Dr Neil Goulbourne on reducing inequality in health

Reducing Inequality Conference Friday 31st October 2008 Sheffield Quaker Meeting House

Verbatim transcript of Dr Neil Goulbourne’s contribution and discussion.

MARTIN: This slightly more democratic arrangement is done specifically so that we can try to make sure that everybody has an equal say and I don’t think either Neil or Kieron feel they have the answers to the universe or anything?

Neil Goulbourne: No, I have to admit I don’t.

MARTIN: But they do have little presentations to do. So we will get them to do their thing and then we’ll have a more wide-ranging discussion if that is okay. We are expecting tea and coffee about 2.30 or thereabouts. We advertised we would finish at 3 which we can. My experience is if you organise something on a Friday afternoon people start sloping off about 3 whenever you say you are going to finish but I have not to go anywhere in particular if people want to stay and chat that’s fine by me.


MARTIN: Who are you?

NEIL GOULBOURNE: I will start with that. My name is Neil Goulbourne, I’m a GP in Coventry, a member of the Socialist Health Association as well and, sorry, I was late. Sorry, I missed your talk, Richard.

I’m sure, though, I know what you would have said, as a great fan of your work, which was largely that health inequalities are driven by inequalities in income and power in society. Have you changed your mind?

RICHARD WILKINSON: Overall standards of health are driven by inequalities of income …

NEIL GOULBOURNE: Which largely means that the poorer you are and I think this is well-recognised, the more likely you are to suffer from illness throughout your life and from early death. But the major causes of that, the way in which that is mediated of course through the standard causes of ill-health; so heart disease, diabetes, obesity, cancer and of course mental health problems as well, the kind of things that you are familiar with.

Martin has asked me to speak about what we can do on the ground to deal with these kinds of issues, these causes of ill-health and in particular to target the people who suffer from them the most because what we need to be careful, of course with preventative measures, which is what we would usually put in place for these kinds of problems, is the fact that preventative measures often are taken up more by those people who are wealthier and have higher status in society and not by the people we particularly need to get to. So we always need to be careful to target these at the people we feel need them most.

So what I thought I’d do is look a little bit at the evidence of what seems to work when you are putting together a programme to deal with health inequalities on the ground. Because there is a reasonable amount of evidence out there I think about certain elements of the programmes that you need to put together and it points us in certain directions. I think the first thing, as I say, is to make sure we are targeting the right kinds of people. Often these are people who are hard to access, as I say middle class people tend to see their GPs and access health services more than others. So we can’t just rely on people coming in to see me as a GP or indeed access any health services.

So targeting is important and getting to hard to reach people is important too.

There’s a good amount of evidence that writing invitation letters to people works. That’s not surprising. It’s quite simple and it does seem to get to people, get people into healthcare effectively. It works for screening programmes and I think it will work in general.

Using lay health workers — I don’t know how many of you are familiar with that idea — but the principle behind them is the assumption that people who are medically trained are somehow distanced from so-called ordinary people partly, I suppose, by dint of the fact that we are medically trained.

MARTIN: And weird!

NEIL GOULBOURNE: And weird. Yes, I accept that. But by getting people who are drawn from the community, as it’s termed, and giving them small amount of medical information, a little bit of training, they may be in a better position to communicate with so-called ordinary people than doctors and nurses are.

Actually that does seem to work. So specific examples of this are health trainers rolled out in most parts of England at the very least. So again these are lay people who have been given small amounts of training in things like smoking cessation or exercise or healthy eating and they are supposed to act essentially as roving ambassadors and go out to places that doctors and nurses don’t get to and they are supposed to connect than we might.

There is evidence that that works so I think that’s something we should advocate.

Visiting people at home, so going out of the surgery and finding individuals and knocking on their doors rather than expecting them to come in to see is, the evidence on that is a little bit equivocal but I think there’s a reasonable chance that works to a degree. It’s obviously pretty high in resources so I think we need to be a bit careful about that but there’s a reasonable amount of evidence it might make a difference.

Finally, patient advocates. I think there are specific uses for patient advocates for people who are particularly, I suppose, disadvantaged. I’m thinking of people, I suppose, with learning difficulties in particular. There’s evidence that giving people like that patient advocates so they have a larger voice in health services does seem to work and that is something we can think about in specific cases, although again that is quite expensive.

So I think those are ways of getting to people who we might not otherwise get to the kind of people we don’t usually see.

