Primary Health Care and Population Mortality 9781032409313, 9781032397375, 9781003355380

Table of contents :
Cover
Half Title
Title Page
Copyright Page
Contents
Preface
Acknowledgements
Author
1. Hard times
2. From certificates to statistics
3. Variations in population mortality and some things that influence them
4. Primary health care and population mortality in low-, middle-and high-income countries
5. Communicable diseases
6. Non-communicable diseases 1: Cardiovascular disease and cancer
7. Non-communicable diseases 2: Respiratory disorders and mental health
8. Organisational features of primary health care
9. The patient–professional relationship
10. Policy and population health management
11. The mechanisms framework
12. New ambitions for primary health care
Index

Citation preview

PRIMARY HEALTH CARE AND POPULATION MORTALITY

Population health management is being increasingly adopted by health systems, yet the importance of primary health care in influencing population mortality and the mechanisms that explain it are not well understood. Too often, primary health care is regarded as a service for minor health problems and for managing access to secondary care. This limited view is no longer tenable and it is time to be much more ambitious about the place of primary health care in health systems worldwide. In delivering and planning health care and in re-building health systems after the pandemic, practitioners and policymakers in low-, middle- and high-income countries need evidence on how primary health care affects population mortality and practical advice to effect change. Primary Health Care and Population Mortality fulfils this need. Drawing on his long experience as both a practitioner and researcher, the author Richard Baker describes how primary health is crucial to the effect of health systems on population mortality, including its potential for reducing inequalities in mortality. This accessible new book will provide invaluable information to leaders in service development and delivery, academics in primary health care and those working within international organisations that are promoting primary health care for improving population health. It will also be of practical value to general practitioners, primary health care nurses and managers and public health staff.

Primary Health Care and Population Mortality Richard Baker

Department of Population Health Sciences University of Leicester, UK

First edition published 2023 by CRC Press 6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742 and by CRC Press 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN CRC Press is an imprint of Taylor & Francis Group, LLC © 2023 Richard Baker This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, access www. copyright.com or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. For works that are not available on CCC please contact [email protected] Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. ISBN: 9781032409313 (hbk) ISBN: 9781032397375 (pbk) ISBN: 9781003355380 (ebk) DOI: 10.1201/9781003355380 Typeset in Sabon LT Std by KnowledgeWorks Global Ltd.

Contents

Preface vii Acknowledgements ix Author x 1 Hard times 1 2 From certificates to statistics 14 3 Variations in population mortality and some things that influence them 27 4 Primary health care and population mortality in low-, middle- and high-income countries 47 5 Communicable diseases 76 6 Non-communicable diseases 1: Cardiovascular disease and cancer 101 7 Non-communicable diseases 2: Respiratory disorders and mental health 120 8 Organisational features of primary health care 141

vi   Contents

9 The patient–professional relationship 164 10 Policy and population health management 184 11 The mechanisms framework 195 12 New ambitions for primary health care 207 Index 213

Preface Richard Baker

It’s time to think differently about primary health care. As the evidence assembled in the following pages shows, it is crucial to the effect of health systems on population mortality. The research responsible for this new understanding of primary health care has been conducted in the last two decades and is so extensive that it has been possible to identify 23 mechanisms that contribute to its beneficial effects. Too often in the past, the policies of many governments and decision makers appear to have been based on the belief that primary health care is the setting for dealing with minor problems and the routine management of chronic disorders, with the overriding objective being to constrain the use of costly hospital services. The consequence of this narrow understanding of primary health care is shorter lives for too many people. The new evidence demands that policymakers should be much more ambitious about the role of primary health care in health systems. Better planned and better resourced services would be followed by fewer premature deaths among current and future generations. Policymakers should also be more ambitious about primary health care’s role in reducing inequalities in mortality. It can make a difference, yet too often services are neither designed nor managed appropriately. It is time for this state of affairs to change. The life-course theory of health inequalities has special relevance to that part of the health service that provides lifelong care – inequalities begin at the beginning of life, and action by primary health care to address them must begin with mothers and children.

viii   Preface

The planning and delivery of primary health care must give greater priority to reducing mortality and inequality in mortality. The mechanisms of primary health care that influence mortality should be used by policymakers to inform the organisation of services. Methods are available for monitoring mortality patterns, and mortality should be one of the key outcomes routinely used to guide services. Practitioners need a supportive policy framework that allows them to learn from both mortality in the populations they care for and the deaths of individuals. Around the world, primary health care is working hard to restore services that were stretched to a breaking point during the pandemic. But even before the pandemic there were serious problems. In low- and middle-income countries, primary health care was often poorly resourced, patchy and fragile; and in high-income countries, failure to anticipate the changing demands on health care caused by ageing populations left many services in a state of unplanned decline. For many countries, rebuilding primary health care will be a long and difficult path. The preparation of this book began during the lockdowns of the pandemic. By the time all the evidence had been sifted, it had become clear that more than re-building will be needed if primary health care is to achieve its full potential in improving health. The evidence and ideas in the following pages are offered in the hope that thinking differently about the role of primary health care will help its potential to be reached.

Acknowledgements

The most important mentor and catalyst to my thinking about and research into primary health care is Robin Fraser, Head of the Department of General Practice during my formative years as a general practitioner researcher. He developed a vision about the core clinical skill – the clinical method – that has inspired me to think systematically about how primary health care affects population mortality, and it is a privilege to acknowledge his influence here. It is a pleasure to thank George Freeman, Mayur Lakhani, Tim Stokes, Steven Levene and Harini Sathanapally for reading selected chapters. Thanks are also owed to Jo Koster of Taylor & Francis/CRC Press and Meeta Singh for their guidance in the preparation of the manuscript. The feedback made an enormous difference to the original text; the errors that remain are all my own. I am grateful to a group of organisations that have made data freely available under Creative Commons Licenses. Many of the tables and figures draw on data they have published; they include the Institute for Health Metrics and Evaluation (IHME) and its associated Global Burden of Disease (GBD) programme, the National Records of Scotland, the Office for Health Improvement and Disparities, NHS Digital that published information from the Health Survey for England, the Office for National Statistics (ONS), the UK Government, the World Bank and the World Health Organisation (WHO). The process of seeking and sifting through the research evidence that is presented in the pages that follow began with the first lockdown in 2020. My partner in life these last 50 years was a calm presence from those first stages and on to the completion of the manuscript. As ever, thank you, Christine.

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Author

Richard Baker is Professor Emeritus in the Department of Population Health Sciences at the University of Leicester, UK. A general practitioner between 1977 and 2013, and with a long-term interest in the quality of primary health care, in 2000 he undertook a clinical audit of the patterns of mortality of the patients of Harold Shipman, a doctor who had been convicted of killing 15 of his patients. The finding of over 230 excess deaths during Shipman’s career as a general practitioner informed the subsequent public inquiry that was followed by reforms to the certification and monitoring of deaths. This experience led Baker to explore the potential of mortality data in helping primary health care teams improve population health. Other research interests have included patients’ experiences of care, continuity of care, methods for clinical audit and the development and implementation of clinical guidelines. He was the first Head of the Department of Population Health Sciences at the University of Leicester and is author of numerous peer-reviewed papers and other publications.

CHAPTER 1

Hard times

I have been a witness to life and death as a physician, first as a junior hospital doctor from 1975, and then from 1977 as a general practitioner. Those first years in general practice were the final stages of the cradle to grave form of primary health care in United Kingdom. It was not unknown, having attended the delivery of a baby in the early hours of the morning, whilst returning home tired but content, to call in at a nursing home to confirm the death of an elderly resident. And like every old general practitioner, it is the deaths of the young that we recall most frequently, the young woman with chronic respiratory disease or cancer, the young man with myocardial infarction or who succumbed to death by suicide, and of course the children and infants. How can primary health care help more people reach the natural completion of their lives? HARD TIMES These are hard times for primary health care around the world. There is relentless pressure on limited resources to establish services in low-income countries or to strengthen services in middle- and high-income countries in response to ageing populations. Health professionals are exhausted in the wake of the pandemic yet must find the energy to repair ravaged health systems. In restoring health care or in justifying investment in more staff and better facilities, evidence is needed on how to deliver key health outcomes. In explaining the benefits of primary health care, professional DOI: 10.1201/9781003355380-1

2   PRIMARY HEALTH CARE AND POPULATION MORTALITY

bodies, representative national and international organisations and governments almost invariably point out that health systems achieve better outcomes when primary health care well resourced and better organised to meet the needs of the population. For example, the World Health Organization (WHO) says ‘… there is considerable evidence that health systems based on primary care services that are first-contact, continuous, comprehensive, coordinated, and people-centred have better health outcomes’.1 Mortality is one of the outcomes of interest to the WHO and two sources of evidence about the effect of primary health care on population mortality are routinely referred to. The first is a series of studies of how higher numbers of family physicians per unit of population in one country – the United States – were associated with lower population mortality. The second involves comparisons of mortality between samples of predominantly high-income countries in which selected features of health systems were used to describe the strength of their primary health care systems, countries with so-called stronger systems in these studies tending to achieve lower population mortality. The evidence, therefore, is reliant on data from a single country or on the use of a constructed measure described as ‘strength’. It is reasonable, surely, to ask whether this is sufficient to justify the claim that primary health care should be a core part of health systems worldwide. The first motivation for this book was to seek out and document as much evidence as possible to test the security of the conclusion that primary health care does indeed reduce population mortality. The second motivation was to identify the potential mechanisms for any association between primary health care and population mortality. A better understanding of the mechanisms that affect mortality would enable governments and their advisers to plan health systems and help practitioners to deliver more effective care. Our current understanding of what the mechanisms may be are most clearly set out by Barbara Starfield and colleagues2 based on their own research and on the review of research by others. They proposed six broad mechanisms: (1) Increased access to health care for socially deprived populations; (2) improved quality of care; (3) prevention of ill health; (4) early management of health problems; (5) dealing with the characteristics of primary care (a focus on the whole person rather than the illness, first contact care and continuity) and (6) reducing unnecessary specialty care. More recent research may elaborate on these potential explanations and clarify how primary health care influences population mortality. It may then be easier to convince policymakers to build and sustain effective primary health care systems worldwide.

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3

STATISTICS AND STORIES In 2000, I conducted a review of the work of English general practitioner Harold Shipman, both reviewing the clinical records of individual cases and conducting a statistical analysis of mortality among his patients compared to those of local doctors caring for patients of similar socioeconomic and ethnic mix.3 The record review was as revealing as the statistical analysis. From the brief notes about their lives and deaths, a message from each person seemed to emerge and be repeated – ‘Tell my story, learn from my story’. The conclusion of the simple statistical analysis was that over a period of 25 years he had unlawfully killed 236 patients. Before then, my exploration of mortality patterns at practice level had been restricted to collecting data in my own practice in the 1980s; interesting though these data were, it was difficult to use them to inform clinical practice since there were no data available from comparable practices and little was then known about how primary health care influenced population mortality. Following the Shipman investigation and after involvement in other investigations for the National Health Service (NHS) and through several research studies, it has become increasingly clear to me that mortality data can be used to guide clinical priorities in primary health care. Review of the care of individual cases can be revealing as well – both statistics and stories teach us how to improve care. But information about deaths is too often given scant priority in resourcing or organising primary health care; the focus is usually on meeting the demand for access and avoiding the use of expensive hospital care.

PRIMARY HEALTH CARE The terms primary care and primary health care are often used interchangeably but can also be used to describe slightly different concepts. Both involve first contact care for people of all ages and for most health problems. Instead of being focused on the care of a specific condition or group of conditions, they are both focused on the care of the person, irrespective of what condition they have. However, primary care tends to be used to refer to the work of primary care physicians or general practitioners and the teams in which they work. Primary health care, in contrast, includes a wider range of health professionals and covers the spectrum of care for the population as well as care of individuals and is the term used by the WHO. I am following the WHO in using the term primary health care because of my interest in the health of populations.

4   PRIMARY HEALTH CARE AND POPULATION MORTALITY

OUTCOMES Mortality and inequity in mortality are the outcomes that I am addressing, but primary health care has many other outcomes, for example, morbidity, quality of life, the patient’s knowledge of their illness and its management or number of hospital admissions. These are all important. Even so, if four or five outcomes are to be chosen as the principal goals of a primary health care service, it would be difficult to justify excluding mortality. Not unreasonably, most people who use health services assume that health professionals will do all they can to avoid their untimely deaths. Confidence and trust that this is the case are needed when seeking help with frightening symptoms that give rise to thoughts of cancer or heart disease. When treatments are exhausted and death no longer avoidable, confidence is needed that compassion and relief from suffering will be available as well. No single outcome is sufficient to describe the product of medicine, but mortality is sufficiently important to justify its inclusion among those chosen to evaluate its effects. The most powerful determinants of mortality are the genes that we are born with and the social, economic, cultural, political and environmental conditions under which we live. Health care plays only a secondary role, usually after all the other determinants of health have set the course of our lives. Even the most cursory inspection of mortality data throws up clear evidence of inequalities between different groups of people – between people in different countries or between localities within countries or between different occupations or social groups or between different ethnicities. It is therefore impossible to understand patterns of mortality without some understanding of inequalities in health. One reason for calling on primary health care services to pay more attention to mortality as an outcome is that this would inevitably highlight inequality and make it an overriding priority to address. If I ruled the health system, mortality and health equity would be two of my four or five priority outcomes. Inequalities in health are ubiquitous and we are unable to change many of them; some of us are born with health problems and all of us are more or less susceptible to one condition or another. However, some inequalities could be reduced or eliminated if we implemented appropriate actions. I will follow Marmot’s definition of health inequities4 to describe these inequalities, namely health inequities are inequalities that could be avoided by reasonable interventions. Today’s leading way of thinking about health inequalities is the lifecourse approach5 that argues that experiences earlier in life influence

Hard times   

5

our ability to respond to later adverse circumstances. It is the effect of problems in early life impairing future capacity to respond to new problems that allows inequalities to mount up. Conditions that impair future health can arise in utero in consequence of maternal stressors more common in poverty or through poor diet or due to smoking. Prematurity, low birth weight, neurodevelopmental impairment and other effects on the fetus prepare the ground for the development of non-communicable diseases in later life, a process sometimes described as early life programming.6 Exactly what biological mechanisms are at work remains uncertain although long-term changes in the infant’s hormone production and in various organs including the brain, kidney, muscle and pancreas have been identified. In England in 2008, the government commissioned an independent review of strategies for reducing health inequalities. The report7 made six groups of recommendations, including ensuring each child the best start in life, education to help children and adults maximise their abilities and control over their lives, fair employment, sufficient income to have a healthy life, a healthy environment and effective ill-health prevention services. Health inequalities that could be avoided by these six interventions meet the definition of health inequities. A report on progress published a decade later found not only lack of progress in reducing inequities but deteriorating conditions in all six of these social determinants of health, including rising child poverty, an increase in precarious employment practices, a rise in homelessness and large numbers of people needing to use food banks.8 Primary health care on its own cannot eliminate health inequities but if it can do something to reduce them, even just by a little, it should do so, and understanding rates of mortality, what explains them and how they may be reduced, will help primary health care do its share.

DEVELOPMENTS IN LOW- AND MIDDLE-INCOME COUNTRIES Although there is variation between countries, mortality rates have tended to decline faster in low- and middle-income than in high-income countries. Even so, progress towards the United Nations Sustainable Development Goals, due to be achieved by 2030, is uneven. For example, one of the health goals is reduction of under-five mortality to less than 25 per 1,000 live births, but in 2019, the rate in South Asia was 40.5 and in Sub-Saharan Africa as a whole it was 74.1. Fifty-three countries are

6   PRIMARY HEALTH CARE AND POPULATION MORTALITY

not on track to reach the goal for under-five mortality, three-quarters of these being in Sub-Saharan Africa.9 The extent to which primary health care is established in all lowand middle-income countries varies widely, from no service at all in some countries to comprehensive and accessible care for all citizens in a few others. Services are often both patchy and fragile. As long ago as 1978, in its Alma-Ata Declaration the WHO described primary health care as key to attaining the target of health for all by the year 2000,10 but the goal of universal primary health care remains unachieved. The WHO says that almost half the world’s population lacks complete coverage of essential health services.9 The divergence from the Declaration began within a few months of its publication when leaders of major aid funding organisations including the World Bank and the United States Agency for International Development (USAID) judged the costs of implementing primary health care too high and put their weight behind disease-specific programmes, using the term selective primary health care to describe collections of such programmes being launched together (for example, the delivery together of vaccinations for children under six months old, the promotion of breastfeeding and chloroquine for children under aged three in malarial areas). In reflecting on the Alma-Ata Declaration in 2018, Ghebreyesus and colleagues11 concluded that despite some gains in health the original vision had not been fulfilled, with private health care, hospital services and stand-alone disease-specific approaches dominating the health systems of some countries in place of primary health care. Inexplicably, the United Nations Millennium Development Goals and the Sustainable Development Goals that replaced them in 2015 made no mention of primary health care as the foundation for effective health systems. The impact on health outcomes of this disconnect between the various international bodies influencing national health policies is difficult to estimate, but it is clear that in too many countries fragmented health systems have persisted. Representatives of governments meeting on the 40th anniversary of the Alma-Ata Declaration reaffirmed commitment to the values and principles of Alma-Ata and issued a new statement, the Declaration of Astana, which proclaimed primary health care as a cornerstone of health systems.12 The representatives committed to building sustainable primary health care, prioritising health promotion and prevention, and meeting everyone’s health needs across the life-course. Two years before the COVID-19 pandemic, the Declaration pointed out the importance of primary health care in detecting and responding to outbreaks of infectious

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7

diseases. In 2020, the WHO called on countries to allocate 1% more of their gross domestic products (GDPs) to primary health care.13 DEVELOPMENTS IN HIGH-INCOME COUNTRIES The epidemiological transition to low birth rates and low death rates is well-advanced in high-income countries and in some, birth rates are falling below replacement levels. The attention of primary health care, therefore, will not only be on managing the problems of old age but also on extending the working lives of the younger economically productive generations. Reducing child morbidity and mortality even further and extending healthy life can be expected to become priorities. In many countries the primary health care workforce is already under pressure caused by the needs of the ageing population and the failure of national policies to react effectively. Shortages of primary health care doctors have been reported in many countries, and in Organisation for Economic Co-operation and Development (OECD) countries, the percentage of all doctors who are primary health care doctors has dropped from 32% in 2000 to 29% in 2016.14 Over the last 10 years, the shortages in England have proved resistant to a succession of national policies and the lack of doctors is being met by an expansion of the workforce with a mix of other staff and the wider use of triage systems to direct patients to different health professionals or alternatives to face-to-face consultations. By 2021, the British Social Attitudes Survey reported that public satisfaction with general practice had fallen to its lowest level since the survey began in 1983.15 In addition to pressure on access, relationship continuity has declined, the range of services available to patients has contracted, and home visits have been curtailed. In many high-income countries, therefore, a process of unplanned decline of primary health care services is underway. The impact on population mortality is unknown. Several decades ago, Julian Tudor Hart demonstrated the potential of what he called the general practitioner as community physician, working with a public health orientation.16 He observed that primary health care teams could review local causes of death to identify ways to reduce mortality. At intervals since then, primary health care has been encouraged to adopt a greater focus on the health of the populations they care for. The case was re-stated in a recent report by the United States Institute of Medicine that urged the integration of primary health care and public health based on the belief that by acting together, they could have a greater effect on population

