Introduction by Croakey: It seems there is a new report every week highlighting health disparities in the United Kingdom, and the terrible toll of a growing health divide there.
One of the latest examples is this ABC TV investigation of poverty and disadvantage in Birmingham, Britain’s second largest city, where austerity measures have hit hard over the past 15 years.
Nearly 50 percent of children in Birmingham live in poverty, compared with 32 percent in London, according to the report, and access to health, disability and social services has deteriorated dramatically.
The UK offers many lessons about the impact of austerity policies upon health, as well as examples of innovation in health and social measures aiming to address the famous Inverse Care Law.
Dr Tim Senior, a prominent GP and Croakey contributor, is packing his bags for some related investigative travels in the UK, courtesy of a Churchill Fellowship, and explains below how readers can share his journey.
Tim Senior writes:
Come away with me! On Monday, 1 July, I’m travelling to the United Kingdom on a Churchill Fellowship, and I think many Croakey readers may be interested in my investigation: what can we do in Australia to support GPs providing care in socioeconomically disadvantaged communities?
Australia has a very good health system, but we really fail in this area. The latest Commonwealth Fund International Survey from 2021 ranks the Australian system third overall; however, our worst ranking is in access to care, mainly because of our poor score for affordability.
We manage to score highly for equity, which measures the difference in cost-related access to health care for the best off and the worst off. Our score is only high because we are unaffordable for everyone!
These rankings predate the latest cost of living crisis and the crisis in general practice funding from the freezing of Medicare rebates, and so the situation is likely to be worse now.
But why does this matter?
Fundamentally, any health system that can’t deal with affordability for those with the least is a health system that isn’t going to work very well.
Let’s tease out the complex set of circumstances that show why this is so.
Many diseases have a social gradient
Most diseases and conditions that have a significant impact on population health aren’t spread evenly through the population. They are more common in communities with fewer financial resources.
This is true for multimorbidity – the presence of two or more chronic diseases in one person, and it’s true for the impact that disease has on you – the burden of disease. Ultimately, it’s true for deaths, too, which at the very least is what health systems try to prevent occurring too early!
The risk factors for many of these conditions are also more common in the most disadvantaged areas. Smoking, obesity, physical inactivity are all causes of these diseases, and all have a social gradient too.
Managing these conditions, and the causes of these conditions, is a job for health professionals, and GPs are the specialists in chronic disease management, multimorbidity, behaviour change and preventive health.
Given this, it shouldn’t take too long to realise that the workload for GPs working in disadvantaged communities is more complex than in richer communities. And yet patients in these communities are slightly less likely to attend a GP, and more likely to attend an Emergency Department.
Part of solving this problem requires effective public health policy, to ensure that the circumstances in which people live protect their health.
Currently, when GPs have conversations with their patients about physical activity, they are talking to patients living where it is the least easy to walk safely, and where they have the worst traffic related air pollution.
When providing advice on healthy eating, we are talking to people with the worst access to unprocessed food. There are social gradients in access to the Internet, employment, transport, and quality housing. No wonder smoking rates are higher too.
To tackle this problem, you’d expect that the health system would prioritise workforce measures that encourage GPs to work in disadvantaged areas. Knowing the increased complexity requiring longer consultations, and that managing the GP’s risk of burnout requires fewer work hours each week, it wouldn’t be enough to just reach parity on GP headcount – we’d need more GPs just for the workload.
However, I can’t find a time where this has even been measured since 2006 (when 11 percent of GPs worked in the most disadvantaged areas, and 25 percent worked in the least disadvantaged). We measure what matters, or at least we should.
Australia views health disparities predominantly through two lenses – rural and remote health, and Aboriginal and Torres Strait Islander peoples’ health. There’s absolutely nothing wrong about this – these disparities are real.
But we need more lenses. If our lens is geographic, we tend to view distance from health services as being the single problem to be solved, and risk having health services that are close to people and unaffordable.
Worse, we often view being Aboriginal or Torres Strait Islander as being the vulnerability, when connection to culture is protective of health. Identifying someone as being Aboriginal or Torres Strait Islander is identifying someone as having been more likely to have experienced racism, to be a member of the Stolen Generations and, in fact, more likely to live in poverty because of the effects of having their land stolen, and other ongoing impacts of colonisation.
