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…..