and impact of #multimorbidity in primary care: a retrospective cohort study BJGP http://www.ncbi.nlm.nih.gov/pubmed/21401985
Multimorbidity, service organization and clinical decision making in primary care: a qualitative study http://fampra.oxfordjournals.org/content/28/5/579.short
Primary care for patient complexity, not only disease: http://www.ncbi.nlm.nih.gov/pubmed/20047353
Multimorbidity: A challenge for evidence based medicine: http://ebm.bmj.com/content/15/6/165.extract
How can we treat multiple chronic conditions? BMJ march 2012 multimorbidity http://www.bmj.com/content/344/bmj.e1487?sso=
The key to the successful management of multimorbidity …– is to ‘see the person in the patient’ http://www.bmj.com/content/344/bmj.e1487/rr/571229
A Productivity Challenge too far. Appleby, John. BMJ 2012; 344 doi: 10.1136/bmj.e2416 (Published 19 June 2012)
Are NHS funds being diverted to the rich? Well they are a bit http://blogs.ft.com/ftdata/author/sallyg/#axzz1wGCfKe8H
Medical education and advocacy
Medical education for social justice. Link to PDF of full article: http://www.springerlink.com/content/7j1rv333170671j2/
Advocacy training and social accountability for health professionals. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2961840-0/fulltext
The physician as health advocate: translating the quest for social responsibility into medical education & practice http://www.ncbi.nlm.nih.gov/pubmed/21785306
Teaching advocacy in medical education (Presentation from Univ. Toronto) http://phsj.org/wp-content/uploads/2007/10/Teaching-Advocacy-in-Medical-Education-University-of-Toronto.pdf
A Better NHS 
“I cannot address medical issues as I have to deal with the patient’s agenda first, which is getting money to feed and heat.”
The Father of the Nation, Donald Dewar, greatly admired the theologian, parish minister, academic, Rev Thomas Chalmers. It was he who acted as secretary of the small group which drafted the Moderator’s speech in 1843.
Dr Chalmers saw himself as the parish fixer responsible for employment, welfare, education public health, any kind of counselling you care to name and fundraising. He thought all the problems in society could be solved if there was someone in each parish who did the same. The opinion of most people in his own day, and the judgement of history was there simply could not be found enough or maybe any people with the energy, contacts, knowledge and respect to do what he did.
I’ve been fortunate to know less an a handful of people who worked in health before 1948 (not all of them in medical professions) for whom others would find ways of getting round the rules, constraints and obstacles for the satisfaction of having helped and because they were asked.
Can this be brought to the attention of the MPs who are responsible for the current situation in the NHS? I mean really brought to their attention, to the extent of them having to read it, discuss it with medical professionals and comment, not just make excuses and utter platitudes?
There is a session tomorrow at the BMA annual representatives meeting in Bournemouth, specifically about Health Inequalities and the impact of the global financial crisis and austerity. The key note speaker is Professor Sir Michael Marmot who knows a thing or two about the social determinants of health.
Eloquent and objective *applauds*
All true — but how many doctors or other professionals will be willing to reduce their incomes by 50% to hand it over to these poor, desperate people? Will you provide a room in your home for a homeless person? We have created a culture of dependency throughout the western world, and then created a group of highly-paid people to manage and maintain that dependency.
Well written,
But, when are people going to take responsibility for their own life including health?
Where as bankers and executives milking money from nowhere, group of people expecting the government to look after them by faking illnesses, the real downtrodden suffer.
We need moral values either secular or religious or both; of course without the slogan of my religion is better than yours.
We need too impart the good values of education, hard work and honesty.
David – if you divide half the average GP income by the average number of patients per GP, you’re going to get a couple of quid per year per patient.
Giving one person a room in your home isn’t going to make much of a dent in local deprivation levels, either. In any given year, approximately twice as many people sleep rough for at least part of the year as there are GPs. That’s the tip of the iceberg because it doesn’t take into account sofa-surfers and people sleeping in hostels.
So for a GP to give away half his money and take a patient into his own home would do very little at all.
Please sign and share Pat’s Petition which calls for the government to “Stop and review the cuts to benefits and services which are falling disproportionately on disabled people, their carers and families”. The link is here http://epetitions.direct.gov.uk/petitions/20968
This is also happening in America. Thank you for writing this article. It was very enlightening.
Thanks Jonathon
Eloquently put. My colleague says you can only be a whole doctor if you can provide holistic care…
Have you heard of Karis Neighbour scheme? He set this up with his colleagues and the practice chaplain to help meet the social needs of the community.
Doctors have the ability and, collectively, the obligation, to advocate for the social needs of their patient populations. The electorate needs to know that healthcare is not the answer to population health (e.g. Marmot & Bell, 2009; http://dx.doi.org/10.1001/jama.2009.363), despite what politicians might assert.
We need armies of parish fixers in every community, whether informally (friends and family), statutory (Councils, welfare state etc), private (care providers) or charitable. Could the work of the Social Determinants of Health Committee in the Department of Family and Community Medicine of St. Michael’s Hospital in Toronto be a helpful model? They seem to be harnessing all sections of community in helping to address the social determinants of health. (http://www.stmichaelshospital.com/media/detail.php?source=hospital_news/2015/20150410_hn)
You are right to predict a perfect storm if the NHS tries valiantly to meet the growing social needs of the UK population. Even without this, the NHS faces a perfect storm, with a predicted minimum £8bn funding gap within 3 years (http://www.health.org.uk/media_manager/public/75/publications_pdfs/Funding%20overview_NHS%20funding%20projections.pdf#page=2).
Is the NHS a sickness service or a health service (Iona Heath, 2007; http://www.bmj.com/content/334/7583/19)? If, as you suggest, it should be both, an urgent and massive increase in resourcing is required, or it will collapse.