Everyone is equally worthwhile, if not our humanity lost
GP training focuses on the practice of medicine at the most fundamental level – the consultation. If we are to understand how we, as doctors, can tackle health inequity we must start here. First, before we can tackle the problem, we must see and understand how it manifests itself in our day to day interactions with patients. This requires us to appreciate the true nature of illness and the difference between illness and disease:
“Illness is what the patient has on the way to see the doctor and a disease is what they have on the way home.”
Iona Heath, The Mystery of General Practice, The Nuffield Trust 1995
Illness is a conglomeration of all that a patient is (their social environment, family life, psychological make-up, their past experiences), their symptoms and the disease that is affecting them, which may be generated and/or maintained by their psychological and social situation. The narrowest possible way of looking at illness is a focus on the disease, its pathology and the way this gives rise to symptoms through purely biological mechanisms. However, we all know that biological mechanisms do not explain why one patient with back pain gets better in 8 weeks and another suffers a lifetime of “unexplained” agony.
To understand this, we must think in terms of illness and the way that life circumstances dictate presentation to the doctor and the way a patient reacts to, recovers from and attaches meaning to disease. We will see that merely searching for and attempting to cure physical disease is a gross over-simplification of the patient’s experience and the doctor’s role in helping the patient. At worst, it can dehumanise the patient and make medicine (and by extension the doctor) the central character, rather than the person seeking help.
Imagine Lisa, who repeatedly attends with her 4 month old baby, Tyler… Lisa smokes 10 cigarettes a day, lives in a 2 bedroom flat rented from a private landlord, her partner left her two months before Tyler was born, Lisa is 21 and left school aged 16 with a few GCSEs, worked as a carer for 4 years and then became pregnant. She has a history of panic attacks, which started when she was a teenager and her step-father was verbally abusive, every day, toward her mother. Lisa’s flat is damp and in poor condition and, at present, her only income is from benefits. She just about makes ends meet through careful planning. She has a few friends nearby but most of them are busy with young children and, between them, they have little money to go out socially. The town where Lisa lives is poor, with high levels of unemployment.
Now, imagine a scenario where Lisa turns up during a busy on call shift with Tyler, who has mild bronchiolitis for the third time. She sees the GP who is under pressure and rushed and who tells her Tyler is fine and that he keeps getting respiratory illnesses due to Lisa smoking. They are in and out of the consulting room within 5 minutes.
Ask yourself… are Lisa and Tyler’s circumstances likely to lead to a high level of wellbeing, including the absence of disease? Does a disease-focussed biological assessment of the situation get at the real problem here? Why is the GP so rushed? What leads GPs to simplify encounters when time is short? Have Lisa and Tyler been treated with humanity and empathy? Has the GP been kind and compassionate?
Any GP will recognise this situation. For GPs working in areas of socioeconomic deprivation where, unfortunately, there are many Lisa and Tylers, this sort of encounter will be commonplace. Lisa, Tyler and the GP are all in positions of personal and professional vulnerability:
“Vulnerability may have its own private causes, but it often reveals what is wounding and damaging on a much larger scale.”
Berger and Mohr, A Fortunate Man, 1967
Lisa and her GP’s vulnerability are encapsulated in the findings of much qualitative research on the content of consultations in “Deep End” primary care. For example, Mercer and Watt (2007) found that:
“The increased burden of ill health and multimorbidity in poor communities results in high demands on clinical encounters in primary care. Poorer access, less time, higher GP stress, and lower patient enablement are some of the ways that the inverse care law continues to operate within the NHS and confounds attempts to narrow health inequalities.”
This is a direct result of the social gradient in ill health being unmet by a similar gradient in resources. The following graph is taken from McLean’s recent work, which concludes that the current arrangements for funding general practice exacerbate the inverse care law (McLean et al, 2015):
Chart 1 – GP funding, consultation rates, morbidity and mortality
Julian Tudor-Hart, a GP who worked in the Welsh valleys in the 1970s and 1980s, was the creator of the now widely understood “Inverse Care Law”. Over decades his practice worked with patients to try and overcome the health inequity by offering longer consultations and blanket application of population health interventions to tackle, in particular, cardiovascular risk. However, his approach went beyond the physical; central to his he thinking about general practice is the notion that health is ‘co-produced’ within the consultation by the GP and the patient working together, he writes:
So, given the current pressures on general practice, particularly in areas of high deprivation, is there any change of doctors and patients working together to co-produce health and over-ruling the inverse care law? Or, to quote Armartya Sen: “to create the conditions for people to have the freedom to live the lives they have reason to value”.
Yes there is. But the challenges are huge and GPs taking on this challenge must do so with the right attitude and the right support. Sadly, some have argued that we now live in a society that is increasingly tolerant of stark economic inequality, extreme poverty, gross health inequity and the dehumanisation of the poor. Inevitably, GPs will struggle to cope with the illness this causes and the attitudes that have enabled such a society to be created will permeate the medical profession. We must guard against this at all costs.
