How Healthcare professionals can tackle
Health Inequalties?
Alia GilaniHealth Inequalities Pharmacist
Plan Of Action: Part 1: Case Study Part 2: Health Inequalities Part 3: Ethnic Inequalities and Culture Part 4: Group work Part 5: Why should we care? Revisit Part 1 Part 6: Glasgow Model: Engaging with
your Hard to Reach Community
Part 1: Case Study
Background:
Mr H Age: 72 years Lives on his own Council flat in Govan which is in
a poor condition Patients mobility is limited Poor attendance to h/care services Cannot read/speak English Lives several miles away from registered practice
but does not wish to change practices due to bi-lingual G.P. Has difficulty getting to the surgery and his form of transport is a bus and some walking.
Disappears to Pakistan for several months in the year to see his much younger wife.
Is non compliant with his meds in Pakistan. Subsequently on his return gets admitted to hospital with poor glycaemic control
Key Issues Referred to MELTS in January 2011 HbA1c 16.4% (June 2010) Frequent falls even when travelling to G.P Refused access to the Home Care
assistant when service was offered No family support available only local
newsagent Is currently admitted to sec care with high
B.M’s
Discuss what your approach would be to tackle the inequalities with Mr H?
Part 2: Health Inequalities
Definition:
“Health Inequalities are differences in health status or
in the distribution of health determinants between
different population groups”
World Health Organisation
Health Inequities are:
“avoidable inequalities that are unfair or unjust”
BMJ 2001;322:591-594
Strategic Drivers:
Black Report (1980)
Acheson Report (1998)
Marmot Review (England 2010)
Equally Well (Scotland 2008)
Life expectancy – a global view
Source: WHO Health Report
Life expectancy
1999 to 2001
72.7 - 76.0
76.1 - 77.4
77.5 - 78.5
78.6 - 79.5
79.6 - 81.2
Source: ONS, 2004. Maps by Ben Wheeler
Life expectancy
1999 to 2001
72.7 - 76.0
76.1 - 77.4
77.5 - 78.5
78.6 - 79.5
79.6 - 81.2
Source: ONS, 2004. Maps by Ben Wheeler
Source: Office for National Statistics
Social Determinants of Health: Rainbow
Model of Health. Dahlgren and Whitehead(1991)
Part 3: Ethnic Inequalities and Culture
Culture and health:
Behaviours Beliefs Organisation of family & kinship Language and communication
Cultural CompetenceCross cultural communication is ……far less knowledge than
a set of skills and attitude
“Understanding patients beliefs about their disease and treatment affects health behaviours and provides opportunities for improvements in health outcomes”
Mann DM et al. J Behav Med 2009; 32: 278-284
Not Understanding Your Patient…..
Language is more than words!
Paralinguistic features
What is “normal” communication?
Confidentiality & Interpreters
Why not learn English?
Poor communication with your patient can lead to:
Distrust Misunderstanding Dislike Label patients Odd or Unpredictable Affect Care Given
Ethnic Group….
“ A group of people who share characteristics such as language,
history, religion, nationality, geographical and ancestral origins
and place”
Dept of Health
Ethnic Inequalities first Noted…..
The condition of the working class in England – Friedrich
Engels 1845
Migration to the UK of Ethnic Groups:
1950’s: Caribbean & India 1960’s: Pakistan 1970’s: Bangladesh 1980’s: Hong Kong 1990’s: Hong Kong Last decade: refugees
Bhopal R. Journal of Public Health 2009;31:315
Factors contributing to Ethnic Inequalities
Genetic Factors Culture & Lifestyle
Access to healthcareservices
Socio-economic statusMigratory
Factors
Part 4: Group Work Discuss your viewpoint as to what is a
HCP’s role and responsibility in tackling health/ethnic inequalities?
Discuss effective strategies to tackling Health Inequalities?
Identify groups with health/ethnic inequalities in Glasgow
Ethnic Groups who have Inequalities
SouthAsian’s
RomaTravellers
AfricanCarribeans
Asylum Seekers
Part 5: Why should we care?
“Health Inequalities are remediable” (AchesonReport)
“The primary determinants of disease are economic and social, and therefore, that its remedies must also be economic and social”
(Geoffrey Rose)
“1.3-2.5 million years lost for those dying prematurely in England”
(Marmot Review)
Tackling H.I will…..
Economic benefit
Social Justice
Extend beyond H.I……
“Poverty being the worlds biggest killer and greatest
cause of ill health and suffering across the globe”
-WHO 1995
Link between poverty and health:
Poor health Poverty
Poverty Poor health
Improved health Way out of poverty
Where do HCP’s fit in?
HCP Role in Social Determinants of Health:
MICRO LEVEL
Health Care MESO LEVELProvider MACRO LEVEL
HealthcareProvider
How do we address Inequalities?
Social Gradient National Policy Local delivery Social determinants Anticipatory care Patient empowerment Start early Improve access More Research e.g. impact of SE inequalities in ethnic
inequalities Recording of ethnicity Racism Workforce focus on social determinants
Part 1 Revisited: Case Study – Mr H
Addressing key issues with Mr H:
Using the newsagent as a key ally Improvement in B.M’s and weight Increased engagement at
secondary care Undergoing a social care review for
new housing/benefits Received a mobile wheeler!
“It is more important to what sort of patient has a disease than what sort of disease a
patient has”
- William Osler 1904
Inverse Care Law:
“the availability of good medical care tends to vary inversely with the need for it in the population serve”
-Julian Tudor Hart 1971 Lancet
Part 6: Glasgow Model – Engaging with your Hard to
Reach Community
Service Development
Old service
Not meeting the needs of South
Asians
Solution……
Stage 1: Changing the NHS invitation process
Targeting practices with South Asian diabetic patients by telephoning
them intheir spoken language of Urdu.
Stage 2: Enabling access through community venues
Mosque
Sikh elderly centre
HinduElderly centreVoluntary
centre
Patient in community
Outreach clinics
Glasgow Central Mosque
Stage 3: Using Community Pharmacies
Community pharmacies accessed by 99% of the population
Targeted a pharmacy located in an area with the highest south asian population in Glasgow
Process Messaging service
Stage 4: Set up of a new access point
MELTS (minority ethnic long term medicines service)
Referral criteria
Who can refer
Pharmacy Minority Ethnic Long Term Medicines Service
Referral Criteria:1. Polypharmacy for Long Term Condition(s)and2. Minority Ethnic Individuals e.g. South Asian, Chinese and/or3. First language not English
And has the capacity to benefit from a 1:1 medication review with a bi-lingual pharmacist (Alia Gilani). Name of Person Referring:_________________________________Contact details:_________________________________ _________________________________________________________________________________________________________________________________________________________________________________Patient’s Name:____________________________________________If possible, please ask the individual consenting to the review to sign below. If this is not possible please complete the details and we will seek consent by contacting the patient ourselves. Patient’s signature:_________________________________________Patient’s address:______________________________________________________________________________________________Date of Birth: ________________GP:______________________Date: _______________________Please fax/post to: Minority Ethnic Long Term Medicines Service, Queens Park House, Victoria Infirmary, G42 9T Phone: 201 5752
Patient
Medication Review with outreach pharmacist
Onward referral into the health and social care team
Onward Referral
Dexa Scan Spirometry Retinal Screen
Falls Team
SecondaryCare
Social WorkLanguage and
Computing CPN and MentalHealth Team
Care of OlderPeoples Team
Physio and Exercise Classes
Podiatry
Patient at medication review clinic
Dixon Hall Community Elderly Centre
Final Thoughts…..