8   PRIMARY HEALTH CARE AND POPULATION MORTALITY

health than either working alone.17 The same idea can be found in current health system developments such as population health management. STALLING LIFE EXPECTANCY IN HIGH-INCOME COUNTRIES The OECD has published an analysis of life expectancy at birth over the period 2005–2016.18 After more than 150 years of steady gains in life expectancy, the rate of improvement in high-income countries in Europe, including France, Germany and the United Kingdom, had slowed. In 22 of the then 28 European countries, the improvements between 2011 and 2016 were lower than those between 2006 and 2011. In 2015, compared with 2014, life expectancy at birth fell for females in all but five of the 28 EU countries and for males in all but 12 EU countries. The OECD analysis pointed to a slowdown in the rate of reduction in mortality caused by cardiovascular diseases that had taken place in many countries, including France, Germany, Italy, Spain, the Netherlands and the United Kingdom. At the same time, deaths from Alzheimer’s disease and dementia increased; there was also a small increase in deaths from drug overdose in some countries, including the United Kingdom and Sweden. The United Kingdom and the United States have experienced greater slowdowns in mortality improvements than other high-income countries. In the United States, in 1990, life expectancy at birth, for males and females combined, was 75.4 years, had reached 76.8 in 2000, and by 2010 was 78.7, but was still 78.7 years in 2018.19 In an analysis of deaths in the United States among people aged 40 to 76 years between 1999 and 2014, higher income was associated with greater life expectancy at age 40, the gap between the richest and poorest being 14.6 years among men and 10.1 years for women.20 Between 2001 and 2014, richer people gained more years of life than poorer people and hence the gap between rich and poor widened. There were also differences between geographical areas with some areas experiencing a gain of four years of life while other areas experienced a loss of two years. In the United Kingdom, although older people account for most deaths, mortality declines have slowed in younger adults, with an increase in the death rate for those aged 45 to 49 between 2011 and 2016. 21 Declines in infant mortality have also slowed, remaining almost unchanged from 2014 to 2018 at around 3.9 deaths per 1,000 live births, whilst among adolescents (age 10 to 19) mortality increased from 17.5 to 18.0 per 100,000 young people. 22 Changes in life expectancy at birth calculated using three-year data periods varied among the countries of

Hard times   

9

TABLE 1.1  Life expectancy at birth (years) in the countries of the United Kingdom

showing changes (weeks) between 2014–2016 and 2017–201923 Males 2014–2016 2017–2019 England Wales Scotland Northern Ireland

79.5 78.4 77.1 78.5

79.8 78.5 77.2 78.8

Females Change in weeks

2014–2016

2017–2019

Change in weeks

12.0 4.2 3.7 11.5

83.1 82.3 81.1 82.3

83.4 82.3 81.1 82.6

12.0 –1.0 0 12.5

the United Kingdom between 2014–2016 and 2017–2019 (Table 1.1) and were smaller in both Wales and Scotland. For females there was no improvement in Scotland and a reduction of one week in Wales.23 In London in 2017–2019, life expectancy among men was 80.9 and among women 84.2, but in the North-East of England the respective figures were 78.0 and 81.8. In some districts there were losses of life expectancy (Table 1.2). TABLE 1.2 Changes in life expectancy at birth between 2014–2016 and 2017–2019 in districts of the United Kingdom with the greatest gains and losses23

Change in life expectancy (weeks) Regions with highest gains Males Shetland Isles Westminster Tower Hamlets Females Uttlesford Ribble Valley Epsom and Ewell Regions with highest reductions Males North Kesteven Tonbridge and Malling Females King’s Lynn and West Norfolk Stoke-on-Trent North Kesteven Highland

133.6 130.5 88.7 84.5 82.4 82.4

–64.2 –57.4 –52.7 –51.7 –52.2 –50.1

10   PRIMARY HEALTH CARE AND POPULATION MORTALITY

Several factors are likely to explain the slow-down or reversal of mortality declines in the United Kingdom. The effect of austerity measures following the global financial crisis of 2008 is difficult to discount; in England life expectancy at birth is lowest in those areas with greatest socio-economic deprivation yet these areas experienced the largest cuts in local government spending.8 Growing levels of obesity and sedentary living may also be partly responsible. A review of the performance of health systems in 11 high-income countries ranked the United States as the worst, one solution proposed to improve outcomes being improved access to primary health care. 24 COVID-19 The WHO regularly reviews threats to global health and the top 10 highlighted in 2019 were air pollution and climate change; non-­communicable diseases; global influenza pandemic; fragile and vulnerable settings; antimicrobial resistance; Ebola and other high-threat pathogens; weak primary health care; vaccine hesitancy; dengue and HIV. 25 Although the pandemic was caused by the SARS-CoV-2 virus rather than an influenza virus, the inclusion of both vaccine hesitancy and a global influenza pandemic shows admirable prescience. COVID-19 will influence national policies on not only health care but also the wider determinants of health. The virus has shone a cruel light onto pre-existing health inequalities and action will be needed by governments in supporting families, in improving education and working lives, in introducing healthy environmental and food policies, and in eliminating the disadvantages associated with ethnicity, gender or other personal characteristics. The life-course model of health inequalities predicts that the adverse effects of lockdowns, reductions in family incomes and lost education will interact with other disadvantages to impair the health and shorten the lives of people in the poorest and most stressed families. The impact of COVID-19 on health services has been heaviest in areas characterised by ethnic diversity and socioeconomic deprivation, and in restoring primary health care, we need evidence on how it affects the health and longevity of all population groups. METHODS In the chapters that follow, I have attempted to discover whether primary health care does reduce population mortality, and if it does, to describe what the potential mechanisms may be.

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11

Evidence was sought through searches of each volume of the following journals from January 2015 to the end of April 2022: African Journal of Primary Health Care & Family Medicine, Annals of Family Medicine, Archives of Disease in Childhood, British Journal of General Practice, British Medical Journal, BMJ Global Health (the first issue was January 2016), European Journal of Public Health, Family Practice, Health and Social Care Delivery Research, Journal of the American Medical Association, Journal of the American Board of Family Medicine, Journal of Public Health, Lancet Global Health, New England Journal of Medicine, Scandinavian Journal of Primary Health Care and Lancet. I also searched the reviews of the Cochrane Effective Practice and Organization of Care review group. Relevant references in identified articles were followed up and some supplementary online searches were undertaken. Greatest weight has been given to systematic reviews of research studies when relevant reviews were available, the outcome of interest being mortality. One limitation was that only publications in the English language were included. Another is that being most familiar with the extensive publicly available data from the UK statistics agencies, I have usually relied on these sources when demonstrating points about mortality rates within countries or in small populations. Nevertheless, the fundamental principles of primary health care are taken to be the same the world over, and the findings from the evidence search and the mechanisms of primary health care identified from them are intended to be widely applicable. In later chapters, I propose mechanisms that enable primary health care to influence population mortality. Relatively informal consideration of the usually broad range and types of evidence relevant to each of the mechanisms was used to summarise the supporting evidence as strong, moderate or weak. The mechanisms may be thought of as provisional theories that have been advanced for future researchers to refute or develop. For the present, they should help health professionals, managers and policymakers think about the impact that changes in the structures or processes of primary health care are likely to have on population mortality. A population is a group of individuals. It is important to note findings about risk factors for disease in a population cannot be directly applied to individuals within the population. For example, an individual may develop lung cancer without ever having smoked but the most powerful factor predicting rates of lung cancer in most populations will be smoking. The individual either does or does not have the disease or risk factor whereas in the population a proportion has the disease or risk.

12   PRIMARY HEALTH CARE AND POPULATION MORTALITY

THE CHAPTERS THAT FOLLOW The next two chapters prepare the ground for understanding patterns of mortality. Chapter 2 considers how mortality may be measured and described, how morality rates are derived and what life expectancy is. Chapter 3 focuses on the issue of variations in mortality that may occur with age, ethnicity, gender and measures of social and economic inequality. Chapters 4–10 then set out evidence on whether and how primary health care influences population mortality. Chapter 4 brings together evidence from low-, middle- and high-income countries on the relationship between the strength of primary health care and the supply of doctors on mortality. Chapter 5 considers the management of communicable diseases, Chapters 6 and 7 address non-communicable diseases, Chapter 8 provides characteristics of the delivery of care such as access or outreach, Chapter 9 considers the influence of the relationship between patients and professionals and Chapter 10 discusses contemporary developments in health care organisation such as practice networks and integrated care. Chapter 11 brings together the mechanisms identified in the preceding chapters to present a framework for thinking about how primary health care affects mortality. Finally, Chapter 12 argues that it is time to see primary health care in a new way, as a service that has important effects on population mortality.

REFERENCES 1. WHO. A vision for primary health care in the 21st century: Towards universal health coverage and the Sustainable Development Goals. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2018 2. Starfield B, Shi L, et al. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502 3. Baker R. Harold Shipman’s clinical practice. London: The Stationery Office, 2001 4. Marmot M. The Health Gap. The Challenge of an Unequal World. London: Bloomsbury Publishing, 2015 5. Bartley M. Health Inequality. Second edition. Cambridge: Polity Press, 2017 6. Williams TC, Drake AJ. What a general paediatrician needs to know about early life programming. Arch Dis Child 2015;100:1058–1063 7. Marmot M. Fair Society, Healthy Lives. The Marmot Review. London: 2010 8. Marmot M. Health Equity in England: The Marmot Review 10 years on. Institute of Health Equity, 2020 9. WHO. World Health Statistics 2021: Monitoring Health for the SDGs, Sustainable Development Goals. Geneva: WHO, 2021 10. WHO & United Nations Children’s Fund. Alma-Ata 1978. Primary Health Care. Geneva: WHO, 1978

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11. Ghebreyesus T, Fore H, et al. Primary health care for the 21st century, universal health coverage, and the Sustainable Development Goals. Lancet 2018;392:1371–1372 12. WHO and Unicef. Declaration of Astana. Geneva: WHO, 2018 13. WHO. Urgent health challenges for the next decade. WHO Newsroom, 2020. www.who.int/news-room/photo-story/photo-story-detail/urgent-healthchallenges-for-the-next-decade 14. OECD. Realising the Full Potential of Primary Health Care. Policy Brief. OECD, 2019 15. Wellings D, Jeffries D, et al. Public satisfaction with the NHS and social care in 2021. Results from the British Social Attitudes Survey. London: The King’s Fund, 2022 16. Hart JT. A New Kind of Doctor. London: Merlin Press, 1988 17. Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: National Academies Press, 2021 18. Raleigh VS. Trends in life expectancy in EU and other OECD countries: Why are improvements slowing? OECD, 2019 19. Bastian B, Tejada Vera B, et al. Mortality Trends in the United States, 1900–2018. National Center for Health Statistics, 2020. www.cdc.gov/ nchs/data-visualization/mortality-trends/index.htm 20. Chetty R, Stepner M, et al. The association between income and life expectancy in the United States, 2001–2014. JAMA 2016;315(16):1750–1766 21. Marshall L, Finch D, et al. Mortality and life expectancy trends in the UK: Stalling progress. London: The Health Foundation, 2019 22. Royal College of Paediatrics and Child Health. State of Child Health in the UK. London: RCPCH, 2020 23. Office for National Statistics. Life expectancy for local areas of the UK: Between 2001 to 2003 and 2017 to 2019. Statistical Bulletin. ONS, 2020 24. Schneider EC, Shah A, et al. Mirror, mirror, 2021. Reflecting poorly: Health care in the U.S. compared to other high-income countries. New York: The Commonwealth Fund, 2021 25 WHO. Ten threats to global health in 2019. WHO, 2019. www.who.int/ news-room/spotlight/ten-threats-to-global-health-in-2019

CHAPTER 2

From certificates to statistics

Systems to confirm and record deaths and identify trends are required for the planning of health and other services. Here, the steps of certification, registration and coding are outlined, and ways of presenting mortality data are discussed. DEATH CERTIFICATION The study of mortality in populations requires accurate information on the fact, date and cause of deaths. The data must be in a standard form to enable investigation of patterns of deaths within countries as well as the comparison of mortality between countries. Ensuring a uniform approach throughout the world in reporting of deaths is a tall order, and there certainly are variations between countries in the accuracy of mortality data. A first step has been standardisation of the death certificate. This has been achieved under the leadership of the WHO and involved development of an International Form of Medical Certificate of Cause of Death (Box 2.1) and an agreed upon system for coding diseases. The international form of death certificate requires the doctor to record the sequence of steps leading to death. Line 1a records the immediate, direct cause of death, with the conditions or events that led to this being recorded in order on lines 1b to 1d. Line 2 is for recording other conditions contributing to death but not related to the disease or condition causing it. An example of such a sequence is line 1a myocardial infarction, due to line 1b coronary thrombosis, due to line 1c coronary atherosclerosis. The lowest line of Part 1 of the form is used to record the DOI: 10.1201/9781003355380-2

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15

BOX 2.1  The International Form of Medical Certificate of Cause of Death1

1. Report disease or condition directly leading to death online (a). Report chain of events in due to order (if applicable). State the underlying cause on the lowest used line.

Time interval from onset Cause of death to death a b

due to

c

due to

d

due to

2. Other significant conditions contributing to death (time intervals can be included in brackets after the condition).

condition that began the sequence leading to death, and this is usually selected as the underlying cause of death. The underlying cause of death is defined as (a) the disease or injury which initiated the train of morbid events leading directly to death, or (b) the circumstances of the accident or violence which produced the fatal injury.1 The underlying cause is used as the cause of death in compiling mortality statistics. It is generally required that the professional completing the certificate is familiar with the patient’s medical history and has access to the medical records. If no health professional is familiar with the patient’s care the death must be investigated by a designated authority such as a medical examiner or coroner, depending on the legal arrangements in different countries. Some deaths must always be reported to such an authority – For example, violent or unexplained deaths. REGISTRATION OF DEATHS The information on a death certificate must be transferred to a register that records all deaths to enable data on numbers and causes of deaths to be compiled. National registration systems are generally governed by

16   PRIMARY HEALTH CARE AND POPULATION MORTALITY

legislation that obliges all deaths to be registered and provides a framework for the collection, storage and processing of the data. In some cases, there may be delay in entering a death on the register. If someone dies overseas, it can take several weeks or months for the details to be transferred to the home nation. In cases in which the cause of death is uncertain, a formal investigation and examination of evidence before a court of law may be required. Consequently, it can take one or two years before a definitive report of all deaths is available. In addition to national registers, there are several national or international disease registers that can provide information about mortality or survival. Many countries have registers to record cases of cancer, for example. Since 1966, there has been an International Association of Cancer Registries that brings together national registries and issues standards and guidance on their operation. WEAKNESSES IN CERTIFICATION AND REGISTRATION SYSTEMS Although guidance and training on completion of death certificates are widely available, the cause of death is not always recorded accurately. Studies that have compared causes of deaths recorded on death certificates with the findings from autopsies usually reveal many discrepancies. Some conditions may be particularly poorly reported on death certificates, dementia for example. Systematic differences in recording causes of death can be a particular problem in international comparisons of mortality patterns, a problem made worse because around 40% of deaths worldwide are not registered.2 International agencies including the WHO, OECD and Eurostat (the statistical office of the European Union) have the expertise and resources to explore recording differences between countries and adjust for them. A major development in the past decade has been the launch of the Global Burden of Disease programme, a consortium of more than 7,000 researchers with sufficient knowledge of national data systems to appraise, collate, analyse and make available mortality data from up to 195 countries.3 The results from the WHO or the Global Burden of Disease programme use data from a variety of sources for each country to provide estimates of mortality for countries or regions where death certification and recording systems are poorly developed. Techniques have been developed to account for gaps or inaccuracies in the data and additional data can be collected in household interviews referred to as verbal autopsies. When combined with other data about the structure of populations and patterns of disease, the calculation of reasonable mortality estimates becomes possible.

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17

There are disadvantages in using these techniques. The methods vary from time to time as experience of them improves and better approaches are introduced, and their complexity creates a barrier to understanding how the data have been derived. The problem of transparency has been reduced somewhat by the adoption of Guidelines for Accurate and Transparent Health Estimates Reporting or GATHER for short.4 I have generally relied on data from agencies familiar with the strengths and weaknesses of the data available from different regions of the world when comparing nations, including the WHO, OECD and the Global Burden of Disease programme. CODING The purpose of coding is to enable the systematic recording and analysis of mortality data that have been collected in different countries and over different periods. The words used by health professionals to describe the causes of death are condensed into specific disease categories, each category having its own unique code. The codes are set out in the International Classification of Diseases (ICD) and provide standard descriptors regardless of local languages that can be stored electronically in readiness for statistical analysis.1 In each country, the coding process needs careful management and must include the training of the coders to improve consistency. For this reason, professionalised and usually government funded organisations have been set up in most countries to undertake this task, in England the body responsible being the Office for National Statistics. For most certificates, causes of death are coded automatically using computer software, trained staff being on hand to assign codes when the computer cannot. The current ICD classification is divided into 22 chapters, the first letter of each alphanumeric code being a letter that is associated with a particular chapter. Chapter 2 covers neoplasms with codes C00 to D48 and Chapter 9 covers diseases of the circulatory system with codes I00 to I99. The emergence of COVID-19 has given rise to the need for new codes, U07.1 for COVID-19 when the virus is identified by a formal test and U07.2 for cases diagnosed clinically only. U codes are reserved for new diseases. DEATH RATES When complete, the steps of certification, registration and coding make data available that can be used to describe patterns of mortality in populations. The calculation of a rate of mortality is commonly the first step. The mortality rate (sometimes referred to as the death rate) is the number

18   PRIMARY HEALTH CARE AND POPULATION MORTALITY

of deaths expressed as a proportion of the population. To produce a rate, information is needed on the number of people in the population who died, otherwise referred to as the numerator, and the total number of people in the population, referred to as the denominator, and the period concerned, for example a week, a month or a year. There are different ways of expressing the mortality rate and those most suited to use in primary health care will be described.

