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Tackling health inequalities in Plymouth

In Plymouth we are planning to develop a health and wellbeing hub in the city. A single overarching aim informs all of this: we are determined to tackle health inequalities.

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The new infrastructure will do this by bringing the best care available in new and innovative ways to those that need it most. Two underlying paradigms inform the model of care, the first is that of primary healthcare and the second trauma informed care.

Primary healthcare
The term primary healthcare (PHC) was first used at the Alma Ata conference hosted by the World Health Organisation (WHO) in 1978. It called for a re-orientation of the world’s health systems away from prioritising hospitals and toward primary healthcare. Importantly this very explicitly included full individual and community participation.

The term primary healthcare has often been shortened to “primary care” and in the UK this is often considered to mean general practice. This is wrong and misses the whole power of PHC, which inherently includes every part of the health service, often including community health workers who may be the first point of contact. The principle is to do as much as possible at the part of the health service nearest to the community – and only to move upwards when that level cannot help.
The other key principle of PHC is multisectoral collaboration- so that the health service works with all other agencies that can influence health. This of course links perfectly in with the much more recent work by Sir Michael Marmot and others around social determinants of health.

In Plymouth we have been working towards a co-located health and wellbeing hub that brings together a wide range of services; general practice will be one of the resources available, a very important one – but only part of the health service that people can access. The PHC principle of “nearest to the community” management will drive us. The Alma Ata convention placed responsibility on governments to empower individuals, families and communities to enable them to assume responsibility for their health and wellbeing, and so doing this will be a key guiding principle.

It is then possible to imagine a chain of help around health issues that stretches from individual, community and right through general practice to specialists such as consultants. Where any of this service is located does not matter and may change depending on resources and on technology. The unhelpful division between “primary” and “secondary” care is eliminated.

The model below can illustrate this. In the “problem” circle consider various possibilities, for example mobility issues, pain and arthritis or depression/anxiety and drug misuse, or breathing difficulties and obesity.

It is useful to start with common problems in the community rather than a particular “diagnosis”. Then consider that the whole circle is available within but extending beyond the new health hub and out into the community.

The “consultant and specialist” circle includes specialist nurses and other practitioners, “general practice” includes primary care nursing, mental health workers, pharmacy and social prescribing, “Individual and community” includes education aimed at increasing self-agency plus the huge range of community, voluntary sector and statutory organisations available to individuals. It may include individuals identified as “change agents” within communities who act as first level of support for individuals.

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To illustrate this and the difference that the new infrastructure can make from the present system, consider these case studies and put them into the “problem” circle. These are all based on real cases.

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In our current situation without a single community health hub all of these people are be asked to access help in a bewildering array of places across the city, and at different times – with no coordination between them.

A huge range of people are involved in helping these individuals, also generally with no coordination or even knowledge of what the others are doing. Care is disjointed, top down and there are many gaps through which people often fall. Critically there is little or no utilisation of community resources or means of increasing individual agency. There is wasteful duplication, and care often occurs at a level much further away from the individual-community than is necessary – which is dis-empowering and expensive.

Trauma-informed care.
Everyone knows that trauma and stress are unpleasant, but the full impact over the life course has not until recently been appreciated. Put simply, adverse experiences during childhood manifest throughout the rest of a person’s life not only as psychological and social difficulties -but as physical illness and lower life expectancy.

It might be expected that such experiences might lead to for example a higher risk of substance misuse or self-harm in later life, and indeed that is true – but we now know that a range of health conditions including heart disease, cancer and type 2 diabetes are more common in those who have suffered childhood trauma. Add to this the huge body of research from Sir Michael Marmot and others showing that chronic stress, low agency (the sense that a person is “in control”) and poor social connections reduce life expectancy, and it is clear that stress and trauma underlie much of what is presented to health services.