Attitudes to poverty and ill health
Sadly, in our discussions about health inequity, we often hear similar arguments and prejudices rehashed. Here, are three fallacies that we should be aware of and confront…
Fallacy Number One: there is nothing GPs can do, it is all about social determinants of health.
Not at all true. Yes, social determinants are more important than health care. But, healthcare still has a big role to play.The Kings Fund estimated around 15-20% of health inequity is amenable to improvement through primary care (Tackling Inequalities in General Practice, 2010). As amply demonstrated by McLean et al (2015), the distribution of healthcare resources is part of the problem when it comes to addressing health inequalities.
Then there is the question of humanity – are we really going to limit our efforts to treat the sickest people in society because of perceived futility in “curing” their various diseases? This fundamentally misunderstands the very nature of illness. As set out above, what we really should be focussing on addressing illness, which can rarely be cured but often soothed.
Michael Marmot neatly rebukes the immoral basis of this fallacy:”We should not add the insult of the lack of access to healthcare to the injury of getting sick in the first place” (Marmot, 2014).
Fallacy Number Two: health inequalities arise because those at the bottom of society are less likely to take responsibility for their own health…
True. Being healthy does depend on an element of taking responsibility for one’s lifestyle. But, that is only part of the picture.
In many cases, ill health starts before birth and even before conception. Should the foetus be expected to take responsibility for its mother’s poor nutrition, alcoholism, smoking habits, decision to reproduce with a cousin and so on? At what point is a child able to take responsibility for itself? Probably after it has already accumulated the disadvantages conferred by issues such as lack of emotional attachment, poorer educational outcomes, poorer nutrition, passive smoking and so on.
Once we have grown old enough to do so, it is less easy to take control when a life lived without meaning or control – people need to be given the reasons and means to take “responsibility” for their health and wellbeing. Why prolong a life already full of suffering?
Most fundamentally of all, even if someone does consciously decide to adopt a healthy lifestyle, there is a gradient in poorer health even after lifestyle factors are controlled for. This has been proven time and time again – the very fact that you are poorer than others around you and the experience of living further down the social gradient in an unequal society means you will lead a sicker and shorter life (see The Spirit Level, The Health Gap, The Black Report, etcetc).
Over half a decade ago, George Orwell captured the problem of castigating the poor for their lifestyle choices…
“Would it not be better if they spent more money on wholesome things like oranges and wholemeal bread or if they even, like the writer of the letter to the New Statesman, saved on fuel and ate their carrots raw? Yes, it would, but the point is that no ordinary human being is ever going to do such a thing. The ordinary human being would sooner starve than live on brown bread and raw carrots. And the peculiar evil is this, that the less money you have, the less inclined you feel to spend it on wholesome food. A millionaire may enjoy breakfasting off orange juice and Ryvita biscuits; an unemployed man doesn’t. Here the tendency of which I spoke at the end of the last chapter comes into play. When you are unemployed, which is to say when you are underfed, harassed, bored, and miserable, you don’t want to eat dull wholesome food. You want something a little bit ‘tasty’. There is always some cheaply pleasant thing to tempt you.”
George Orwell, The Road to Wigan Pier, 1937
Fallacy Number Three: current crises in health are the result of an aging population, not deprivation and health inequity
Proximity to death is the main determinant of healthcare need, not age per se. People experiencing socioeconomic deprivation and multiple processes of social exclusion lead shorter sicker lives, primarily due to the now well understood “social determinants of health”. The onset of multimorbidity is around 20 years sooner in the most versus least deprived decile of the population and there is a 10 year difference in both actual and disease free life expectancy(Barnett, 2014). Hence, there may be slightly fewer older people in deprived areas as a result of early mortality, but there will be a larger proportion of people in close proximity to death.
Chart 2 – Life expectancy and disability-free life expectancy (DFLE) at birth, males by neighborhood deprivation, England, 1999–2003 and 2009-2013
Recently, the Centre for Health Economics at York University have published an analysis suggesting that health inequity and the associated problems of early morbidity and mortality account for £4.8billion of increased hospital inpatient costs annually in the NHS (Asaria, 2016):
Chart 3 – Hospital episodes and costs (by deprivation)
This illustrates that there is both a moral and economic case for tackling health inequity.
And finally, this chart from the National Statistics Office clearly demonstrates the astounding variation in onset disability according to socioeconomic deprivation:
Chart 4 – Disability and health inequity
Failing to tackle health inequity is a failure of our humanity. A failure to understand and tackle illness at the level of the consultation, a failure to see the vulnerabilities created by an unequal society in our day to day interaction with people and a failure to grasp the stark fact that health inequity is a product of the society we have created and that this demands a response. To do otherwise is to say to the poorest people in our society: “your lives are less worthwhile”. That would be inhuman.
Marmot, M. The Health Gap: the challenge of an unequal society. London (Bloomsbury) 2015
McLean, G. M. (2015). General practice funding underpins the persistence of the inverse care law: a cross-sectional study in Scotland. British Journal of General Practice , 799.
Mercer, W. (2007). The Inverse Care Law: Clinical Primary Care Encounters in Deprived and Affluent Areas of Scotland. Annals of Family Medicine , 5: 503.