Crude death rates Crude death or mortality rates are simple to calculate. The numerator is divided by the denominator and the result is adjusted to the size of a standard unit of population. Let us assume our population, the denominator, has 2,371 people. Over a period of one year, 11 die. For an individual, the risk of death in that year is 11/2,371 = 0.0046. We wish to use a standard population size of 1,000 people and therefore multiply the 0.0046 by 1,000 to produce a mortality rate of 4.6 deaths per year per 1,000 people. Crude death rates have limitations if death rates in different populations are being compared. Characteristics of populations often differ in ways that influence mortality rates. In high-income countries, there will be more deaths in a population with a median age of 70 years than in a population with a median age of 20 years. One way to account for this problem is to report crude rates for sub-groups of the population according to age – the age-specific death rate. Displaying rates for different age groups reveals which groups suffer the greatest mortality. In high-income countries the highest rates of death will be in the older age groups. Another way to account for the effect of the age-structure of a population on mortality rates is to calculate a standardised rate.

Standardised mortality rate The standardised mortality rate (or standardised death rate, SDR) is the death rate adjusted to a standard population. It may be undertaken for age, sex or both.5 The adjusted rates in different populations may then be compared. It may be calculated by either direct or indirect methods. The direct method uses the age distribution of a standard population, but with the indirect method, the standard population provides an expected mortality rate that is compared to the rate in the population of interest. Direct standardisation makes use of an internationally agreed standard population, one such being the European Standard Population produced by Eurostat, the statistics agency of the European Union.6 This

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TABLE 2.1  Calculation of directly age-standardised mortality rate using mortality

data for Scotland, 20187 (e) Number (f) Scotland death (d) Crude (b) European (c) Scotland death rates per of deaths, rate applied to the population 1,000, persons, Scotland, European Standard standard (a) Age (number of deaths) 2018 Scotland, 2018 2018 population group 0 1–4 5–9 10–14 15–24 25–34 35–44 45–54 55–64 65–74 75–84 85–89 90 / + Totals

1,000 4,000 5,500 5,500 11,500 12,500 14,000 14,000 12,500 10,500 6,500 1,500 1,000 100,000

52,310 224,552 301,089 287,790 635,188 743,598 665,519 778,974 722,966 571,378 331,360 81,449 41,927 5,438,100

3.1 0.1 0.1 0.1 0.5 0.8 2.0 3.7 7.6 18.8 52.8 118.6 232.1

163 28 23 32 291 627 1,302 2,860 5,516 10,759 17,511 9,658 9,733 58,503

3.1 0.4 0.55 0.55 5.75 10 28 51.8 95 197.4 343.2 177.9 232.1 1,145.75

(f) = [(b) × (d)] / 1, 000 (d) = [(e) / (c)] × 1, 000

was based on the unweighted average age structure of the populations of EU-27 and EFTA countries. The worked example in Table 2.1 uses data for all persons in Scotland for 2018, the crude death rate in 2018 being (58,503/5,438,100) × 1,000 = 10.8 deaths per 1,000 population. In each age group, the size of the standard population is multiplied by the crude death rate for that age group for Scotland. The sum of these (1,145.75) is then divided by the total of the standard population in thousands (100 since the standard population includes 100,000 people) to give a rate per 1,000 population. The resulting figure of 11.46 per 1,000 has not been adjusted for sex.

Rate per thousand by direct method =

1,145.75 = 11.46 100

When the age-specific death rates for a population are not available, the indirect method of standardisation can be used. In this approach, the death rates of the standard population are applied to the study population to calculate the number of deaths expected if the rate of death in the study population had been the same as in the standard population. The expected deaths calculated in this way are then related to the number of deaths that occurred, also referred to as the observed deaths. The result

20   PRIMARY HEALTH CARE AND POPULATION MORTALITY

is usually expressed as a percentage and referred to as the standardised mortality ratio (SMR). In this case, a ratio of 100 indicates the observed mortality rate in the study population is the same as the expected rate, a ratio of above 100 indicating that the observed mortality is higher than the expected rate, and a ratio of below 100 indicating mortality lower than expected. One disadvantage is that SMRs for different populations cannot be compared unless the same standard population has been used, and for this reason direct standardisation is usually preferred.

Indirect method ( SMR ) =

Total observed deaths Expected deaths

OTHER MEASURES OF MORTALITY

Mothers and children Perinatal, neonatal, infant and child mortality are examples of age-specific mortality rates. Perinatal mortality is defined as the death of a baby between the 24th week of gestation and the end of the first week of life. This includes stillbirths and is usually reported as a rate per 1,000 births per annum. Neonatal mortality is defined as the death of a baby before the age of 28 days of birth and is usually expressed as a rate per 1,000 live births per annum. It is sometimes divided into early neonatal deaths (up to 7 days) and late (from 8 to 28 days). Infant mortality is the death of a child before the age of one year and again is expressed as a rate per 1,000 live births per annum. Child mortality is generally divided into deaths before the age of five years, and deaths between 5 and 14 years. Maternal mortality is the death of a woman from any cause related to pregnancy or within 42 days of the end of a pregnancy. It excludes deaths due to accidents or coincidental causes. It is often expressed as the number of deaths per 100,000 live births per annum, and in this form is referred to as the maternal mortality ratio.

Disease-specific mortality When studying factors that may influence the onset or course of a disease, disease-specific mortality rates have a role to play. One disadvantage for primary health care is that the number of deaths in the usually small populations involved are too few for reliable mortality rate estimates for many causes of deaths. Relatively uncommon diseases require large populations for studies of mortality. Restricting analysis to major disease groups can reduce the big fluctuations in annual mortality rates

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21

inevitable when the number of cases is small, but even then, large population sizes are needed to produce stable rates. Another disadvantage is the inaccuracies that can occur in death certification and coding. This is illustrated by the recent pandemic, when caution was needed in interpreting reported death rates for COVID-19 because the virus may have played a role in causing death even when it had not been mentioned on the certificate. The use of data on all deaths – all-cause mortality – overcomes the problem of inaccurate information on the cause of death.

Premature mortality The days of our years are three score years and ten, according to the Old Testament (Psalms 90, verse 10). Premature mortality is death before completing our natural span, and the idea that it may indicate lost opportunities for preventing or treating disease has made it attractive as a measure. Of course, deaths that occur before an arbitrary age cannot always be avoided through the intervention of health systems, but some can. There is no generally agreed upon age before which death is classed as premature. The chosen age varies between studies, or the policy adopted in each country. In high-income countries, the age is commonly set at 70 or 75 years. However, the average age of death is lower for some diseases when compared to others, and defining premature as aged below 75 years would not be informative if most people with the disease of interest die before the age of 65 years.

Avoidable mortality Avoidable mortality is a development of the concept of premature mortality. It builds on the notion that some deaths could be avoided if health care was delivered more effectively. In the United States, Rutstein8 and colleagues described a method for assessing the quality of care using the idea of avoidable deaths. A list of conditions was proposed for which effective health care was expected to lead to the avoidance of what were defined as unnecessary untimely deaths. Such deaths might be avoided through prevention of the disease in the first place or through effective treatment of the disease after it has developed. Death from measles, for example, could be avoided through prevention by immunisation whereas death from appendicitis could be avoided by treatment (acute appendectomy). In the years that have followed, the methods for classifying causes of deaths as avoidable have

22   PRIMARY HEALTH CARE AND POPULATION MORTALITY

become more systematic, and a variety of classifications or lists are now available, including some that have been evaluated for use in making comparisons between countries.9 Although the availability of several different lists is an advantage in enabling new methods to be developed and in providing lists for specific settings or circumstances, different lists tend to produce slightly different estimates of avoidable mortality. The lists also require regular updates as new therapies become available or as new diseases such as COVID-19 emerge. In investigating avoidable mortality, therefore, the list to be used must be chosen carefully. In an attempt at standardisation, a new internationally agreed definition of avoidable mortality and a list of included conditions has been published by the OECD and Eurostat.10 Avoidable mortality was divided into preventable and treatable categories, preventable mortality being defined as deaths under the age of 75 that can be avoided through effective public health and primary prevention interventions, and treatable (or amenable) mortality as deaths under aged 75 that can be avoided through timely and effective health care interventions, including secondary prevention and treatment. The list has 47 conditions regarded as potentially preventable, and 57 as treatable, including infectious diseases, cancer, metabolic disorders, diseases of the nervous, circulatory, respiratory, digestive or genitourinary systems, pregnancy and childbirth, congenital malformations, the adverse effects of medical or surgical care, injuries and alcohol- or drugrelated deaths. Both prevention and treatment may have roles to play in avoiding deaths from some conditions. In the case of ischaemic heart disease, for example, prevention can reduce the incidence and therefore avoid some deaths, and among those who do develop the disease effective treatment can reduce the proportion who die as a result. For such conditions, the list gives a percentage of deaths avoidable through prevention and a percentage avoidable through treatment, for example 50% of avoided deaths being due to prevention and 50% due to treatment. The measure of avoidable mortality is a careful attempt to distinguish a group of deaths that might be reduced in number if effective health care could be delivered consistently. It is important to note several reservations, however. First, the inclusion of a condition in the list of avoidable causes of death does not mean that a particular death could have been avoided, merely that in a group of such deaths, it is likely that some might have been avoided. Confirmation that a particular death or a series of deaths could have been avoided requires a detailed review of the care provided. Second, although a standard list such as that of the OECD and Eurostat may have been systematically developed, caution is still required in making comparisons between countries since the rates

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23

of specific diseases varies between countries. Third, avoidable mortality relies on disease-specific mortality data and we know that inaccuracies in completion of death certificates and the coding of underlying causes of death will be inevitable. Avoidable mortality will therefore be an unreliable measure in countries that have partially developed systems for certifying and recording deaths. Fourth, disease incidence and medical treatments vary over time, and therefore the study of trends in avoidable mortality over long periods should be interpreted with caution. SURVIVAL RATES AND POTENTIAL YEARS OF LIFE LOST Survival rates describe the proportion of people alive after a defined interval and are usually used to present information about the natural history of specific diseases or the effects of treatment. A common example is the five-year survival rate from different cancers. Disease-free survival is a type of survival rate used in evaluating cancer treatments in which the return of disease defines the end point. Potential years of life lost is a computed measure that has a similar use to survival years a person would have been expected to live if they had not died when they did and is calculated by subtracting the age at death from the age of expected death. The age of expected death is unknown and therefore a choice or guess is made as to what that age might have been. Often referred to as the standard age, typical examples are 65, 70 or 75 years of age. When presenting the results, the standard age can be made clear in a short-hand fashion, for example YPLL-75 indicates years of potential life lost when the standard age applied is 75 years. The estimate may be presented as the number of years of life lost or as a rate of years of life lost per 100,000 population. LIFE EXPECTANCY The concept of life expectancy is deceptively simple and commonly used to describe the health of a population. The differentiation of two groups of people, one with a privileged background and having a life expectancy of 89 years, and the other from a disadvantaged background with a life expectancy of only 75 years conveys a powerful message that we can readily grasp. Life expectancy data can appear more meaningful than the more abstract numbers of mortality rates. However, like years of potential life lost, life expectancy is a computed variable and some appreciation of how it is arrived at is needed to fully understand what life expectancy means.

24   PRIMARY HEALTH CARE AND POPULATION MORTALITY

Whereas mortality rates report what has happened, life expectancy as commonly used is a measure of what is expected but not guaranteed to happen in the future. It is calculated by national statistics authorities and there can be some differences in methodology between countries. The methods use life tables relating to defined periods that show for each age the probability that a person will die before their next birthday.11 There are two types of life expectancy – cohort and period. Cohort life expectancy takes a cohort of people, say people born in 1910, and uses data on mortality to present life tables showing the probability of dying in each year until the entire cohort has died. The data in the life table can then be used to calculate an average length of life – the life expectancy. The disadvantage with this approach is that it cannot be directly applied to living populations. This problem can be addressed by using predictions about future mortality patterns based on past trends, a form of educated guess work. These predictions can and do get it wrong – for example, when expected declines in cardiovascular disease mortality fail to materialise or an influenza or COVID-19 pandemic sweeps through the world. Period life expectancy takes a different approach to the problem of producing estimates for living populations. For a population born in the chosen year, say 2019, the mortality rates of people in that year are used to provide the probabilities of death for people, who in 2019, are aged 1, 2, 3, 4 and so on, up to 100 years old or above. The assumption is that future mortality rates will be the same as they are in the chosen year of 2019. This approach has the advantage of providing a measure of aspects of population health in the current year, but it cannot be assumed to represent an accurate measure of what can be expected in future years. Medical advances, pandemics, wars and climate change are just a few of the factors that will render assumptions about future life expectancy incorrect. Life expectancy does not account for health status or disability, although these are important aspects of population health. Disabilityfree life expectancy (DFLE) is a summary measure of functional health status, an estimate of the number of years of life expected to be lived without restricted activities because of a physical or mental health condition.12 The life tables created for estimating life expectancy are enlarged through the addition of age-specific prevalence rates for being healthy or not, or for disability or not. It is a measure of the number of years a person at a particular age can expect to live in a healthy state, the difference between disability-free life expectancy and total life expectancy giving the time that will be lived with reduced health.

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Quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs) are measures of the burden of ill-health in populations. They incorporate the years of life lived with reduced quality of life or with disability, respectively, and are often used for the analysis of the costeffectiveness of treatments or services. DATA FOR RESEARCH AND PRACTICE We have now discussed how information about deaths and causes of deaths is collected and how it can be coded and prepared for reporting. Comparisons between countries using data taken from national registration systems should be approached with care. If the national systems are known to be well managed and reliable and there is evidence of coding consistency, then the use of these data is reasonable, but if there is any doubt then it is better to use data that have been evaluated by an international agency such as the WHO, OECD or the Global Burden of Disease programme. There are several ways in which deaths in populations can be measured and described, from the simple reporting of numbers to mathematical procedures for predicting life expectancy or taking account of disability as well as mortality. Many research studies make use of constructed measures such as these to test the effectiveness of treatments and systems of care. For use in the routine management of primary health care, however, they are less useful. Primary health care teams almost always serve relatively small populations in specific settings and with particular local challenges to health. It does not aid understanding to interpose statistical procedures between the original data and the clinical observer. For health professionals using data themselves to understand the outcomes of their patients and what might be done to improve them it is usually better to use simple measures. All-cause mortality is one such measure, preferably standardised for age and sex or presented for males and females separately. Age-specific mortality rates are an alternative to standardised rates. If investigation of the death rates of specific diseases is necessary, then it would be wise to limit this to major disease groups that account for high proportions of deaths (for example, cardiovascular disease or cancers) and, if feasible, to employ administrative units of primary care that have large population sizes. In the next chapter, we explore variations in mortality rates in relation to factors such as national incomes, social determinants of health and ethnicity in preparation for discussing the effects of primary health care.

26   PRIMARY HEALTH CARE AND POPULATION MORTALITY

REFERENCES 1. WHO. ICD-10. International statistical classification of diseases and related health problems. 10th Edition. Volume 2. Instruction Manual. Geneva: WHO, 2016 2. WHO. World health statistics 2021: Monitoring health for the SDGs, Sustainable Development Goals. Geneva: WHO, 2021 3. IHME. The Global Burden of Disease: A critical resource for informed policymaking. Seattle: Institute for Health Metrics and Evaluation, 2020 4. Stevens GA, Alkema L, et al. Guidelines for Accurate and Transparent Health Estimates Reporting: The GATHER Statement. PLoS Med 2016;13(6):e1002056 5. Bhopal R. Concepts of Epidemiology. Oxford: Oxford University Press, 2002 6. Eurostat. Revision of the European Standard Population Report of Eurostat’s task force. Luxembourg: Publications Office of the European Union, 2013 7. National Records of Scotland. Vital Events Reference Tables 2018. National Records of Scotland, 2019. https://www.nrscotland.gov.uk/ statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/deathstime-series-data 8. Rutstein DD, Berenberg W, et al. Measuring the quality of medical care: A clinical method. N Eng J Med 1976;294:582–588 9. Nolte E, McKee M. Does Health Care Save Lives? Avoidable mortality revisited. London: The Nuffield Trust, 2004 10. OECD. Avoidable mortality: OECD/Eurostat lists of preventable and treatable causes of death. Paris: Organization for Economic Cooperation and Development, 2022 11. Arias E, Xu J. United States Life Tables, 2017. National Vital Statistics Reports 68:7. Washington, DC: Centers for Disease Control and Prevention, 2019 12. ONS. Health state life expectancies, UK: 2016 to 2018. ONS Statistical bulletin. Office for National Statistics, London: 2019

CHAPTER 3

Variations in population mortality and some things that influence them

Variations can be found in mortality rates between different populations and at different times. In exploring research into the effects of primary health care, we need to distinguish between variations due to health care and variations due to other factors. In this chapter, the focus is on factors that health care is unable to address directly. PATTERNS OF MORTALITY IN POPULATIONS

Practice-level mortality The median number of patients registered with each of England’s 7,096 practices in 2018 was 7,375, although there was wide variation in practice list size. Table 3.1 shows the most common causes of deaths in 2018 by ICD-10 chapter. The age-standardised rate in the Table for a population size of 1,000 to enable extrapolation to practices of different sizes. Thus, a practice with the median number of patients and the same proportions of male and female patients as the national population would expect to have had 70.6 deaths (all causes) in 2018, two-thirds of which are accounted for by three groups of diseases, 19.6 deaths being due to cancers, 17.2 due to diseases of the circulatory system and 10.0 deaths due to diseases of the respiratory system. Life expectancy data for practice populations have been published by the Office for Health Improvement and Disparities, calculated from deaths over five-year periods to overcome fluctuations from year to year. 2 For the quinquennium 2013 to 2017, data for 6,839 practices is available, DOI: 10.1201/9781003355380-3

28   PRIMARY HEALTH CARE AND POPULATION MORTALITY TABLE 3.1 Most common causes of deaths, grouped by ICD chapters, in

England, 20181 Both males and females ICD-10 chapters

N

Rate

C00-D48 II Neoplasms 140,191 2.66 (Cancers) I00-I99 IX Circulatory system 123,214 2.33 J00-J99 X Respiratory 71,159 1.35 system 47,549 0.90 F00-F99 V Mental and behavioural disorders (includes vascular and unspecified dementia F01) G00-G99 VI Nervous system 33,836 0.64 (includes Alzheimer’s disease, G30). K00-K93 XI Digestive system 23,898 0.45 21,504 0.40 U509, V01-Y89 XX External causes (accidents, injuries, assaults, complications of health care) Other causes 42,743 0.54 Total deaths in 2018 505,859 9.57

Males N

Rate

Females N

Rate

75,106

3.23

65,085 2.24

64,874 34,825

2.9 1.60

58,340 1.87 36,334 1.17

16,891

0.83

30,658 0.93

14,448

0.65

19,388 0.62

12,043 13,442

0.51 0.54

11,855 0.40 8,062 0.27

17,395 0.81 250,012 11.11

25,348 0.28 255,847 8.31

N = numbers; rate = age-standardised rate per 1,000 population.

the mean life expectancy per practice for males being 79.3 years and for females being 83.2 years. The variations between practices were wide, the gap between practices with the lowest and highest life expectancy exceeding 11 years among both males and females (Figures 3.1 and 3.2). There are variations between practices in changes in life expectancy as well. Between the 2006–2010 and 2013–2017 quinquennia female life expectancy declined in 1,087 practices and male life expectancy in 706 practices. There were increases in life expectancy of three to four years for females in 1,060 practices and for males in 1,522 practices. In most practices, however, average gains were less than two years. Factors explaining changes in life expectancy will vary from practice to practice, including for example characteristics of the population served. For example, a practice may have taken on the care of people in a hostel for the homeless, with a consequent fall in life expectancy of the total practice population. The finding that life expectancy in women has declined in 16% of general practices and declined for men in 10% of practices is

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FIGURE 3.1  Life expectancies of males in England by general practice, 2013–2017.2

FIGURE 3.2  Life expectancies of females in England by general practice, 2013–2017.2

of serious concern, however, and unlikely to be fully explained by unusual shifts in local population characteristics. More probable is that the declines reflect the stalling life expectancy found in national level data; some practice populations have been more adversely affected by the new trend in life expectancy changes than others.