Importantly, past or current trauma often appears as physical symptoms, and we know that anything up to 50% of presentations to both GPs and specialists are actually related to underlying trauma. Doctors have labelled this variously as “medically unexplained symptoms”, “psychosomatic disorders”, “functional illness” or even “heartsink patients”. If the underlying trauma is not recognised and explored there is a great risk of over-medicalisation (and even “over-surgicalisation” too).
There is good evidence that a “trauma-informed” approach can reduce these risks, reduce dependence on health services and promote healing. Since past or present trauma is much more common in areas of high deprivation such as Stonehouse in Plymouth and adjacent areas it is imperative that all our services reflect this approach.

So how can a new model of care materially tackle health inequalities and draw from and reflect these complex issues?
The two components of health inequalities are reduced life expectancy and more time lived in poor health. Both apply to people living in and around Stonehouse and we plan to prevent or modify both by better care throughout life. This will be done by utilising the benefits of co-location, collaboration and co-production set out below:

Co-location
The “one stop shop” model has been shown to work in many parts of the world and the message came through loud and clear in our community consultation that people want everything that they need available in one place.

Applied to our case-studies, it is clear that simply making all the needed services available under one roof would transform the patient-experience. In both cases 1 and 2, simply being able to access services in one place rather than all over the city would make a huge difference, similarly to coordinate rehabilitation for case 3 and physical, psychological and social care for case 4. In both case 1 and 2, adverse experiences in childhood contribute in all kinds of ways to the current situation and by providing services that recognise and address trauma, deeply embedded behaviour can be changed.

Collaboration
Our cases demonstrate how disconnected the experience of healthcare often is for patients. One agency often has no idea what the other is doing. As hospital care has become more and more specialised the response to this problem in hospitals has been to form “multi-disciplinary teams” that meet regularly explicitly to bring everyone together to make decisions about patients.

The new model will do exactly this, but crucially can include also primary care and the wider community team. For example for case 2, such meetings would include everyone involved in her diabetic care, in case 1 everyone involved in the care of both child and parents. This will be facilitated by shared records – and simply by having all carers in the same place.

Co-production
This is potentially the most powerful part of our model. It means that the resources within individuals, families and communities form part of the chain of care. Such thinking has been found in the NHS before, for example in the “fully-engaged” scenario described in the 2003 “Wanless report”, and of course it is exactly what was envisaged at Alma Ata in 1978. Perhaps more useful is to explore the literature on community-development in which community “empowerment” is a critical theme and is all about increasing the agency of people and communities to tackle their own issues, including health.

Fortunately, a thriving grass-roots community movement in Stonehouse called “nudge community builders” has emerged and is part of our team. We propose a model in which we work collaboratively to address health issues so that the health service is only part of the resource available – and the intent is always to promote care at the level nearest to individual and community as possible. This often works both ways – an empowered community linked in comprehensively to health services can achieve far more than either alone.

Summary
A new health and wellbeing centre in Plymouth would espouse a radical model of care that would do things differently – and in particular remove current barriers between individual/community resources and the health service, and between “primary” and “secondary” care. These barriers have hindered healthcare for years, especially so for the most vulnerable.

Employing a primary health care and a trauma-focussed care approach provides an underlying philosophical model that we all sign up to, and which would help us to fundamentally tackle the unacceptable health inequalities in our city.

Richard Ayres is a GP partner at Adelaide Surgery in Stonehouse, Plymouth. Our neighbourhood is in the 1% most deprived in England and as well as ongoing care for our population we provide outreach services to the homeless in the city including care for complex needs and substance misuse.

I set up the Plymouth Deep End GP group and am joint chair of the RCGP Health Inequalities standing group. I am clinical lead for the Cavell West End health and wellbeing centre project in Plymouth.

I also work as a clinical academic at Plymouth University where I am Associate Professor at the Peninsula Medical School and Lead for Population Health. My interests are in Health Inequalities and anything concerning the role of “place” in health.

Last Updated on 5 December 2022