The next question is what you actually have in a programme to deal with ill-health and health inequality on the ground. This might look a little bit disparate these elements but this is where the evidence points, I think. So one of the things that we know makes a difference is rather than just having short-term intervention programmes for six or eight weeks, making sure that you follow people up over a period of a year very often, probably at intervals of three months or six months. Again, that’s not surprising but there are so many programmes that don’t involve that kind of continued follow-up to make sure people aren’t falling by the wayside. So smoking cessation programmes, for example, work very often on that model but weight loss programmes, exercise programmes don’t typically but there’s lots of evidence that that makes a big difference.

Doctors and nurses are forever berating people about their lifestyles and our typical approach to behavioural change is simply to tell people off a bit and then, you know, kick them out and see them in a month’s time making sure you have changed. It’s not surprising I don’t think that that is a limited effect. Using motivational techniques does make a difference. It’s better than just trying to shout at people and, again, that’s not surprising but it isn’t very often that we go down that road. I think we all need within the Health Service more training in that kind of thing.

Some exercise programmes and weight loss programmes involve taking people to gyms and using quite complicated machinery. The evidence is that actually the more machinery you use, the more high tech the kinds of programmes you put people on, the less likely they are to maintain them. That’s really not surprising. The less equipment you use the more likely people are to maintain things at home on their own.

Target-setting is really important too. Lots of people already do that but lots of people don’t as well. So working out a target for a patient of what weight they should get to or how much exercise they should do, etc, makes a difference and finally handing over control of the target and of the mechanisms and techniques to patients through a patient-held record makes a difference.

nybody who has been pregnant or knows anyone who has been pregnant might be familiar with the patient-held records that you get when you are waiting to deliver. We don’t really see it in anything else. It’s really just when you are pregnant, but that should be applied across lots of different areas, a little book with a bit of information about your condition, who you see, when you are going to see them and your targets written inside but it does make a difference to give people ownership of whatever it is you are helping them with.

So finally a couple of little ideas for very low cost things I think that GPs can do themselves really, really straight forwards things. GPs are always banging on about how well they know their patients and always saying to the Government keep your hands off, we know our patients better than you do. But I don’t think many of them have bothered thinking about which of their patients suffer particularly or are likely to suffer particularly from ill-health because of the kind of factors that we have talked about.

So people who are in overcrowded households, for example, it’s very easy to search for that data on most GP computer programmes. You could compile a list of people in overcrowded households. Similarly people signed off work it is the GP who signs the sick note in the first place. You can compile a list of those people, you can look at ethnicity and language, that is data we keep as well.

MARTIN: When you sign people — I never thought about it before – but when you sign people’s sicknotes, do you record it in their notes?

NEIL GOULBOURNE: If you are a decent doctor you do, certainly.

MARTIN: So you can say how many of your punters are on the sick at any one time?

NEIL GOULBOURNE: Yes, and you should be able to say what they are off for and how long. So that is data we should all have.

So I think using data like that is pretty easy. You can just fish it off the computer, have a monthly list of people who you thought were most at risk of ill-health because of that. Then you can look at their general parameters of ill-health. So you can look at whether we have been checking their blood pressure enough, check their diabetes and so on because it is quite likely those people are not seeing us as much as we are seeing other people, not treating them as well as we are treating other people. So I think that’s quite a straightforward thing we can do.

Another pet idea of mine relates to the National Child Measurement Scheme. I don’t know how many people have heard of that but —

MARTIN: We had a discussion about it.

Catherine Gleeson: See you afterwards!

NEIL GOULBOURNE: Every child is being weighed at school at a certain age — I can’t remember what age it is — but that’s the plan anyway and I think it’s quite a good opportunity if it’s carried out properly to access not just children who are overweight but families that are overweight or unhealthy because often parents of young children don’t come to see their doctor very often because they are not at the age at which they think there is anything wrong with them, but what this is telling us is that if they have an overweight child, they are quite likely to be unhealthy themselves as well. So I think it’s a good way of accessing families that might not do otherwise. But I would be interested to hear what you have to say about that. Or maybe I wouldn’t …

NEW SPEAKER: What is the difference between that and the health visitor’s role earlier in their lives then?


NEIL GOULBOURNE: My understanding is that health visitors — it depends —

NEW SPEAKER: They go into the homes and get the environment as to —

NEW SPEAKER: Only when they are very young.

NEIL GOULBOURNE: My understanding is that health visitors see people when they are younger than that and when they get to school age they are handed over to the school nurse. So it’s just later on.

MARTIN: There is a serious problem with health visiting in as much as the profession is in real difficulties.

Catherine Gleeson: With capacity, yes.

MARTIN: For a whole heap of complicated reasons.

NEW SPEAKER: One of the things that health visitors have started to do is target the most at risk families and if they do that, they begin to address some of the health inequality issues.