Mortality at the level of primary health care administrative units In 2018, each of the 191 clinical commissioning groups (CCGs, the administrative units in place for primary health care in England since 2013) covered a population of around 250,000 people. A CCG of this size would expect to have had 2,366 deaths in 2018, including 658

30

PRIMARY HEALTH CARE AND POPULATION MORTALITY

FIGURE 3.3 Number of CCGs with different age-standardised mortality rates per

100,000 population from cancer in people aged under 75, England, 2018. Total number of CCGs = 191.2

caused by neoplasms, 576 caused by diseases of the circulatory system, and 334 caused by diseases of the respiratory system. In 2018, the mean directly age-standardised mortality rate from cardiovascular disease among males aged under 75 was 98.0 per 100,000 people, ranging from 54.5 in the CCG with the lowest rate to 181.8 in the CCG with the highest rate, and among females aged under 75 was 44.5 (ranging from 16.5 to 99.6). Variation between CCGs is also evident in deaths due to cancer in people aged under 75 (Figure 3.3). The mortality rtes in the histogram are age-standardised and therefore the variation is not explained by variation in the age structure of populations. Identifying the other factors responsible for the variation is necessary if the contribution of primary health care is to be clarified.

Variation in mortality rates between countries In 2019, there were an estimated 56.5 million deaths worldwide, over 5 million of which occurred in children younger than five-years-old.3 There are wide variations in mortality between countries and these can help throw some light on factors that may influence rates within countries. Average life expectancy at birth of the global population has increased from 51.1 years (males and females combined) in 1950, to 67.2 years in 2000, and to 73.5 years in 2019. The World Bank classifies countries according to gross national income per capita into low-, lowermiddle-, upper-middle- and high-income.4 The divisions for 2020–2021

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for income were low-income less than 1,036 US dollars per person per year, lower-middle income 1,036–4,045 US dollars per person per year, upper-middle-income 4,046–12,535 US dollars per person per year and high-income over 12,535 US dollars per person per year. Life expectancy is lowest in low-income countries and increases steadily through the middle- and high-income groups (Table 3.2). There are still wide differences between countries in the same income group, however. TABLE 3.2 Life expectancy at birth (years), males and

females combined, in 2018 in selected low-, lower-middle-, upper-middle- and high-income countries Life expectancy (years) at birth in 2018 Low-income countries – Mean Central African Republic Afghanistan Ethiopia Yemen, Rep. Rwanda Tajikistan

63 53 64 66 66 69 71

Lower-middle-income countries – Mean Cameroon Angola Pakistan India Egypt Ukraine

69

Upper-middle-income countries – Mean South Africa Botswana Venezuela Jamaica Brazil China

76 64 69 72 74 76 77

High-income countries – Mean Saudi Arabia United States Chile United Kingdom France Sweden

81 75 79 80 81 83 83

Source: World Bank.5

59 61 67 69 72 72

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The epidemiological transition The theory of epidemiological transition relates changes in the health of populations to four long-term processes: (1) Changes in socio-economic conditions, (2) the replacement of infectious diseases as the leading causes of mortality by the degenerative diseases of ageing, (3) declines in infant and maternal mortality and (4) declines in fertility. The transition began in the 19th century in some high-income countries and is now underway virtually everywhere. Local factors commonly influence the speed and direction of change within countries. War, famine and the effect of risk factors such as diet and exercise can disturb the transition. Among some indigenous nations, the initial stages of colonialism forced the transition into reverse as newly introduced infectious diseases caused mortality rates to increase. The most common causes of deaths in countries in different World Bank income groups tend to reflect the epidemiological transition, communicable diseases and neonatal conditions being among the top 10 causes in low-income countries and non-communicable diseases in highincome countries (Table 3.3). FACTORS THAT MAY EXPLAIN VARIATIONS IN MORTALITY

Age, sex and gender Having discovered that mortality varies between populations, we now turn our attention to possible explanations for these variations. We begin with age, sex and gender. Age, of course, is a powerful predictor of mortality. After the first few years of life, the risk of death increases as we age, and as mortality statistics from Scotland demonstrate, increases steeply at around 70 years of age (Table 3.4). In almost all age groups, mortality rates are a little higher among males than females. Sex is a biological construct that rests on the role of the X and Y chromosomes in influencing molecular activities within cells. Gender is a social construct that defines the social norms that underpin an individual’s roles and relationships. Gender is not a binary concept, and it is common for behaviours or roles typical of either males or females to occur in the same person. Most of the available mortality statistics are classified by sex and our understanding of any differences in mortality related to gender is very patchy. Data from the Global Burden of Disease group show that in almost every country, the life expectancy of people of female sex exceeds males, the exceptions including Afghanistan (females 63.2, males 63.5); Qatar (females 75.3, males 76.7) and Tokelau (females 71.3, males 73.3).3 The

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TABLE 3.3  Top 10 causes of deaths in 2019 by World Bank country income group

Low-income countries

Lower-middleincome countries

Upper-middleincome countries

1 Neonatal conditions 2 Lower respiratory infections 3 Ischaemic heart disease 4 Stroke

Ischaemic heart disease Stroke

Ischaemic heart disease Stroke

High-income countries

Ischaemic heart disease Alzheimer’s disease and other dementias Neonatal Chronic obstructive Stroke conditions pulmonary disease Trachea, bronchus, Chronic obstructive Trachea, lung cancers bronchus, lung pulmonary cancers disease 5 Diarrhoeal Lower respiratory Lower respiratory Chronic obstructive diseases infections infections pulmonary disease 6 Malaria Diarrhoeal Diabetes mellitus Lower respiratory diseases infections 7 Road injury Tuberculosis Hypertensive Colon and rectum heart disease cancers 8 Tuberculosis Cirrhosis of the Alzheimer disease Kidney diseases liver and other dementias 9 HIV/AIDS Diabetes mellitus Stomach cancer Hypertensive heart disease 10 Cirrhosis of Road injury Road injury Diabetes mellitus the liver Source: WHO.6 TABLE 3.4  Age-specific mortality rates (per 1,000 population), Scotland, 20197

Age group (years) Under 1 1–4 5–9 10–14 15–24 25–34 35–44 45–54 55–64 65–74 75–84 85–89 90 and older

All persons

Males

Females

3.2 0.1 0.1 0.1 0.5 0.8 2.1 3.7 7.5 18.3 50.7 116.3 222.9

4.0 0.1 0.1 0.1 0.6 1.2 2.7 4.6 8.8 21.7 58.9 133.0 228.5

2.5 0.2 0.1 0.1 0.3 0.5 1.5 2.8 6.2 15.3 44.4 106.1 220.5

34   PRIMARY HEALTH CARE AND POPULATION MORTALITY

differences in mortality rates due to sex can be traced to underlying biological processes, but differences due to gender involve social interactions, norms, power relationships and perceptions, including those of health professionals. Violence against women and girls, including sexual violence, increases the risk of developing non-communicable diseases and all-cause mortality in later life.8 In a UK study of women experiencing domestic abuse that was reported to their general practitioners, over a period of two years of follow-up, the incidence of both cardiovascular disease and diabetes was higher than in a control group of women and all-cause mortality was 44% higher.9 Both sex and gender can play roles in mortality differences in the same condition. Ischaemic heart disease develops at an earlier age in males than females, with men being more likely to have large coronary vessel obstruction and women microvascular obstruction. These features have biological origins but failure to recognise ischaemic heart disease and lower use of reperfusion in women are disparities in management linked to gender. Mortality from cancers is higher among men than women (Figure 3.3) and underlying genetic and hormonal mechanisms have been suggested. Differences between males and females in smoking, diet and alcohol use also explain some of the difference. Differences in roles, status and power related to sex or gender create inequities in health. An extreme example is the preference for male children in some countries. In India and China, the proportion of females in the population is lower than expected. Some of the deficit is likely to be explained by prenatal sex selection.10

Social determinants of health If we wish to investigate the role of social determinants on mortality, we need to define them and develop ways to measure them. Both income and education can be defined relatively easily, and it is possible to collect data about both. The highest level of education a person has received – primary or secondary school education, a higher qualification, or postgraduate study – can be readily recorded in population surveys. Data on annual income can also be collected in this way, although additional information will be needed for people who are not employed because of disability, retirement, caring responsibilities or difficulty in finding a job. Personal wealth and income are predictors of health and longevity. People who are wealthy can overcome financial barriers to health care and education; they can afford well-heated, uncrowded homes and healthy diets. More education may lead to better paid employment, but

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even when income is taken into account, education confers an additional health advantage. A potential explanation is that education leads to different thinking and choices in life that bring benefits for health. The life-course theory offers two potential explanations. The first is that education helps us mitigate the effects of adverse experiences as they occur or even helps us avoid them. The second is that adverse experiences early in life impair our ability to take a full part in education. The association between education and health is found worldwide. In a group of 26 OECD countries, all high-income, more time spent in education was associated with lower infant mortality rates and longer life expectancy.11 Education of mothers in Sub-Saharan Africa is associated with reduced mortality in children aged under five although the effect varies from one country to another.12 Employment provides an income, but it can have other benefits. Work that involves a reasonable degree of job security and personal development improves health in comparison with work that does not have these characteristics. Norman Beale was a general practitioner in Calne in Wiltshire, England, who followed the consequences of unemployment on his patients. Between 1980 and 1982, a local meat products factory was first reduced in size and then fully closed, with many of the people who lost their jobs being patients of Dr Beale.13 It was possible to document health events during the four years of secure employment (1976–1980), the two years of insecure employment (1980–1982), and the four years after the loss of employment, and compare the findings with a control group of patients in the same general practice. The findings suggested that during the period of insecure employment people refrained from reporting illnesses to their doctors, but the number of consultations increased when unemployment occurred. Hypertension and myocardial ischaemia were the most frequent chronic disorders diagnosed in the unemployed men.14 This small epidemiological study from general practice reaches conclusions shared by larger and more recent studies. Although there may be some selection by employers of less healthy workers for redundancy, the loss of employment does itself have a negative and large effect on general and mental health. Furthermore, precarious employment has negative social effects that lead to health problems, including risky health behaviours and mental health disorders. Instead of focusing on a specific health determinant such as income or education, various measures have been used to describe social circumstances, including social class, social position, socio-economic status and deprivation. The Office for National Statistics uses an occupational classification, the National Statistics Socio-economic Classification that also accounts for people not in work.15 It has nine broad categories, each

36   PRIMARY HEALTH CARE AND POPULATION MORTALITY TABLE 3.5 Major categories in the National Statistics Socio-economic

Classification15 Class

Description

1

Higher managerial, administrative and professional occupations 1.1 Large employers and higher managerial and administrative occupations 1.2 Higher professional occupations Lower managerial, administrative and professional occupations Intermediate occupations Small employers and own account workers Lower supervisory and technical occupations Semi-routine occupations Routine occupations Never worked and long-term unemployed

2 3 4 5 6 7 8

category including several subdivisions (Table 3.5). A similar system has been developed by the European Commission to enable international comparisons. An individual’s place of residence can be used to give an indication of their social conditions. In many countries the wealth and wellbeing of residents varies from one locality to the next; some localities are more desirable, others less so, and people with fewer resources find themselves clustering in those areas where housing is less costly. Area-based measures have been developed to take advantage of the probability that people living in the same area will share a similar socio-economic status. Although such measures cannot be relied on to describe the social circumstances of an individual, they do provide useful information about populations. Measures of this type have been developed in several countries, and the English Index of Multiple Deprivation (IMD) is an example. Updated regularly to account for changes in populations and localities, the current version is the 2019 edition, IMD 2019.16 It is derived from seven domains of deprivation – income, employment, health and disability, education, skills and training, barriers to housing and services, living environment and crime. The IMD therefore considers many of the social determinants of health with the notable exception of specific items about the social and emotional development of children. There are, however, two supplementary indices designed for deprivation affecting children and older people although these measures have not been widely used. The IMD provides a numerical index for an area that enables comparisons between areas, higher scores indicating greater deprivation. Deprivation measures have been developed for use in several other countries.

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TABLE 3.6  Life expectancy of general practice populations by deciles of practice deprivation scores (IMD)2

Mean life expectancy (years) (Calculated from deaths 2013–2019) IMD decile

Males

Females

1 (least deprived) 2 3 4 5 6 7 8 9 10 (most deprived)

82.0 81.2 80.9 80.3 79.7 79.1 78.5 77.9 77.3 75.8

85.4 84.7 84.4 84.0 83.5 83.1 82.7 82.2 81.8 80.3

The association between deprivation and life expectancy can be found in comparisons between general practices in England. Using life expectancy data for general practice populations over the period 2013 to 2017 published by the Office for Health Improvement and Disparities, 2 and the deprivation of practice populations as measured by the IMD2015, Table 3.6 shows how the mean life expectancy of practice populations falls and deprivation increases. The least deprived practice had an IMD score of 3.2 and the most deprived a score of 65.6. In Table 3.6, the 6,839 practices are divided by level of deprivation into ten more or less equally sized groups (i.e. deciles). Among males, there is a gap of 6.2 years in life expectancy between the group of practices with the lowest and the group with the highest level of deprivation, the gap among females being 5.1 years. The table also shows that there is a steady gradient from highest to lowest level of deprivation, and it follows those strategies to reduce inequity between general practice populations cannot be limited to a sub-group of the most deprived practices. The same association between life expectancy and deprivation can be seen at the level of general practices within a local geography. Figures 3.4 and 3.5 show the relationship in scatter plots for two clinical commissioning groups, Leicester City and Gloucestershire, chosen because I have worked as a general practitioner in both localities. The figures show the gradient of declining life expectancy with increasing deprivation in both males and females, in Leicester City where most practices have an IMD score of above 30 and in Gloucestershire where

38   PRIMARY HEALTH CARE AND POPULATION MORTALITY

FIGURE 3.4 Life expectancy (2013–2017) of patients (males and females) of 54 practices of NHS Leicester City Clinical Commissioning Group and practice deprivation (IMD 2015).2

most practices have an IMD of below 20. The plots also reveal wide variation between practices with similar levels of deprivation. For example, in Leicester City, life expectancy of practices with an IMD of 30 vary among males from just over 74 years to 78 years and among females from just over 80 years to almost 84 years. In Gloucestershire, life expectancy in practices with an IMD of 10 varies in males from a little over 78 years to almost 82 years and among females from 81 years to 85 years. The plots help us account for the population characteristics of age, sex and deprivation in explaining variation in life expectancy, and

FIGURE 3.5 Life expectancy (2013–2017) of patients of 71 practices of NHS

Gloucestershire CCG and practice deprivation (IMD 2015).2

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39

therefore other factors must be playing a role – some of these will be considered next. However, if primary health care does have some influence on mortality, we must ask whether some of the variation is related to variation in clinical practice. Can we learn from this variation both within practices and through collaboration between practices to maximise the benefits of primary health care? To what extent do measures of individual social determinants such as education or income, or area-based measures compute the same thing? It is true that they relate to slightly different concepts, and we cannot assume they are always interchangeable. They represent different ways of thinking about as well as measuring the inequalities associated with wealth and opportunity, but those inequalities are so pervasive that on most occasions the inequalities become obvious no matter how we choose to measure them.