The consequences for the health system were easily seen as the COVID pandemic hit Sydney in 2021. Disadvantaged areas in our major cities were invisible to a health system only primed to see vulnerability in rural and remote areas or Aboriginal and Torres Strait Islander communities. There’s a lot of overlap, but poverty cross-cuts all other health disadvantages, making them harder to manage.
Poverty is not a wicked problem. Poverty is a policy choice.
Once again, the COVID pandemic is instructive. When the coronavirus supplement was raised, 425,000 people were lifted out of poverty.
We could easily be generous again, and lift people out of poverty and it would be affordable.
GPs at the Deep End
I’m not trying to solve the problem of poverty. I’m not even trying to improve public health.
I want GPs and primary healthcare teams to feel supported in providing clinical care in disadvantaged communities.
GPs working in these communities already love their work, love their communities, and know how important their contribution is.
However, it’s under-supported – Medicare doesn’t fund complex care or mental health well. You’ve got to love the work when you know you can earn significantly more managing less complex chronic disease, less severe mental health, in social circumstances supportive of health.
In Glasgow, they’ve been thinking about GP care in their most deprived communities for over a decade. I first came across their work in the British Journal of General Practice in 2011.
Even though I was reading this while working in an Aboriginal Community Controlled Health Service on the other side of the world, they were describing my work.
Among their simple achievements was improving the sense of collegiality and identity in the group of GPs. They had some success in advocating to the Scottish Parliament, and increasingly were recognised for their expertise.
Other Deep End groups formed around the UK and internationally, each with their own focusses. Some had an interest in the training of GP registrars, some focussed on developing more workforce, some on supporting each other, some on research.
My Churchill Fellowship allows me to visit the Glasgow group, as well as groups in London, Plymouth, Sheffield and Dublin, as well as attending the Society of Academic Primary Care Conference in Bristol, with a specific Deep End/Inclusion interest group.
In early September, I hope to bring back something of their expertise and enthusiasm, and I’ve already experienced their generosity and kindness. The context is different and challenging in the UK at the moment (though I will be there for the general election, so the context may or may not be changing while I am there).
Poverty and health is recognised and talked about in the UK in a way that perhaps is only a niche subject for Croakey readers in Australia.
There are also similarities. Despite vastly different ways of funding general practice in each country, both manage to direct funding away from where it is needed most.
The Inverse Care Law operates in both countries. Like poverty, this is not a law of physics, this is a law that’s a policy choice – not gravity, but seat belts in cars!
Shared values
Also familiar is the attitude towards GPs that the Glasgow group protected themselves from. I’m quoting this in full, because this is an object lesson in working with GPs:
“The group made three early decisions.
- First, it would not replicate the many previous and largely ineffective reports on inequalities in health, reviewing the partial literature and drawing partial conclusions.
- Second, it would not issue GPs with a ‘toolkit’, the approach of technocrats, which assumes that GPs only need to be told what to do.
- Third, it would listen to what GPs from the front line had to say.”
Finally, the shared values of primary healthcare shone through their work:
“Meetings took for granted, indeed affirmed, the value of general practice, improving population health not only via the mass delivery of evidence-based medicine, but also via the unconditional, personal continuity of care provided for all patients, whatever condition or combination of conditions they present.
The contribution of general practice to improving health and narrowing inequalities in health is not so much via the learning of new tricks and delivery of externally devised toolkits as by increasing the volume and quality of what Deep End practices do.”
One of the most exciting things about the Churchill Fellowship is the number of people who are interested in what I find, and in collaborating to improve the way we support GPs and primary healthcare teams to work in disadvantaged communities, whether they are Aboriginal and Torres Strait Islander communities, rural or remote communities, regional centres, or in our major cities.
Everyone knows we have some important work to do.
So, please, come join me on this journey.
* Dr Tim Senior is a GP living and working on Dharawal country, and a member of Croakey Health Media. You can follow his Churchill Fellowship travel here on Croakey, and on Twitter/X @timsenior, using the hashtag #ChurchillDeepEnd.
See #WonkyHealth, a crowdfunded series of columns and e-book published by Dr Tim Senior in 2015.
Well done Tim. I shall read your articles with great interest.