NEIL GOULBOURNE: I will just give you a final example of an idea that I thought was quite exciting. I see an awful lot of patients who are overweight or whatever and need to change their behaviour but I also see a lot of people who show the kind of behaviour that we would want to see, people who do go, walking all the time or have excellent diet and all the rest of it who very often perhaps because they are retired or whatever don’t have all that much to do with their time. If we can only marry the two up, I think we would have a really good result.

So my idea is an exercise buddy scheme. So you find people who need to do more exercise, people who do a lot of exercise, yes essentially put them in contact and them to go out and play. I think it might work but, you know, it might be a little bit radical.

So I’m not sure where that all gets us. I first gave this talk, a more extended version, to a conference of GPs a few months ago and I had been asked specifically to give examples of things that people could do in their own practices easily and these were some of them and I had a few other ideas too. Much to my disappointment at the end of the talk all of the questions were about why GPs should bother doing this if they weren’t funded to which was disappointing, I thought. But hopefully I think the only way to deal with the that kind of problem is to have a cultural change, a difference in understanding of the role of the NHS such that people on the ground do start to feel that dealing with health inequalities is an essential part of their job not peripheral for primary care trusts and public health to deal with.

MARTIN: If you did all that with all your unfit punters, would you have more time to play golf or come to political meetings or whatever you like to do in your spare time? Isn’t the pay-off for GPs that if their punters are healthier they won’t be coming to see doctors so often?

NEIL GOULBOURNE: I don’t think so. I think — I mean, there is always that argument if you prevent ill-health you reduce your workload somehow. I don’t think it would work like that actually. I think you would increase your workload. GPs are paid more than enough to do that. I think we have enough capacity.

NEW SPEAKER: I’ve already said that doing a lot of those things, which I agree are good and I have been doing some of them for a long time, makes no difference if on the macro scale the inequalities continue. It’s a higher level which you can say is more prevention but actually people are more and more people are falling in the river further up.

NEIL GOULBOURNE: There’s no doubt about that whatsoever and I’ve long wondered, as you will know Martin, whether by talking about these things that we can do on the ground whether we actually just allow ourselves to be distracted from the bigger picture which is all about income and status inequality. So yes, I agree with that.

NEW SPEAKER: Do you not think it smacks of big brother you have a fat boy register. Fat boy, alcoholic …

NEIL GOULBOURNE: Yes, it does.

NEW SPEAKER: Everybody is watching what everybody else is doing.

NEIL GOULBOURNE: Yes, it does and that’s always the problem, isn’t it, with progressive measures, progressive governments in general. If you leave society as it is, though, then you end up with quite regressive results, I think. So yes, I agree with that and you have got to be careful how you do it which is why things like patient-held records can be quite useful. So you say it’s your information, you do what you like but I’m here to advise you.

NEW SPEAKER: I like an element of choice in accessing what you want to access.

NEIL GOULBOURNE: Even if that results in inequality?

NEW SPEAKER: Well, I just think society in general we’re getting more and more restrictive and not realising it’s happening to us and more people are looking what everybody else is doing and to some it’s healthy but in other elements it’s not healthy. I choose not to smoke. I don’t like sitting next to somebody who smokes all over me but it’s my choice such as … I don’t know.

MARTIN: There’s also the stuff about labelling. If we say you’re a fat boy, that won’t do your self-esteem and what-have-you any good at all, will it?

Catherine Gleeson: The thing about the fat boy is one of the things against the National Child Measurement Programme and that’s exactly what’s happened a lot. There’s been quite high levels of opt-outs by mainly by the 10 and 11 year olds “Well, I’m I know I’m fat, miss. I don’t want to get measured”. So it’s been quite high levels of opt-outs. So the figures that the Government is collecting through schools measurement in schools are of rather dubious of quality; whereas if children were measured opportunistically at the GP practice, which would be very easy, you could then take a retrospective sample of children’s weights to see what’s happening locally if you want to know that or within a PCT. So long as the GP practices have decent data using accurate equipment.

MARTIN: And they are paid to do it.

NEW SPEAKER: They shouldn’t need to be paid.

NEW SPEAKER: You wouldn’t have children going — the obese children, they have parents who probably have ill-health. They wouldn’t go to the GP practice.

Catherine Gleeson: Not many children go but most children will see a GP possibly once a year, something like that. I know it’s a lot less than adults and certainly a lot less than older people but you could over time build up a child’s track record, as it were, you know, building on from the health visitor. So you have it in the electronic record and you can then track things where with the national child measurement programme. It’s a snapshot of the whole population and next year’s population is totally different.

NEW SPEAKER: It’s not longitudinal at all.

Catherine Gleeson: No, it’s ill-conceived. It’s thought up so it looks as if we are doing something – measuring … there’s a lot of problems with the methods whereas doing it in general practices if you have good equipment and healthcare assistants who measure them.