Ethnicity Race is a social construct and has no biological basis although false assumptions about biological difference were used to justify slavery and colonisation. Ethnicity is also a social construct but without spurious biological pretensions. An ethnic group is a social group that has a shared culture; rather like gender, it is a way of describing ourselves. The categories used in England in government social surveys are shown in Box 3.1.17 Information on ethnic identity has rarely been collected routinely on death certificates and therefore few countries report mortality rates by ethnic group. The unequal impact of COVID-19 on ethnic groups is likely to accelerate plans to add ethnicity to certification data. A recently published report from the Office for National Statistics linked data about ethnicity from the national census to mortality data for the years 2011–2014.18 In an analysis that did not account for socioeconomic status, mortality in England and Wales was found to be higher among White and Mixed ethnicity groups than all other ethnic groups. Life expectancy for White males was 79.7 and 83.1 for White females, compared to 83.8 and 88.9, respectively, for the Black African group, 82.3 and 84.8 for the Pakistani group and 82.3 and 85.4 for the Indian group. Some of the differences in life expectancy may be linked to differences in causes of deaths. Age-standardised mortality rates for cancer were higher among male and female people belonging to White ethnic groups compared to Black or Asian ethnic groups, and age-­ standardised mortality rates from circulatory diseases were higher among Indian, Bangladeshi and Mixed males and Pakistani, Indian and Mixed

40   PRIMARY HEALTH CARE AND POPULATION MORTALITY

BOX 3.1  Ethnic Groups Used in Government Surveys in England17

Asian/Asian British 1. Indian 2. Pakistani 3. Bangladeshi 4. Chinese 5. Any other Asian background Black/African/Caribbean/Black British 1. African 2. Caribbean 3. Any other Black/African/Caribbean background Mixed/Multiple Ethnic Groups 1. White and Black Caribbean 2. White and Black African 3. White and Asian 4. Any other Mixed/Multiple ethnic background White 1. English, Welsh, Scottish, Northern Irish or British 2. Irish 3. Gypsy or Irish Traveller 4. Roma 5. Any other White background, please describe Other Ethnic Group 1. Arab 2. Any other ethnic group

females compared to the White ethnic group. Migration may also be an explanation; the death rates early in life among some migrants are unknown and people who migrate tend to have better health than those who do not. A study that used ONS longitudinal data from England and Wales and investigated all-cause mortality aged under 80 years found that Black Caribbeans born outside the United Kingdom had a lower mortality than

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UK-born Whites, but the UK-born Black Caribbean group had a higher mortality than UK-born Whites.19 The excess mortality among UK-born Black Caribbeans was largely explained by socio-economic disadvantage. In the United Kingdom, therefore, we can identify three factors apparently related to differences in mortality between ethnic groups: (1) Differences in the patterns of disease that lead to deaths, cancer being more common in White groups and circulatory diseases more common in some other groups; (2) the selection of healthy individuals that occurs during migration and (3) the distribution of socio-economic disadvantage between ethnic groups. Are there other factors that help explain differences in mortality between ethnic groups? A recent report from a committee of the House of Commons highlighted differences in maternal mortality between ethnic groups in the United Kingdom. The figures were as follows: Seven deaths in every 100,000 women who give birth among White women, 13 in 100,000 among Asian women, 23 per 100,000 in women of Mixed ethnic identity and 39 per 100,000 in Black women.20 A mix of factors may contribute to these wide differences, including socio-economic status, but structural racism was also thought by the committee to be a contributory factor. The data presented in this section have been taken from public sources in England and Wales, but differences in mortality between ethnic groups are found in other countries. In a study of mortality under aged five years in 36 low- or middle-income countries, differences in mortality by ethnic group were found in 25 countries.21 In New Zealand, the age-adjusted mortality rate per 100,000 in 2016 was 621.8 for Māori but only 337.4 for non-Māori. 22 In Australia, for the period 2006–2010, the age-adjusted mortality rate for Aboriginal and Torres Strait Islander peoples was 1,151 per 100,000 compared with 597 for non-Indigenous Australians. 23 The classification of ethnic groups used in the US Census has five broad categories – White, Black or African American, American Indian or Alaska Native, Asian and Native Hawaiian or Other Pacific Islander. The term Hispanic is also frequently used by people of South American or Spanish heritage, who may belong to any ethnic group. There are consistent differences between these groups, with the Black population in particular experiencing higher mortality rates. In 2017, life expectancy at birth of non-Hispanic White males was 76.1 and females 81.0, non-Hispanic Black males 71.5 and females 78.1 and Hispanic males 79.1 and females 84.3. 24 In the United States, Black newborns die in their first year at a rate of 1,090 per 100,000 births compared to 490 per 100,000 births among

42   PRIMARY HEALTH CARE AND POPULATION MORTALITY

White newborns. An analysis of 1.8 million hospital births in the state of Florida, 1992 to 2015, investigated some of the potential explanations for this inequity. 25 Under the care of White physicians, the newborn mortality rate of White babies was 290 per 100,000 births; there was no significant difference if White newborns were cared for by Black physicians. However, when Black newborns were cared for by White physicians, there were an additional 430 deaths per 100,000 births. When Black newborns were cared for by Black physicians, the excess deaths were reduced from 430 to 173 deaths per 100,000. The study took account of potentially confounding variables such as health insurance and socioeconomic status, but not the process by which patients were assigned to their physicians. The explanations for these differences are likely to vary from country to country and may be partly explained by the patterns of disease in different ethnic groups, migration effects or socio-economic disadvantage. The contribution of racism to unequal mortality rates has begun to be investigated and the early findings tend to rule in rather than rule out an effect. The levels of racism framework provides one approach for thinking about the role of racism in health and health care. 26 The framework has three levels, all of which have the ability to affect health and health care. The first level, institutional or structural racism, is the differential access to goods, services and opportunities experienced by ethnic groups. It is structural, being codified in institutions such as health systems, in customs, in practices and sometimes in laws. Personally mediated racism, the second level, is what we most often assume racism to be. It is discrimination in the relationships and interactions between people, and may be intentional or unintentional, and may be experienced in interactions with health system staff. The third level is internalised racism, the acceptance by members of the group facing discrimination of the negative views of their worth or abilities. It can lead to risky health behaviours and mental illness, a process that may help to explain the higher incidence of serious mental illness in Black compared to White men. In addition to direct effects on health, racism can interact with the social determinants of health by affecting opportunities in education, employment and housing. The workings of structural racism on the health of children in the United States can be illustrated by housing and mortgage policies that created the segregation of Black communities, leading to greater risk for Black children of exposure to environmental pollutants, less green open spaces and the use of local hospitals that achieve worse outcomes than those in other areas. 27 A recent review of ethnicity-related inequalities in the outcomes of health care in the United Kingdom’s NHS concluded that

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they were rooted in experiences of structural, institutional and interpersonal racism. 28

Environment On the 16 December 2020, a coroner’s court in London ruled that air pollution had made a material contribution to the death of Ella AdooKissi-Debrah, a nine-year-old girl who had died in 2013 of an asthma attack. 29 She had lived next to a congested road. This was the first time in the United Kingdom that air pollution had been formally recognised as contributing to the cause of death of an individual, but this verdict would not have been reached had it not been for the determination of the child’s mother to understand why her daughter had died. A Public Health England report estimated that the annual number of deaths in the United Kingdom attributable to air pollution was between 28,000 and 36,000.30 Long-term exposure to air pollution reduces life expectancy through its effects on the cardiovascular and respiratory systems. Short-term exposure can also cause exacerbations of asthma and adverse events in people with pre-existing respiratory and cardiovascular disease. Sources of air pollution include transport, domestic and commercial heating systems, agriculture and industry. Household air pollution is often caused by burning wood, coal, crop waste, animal dung or charcoal. These are fuels that are relied on by households in many lowand lower-middle-income countries. A review of studies of household air pollution estimated that it was associated with 1.8 million deaths worldwide in 2017.31 Socio-economic factors and air pollution are associated, less wealthy people being more likely to live in areas exposed to greater pollution from transport or industry. Air pollution is not routinely considered in analyses of primary health care population mortality, but greater awareness of the problem is likely to change this situation in coming years.

The climate The recent pandemic was a powerful demonstration of the preference of respiratory viruses for cooler months of the year. Infections and deaths caused by COVID-19 were high in the early months of 2020, fell during the summer, and rose again in the winter of 2020–2021. Influenza is another infection that finds it easier to pass from one person to another during the winter months. Cold weather also increases the risk of deaths from some non-infectious diseases, for example from ischaemic heart disease and strokes.

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In England and Wales, there are about 25,000 deaths in each twoweek period between January and March, but this falls to about 17,000 in the summer months, rising gradually again from September to over 20,000 per two-week period up to the end of December. The variation throughout the year has implications for monitoring trends in deaths; the periods chosen for calculating mortality rates has to account for seasonal variation and for this reason trends are usually studied using data relating to annual periods. Excess winter deaths can be defined as the number of deaths that occur in the winter period (December to March) minus the expected number of deaths, a number calculated from deaths in the preceding August to November plus those of the following April to July. Over the last 50 years, there has been a decline in the number of excess winter deaths in England and Wales, the figure being 23,200 in the winter of 2018 to 2019.32 Excess winter deaths are more common among people with low incomes living in cold housing. Heat as well as cold can increase deaths. A study of 13 countries from 1985 to 2012 that tracked the association between ambient temperature and deaths concluded that 7.7% of deaths were attributable to unusual high or low temperatures. 33 The countries included represented a range of climates from Scandinavian (Sweden), temperate (United Kingdom), to warm (Thailand), as well as geographically large countries such as China and Canada. Cold rather than heat in these countries was responsible for most of the excess deaths. Globally, there has been an increase in heat-related mortality over the past 20 years in people aged over 65 years, Europe being the most affected region. 34 It is not only the elderly and vulnerable who are affected by hot weather; the adverse health effects includes preterm birth, excess weight gain in the first year of life, and increased hospital admissions in older children. 35 The global mean temperature has already increased above pre-industrialised levels by 1.2°C, and climate change will become an increasingly important determinant of human health in the decades to come. VARIATIONS IN MORTALITY AND PRIMARY HEALTH CARE There are then, variations in mortality in both small and large populations and much of the variation is associated with factors other than health care. These include age, sex and gender, ethnicity, racism, environmental pollution and the climate. The social determinants of health are powerful predictors of population mortality that can act directly to shorten lives or indirectly through interactions with other factors.

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Although all these factors affect mortality rates, is some of the variation accounted for by primary health care? We begin to address this question in the next chapter.

REFERENCES 1. ONS. Data from the ONS Nomis reporting tool. ONS, 2020. https://www. nomisweb.co.uk/datasets/mortsa 2. Office for Health Improvement and Disparities. National General Practice Profiles. December 2020 update. https://fingertips.phe.org.uk/profile/ general-practice 3. GBD 2019 Demographics Collaborators. Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019. Lancet 2020;396:1160–203 4. World Bank. World Bank Country and Lending Groups. 2020. https:// datahelpdesk.worldbank.org/knowledgebase/articles/906519 5. World Bank. Life expectancy at birth, total (years). 2020. https://data. worldbank.org/indicator/SP.DYN.LE00.IN 6. WHO. Global Health Estimates 2019: Deaths by Cause, Age, Sex, by Country and by Region, 2000–2019. Geneva: World Health Organization, 2021. https:// www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death 7. National Records of Scotland. List of data tables. Section 5: Deaths, 2019. 8. Chandan JS, Thomas T, et al. Risk of cardiometabolic disease and allcause mortality in female survivors of domestic abuse. J Am Heart Assoc 2020;9:e014580 9. Chandan JS, Thomas T et al. Risk of cardiometabolic disease and allcause mortality in female survivors of domestic abuse. J Am Heart Assoc 2020;9:e014580 10. Guilmoto CZ, Saikia N, et al. Excess under-5 female mortality across India: A spatial analysis using 2011 census data. Lancet Glob Health 2018;6:e650–58 11. Raghupathi V, Raghupathi W. The influence of education on health: An empirical assessment of OECD countries for the period 1995–2015. Archives of Public Health 2020;78:20 12. Bado AR, Susuman AS. Women’s education and health inequalities in under five mortality in selected Sub-Saharan African countries, 1990–2015. PLoS One 2016;11(7):e0159186 13. Beale N, Nethercott S. The nature of unemployment morbidity. 1. Recognition. J R Coll Gen Pract, 1988;38:197–199 14. Beale N, Nethercott S. The nature of unemployment morbidity. 2. Description. J R Coll Gen Pract, 1988;38:200–202 15. ONS. The National Statistics Socio-economic Classification (NS-SEC). London: Office for National Statistics, 2018 16. Ministry of Housing, Communities & Local Government (2019). English indices of deprivation, National Statistics 2019. www.gov.uk/government/ statistics/english-indices-of-deprivation-2019 17. UK Government. Race Disparity Unit. List of Ethnic Groups. https:// w w w.ethnicity-facts-figures.service.gov.uk/style-guide/ethnic-groups (accessed July 2022) 18. ONS. Ethnic differences in life expectancy and mortality from selected causes in England and Wales: 2011 to 2014. London: Office for National Statistics, 2021

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19. Scott AP, Timæus IM. Mortality differentials 1991−2005 by self-reported ethnicity: Findings from the ONS Longitudinal Study. J Epidemiol Community Health 2013;67:743–750 20. Joint Committee on Human Rights. Black people, racism and human rights. Eleventh Report of Session 2019–21. London: House of Commons, 2020 21. Victora CG, Barros AJD, et al. Association between ethnicity and under-5 mortality: Analysis of data from demographic surveys from 36 low-income and middle-income countries. Lancet Glob Health 2020;8: e352–e361 2 2. Ministry of Health. Mortality 2016 data tables. New Zealand Health Statistics, 2020. www.health.govt.nz/publication/mortality-2016-data-tables 23. Department of Health. Aboriginal and Torres Strait Islander Health Performance Framework (HPF) 2012. Tier 1 – Deaths – 1.22 All causes agestandardised death rate. 2012. www1.health.gov.au/internet/publications/ publishing.nsf/Content/oatsih-hpf-2012-toc˜tier1˜deaths˜122 24. Arias E, Xu J. United States Life Tables, 2017. National Vital Statistics Reports 68:7. Washington, DC: Centers for Disease Control and Prevention, 2019 25. Greenwood BN, Hardeman RR, et al. Physician–patient racial concordance and disparities in birthing mortality for newborns. Proceedings of the National Academy of Sciences 2020;117(35):21194–21200 26. Jones CP. Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health 2000;90(8):1212–1215 27. Tiako MJN, South EC, et al. Lethality of racism for Black children in the USA: A primer. Arch Dis Child March 2022;107:212–213 28. Kapadia D, Zhang J, et al. Ethnic Inequalities in Healthcare: A rapid evidence review. NHS Race & Health Observatory, 2022 29. BBC. Ella Adoo-Kissi-Debrah: Air pollution a factor in girl’s death, inquest finds. 2020. www.bbc.co.uk/news/uk-england-london-55330945 30. PHE. Review of interventions to improve outdoor air quality and public health. London: Public Health England, 2019 31. Lee KK, Bing R, et al. Adverse health effects associated with household air pollution: A systematic review, meta-analysis, and burden estimation study. Lancet Glob Health 2020;8: e1427–e1434 32. ONS. Excess winter mortality in England and Wales: 2018 to 2019 (provisional) and 2017 to 2018 (final). Statistical Bulletin. London: Office for National Statistics, 2019. Office for National Statistics (2021). Deaths registered weekly in England and Wales, provisional. https://www.ons. gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/ datasets/weeklyprovisionalfiguresondeathsregisteredinenglandandwales 33. Gasparrini A, Guo Y, et al. Mortality risk attributable to high and low ambient temperature: A multicountry observational study. Lancet 2015;386: 369–375 34. Watts N, Amann M, et al. The 2020 report of the Lancet Countdown on health and climate change: Responding to converging crises. Lancet 2021;397:129–170 35. Wesselink AK, Wellenius GA. Impacts of climate change on reproductive, perinatal and paediatric health. Paediatr Perinat Epidemiol 2022;36:1–3

CHAPTER 4

Primary health care and population mortality in low-, middleand high-income countries

This chapter reviews evidence from low-, middle- and high-income countries on the effect of primary health care on population mortality. It concludes that there is an effect on population mortality and introduces one mechanism by which this effect is brought about – as the number of primary health care doctors available to serve the population increases, more medical care is available to more people and mortality tends to fall. INTRODUCTION The finding that one variable, for example population mortality, varies in association with changes in another variable, for example the funding of primary health care, does not establish causation. The ideal study design for investigating the effect primary health care may have on population mortality would be to randomly allocate people to two groups and allow one and prevent the other group from having access to primary health care. Of course, this would be unethical, but we can, however, take advantage of the prevailing inequality in access to primary health care between and within countries to explore its effects. If primary health care does reduce population mortality, we would expect to find that greater access to it is associated with lower mortality, and perhaps some evidence that it reduces differences in mortality due to socio-economic inequalities. The introduction of primary health care into low- and middle-income countries has been uneven. Some countries have relied on top-down DOI: 10.1201/9781003355380-4

48   PRIMARY HEALTH CARE AND POPULATION MORTALITY

disease programmes supported by international bodies and non-governmental organisations, while others have invested in primary health care systems and therefore provide examples of the benefits. In high-income countries the number of primary health care doctors per unit of population has come to be used as an indicator of investment in, or amount of, primary health care for investigating differences between and within countries. This is an imperfect measure since doctors commonly work in multi-professional teams, but detailed information about staff other than doctors is often not available. In exploring the evidence, we should begin by summarising four relevant reviews that have been completed since the work of Starfield and colleagues.1 A review of 36 studies concentrated on health outcomes in low- and middle-income countries, most studies being concerned with infant and child mortality. 2 The studies investigated local or national primary health care initiatives and reported an average reduction in infant mortality of 40% (ranging from 0% to 71% between studies) over periods of 2 to 10 years. Another review of outcomes in low- and middle-income countries investigated both large scale national programmes and more circumscribed initiatives.3 There were reductions in mortality, particularly child mortality and mortality due to infectious diseases, leading to primary health care being claimed as the foundation for strengthening health systems. A third review that included over 200 studies addressing various aspects of primary health care and not restricted to mortality, reported that it was associated with better health outcomes in both low- and highincome countries and could also reduce health inequities.4 The fourth report is from the OECD and reflects the current opinion of authoritative national and international bodies that strong primary health care improves population outcomes as well as reducing health inequities.5 The report concluded that primary health care reduces costs and saves lives. Table 4.1 presents information from the Institute for Health Metrics and Evaluation country profiles.6 The countries in Table 4.1 were selected because there is a reasonable body of published research about health care and outcomes relating to each country, and because they individually and collectively convey messages about the role of primary health care. They are not a random sample and the discussion about them that follows does not replace the findings of the reviews considered above. The aim is to explore the links between primary health care and mortality reported in the reviews.

TABLE 4.1  Life expectancy and mortality under the age of five in selected countries6

Population (millions), 2019

Total spent per person on health, 2017 (in $)

Life expectancy at birth, 1990

Life expectancy at birth, 2017

Age < 5 mortality / 1,000 live births in 1990

Age < 5 mortality / 1,000 live births in 2019

Males

Females

Males

31 45

48.8 51.4

45.6 47.4

70.4 70.8

66.7 65.8

187.3 168.6

51.8 46.2

162 37

64.0 61.6

58.6 61.7

73.7 67.4

64.5 66.3

89.7 112.6

17.2 62.9

216.7 1,400

799 455

71.6 70.7

63.8 66.9

79.1 79.9

72.0 74.5

69.3 54.7

20.2 8.8

High-income countries Germany 84.9 Japan 127.8 Norway 5.3 Slovak Republic 5.4 United Kingdom 67.2 United States 328.0

5,110 4,290 8,102 1,249 3,883 10,243

78.6 82.2 80.0 77.5 78.5 79.0

72.1 76.2 73.4 66.7 72.9 72.1

83.0 87.2 84.2 80.6 82.7 81.1

78.2 81.1 80.5 74.1 79.2 76.1

8.7 6.5 8.5 14.8 9.3 10.9

3.3 2.5 2.5 5.4 4.1 6.5

Low-income countries Ethiopia 107.6 Rwanda 12.7 Lower-middle-income countries Mongolia 3.4 Pakistan 224.1 Upper-middle-income countries Brazil China

Source: Institute for Health Metrics Evaluation. Used with permission. All rights reserved.

