The role of Primary Health Care Research in developing an evidence base for Primary Care practitioners to reduce health

1. The role of Primary Health Care Research in developing an evidence base for Primary Care practitioners to reduce health disparities in their communities and countries. Mark Harris and Elizabeth Harris University of NSW, Sydney, Australia John Furler University of Melbourne, Melbourne Australia Michael Kidd University of Sydney and Royal Australian College of General Practitioners, Sydney, Australia.

2. Aim of workshop To identify researchers with an interest in developing an evidence base for Primary Care Practitioners and their professional and training organisations to reduce health disparities in their countries. To discuss the feasibility of establishing a network of PHC researchers addressing these issues.

3. Program

4. 1. Health disparities in western industrialised countries

5. All deaths, NSW Australia

6. Life Expectancy at birth NSW 1994-98

7. 2. Why PHC has an important role in addressing disparities

8. Role of PHC Health disparities often felt to be the result of �social determinants� where health care plays little role Increasing recognition that much mortality and morbidity amenable to health care interventions Empirical evidence and theoretical rationale supporting the particular importance of primary care in both improving health and reducing disparities Better health outcomes and reduced disparities consistently associated with Supply and availability of PC physicians Receiving ongoing care from a PC physician Strength of PC characteristics Within US studies International comparisons Starfield, B Milbank Quarterly Origins in the McKeown argument that health largely a result of non health factorsOrigins in the McKeown argument that health largely a result of non health factors

9. Implications for action Policy can influence PC practice Regulation of distribution, reducing financial barriers to access, Training and supportive payment and work conditions Targeted funding of PHC working in disadvantaged communities What about researchers and practitioners? Equity of access Availability, quality (technical and interpersonal) Quality Access and effectiveness (technical, interpersonal) Potential for focus at both macro and micro levels Policy support =Regulation of distribution, Reducing financial barriers to access through universal coverage, trainign and supply of PC physicians, supportive payment and work conditions for PC physicians Policy support =Regulation of distribution, Reducing financial barriers to access through universal coverage, trainign and supply of PC physicians, supportive payment and work conditions for PC physicians

10. Case study 1: consultation length

11. Consultation length In Australia, all general practice consultations are billed in part on the basis of time spent with the patient Short: <5 mins Standard: 5-20 mins Long: 20-40 mins Prolonged: >40 mins Billing data held nationally, linked to postcode (which can be scored for socioeconomic disadvantage) Prolonged consultations associated with higher quality management of chronic disease and co-morbidity Higher burden of chronic disease and co-morbidity in socioeconomically disadvantaged areas Australia scores relatively highly for strength of PC characteristics (starfield)Australia scores relatively highly for strength of PC characteristics (starfield)

12. Disparities in consultations with GPs People in disadvantaged areas visit GPs more often annually, but they are less likely to have a long consultation. The rate of long plus prolonged consultations per person increased by almost 4% with each step up in socioeconomic status. This is despite the increased burden of chronic disease and need for preventive care in patients from disadvantaged areas. Inverse care law persists despite our high PC scores�.People in disadvantaged areas visit GPs more often annually, but they are less likely to have a long consultation. The rate of long plus prolonged consultations per person increased by almost 4% with each step up in socioeconomic status. This is despite the increased burden of chronic disease and need for preventive care in patients from disadvantaged areas. Inverse care law persists despite our high PC scores�.

13. Implications for action GPs in disadvantaged areas facing overwhelming need, work harder see more patients for shorter times dealing only with immediate and pressing needs? Responses? Recruitment (training and regulation of distribution) Payment systems Investment in more surrounding and supportive services Patient expectations Ongoing monitoring

14. Case study 2:Annual cycle of care for diabetes

15. Service incentive payments In 2001 the Australian government introduced a service incentive payment (SIP) for practices that provided an annual cycle of care for people with diabetes: Monitoring of HbA1c, lipids and urinary microalbumin at least annually Monitoring of BP, Weight at least every 6 months Screening for foot complications at least every 6 months Screening for eye complications at least every 24 months By May 2005, there were 4,202 practices signed on to receive the diabetes PIP representing 90% of eligible practices. 69% of eligible practices had received SIP payments and 34% of the estimated number of GPs in eligible practices had received SIP payments during the quarter.

16. Variability in coverage of SIP ? Hypothesis about variability ? Capacity ? Other ????? Hypothesis about variability ? Capacity ? Other ????

17. Coverage by SES Divisions with low socioeconomic populations were likely to achieve higher coverage. This suggests that divisions may be supporting practices serving low socio-economic communities to achieve at least comparable quality of care. IE policy interventions can reduce disparities (but this was not specifically targeted to reduce disparities???)IE policy interventions can reduce disparities (but this was not specifically targeted to reduce disparities???)

18. Implications Incentives can increase access to systematic preventive care care in general practice Key role of Primary Care Organisations (Divisions) in supporting practices in disadvantaged communities Co-payments are a disincentive to preventive care

19. Case study 3: Comprehensive Primary Care Population level interventions in PC can make a difference and primary medical care can be a part of that???Population level interventions in PC can make a difference and primary medical care can be a part of that???

20. Comprehensive PHC Interventions A long term evaluation of a complex community based intervention in a disadvantaged community in outer Sydney: Improved service delivery Community capacity building A combination of surveys, key stakeholder interviews and document reviews Preliminary reflections on findings at T1 &T2

21. Community in crisis 1998

22. Population intervention1999-2001

23. The intervention WBIV ($200,000pa): led by Health Co-location of GPs and Community Health The HUB: information resources Supporting difference: people chronic mental illness Community Arts Community 2168($90,000pa): intersectoral Employment Safety Urban regeneration

24. Change is noticeable

25. Self-rated health 1999-2002

26. Perceptions of crime & safety 1999-2002

27. Implications Seeing practice population as a population helps to identify common problems in the community General practice has an important role in increasing access to preventive, acute and rehabilitative care Referral to a wide range of MD services for: Child protection Drug and alcohol Mental health

28. Small group discussion How can we shift our research from describing patterns of health disparities to evaluating the effectiveness of policies and interventions at Practice, Local community Policy level to address disparities? How could an international network assist and support such action

29. Establishing a network of Researchers Experience of Health Inequalities Research Collaboration in Australia http://www.health.gov.au/internet/wcms/publishing.nsf/content/hirc-index.htm Possibilities through International Society for Equity in Health (ISEqH) http://www.iseqh.org/

30. Summary, evaluation and staying in touch m.f.harris@unsw.edu.au e.harris@unsw.edu.au j.furler@unimelb.edu.au