Primary Care Health Inequalities Short-Life Working Group: report

Introduction

Health inequalities are unjust and avoidable differences in people's health across the population and between different groups.^[1] Scotland compares poorly on health inequalities compared to most of Western Europe,^[2] which means that the right of everyone to the highest attainable standard of physical and mental health is not being enjoyed equally (Scottish Parliament Health and Sport Committee 2015). This longstanding injustice has been brought into sharper focus by the COVID-19 pandemic (Bambra et al 2020).

The root causes of health inequalities largely lie outside of health services. Inequalities in society are caused by inequity in the distribution of money, resources and power, which impact on opportunities for good-quality work, education, income, and housing. In turn, these determinants shape individual experiences of health.^[3] A wide range of commercial determinants also impact on health.^{[4] [5]}

Health inequalities and climate injustice are also closely interconnected and share common root causes. To give two examples: unsustainable food production and marketing of low nutrient food lead to obesity, malnutrition, liver disease and cancer (WHO 2021). Car-based transport systems, air pollution (Pye et al 2007), poorly insulated housing and reliance on carbon fuels for energy (Oxfam 2020) lead to respiratory and cardiovascular disease, fuel poverty and lack of community access to green and health spaces. All of these impact most heavily on the most vulnerable. Many actions to address health and climate injustice have co-benefits for both achieving carbon net zero and creating health sustaining communities (Deep End Group 2021).

Recognition that the causes of poor health largely lie outside the health system is reflected throughout public policy in Scotland. Some longer-standing examples have been the Christie Commission on the future delivery of public services (Public Services Commission 2014), the six Public Health Priorities (Scottish Government 2018a) and national policies on early years, alongside more recent documents, such as the "Housing to 2040" vision (Scottish Government 2021a), and the national COVID-19 Recovery Strategy (Scottish Government 2021b).

Modern health care does, however, have enormous potential to prevent the onset of illness and to delay its progression. Access to health care is itself a social determinant of health. As a result, inequitable access to effective health care is an inadvertent yet powerful driver of health inequalities.^[6]

Primary Care in Scotland: a definition from clinical professionals

"Most of the time, people use their own personal and community assets to manage their health and wellbeing and achieve the outcomes that matter to them. Primary care professionals enhance this by providing accessible health care and support to individuals and families in the community, when it is needed, at whatever stage of life.

"Primary care is provided by generalist health professionals, working together in multidisciplinary and multiagency networks across sectors, with access to the expertise of specialist colleagues. All primary care professionals work flexibly using local knowledge, clinical expertise and a continuously supportive and enabling relationship with the person to make shared decisions about their care and help them to manage their own health and wellbeing. Primary care is delivered 24 hours a day, 7 days a week. When people need urgent care out of core service hours, generalist primary care professionals provide support and advice which connects people to the services they need, in a crisis, in a timely way."

From "The Future of Primary Care: a view from the professions" (2017) - https://www.rcn.org.uk/About-us/Our-Influencing-work/Policy-briefings/sco-pol-future-of-primary-care-1-sept

This short report sets out recommendations for actions to be taken by primary care health services to help reduce health inequalities and improve health equity in Scotland. Primary care is provided by a wide range of health care workers (such as nurses, GPs, optometrists, pharmacists, allied health professionals) and other key staff (such as practice receptionists and community link workers), who are usually based in the community and offer the first point of contact when people need support to maintain their own health. Primary care services focus on the needs of individuals and defined populations, rather than on specific diseases, usually offer care over a long period of time, and provide coordination of care for people with complex health problems.

The 2013 Scottish Ministerial Task Force on Health Inequalities (Scottish Government 2015) recommended that tacking health inequalities required work to mitigate (make less harmful) the negative impact on individuals, as well as undoing the root causes and harmful environments. By virtue of being embedded across all our communities, and operating at the 'frontline' of the NHS, primary care can play a pivotal role in mitigating the effects of health inequalities at a number of levels (Scottish Parliament Health and Sport Committee 2021): through preventative and anticipatory clinical care; wider patient advocacy; community engagement; and influencing the wider health and social care agenda, as well as responding directly to complex clinical needs (Watt 2019). However, existing commitments to reform primary care will not be sufficient to meet the challenges of health inequality.

The volume and nature of demand for primary care, and the complexity of the response required, are also influenced by health inequalities and deprivation. Primary care is partly demand-led and, so, is easier for some groups of people to navigate than others, with various forms of disadvantage (such as power relationships, racism, education, social status) playing a part. Inequity of access, or a mismatch between resources and need, can inadvertently widen health inequalities. Many of the findings and recommendations in landmark reviews, led by Michael Marmot for the Health Foundation, into health inequalities in Englandapply to Scotland, including the need for policies and delivery broadly founded on 'proportionate universalism' (Marmot 2010; Marmot et al. 2020a, 2020b). In the context of this report, this mean that primary care needs to be best where it is needed most (Ashwell et al. 2020).

Reflections from a GP

A hospital discharge letter recently documented that the patient concerned had missed five renal clinic appointments in the preceding two years. Their kidney function had dropped so sharply in this time that the specialist advised the window of opportunity for intervention had been missed, and they would need life-long renal dialysis within the year.

For the person and their family this will mean life-changing illness, premature disability, burdensome treatment, loss of income and reduced life expectancy, all of which could have been prevented. For society it will mean the enormous cost of high tech downstream medical treatments, loss of economic activity and future dependence on social support. There might be many reasons why someone struggles to access health care.

For this individual, possible factors might have been the cost of bus fares (£4.60); the length and complexity of travel by public transport (a three-hour round trip involving four buses); an employer who will not allow time away from work; literacy issues or poor communication on the part of the NHS; not understanding or denying the potential consequences of their kidney problem; or having to deal with competing challenges, such as other physical or mental health conditions, caring responsibilities or other personal circumstances.

Barriers to health care such as these fall most heavily on those who are already most at risk of illness and disability. This personal tragedy is one snapshot from the hundreds of thousands of individual stories that lie behind health inequalities in Scotland. For a nation to be truly modern, prosperous and progressive, it must be able to ensure that access to effective health care is available to all on an equal basis of human dignity alone, and not influenced by factors such as bank balance, postcode and birthplace.

Dr Peter Cawston, Member of the SLWG and GP in a Deep End practice in Glasgow