PRIMARY HEALTH CARE AND POPULATION MORTALITY   

Females

49

50   PRIMARY HEALTH CARE AND POPULATION MORTALITY

LOW-INCOME COUNTRIES

Ethiopia A devastating war has broken out in Ethiopia, a catastrophe for its peoples and destructive of its health services. Until the war broke out, the country was making progress in improving population health. In 2003, Ethiopia began implementing primary health care in an initiative referred to as the Health Extension Programme. This was an Ethiopian version of a community health programme, examples of which have been rolled out in several low-income countries. Under the aegis of an explicit national strategy committed to extending primary health care, female community health workers were trained and employed, the number of health centres increased steeply, and access to care steadily improved. Life expectancy increased and mortality for children under five fell substantially (Table 4.1). There were also reductions in maternal mortality, and in deaths due to tuberculosis and malaria.7 A review of studies of the Health Extension Programme concluded that it had achieved significant improvements in maternal and child health, infectious diseases, hygiene and sanitation and health knowledge and care seeking.8 However, inequities persist, with more wealthy populations having access to higher levels of staffing and more facilities.9 A shortage of resources limits the training and support that can be provided to the community health workers, with knock on effects on the quality of care.10 Initiatives have been launched to improve quality; for example, the introduction of clinical and administrative standards together with tailored support of managers to help them improve working conditions and provide leadership, but the shortage of funding remains a significant obstacle for developments.

Rwanda In the aftermath of the genocide against the Tutsis in 1994 in which one million Rwandans died, a government initiative was launched in 1995 in which community health workers began to provide essential services at the village level.11 A consultation was launched in 1998 leading to the agreement of a national plan that featured health equity as a priority, and in 2003 the new constitution formalised the right to health. In each of Rwanda’s 14,837 villages, three community health workers were elected by the villagers and provided with equipment and training. The coherence of the national health policy was enhanced by channelling

PRIMARY HEALTH CARE AND POPULATION MORTALITY   

51

most of the external aid for health through national systems rather than through foreign aid organisations. There are now around 45,000 community health workers in two categories, binomes being a male and female worker delivering integrated management of childhood illnesses and family planning, and females in charge of maternal and newborn care.12 The health system has evolved with community involvement, and a community-based health insurance scheme has been introduced. A reduction of 70% in under aged five mortality has been achieved in a decade and maternal mortality dropped by 50% over the same period. Childhood vaccination rates have risen to 97%. In the view of health managers in Rwanda, community health workers and health insurance were the two most important factors in these improvements, but other factors including effective management, attention given to key indicators and broad support for the national plan to improve health were also responsible.13 In comparison, the neighbouring country of Burundi has made less progress, life expectancy being 61 years for males and 63 years for females compared to 66 years and 71 years, respectively, in Rwanda.14 An analysis of the reasons for the differences between the countries pointed to stronger leadership, data-driven policy-making and greater commitment to equitable health care.15 Without these features, Burundi was less successful in building a primary health care workforce to enable access and effective health care delivery. The improvements in health in Rwanda are impressive, but more remains to be done. Investigation of the delivery of essential clinical actions by health staff in key domains (history, examination, counselling, antenatal care and care of the sick child) revealed substantial gaps.16 This is perhaps not surprising in view of the limited funding available for health care and that Rwanda has only 6 physicians per 100,000 population.

LOWER-MIDDLE-INCOME COUNTRIES

Mongolia After emerging from the shadow of the Soviet system in 1990, Mongolia adopted a democratic regime with a free-market economy; primary health care was reorganised into privately operated group practices backed by a social health insurance system. A shift from hospital-based curative services towards prevention and primary health care took place over several decades of reforms. New standards for primary health care facilities were implemented in 2011 and a capitation funding model was

52   PRIMARY HEALTH CARE AND POPULATION MORTALITY

introduced in 2015.17 Care is now provided by teams of generalist doctors and nurses based in family health centres,18 and is funded by the government without direct charges for use although out of pocket expenditures, including the costs of medicines, are high. Immunisation coverage for the under-one-year age group exceeds 98%, the fifth highest among the 27 countries of the Asia–Pacific region.19 Maternal mortality rates have fallen from 199 per 100,000 births in 1990 to 26 in 2015, infant mortality falling over the same period from 63.4 per 1,000 live births to 15.3. Crude all-cause mortality fell from 7.9 per 1,000 in 1990 to 5.1 per 1,000 in 2017.17 Some evidence is also available from a study of amenable mortality in Mongolia for the period 2007 to 2014. 20 Age-standardised amenable mortality accounted for 34.4% of all deaths in these years, but declined from 226.6 to 169.2 per 100,000 population over the period. There were differences in amenable mortality rates between regions, those regions with higher levels of poverty, poor infrastructure, adverse weather conditions and higher proportions of people from ethnic minorities tending to have higher mortality. An association was found between the number of doctors per 10,000 population and some age-specific amenable mortality rates, mortality being slightly lower in the age groups over 50 years in regions with higher number of doctors.

Pakistan Except for Afghanistan, life expectancy gains in Pakistan have been slower than in other countries in South Asia.21 Neonatal mortality is among the highest in the world at 42 per 1,000 births and has changed little over the past 20 years, but infant and under aged 5 mortalities have declined over the same period. 22 Pakistan spends only 2.8% of its GDP on health. Around 30% of the population rely on the public provision of health care, with private providers serving the remainder. Primary health care is delivered through a combination of government first-level health care facilities, and vertical public health programmes. The lady health worker programme was launched in 1994, each worker being responsible for around 200 houses and 1,000 people, with their role being to provide basic family planning, support for maternal and child health, treatment for diarrhoea, malaria and respiratory infections, and promote public health. By 2007, the programme had provided access to basic primary health care for over half the population. 23 The first-level health facilities include maternal and child health centres, basic health units, rural health units and dispensaries. However,

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53

the distribution of first-level facilities is variable and low in some urban areas and in consequence hospital services find themselves delivering a significant amount of the available primary health care. Examples of the vertical programmes include the Enhanced HIV/AIDS Control Programme, the National Tuberculosis Control Programme, and the Improvement of Nutrition through Primary Health Care programme. Integration of these programmes could improve efficiency and help primary health care to develop, but progress has been slow because of resistance among federal and provincial managers. 24 The achievements of the network of public and private primary health care services and vertical programmes are mixed. In addition to relatively slow progress in reducing mortality rates, levels of childhood vaccination are low in comparison with other lower-middle-income countries, Pakistan being one of only two countries in which polio is endemic. Access is variable between regions and between poorer and wealthier citizens, and the quality of care is variable, and the levels of patient satisfaction are low. Initiatives in primary health care have been under-funded and poorly implemented, health sector spending being too heavily concentrated on tertiary care whereas management of infectious diseases and illness prevention in the community would produce greater effects on health and mortality. 25 Disparities in health between rich and poor are widespread. A national survey of 16,240 households discovered that children with diarrhoea or cough in households with greater wealth, improved sanitation or educated mothers were more likely to receive treatment than children without these advantages. 26

UPPER-MIDDLE-INCOME COUNTRIES

Brazil The development of primary health care in Brazil has been extensively studied as an example of what can be achieved. The country initiated its Family Health Programme in 1994, a scheme designed to deliver accessible, comprehensive care in the context of families and communities. Teams of one physician, one nurse, one medical assistant and four to six community health workers have been allocated to populations of about 1,000 families, undertaking home visits and health promotion activities, drawing on local health data to plan their services.27 The programme has gradually expanded and by 2014 covered 62% of the population. An analysis by the Global Burden of Disease group confirmed a decrease of 34% in all-cause age-standardised mortality rates between

54   PRIMARY HEALTH CARE AND POPULATION MORTALITY

1990 and 2016, healthy life expectancy increasing over the same period from 59.8 years to 65.5 years. 28 The proportion of deaths caused by non-communicable diseases increased, reflecting the epidemiological transition. Several studies have shown a decline in mortality rates in association with the Family Health Programme. Age-standardised mortality due to cerebrovascular and heart disease between 2000 and 2009 fell faster in areas served by the programme than in other areas. 29 Reductions in infant mortality were greater among areas covered by the programme, 30 and greater in areas with higher numbers of primary health care physicians.31 Some studies do suggest that disadvantaged groups have benefited.32 The effect of improved access to primary health care on inequities in amenable mortality was investigated in a study of 95 city districts of São Paulo over the period 2003 to 2013.33 In low-income districts, amenable mortality was more than one and a half times greater than in highincome districts. When access was improved, residents increased their use of health care in low-income but not in middle- or high-income districts. Increasing attendance at health centres was associated with reductions in amenable mortality in low-income districts, although the gap in mortality between the low- and high-income districts persisted. In a study of trends in age-standardised mortality from ambulatory caresensitive conditions between 2003 and 2013, the decline was 37.9% in Black or Mixed ethnic groups and 34.9% in White ethnic groups.34 After adjusting for socio-economic development and health system factors, in areas served by the Family Health Programme, a 15.4% reduction in age-standardised ambulatory care sensitive conditions occurred in the Black or Mixed ethnic group compared with 6.8% among the White ethnic groups.

China China’s health system provides care for one-fifth of the global population. It remained poorly developed after the Chinese Communist Party took power in 1949, but on recognising the inequality in medical care provision between cities and the countryside, in 1968 Chairman Mao introduced a new scheme to deliver health care throughout rural China. Thousands of people were given basic training and became known as barefoot doctors. They provided basic medical treatment, vaccinations, care during the delivery of babies and worked to improve sanitation. 35 The infant mortality rate fell from 200 per 1,000 live births in 1952 to 34 per 1,000 live births in 1982.36 The barefoot doctor became a source of inspiration for initiatives in low-income countries to provide brief

PRIMARY HEALTH CARE AND POPULATION MORTALITY   

55

training to people who would then become community health workers responsible for providing basic health care. In the mid-1990s, pilots were launched for a new version of rural cooperative medical systems based on a health insurance scheme, but this led to different levels of coverage between Chinese counties, and in 2009 China embarked on reforms designed to provide all citizens by 2020 with access to basic health care of reasonable quality and with protection from financial risk.37 Government expenditure on health care quadrupled and health insurance coverage expanded to cover 95% of the population. A nationwide network of primary health care clinics was launched at the same time and has continued to gradually develop since then. Beginning in 2016, Chinese residents could register with a primary health care team funded through a capitation system responsible for delivering basic health and preventive care and acting as gatekeeper to other sectors of the health system. Plans were laid for increasing the numbers of primary health care doctors, targets being set for two to three doctors per 10,000 people by 2020 and five doctors per 10,000 people by 2030. The primary health care clinics are a mix of community health centres and community health stations, township health centres and village clinics. The health professionals involved include doctors, nurses, pharmacists and other health workers. The two leading causes of years of life lost in 1990 were lower respiratory infections and neonatal disorders, but by 2017, these had been superseded by ischaemic heart disease and stroke, the leading risk factors being high blood pressure, smoking, a high salt diet and particulate matter pollution.38 Inequalities persist, with health being better in the industrialised, wealthier eastern provinces compared to the rural, poorer provinces of the west. In 2015, the under age five mortality in western rural areas was 22.4 per 1,000 live births compared to 6.5 in eastern rural areas and even lower in eastern urban areas.39 A few studies throw light on the role of primary health care in improving health in China. In a study of all 63 counties in one province, after accounting for socio-demographic factors and hospital services, a higher proportion of total visits to health services that were to primary health care facilities was associated with reduced infant and under age five mortality among poorer people who had migrated to richer provinces to improve their livelihoods.40 A greater number of primary health care doctors per 10,000 people was also associated with lower maternal mortality among inter-provincial migrants, although there was no association for non-migrants. In a study focused on those aged 45 and above, 5,332 persons in 207 urban or rural communities taking part in a nationally representative

56   PRIMARY HEALTH CARE AND POPULATION MORTALITY

survey were followed up for a period of four years.41 Community health care centres were present in 21% of communities. After taking account of variables that influence mortality including level of health in the population and socio-economic status, the presence of a community health centre was associated with a 31% reduction in mortality risk during the four years of follow-up. Challenges remain, including deficiencies in the quality of care, the patchy and sometimes poor quality of training of health professionals, a fee-for-service payment system that rewards testing and treatment rather than prevention, and fragmentation between services. Even so, the available evidence indicates that investments in primary health care in recent years in China are leading to greater access to care and reduced population mortality. LOW- AND MIDDLE-INCOME COUNTRIES – REFLECTIONS These overviews of developments in a few low- and middle-income countries suggest that when national policy and funding are brought together to enable health workers to offer primary health care to most citizens, mortality can be reduced. Regrettably, primary health care systems in low- and middle-income countries remain patchy, some countries offering very little to patients and others offering well-organised and comprehensive services. There is also variation within countries, with some regions being better served than others. Systems are also fragile; political upheaval, warfare and economic crises can derail efforts to improve health. The impact COVID-19 continues to have on the health systems of low- and middle-income countries has yet to be fully documented, but it is inevitable that damage will have occurred. The recovery of primary health care in countries where it was already struggling before the pandemic arrived is likely to be prolonged and challenging. The country accounts illustrate a progression from vertical programmes addressing individual communicable diseases through services that begin to focus on groups of people rather than conditions, most often mothers and children, and onwards to care for all patient groups. Each step in this process is followed by reductions in population mortality. Much of the progress in health outcomes is of course achieved through socio-economic improvements, but effective primary health care systems increase the pace of change. They act as accelerants, as part of a suite of processes that together transform the health of nations, alongside sanitation and water supply, education, transport, productive labour, political development and the empowerment of communities. On the other hand, the national stories do not show that primary health

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57

care invariably reduces health inequities; there are examples of reductions in inequities in the countries examined, but there are also examples of inequities being unaltered or even increased. How primary health care is delivered appears to be important in explaining whether or not it reduces inequities. HIGH-INCOME COUNTRIES Research into the impact of primary health care in high-income countries has concentrated on the two concepts of supply and strength. Supply is a measure of how much primary health care a population has available to it, and we have already encountered the use of this idea in some of the studies from Brazil and China. The most commonly used indicator of supply is the number of primary health care doctors per unit of population, data which have the advantage of being relatively easy to collect. As a measure of supply, however, it overlooks the critical roles played by other health professionals. Strength is a measure of the extent to which a primary health care service possesses desirable attributes, for example, adequate funding, comprehensiveness, continuity or accessibility. Services with attributes such as these are believed to achieve better outcomes than services that do not. Strength therefore considers a range of attributes whereas supply takes account of only one. Many studies of the association between supply and mortality have been undertaken in the United States, often with the aim of making the case for a greater role for primary health care in the US health system. The findings of these US studies are considered first, followed by similar research in other countries. Studies employing the concept of strength are then explored for evidence that primary health care reduces population mortality. STUDIES OF SUPPLY

US studies Much of the evidence on the effects of primary health care in reducing population mortality in high-income countries lies in a landmark series of studies by Barbara Starfield, Leiyu Shi and colleagues conducted at the end of the 20th and beginning of the 21st centuries. The first part of Table 4.2 summarises nine of their studies conducted within the United States. These involved analyses of the relationship between measures of mortality and the supply of primary health care

First author and year of publication

Setting

Design

Measure of mortality

Findings

Studies by Starfield and team All-cause mortality and heart disease, cancer, neonatal mortality and life expectancy 273 metropolitan Cross-sectional ecological All-cause age-standardised areas analysis using 1990 data mortality 50 states Longitudinal ecological Age-standardised stroke analysis, 1985–1995 mortality

Shi, 199443 50 states and District of Columbia Shi, 200144 Shi, 200345

Cross-sectional ecological study

Shi, 200346 50 states

Ecological cross-sectional Age-standardised all-cause mortality per design, with time lagged 100,000 population variables, 1980–1995

Shi, 200447 50 states

Ecological pooled crosssectional time series analysis, 1985–1995

Infant mortality (number of deaths of infants under 1 year of age per 1,000 live births during the same year)

Increased supply of primary health care doctors consistently associated with lower allcause heart disease, cancer and neonatal mortalities, and increased life expectancy Increased supply was associated with lower mortality among White, but not Black groups An increase of one primary health care doctor per 10,000 population was associated with a reduction of 1.5 deaths per 100,000 population from strokes In 1995, an increase of one primary health care doctor per 10,000 persons was associated with a reduction of 35 deaths (all-cause) per 100,000 people Supply was negatively associated with infant mortality. An increase of one doctor per 10,000 population was associated, on average, with a 2.5% reduction in infant mortality and a 3.2% reduction in low birth weight (Continued)

58   PRIMARY HEALTH CARE AND POPULATION MORTALITY

TABLE 4.2  Studies of associations between supply of primary health care doctors and population mortality in the United States

TABLE 4.2  Studies of associations between supply of primary health care doctors and population mortality in the United States­  (Continued)

First author and year of publication

Setting

Shi, 200548 3,081 counties

Starfield, 200550

3,075 counties

Macinko, 200751

United States

Measure of mortality

Findings

(Continued)

59

In non-metropolitan counties, higher supply was associated with lower all-cause, heart disease and cancer mortality, but this relationship was not found in metropolitan counties. Metropolitan counties had more primary health care doctors than nonmetropolitan counties Longitudinal ecological Age-standardised all-cause An increase in supply of one doctor per 10,000 study over 1985–1995 mortality population was associated with a reduction of 14.4 deaths per 100,000. The reduction was greater for Black than White patients Cross-sectional ecological All-cause, cancer and heart An increase of one doctor per 10,000 population was associated with a 6% reduction in allstudy, 1996–2000 disease age-standardised cause and 3% decrease in stroke mortality mortality rates All-cause and causeAn increase in supply was associated with Review and reanalysis of specific mortality reductions in all-cause and cause-specific 10 studies published mortality, with greater reductions in Black between 1985 and 2005 compared to White people. An increase of one doctor per 10,000 patients was associated with a 5.3% mortality reduction (49 fewer deaths per 100,000 population) Cross-sectional ecological All-cause, heart disease analysis using 1990 data and cancer age- and sex-standardised mortality rates

PRIMARY HEALTH CARE AND POPULATION MORTALITY   

Shi, 200549 50 states

Design

First author and year of publication

Setting

Design

Measure of mortality

Findings

US studies by other researchers Krakauer, 199652

Franks, 199853

Ricketts, 200754

All-cause crude death rate 803 health care Cross-sectional service areas observational nonecological study of a 5% sample of Medicare beneficiaries in 1992 All-cause mortality Non-ecological, using Nationally individual patient representative data, with five years sample of of follow-up after 13,270 adults completion of the survey completing the National Medical Expenditure Survey 3,070 counties Cross-sectional ecological All-cause age-adjusted and heart and cancer study, pooled data mortality per 10,000 1996–2000 population

Physician supply had no impact on mortality except for areas with very low levels of supply