NEIL GOULBOURNE: I accept that entirely.

Catherine Gleeson: Then you can track them. So there are other ways. I’m not saying it’s a bad thing to monitor, it’s just the method wasting a lot of time.

NEIL GOULBOURNE: I was saying that if we are weighing them anyway, then there’s no point, as you say, doing it if we’re not going to know a way then of doing something about people’s weight afterwards. So if you do find a child in whatever context who is overweight there should be a mechanism for dealing with that.

Catherine Gleeson: Follow-up the family and etc and do the other things.

MARTIN: Maybe the fat boys who don’t want to be weighed would be less unhappy if someone was going to help in a positive way.

NEW SPEAKER: Do you weigh someone or you might not weigh someone, what happens? Do you record the information, nothing …

Catherine Gleeson: It’s for the National Measurement Programme, it’s put into national data and there are results now from 2005-6… it started in 2005. So you can look it up in the DH website.

NEW SPEAKER: You don’t talk to the child about —

Catherine Gleeson: Who has the capacity to do that? They haven’t thought it through. There just aren’t the staff.

NEW SPEAKER: My service managers support a dual weighing system — get on the scales once for the Department of Health and once for them — because it’s about who owns the data. Oh no, they are apoplectic about it.

Catherine Gleeson: We’ve never met before, we’re in different areas. So it is a real widespread target problem. It’s a good illustration of a government target that needs rethinking.

NEW SPEAKER: I think we both agree we can see value in establishing that sort of level because we didn’t know it, that sort of baseline measurement.

Catherine Gleeson: But a lot could be done for very little money really if it were more carefully thought about and done through the practice. Most GP practices don’t know who the school nurse is.

NEIL GOULBOURNE: Quite. Exactly. I agree with that. One way or the other there certainly needs to be a better link between schools as and GPs and other community facilities.

Catherine Gleeson: They should be using, the same electronic record. The other thing with the national measurement programme is it is collecting data as well but in a kind of hidden sort of way. You know, like you can read it all yourselves like 50-odd pages of guidance from the Department of Health as to how these measurements should be taken and no extra staff. So although now they say you can feed it back to the parents, there still isn’t any increase in capacity of staff to do that and, as you say, you feed it back, then what do you do? So it does need looking at.

MARTIN: “Dear Mrs Fatty, your son is fat”.

Catherine Gleeson: The Government then says well, it’s up to the parents then. So it’s not really —

MARTIN: To do what exactly?

Catherine Gleeson: It’s piling more difficulties on to parents.

MARTIN: My child comes home with a letter telling me they are fat. I knew that. So what. What do I then do?

Catherine Gleeson: It’s more about good access — we don’t need kind of rocket science to tell us you need access to a supermarket or a market with decent food, you need to know how to cook a few basic things. Jamie Oliver’s probably doing more for obesity reduction and raising parents’ self-esteem than lots of other things.

NEW SPEAKER: Careful which towns you mention that name in … only joking.

Catherine Gleeson: He’s getting people — I wouldn’t criticise him. I don’t like his swearing but the rest of it, getting people to think about how they can look after their family.

NEW SPEAKER: I was interested in you were talking about how GPs can look at their practice population and I’m just conscious that isn’t something that GPs do generally and we don’t do for primary care generally. Primary care, the Health Service in this country is very much based on a one-to-one relationship with the patient and looking at the person in front of me, what are your health needs now, not a practice thinking, well, actually in my population I’ve got a high proportion of people through out of work, I’ve got a high proportion of people at risk of particular conditions, and although some of that information will be there for the practices, they are not required to look at it in any way that impacts on them. Alongside that, also — and I guess I have in some ways many questions about this, but if you were to talk about a school what we have now in this country is this slightly over-onerous regime of looking at how good that school is through a whole number of measures. There is no way of me saying I’ve got a good GP practice or not or Sheffield as a city working out what areas of the city have poor quality primary care provision that isn’t meeting the needs of the people that live there. So as a result you have a healthcare system that is potentially —

NEW SPEAKER: Strangely the QOF data was supposed to do that but in fact there’s very little. It’s overformed to the new contracts.

MARTIN: There’s lots of data but it doesn’t tell you a great deal.

NEW SPEAKER: It didn’t do what it sought to do, to show variability, but it doesn’t show any at all.

NEW SPEAKER: The Department of Health’s national support team that have been working on the health inequality areas, Chris Bentley has done a lot of work looking at QOF data analysing it and saying you can pick up poor provision by primary care, it’s just not done, and picking up particularly really quite difficult things with some practice striking people off their register who are a difficult patient, exactly the people who will end up having poor health in the long run.