Survey respondents who had a primary health care doctor as their personal physician were less likely to die during the five years follow up period than those who had a specialist in that role (6.2% vs 8.1%)

The relationship between supply and mortality varied by geographic region. Primary health care doctors were associated with decreased mortality on the east coast and upper Midwest, but the correlation disappeared or was reversed in the west (apart from Washington State) and south-central states (Continued)

60   PRIMARY HEALTH CARE AND POPULATION MORTALITY

TABLE 4.2  Studies of associations between supply of primary health care doctors and population mortality in the United States  (Continued)

TABLE 4.2  Studies of associations between supply of primary health care doctors and population mortality in the United States  (Continued)

First author and year of publication

Basu, 201956

Design

Measure of mortality

Findings

All-cause mortality per Greater supply using a measure that may more Cross-sectional non100 beneficiaries accurately reflect hours worked by doctors, ecological analysis of was generally associated with lower mortality. 5,132,936 fee-for-service Residents in the top 20% of areas for numbers Medicare beneficiaries of doctors had 5% lower mortality aged 65 years or older All-cause age-standardised Supply decreased from 46.6 to 41.4 primary 3,142 counties, Longitudinal ecological health care doctors per 100,000 over the study life expectancy at birth analysis, 2005–2015 7,144 primary period. An increase of 10 primary physicians and five specific causes, relating changes in care service per 100,000 was associated with a 51.5 day age-adjusted per primary health care areas and increase in all-cause life expectancy, ten 100,000: Cardiovascular doctor supply to 306 hospital specialist physicians being associated with disease, cancer, mortality measures referral an increase of only 19.2 days. Increase in infectious diseases, regions primary health care physician supply was also respiratory tract diseases associated with lower cardiovascular, cancer and substance use or and respiratory mortality injury 6,542 primary care service areas

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Setting

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doctors, taking account of the features of populations such as socioeconomic status, location, and ethnicity. Most of the studies showed negative associations between the number of primary health care doctors per 100,000 population and mortality rates, although the size of the effect varied between studies and in one study there was no evidence of an effect in metropolitan counties. Effects were found for: All-cause mortality, cardiovascular disease, cancer, maternal outcomes and infant mortalities, but not for infectious diseases, substance abuse or injury. In some studies, the benefits were greater for Black than White patient groups. Two important reservations can be identified in these studies. First, they are ecological, that is, the outcome and predictors are measured at the level of the population. We cannot assume that interventions delivered to populations have a similar effect at the individual level. Second, the American health care system is dependent on commercial health insurance unless patients are covered by a national scheme for the elderly (Medicare) or a means-tested scheme for people with limited income or resources (Medicaid). At the time of many of the studies, poverty alone did not necessarily qualify someone for Medicaid and substantial portions of the population were uninsured. Although Shi and Starfield attempted to account for socio-economic and insurance status in their studies, caution is required in extrapolating the findings to other countries that have fewer financial barriers to access to health care. Other US researchers have investigated the effect of supply. One early study combined the number of doctors and nurses into a measure of primary health care staffing, and used age- and sex-specific mortality rates for 392 county groups over the years 1978 to 1982. After accounting for poverty, it reported that as staffing levels increased, mortality rates fell.42 In five other US studies by other researchers, the findings of reduced mortality with greater supply were supported by four studies53–56 but in the fifth, 52 the association was restricted to a few geographical areas with a very low supply of doctors (see Table 4.2).

United Kingdom Gulliford conducted two studies to investigate the possibility of an association between the number of general practitioners per 10,000 population and all-cause mortality. The first was a cross-sectional ecological analysis at the level of health authorities (99 in England in 1999, the year of the study) adjusting for the potential confounders of deprivation, ethnicity of populations and proportions of people with limiting long-term illness.57 Although an association between general practitioner numbers

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and standardised mortality in the 15–64 age group was found in the univariable analysis, there was no association after adjusting for the confounders. In the second study, again using the 99 health authorities and data from 1999, the analysis adjusted for distinct features of practices including size, location (rural or not), proportion of general practitioners aged 61 or over and the range of services offered. 58 In the final statistical model, the number of general practitioners per unit of population was not associated with mortality, but increasing the size of general practices was associated with decreasing all-cause and avoidable mortality and mortality due to myocardial infarction. A cross-sectional ecological study at the level of 152 primary care trusts (the administrative unit for primary health care in England at the time) and using data for 2006–2008 did not show an association between either the number of general practitioners or the quantity of practice staff per 100,000 patients and coronary heart disease mortality.59 However, mortality was lower in trusts in which greater proportions of the population had been diagnosed with hypertension. The likely explanation for this finding is that hypertension was under-diagnosed, with those not diagnosed and therefore not treated being at increased risk of developing and dying from coronary heart disease. Levels of detection of hypertension have been found to be higher in practices with more general practitioners per unit of population.60 Mirroring this finding, a study restricted to people aged 50 or over-related quality of care measures to the number of general practitioners and concluded that people living in areas with more general practitioners were more likely to receive care meeting the minimum standards.61 As levels of hypertension detection improve, the data will more closely reflect prevalence and the observed association between detection and mortality will disappear. Reflecting improved detection rates, a recent study from England has identified a weakly negative association between the number of doctors available and detection.62 Using standardised mortality ratios for premature mortality (aged under 75 years) for 7,858 general practices in England, and adjusting for population characteristics (deprivation, percentage of the practice population of White ethnicity, percentage who were smokers, and percentage diagnosed with diabetes as a measure of morbidity), a higher number of general practitioners per 1,000 patients in practices was associated with lower mortality.63 An increase of 0.16 general practitioners/1,000 patients throughout England equated to 1,078 fewer deaths nationally. One explanation for the finding of an association of general practitioner numbers in this study but not in those by Gulliford and colleagues is that the demands on general practice increased between 1999 when the

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earlier studies were undertaken and 2006–2010, the period covered in the more recent study. An early study investigated inpatient hospital death rates in England.64 Hospital standardised mortality ratios were calculated from deaths over the four-year period 1991–1992 to 1994–1995 for 183 acute hospitals and account was taken of comorbidity among those admitted, levels of long-term illness among the local community, features of the hospitals, and the number of both hospital doctors and general practitioners in each locality. In an analysis that included both emergency and elective hospital admissions, the best predictors of mortality were the percentage of admissions that were emergencies, the number of hospital doctors per 100 hospital beds and the number of general practitioners per 100,000 population. Higher numbers of both hospital doctors and general practitioners were associated with lower mortality. A 1% increase in the number of general practitioners was estimated as equating to 575 fewer hospital deaths in England. This finding is mirrored in a study from 2004/2005. A cross-sectional study of the then 303 English primary care trusts compared various performance indicators including in-hospital mortality ratios, that is, the ratio of the observed to expected deaths of in-patients adjusted for casemix.65 There was a small negative relationship between mortality and the number of general practitioners per unit of population and primary care trust expenditure per unit of population. In a more recent study restricted to patients with heart failure or chronic obstructive pulmonary disease (COPD), and investigating readmission within 30 days and mortality within one year of admission, more hospital doctors per 100 beds was associated with lower mortality in both conditions, with more general practitioners per 1,000 patients being associated with lower mortality rates for COPD but not for heart failure.66

Studies in other countries In South Africa, where there are as yet very few primary health care doctors, no correlation was found between numbers of doctors and measures of mortality.67 A longitudinal study in all 435 municipalities of Norway using data over a 16-year period from 1986 to 2001, investigated associations between numbers of general practitioners and all-cause mortality and mortality due to cancers, circulatory disease, respiratory disease and other causes.68 After adjusting for population variables including employment, age and disability, no measure of mortality was associated with total numbers of general practitioners, but mortality was lower

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where greater proportions of general practitioners held independent contracts rather than worked as employees of the municipality. Longer waiting times and poorer access have been reported for municipality provided services. A study of amenable mortality in the Slovak Republic over the period 1998 to 2015 found that as the number of general practitioners increased mortality also increased, although an increase in the number of pharmacies was associated with a reduction in amenable mortality rates.69 This finding is in contrast to the majority of the other studies of supply and the explanation is unclear, the study authors suggesting that there is an excess of general practitioners in the country such that increasing their numbers cannot improve access or lower the mortality rate. Inequity in the distribution of primary health care services and the effect of parttime working may also explain the findings. A study from Japan investigated mortality data for the years 2003 to 2007 and included all 358 health care districts in the country. Life expectancy of males was longer when the number of physicians in community clinics was higher, after accounting for socio-economic and other health care resources.70 In another study from Japan using primary health care facilities per 10,000 population as the measure of supply, a greater number of facilities were associated with lower mortality due to ischaemic heart disease, although there was no such association in the case of stroke.71 Distance from a primary health care facility, however, was found to predict the risk of stroke mortality, with greater distance from a facility being associated with increased risk.72 In Korea, in an individual patient-level analysis, a greater supply of primary health care physicians was found to be associated with lower all-cause cancer and cardiovascular mortality.73 STUDIES OF STRENGTH An early study by Barbara Starfield described characteristics of primary health care in 10 industrialised countries, the characteristics including age-adjusted death rates, the extent to which primary health care was the first point of contact for patients with health problems, the comprehensiveness of care and the satisfaction of the population in relation to costs.74 Using data from the mid-1980s, there was a general tendency for countries with more positive primary health care characteristics and higher satisfaction with costs to also have lower mortality rates. In a study of 13 industrialised countries using data from the early to mid-1990s, a variety of indicators were used to classify the strength of primary health care into high, intermediate and low categories.75 Life

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expectancy, neonatal mortality, post-neonatal mortality and infant mortality were all investigated. Countries with the strongest primary health care did better than the intermediate- and low-strength countries with respect to neonatal, post-neonatal and infant mortality, although in the case of life expectancy, intermediate countries outperformed both lowand high-strength countries. In a later study that included 18 OECD countries from 1970 to 1998, Starfield and colleagues the relationship between what they described as the strength of national primary health care systems and outcomes.76 After adjusting for GDP and the proportion of populations over 65, countries with stronger systems had lower all-cause mortality, all-cause premature mortality and premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease and heart disease. In 2008, reforms were introduced to strengthen Germany’s primary health care system. These included capitation-based reimbursement, coordination of access to specialists and increasingly systematic management of chronic conditions. Patients gained improved access to primary health care with shorter waiting times and no out-of-pocket expenses for medications. In an investigation of the effects of the programme over the five years 2012 to 2016, the outcomes of a total of 1,003,336 adults enrolled in the programme in one province were compared with a control group of 725,310 adults from the same province who had not enrolled.77 All-cause mortality was lower among patients enrolled in the programme, with 1,672 fewer deaths than would have been expected if the mortality rate had been the same as in the control group. In a study involving 31 European countries, structure (coverage, distribution of providers and facilities), accessibility, continuity, coordination and comprehensiveness were used to derive a measure of primary health care strength.78 Disease-specific mortality was measured as potential years of life lost due to diabetes, ischemic heart disease, cerebrovascular disease and obstructive airway conditions (asthma, bronchitis and emphysema). Both the structure of primary health care, its comprehensiveness and coordination of care were associated with lower mortality due to ischemic heart disease, cerebrovascular disease and asthma, bronchitis and emphysema. Only for people with diabetes was such an association not evident. In a longitudinal study 2000–2005 using patient-level data and involving 52,241 US adults who had completed a national survey, the association of five primary health care attributes with all-cause mortality was investigated.79 The attributes were used to create a score, much like the concept of primary health care strength. The chosen attributes were care for new problems, preventive care, referrals to other health professionals,

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enhanced access, and patient-centredness. After accounting for income, education and health insurance, adults experiencing care with more attributes had a lower all-cause mortality than those experiencing care with fewer attributes. Contrasting evidence is provided by the pay-for-performance scheme introduced in the United Kingdom in 2004. Named the Quality and Outcomes Framework, the scheme rewarded practices for achieving targets for patient access and the management of chronic conditions. In a study of the period 2007 to 2012, no relationship was found between performance in the management of chronic conditions and all-cause and cause-specific premature standardised mortality rates.80 The reasons for the failure of this scheme to reduce mortality rates are uncertain, but the likely explanation is that it concentrated on the management of chronic conditions that had already being diagnosed and not on population outcomes or the broader attributes used to define strong primary health care.72,74

WHAT THIS MEANS

Does primary health care reduce population mortality? The national examples of the development of primary health care systems and other studies that relate strength of primary health care to population mortality help to provide an answer. Not only is the evidence broadly consistent but it also presents a picture of primary health care reducing mortality in countries facing widely divergent challenges to health and with very different economies and health care systems. In lowincome countries, the first signs of an effect on mortality can be found in the stand-alone vertical programmes targeting specific problems, for example, malaria or HIV. When two or more of these programmes work together, an early form of primary health care comes into being. The conditions then exist for health workers to deliver interventions for a defined population, beginning with mothers and children and leading to reduced maternal and child mortality through a mix of preventive and curative interventions. As the experiences of Ethiopia and Rwanda show, primary health care teams, health centres and clinics can grow from these beginnings to address the care needs of local populations. Improvements in living conditions, including clean water, sanitation and education make an enormous difference but primary health care plays a part as well. The evidence indicates that low-cost services, often based on community

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health workers with relatively little training, but are targeted at maternal supports, infant maintenance and childcare and the prevention and management of common infectious diseases, can bring about improvements in health and reductions in mortality rates. Factors that help increase effectiveness appear to include consistent national policies and leadership, coverage of the whole population including those geographically isolated or socio-economically disadvantaged and the organisation of teams or other groupings that enable frontline health workers to access more highly skilled professionals such as nurses or doctors for advice, training and support. Such health systems can be fragile, however, and wars, famine and pandemics can devastate services. In lower-middle-income countries, primary health care adapts to meet the needs of populations experiencing the epidemiological transition, with the prevention of chronic conditions being given increasing priority. In these circumstances, a well-organised primary health care system has advantages over a poorly integrated system, as the contrasting examples of Mongolia and Pakistan illustrate. Coverage of the whole population can reduce maternal, child and infant mortality, and also mortality caused by non-communicable diseases. Services are often delivered at clinics or health centres, and the health care workforce is increasingly skilled, with more nurses and doctors. Doctors as the professionals of first contact, however, remain relatively unusual. The epidemiological transition has advanced further in most uppermiddle-income countries and primary health care systems can be found that share many of the features common in high-income countries. Teams of nurses, doctors and health workers are increasingly common and where such teams are more numerous, research studies show reduced population mortality. In high-income countries, primary health care is widely established and research to identify any effects on population mortality is limited to investigating relatively small differences in services between countries or between regions within countries. Almost every citizen has access to some primary health care. Despite this, reductions in population mortality can be found when there are more doctors or when primary health care is stronger.

Does primary health care reduce health inequities? The evidence reviewed does not confirm that primary health care invariably reduces inequity in mortality. The introduction or enhancement of primary health care can be followed by more equal health in populations, but this is not automatic. Instead, there can be either no effect or even increased inequity. Examples of these three possible impacts on

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health inequities can be found in research from low-, middle- and highincome countries and the conclusion must be that a tendency to reduce inequity is not an inherent characteristic of primary health care. The effect on health inequities rests on how primary health care is organised and delivered rather than on whether it exists in a health system. The distribution of services and access to them must be such as to ensure the most disadvantaged can use them when needed.

Limitations of the evidence The first limitation is that there are no formal experimental studies designed with the specific intention of testing the effect on population mortality. There are many non-experimental studies, however, including evaluations of national initiatives to improve the strength of primary health care. The findings indicate that stronger services or greater supply can lead to lower mortality. A second limitation is that many of the observational studies are ecological in design, that is, the data used relate to administrative health system units or districts rather than being data at the level of individual patients. Nevertheless, the findings of these studies are supported by other studies that are not ecological. The research evidence also bears out the underlying theory of primary health care embodied by the Astana Declaration (see Chapter 1) and backed by authoritative international bodies including the WHO and OECD as well as national health systems and research organisations. This concept predicts that stronger primary health care will bring about greater reductions in population mortality, and this is precisely what is found to be evident in the available research. Having established that there is an effect on mortality we can now start to think about the mechanisms, and the evidence we have already examined allows us to describe the first one.

THE FIRST MECHANISM

Mechanism I An increase in the supply of primary health care doctors makes more medical care available to more patients, leading to reduced population mortality. This effect is not seen when the supply is very low and the increase is too small to have an impact, nor when the supply is already generous, in which case further increases bring no additional mortality advantage. Level of Evidence – Moderate

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COMMENTARY If the starting point is no primary health care doctors or very few, the addition of small numbers cannot be expected to have much effect on population mortality,65 but as the numbers increase an effect begins to be detectable. In Mongolia, Brazil and China, where some development has taken place, an increase in doctors has been associated with reduced mortality. In high-income countries too, including the United States, Japan and the United Kingdom, an association between the number of primary health care doctors and population mortality has been identified. However, in Norway and the Slovak Republic, an association was not found, with possible explanations including particular characteristics of the health systems involved, an already high number of doctors being in place, and how doctors were deployed within the countries. Most of the studies from high-income countries reported between 5 and 10 primary health care doctors per 10,000 population, but it is difficult to estimate the ideal number of doctors required to serve a particular population because of the differences between health systems and the variable burden of disease between populations. The problem of judging the number of doctors required is made more difficult by inconsistency in how the number of doctors was defined, with some studies using a simple head count and others a measure accounting for hours worked. Rather than being a straight line in a graph, the relationship, as far as supply of primary care doctors is concerned, is more likely to be non-linear as in the hypothetical graph shown in Figure 4.1. When the number of doctors is relatively high, adding more has little or no added benefit. When the number of doctors is very low, the addition of a few more will not have much detectable impact either.

FIGURE 4.1  Hypothesised graph of the relationship between supply of primary health

care doctors and all-cause standardised population mortality rate/100,000 population.

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The relationship between supply and mortality will be influenced by other factors. The available studies have concentrated on the impact of doctors but other health professionals work in primary health care and they may also affect population mortality, whether working independently or alongside doctors in multi-professional teams. Evidence about the effect of other professionals will be explored in Chapter 8. The distribution of doctors amongst the population may have an effect, and the prevailing patterns of disease responsible for most deaths will play a part since some diseases are more amenable to primary health care interventions than others. And it is not simply the number of doctors that matters – what they do is important as well. The actions of health professionals that affect mortality will be set out in many of the mechanisms that are presented in the following pages. The next chapter begins this process by considering mortality from communicable diseases. REFERENCES 1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502 2. Macinko J, Starfield B, et al. The impact of primary healthcare on population health in low- and middle-income countries. J Ambul Care Manage 2009;32(2):150–171 3. Kruk ME, Porignon D, et al. The contribution of primary care to health and health systems in low- and middle-income countries: A critical review of major primary care initiatives. Soc Sci Med 2010;70:904–911 4. Shi L. The impact of primary care: A focused review. Scientifica 2012;432892 5. OECD. Realising the Potential of Primary Health Care. OECD Health Policy Studies. Paris: OECD Publishing, 2020 6. IHME (Institute for Health Metrics and Evaluation). Country profiles, 2018. Seattle, WA: IHME, University of Washington, 2021 7. Assefa Y, Van Damme W, et al. Successes and challenges of the millennium development goals in Ethiopia: Lessons for the Sustainable Development Goals. BMJ Glob Health 2017;2:e000318 8. Assefa Y, Gelaw YA, et al. Community health extension program of Ethiopia, 2003–2018: Successes and challenges toward universal coverage for primary healthcare services. Global Health 2019;15:24 9. Woldemichael A, Takian A, et al. Inequalities in healthcare resources and outcomes threatening sustainable health development in Ethiopia: Panel data analysis. BMJ Open 2019;9:e022923 10. Getachew T, Abebe SM, et al. Assessing the quality of care in sick child services at health facilities in Ethiopia. BMC Health Serv Res 2020;20:574 11. Binagwaho A, Farmer PE, et al. Rwanda 20 years on: Investing in life. Lancet 2014;384:371–375 12. Ministry of Health Rwanda, et al. Success Factors for Women’s and Children’s Health: Rwanda. World Health Organisation: Geneva, 2015 13. Sayinzoga F, Bijlmakers L. Drivers of improved health sector performance in Rwanda: A qualitative view from within. BMC Health Serv Res 2016;16:123 14. World Bank. Data. Life expectancy at birth, total (years), 2020. https:// data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=RW

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77. Wensing M, Szecsenyi J, et al. Strong primary care and patients’ survival. Sci Rep 2019;9:10859 78. Kringos DS, Boerma W, et al. Europe’s strong primary care systems are linked to better population health but also to higher health spending. Health Aff 2013;32:686–694 79. Jerant A, Fenton JJ, et al. Primary care attributes and mortality: A national person-level study. Ann Fam Med 2012;10:34–41 80. Kontopantelis E, Springate DA, et al. Investigating the relationship between quality of primary care and premature mortality in England: A spatial whole-population study. BMJ 2015;350:h904

CHAPTER 5

Communicable diseases

INTRODUCTION Worldwide, deaths caused by communicable diseases have been in decline (Table 5.1). They accounted for 8,142,500 deaths in 2017, 14.6% of the 55,945,700 total deaths in that year.1 Improvements in living conditions are responsible for much of the reduction, but as we shall see, health care plays a role as well. There are numerous communicable diseases and it is impossible to consider them all. To describe the role of primary health care, the four most common causes of deaths globally are discussed, namely lower respiratory infections, diarrhoeal diseases, tuberculosis (TB) and HIV/AIDS (Table 5.1). The management of these conditions in low-, middle- and high-income countries is addressed first, followed by a discussion of vaccination and the COVID-19 pandemic. Finally, three mechanisms by which primary health care affects population mortality are presented: providing comprehensive care for communicable diseases, delivering vaccinations in the context of an established relationship with patients and prevention and management of the communicable diseases of childhood. MANAGEMENT OF INFECTIONS

Lower respiratory infections Primary health care provides treatment for the majority of people who have lower respiratory infections and also provides vaccination against influenza, Streptococcus pneumoniae and COVID-19, and is therefore DOI: 10.1201/9781003355380-5

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TABLE 5.1  Global numbers and rates of death of selected communicable diseases, 20171

Lower respiratory infections Diarrhoeal diseases Tuberculosis HIV/AIDS Malaria Meningitis Acute hepatitis Whooping cough Measles Tetanus Diphtheria

Number of deaths (thousands)

Age-standardised death rate (per 100,000)

Change in rate, 2007–2017 (%)

2558.6

35.4

−21.1

1569.6

21.6

−30.2

1183.7 954.5 619.8 288.0 126.4 91.8 95.3 38.1 3.6

14.9 12.1 8.7 4.0 1.6 1.4 1.4 0.5 0.1

−31.4 −56.5 −37.3 −27.8 −24.5 −27.1 −59.3 −59.6 −28.6

central in controlling mortality from these conditions. Mortality from lower respiratory infections is higher among children under aged five and those over 70 than among other age groups (in years). Streptococcus pneumoniae is the leading cause of lower respiratory infection deaths, accounting for almost 1.9 million lives lost in 2016, 3.4% of all deaths worldwide. 2 Vaccination against Streptococcus pneumoniae is available for people at higher risk of infection in many middle- and highincome countries and is being increasingly used in low-income countries. Respiratory syncytial virus was the next most common cause of death from lower respiratory infections, with 54% of these deaths being among children under aged five. The role of primary health care involves making the diagnosis, assessing the severity of the condition, prescribing antibiotics when indicated for bacterial infections, arranging hospital admission for those severely ill, and organising follow-up. It is also involved in reducing the risk of infections through preventive measures including helping smokers to quit and offering vaccination to those at greatest risk. Between 1990 and 2017, the global mortality rate from lower respiratory infections among children under aged five declined by 67%.3 Globally, among children under aged five, inadequate nutrition is the most common risk factor for death from lower respiratory infections, with household air pollution from solid fuels being another important risk factor. The Global Burden of Disease respiratory infection collaborators have estimated that increased access to antibiotics was responsible for a 1.9% global decrease in mortality from lower respiratory infections

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among children under five between 2000 and 2016, but also concluded that 30.2% of deaths caused by lower respiratory infections in children under aged five remained attributable to the lack of antibiotic treatment. Childhood mortality from lower respiratory infections also decreases with improving social circumstances, with improved household income playing a role in both nutrition and access to health care. In contrast with reductions in childhood mortality from lower respiratory infections, global mortality rates in the age group of 70 years and older have remained relatively stable over the last 25 years. The care of children with lower respiratory infection in many lowand middle-income countries in the last 20 years has been informed by a strategy developed jointly by WHO and UNICEF called Integrated Management of Childhood and Neonatal Illness (IMNCI).4 The strategy has three components: (1) the training of health workers supported by locally adapted guidelines on a variety of conditions, (2) improving health systems in managing childhood illness and (3) helping families and communities to prevent infections and manage them when they occur, including education about the symptoms and treatment of lower respiratory infections and encouraging improvement in living conditions. In promoting both preventive and curative interventions for several conditions, the IMNCI represents an attempt to establish an integrated health service for children rather than one composed of multiple separate disease-specific programmes. Countries that fully implemented the IMNCI were 3.6 times more likely than other countries to achieve the fourth millennium development goal – a two-thirds reduction between 1990 and 2015 in the under aged five mortality rate.5 A Cochrane Systematic Review of two randomised trials and two controlled before-and-after studies of the implementation of IMNCI concluded that its use may lead to fewer deaths of children under aged five, although the focus of the review was on all childhood conditions covered by IMNCI rather than respiratory infections alone.6 Reviews specific to respiratory infections indicate substantial reductions in all-cause and pneumonia mortality following use of the IMNCI guidelines7 and a meta-analysis of nine community-based studies, seven of which had investigated under aged five childhood mortality, showed a consistent reduction in deaths, the effect being significant in five of the seven studies.8 The summary effect across studies was a reduction in deaths of 24% among the under aged five group. IMNCI needs to be targeted on those localities most in need if it is to reduce health inequities.9 In a study of determinants of the prevalence of lower respiratory infections in children under aged five in Sub-Saharan Africa, children of mothers who were employed and those whose

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households had improved toilet facilities had lower odds of contracting an infection.10 Those who are employed are better able to afford the necessities of life including access to health care and the costs of medications. Lower respiratory infections tend to cause more deaths among older people in high-income countries than among young children. The infective organism is often a virus; in a prospective study of 3,104 affected adults in European countries, bacteria were isolated in one in five cases, and a virus in almost a half.11 Nevertheless, most patients diagnosed as having a lower respiratory tract infection are prescribed antibiotics.12 In addition to providing all the care required by most patients, primary health care identifies those patients with severe disease who require hospital admission. A comparison of respiratory mortality among adults between 1985 and 2015 in 15 EU countries plus Australia, Canada and the United States reported declines in most countries over the period. However, deaths due to respiratory infections tended to be higher in the UK than other countries for both men and women.13 It is unclear whether the higher mortality in the UK is accounted for by smoking, obesity, environmental pollution or to health care factors, but socioeconomic deprivation is almost certainly involved. Years of life lost due to respiratory infections in England are much higher in the most deprived local authorities in comparison with the least deprived.14 In reviewing the burden of respiratory disease in the UK compared to other high-income countries, the British Lung Foundation recommended the agreement of a national strategy, the development of clinical networks, steps to reduce air pollution, identification of respiratory disorders during the health checks undertaken in primary health care, and greater investment in prevention including services to address smoking, obesity and physical inactivity.15 The pandemic has underlined the case for acting on these recommendations.

Diarrhoeal diseases Diarrhoeal diseases were responsible for around 1.6 million deaths worldwide in 2017, approximately 2.8% of all deaths.1 A high proportion of these deaths were of children, and in low- and middle-income countries, diarrhoeal diseases account for one in ten deaths of children younger than five years.16 Deaths are declining, data from 94 low- and middle-income countries showing declines in most parts of the world. There is substantial variation both between and within countries in mortality rates, improved water supply, sanitation and hygiene being associated with greater declines in mortality. Oral rehydration solution, which

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in low-income settings can be provided by community health workers, can greatly reduce mortality, but its availability is often poor in areas with the highest mortality.17 Improvement in the socio-economic conditions of families is key to better sanitation and water supplies. Primary health care has roles in the prevention and treatment of diarrhoeal disease and, consequently, is important for minimising mortality. Education of the community about handwashing and promotion of improved sanitation and nutrition are elements of the prevention function, and vaccination against rotavirus infections is increasingly common. Other risk factors include not exclusively breast feeding younger infants, under-nutrition, zinc deficiency and vitamin A deficiency.18 Launched in 2013, the integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) set the goal of reducing mortality from diarrhoea in children less than five years of age to fewer than 1 per 1,000 live births and deaths from pneumonia in children in the same age group to fewer than 3 per 1,000 live births.19 The plan recognised the need for health system strengthening and discussed the potential of community health workers as well as the need for safe drinking water, sanitation and handwashing facilities. The IMNCI Handbook provides guidance on the treatment of diarrhoea at home, including extra fluids, the administration of zinc and advice on feeding, oral rehydration solution, and the use of intravenous rehydration if available. 20 In the UK, diarrhoeal infections are an uncommon cause of death although episodes of infection are common, giving rise to an estimated one million primary health care consultations annually. 21 The most common organism responsible among people presenting to their general practitioner is the norovirus, with campylobacter being the most common bacterial culprit. In addition to managing individual cases, primary health care has responsibility for advising affected individuals on hygiene to reduce the risk of spread and for notifying certain cases to the public health authorities so that steps can be taken to avoid or contain disease outbreaks. It has been estimated that norovirus causes around 80 deaths a year among people aged 65 or older in England and Wales, making the virus a relatively uncommon cause of death. The low number of deaths reflects the improved socio-economic conditions of high-income countries that enable effective sanitation, access to clean water for drinking or handwashing, and education on how to avoid intestinal infections. In high-income countries, therefore, primary health care has only a small role to play in reducing mortality from diarrhoeal infections, but the evidence from low- and middle-income countries shows clear benefits.

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Tuberculosis (TB) There were 1.3 million deaths due to TB in 2015 (around 2.3% of all deaths worldwide), 1.1 million among people HIV-negative and 0.2 million among HIV-positive individuals. 22 Mortality is declining (Table 5.1), and is related to national socio-demographic status, with mortality rates being higher in countries with worse socio-economic indicators. Among HIV-negative individuals, death rates are higher among males than females and reach a peak in the 60–64 age group. In England, the incidence of TB has fallen to its lowest level since records began in 1960.23 People born outside the UK accounted for 72% of the new cases in 2018, most commonly in India, Pakistan, Romania, Bangladesh and Somalia. Cases in England were higher among males than females and most common in the 30–39-year age group. Community health workers have important roles in the prevention, detection and treatment of TB in low-income countries, but in highincome countries where TB is less common, specialists more commonly undertake treatment and contact tracing with primary health care being involved in the initial detection of potential cases. A key part of the role of primary health care in all countries, however, is ensuring that all those people who may have TB have access to care. Although pulmonary TB is the most common presentation, the infection may also present elsewhere, including in the central nervous system, lymph nodes, bones or joints. This makes diagnosis challenging and may only occur post-mortem; among those dying of TB in the UK between 2001 and 2014, 21.4% were not diagnosed until after death. 24 Among people with TB, increasing age, male sex and the presence of one or more social risk factors (homelessness, imprisonment or drug or alcohol misuse) are associated with a greater risk of death. Recent recommendations from Public Health England to reduce the burden of TB include improved support for underserved populations. 22 In addition to increasing opportunities for the disease to spread to other people, delays in diagnosis increase the risk both of more severe disease and of mortality, but delay continues to be a problem in both low- and high-income countries. In England, the median delay between symptom onset and start of treatment was 75 days in 2018, but delays of four months or longer occurred in 30% of cases. In a study of diagnostic delay, with delay defined as longer than four months between the onset of symptoms and start of treatment, delay was more common among women, those aged 45 years or over, living outside London, and having extra-pulmonary TB. 25 A review of studies of the barriers to diagnostic

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and treatment services in countries with low or moderate levels of TB reported that patients’ appreciation of the symptoms of TB as one factor and stigma another.26 Drug users feared withdrawal of their drugs and hospital admission. Access to care was seen as more difficult for some patient groups, including migrants, Roma, the homeless, and those unable to speak the local language. Discontinuity in primary health care was also identified as a potential factor in delayed diagnosis. Recommended ways to overcome these problems included improving accessibility of services, developing health workers’ sensitivity to culture and gender and providing outreach services. In a review of studies of diagnostic delay in low- and middle-income countries, the median diagnostic delay ranged from 30 to 366 days. 27 Patient factors related to delay included poor literacy, poor knowledge of, or beliefs about TB, self-medication and having mild symptoms. Health system delays were related to the first visit being to a private or informal provider, living a long distance from health care or local health facilities lacking TB diagnostic services. Delays tend to be longer in lowand lower-middle-income countries compared to upper-middle-income countries and are related to problems in gaining access to health care or to services with the expertise to manage TB effectively. 28 In most people, the immune system contains the infection, a condition referred to as latent TB. In some people, latent TB can progress to active TB and therefore its detection and treatment can be important for those patients at risk. Screening in primary health care of high-risk groups and treatment of those found affected is increasingly part of the strategy to reduce the impact of TB, the high-risk groups including people with HIV, close contacts of people with TB and patients receiving immunosuppressive therapies. Latent TB may be detected with tuberculin skin tests or selective immunological tests. In England, primary health care offers testing for latent TB to new entrants to the UK from countries with high TB incidence who are aged between 16 and 35 years. The treatment of those testing positive is provided either by primary health care, community-based TB teams or secondary care services.

HIV/AIDS Sometimes referred to as a pandemic and at other times as a global epidemic, HIV/AIDS became an international concern during the 1980s. Progress in managing the disease has been made in recent decades, and the annual number of deaths worldwide from HIV has fallen from 1.95

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million in 2006 to 0.95 million in 2017, around 1.7% of deaths worldwide. 29 Although deaths have declined, antiviral treatment has ensured that the numbers living with HIV have increased. Prevalence is particularly high in Sub-Saharan Africa. One of the Sustainable Development Goals is to end AIDS as a public health threat by 2030. The Joint United Nations Programme on HIV/ AIDS (UNAIDS) that leads international policies set an interim target for 2020 of 90-90-90, that is, 90% of people living with HIV should be diagnosed, of whom 90% should be on anti-retroviral treatment, of whom 90% should be virally suppressed. The target for 2030 was 95-95-95. The UNAIDS 2020 report admitted that although there had been progress, none of the targets for 2020 had been met and the world had failed to diagnose and start treatment for almost half the children living with HIV.30 There are gaps in care in high- as well as low- and middle-income income countries. In 2013, there were an estimated 108,000 people in the UK with HIV, including 26,000 who had yet to be diagnosed.31 Of those diagnosed during that year, 42% had an advanced infection at the time, indicative of late diagnosis, a problem that increases the risk of early deaths. The World Bank and WHO among other international agencies have been involved in creating and administering programmes in low- and middle-income countries to reduce the burden of HIV. Often, these have been stand-alone schemes but in some situations integration of HIV services with maternal and child health or family planning services has helped make antiviral drugs more available to mothers. Services have also had to adapt to the needs of specific patient groups, for example, sex workers or those who inject drugs. UNAIDS argues that the elimination of mother-to-child transmission requires the end of discrimination in health care settings towards women living with HIV. HIV adversely affects disadvantaged groups, including those with less education and some ethnic minority groups such as Black people in the United States. In England, late diagnoses are more common among those of Black African ethnicity.32 The advent of antiretroviral therapy in the United States was followed by greater declines in mortality among socio-economically advantaged compared with disadvantaged groups and White compared with Black populations and there is clearly a challenge for health systems, including primary health care, to avoid such inequity. 33 In low- and middle- as much as in high-income countries, primary health care has roles in detecting and managing HIV and is key to meeting the targets for HIV control.34 In addition, primary health care has a role in the continuing care of people with HIV. The success of antiviral

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therapy will ensure that more people with HIV will have normal life spans although some may develop chronic conditions that require longterm management. WHO has argued for the integration of HIV care into well-resourced primary health care both to improve care for people with HIV but also to strengthen services for people with other chronic conditions or multimorbidity.35 Integration can help to reduce stigma and make care more acceptable and accessible.36 In South Africa, integration with primary health care is key given the high number of affected people although adequate staffing and equipment are essential.37 Community-based interventions linked to health facilities and clinics have been shown to achieve high levels of testing and treatment.38 Despite the benefits of integration, in some low- and middle-income countries top-down programmes continue to bypass primary health care services. The development of trusting relationships with primary health care is important for the avoidance of stigma and to enabling open communication between patients and professionals.39 People may present to primary health care with symptoms associated with HIV or they may be free of symptoms but at risk of HIV. The features of primary HIV infection such as fever, sore throat, maculopapular rash on the trunk or arthralgia may suggest the need for an HIV test. Presentation at later stages of the condition can involve a wide range of symptoms that can be confused with other illnesses and the clinician must be conscious of the possibility of HIV as the explanation. In Europe, 47% of patients have a delayed diagnosis and the challenge for primary health care is to increase testing and improve diagnosis in both symptomatic and asymptomatic individuals.40 NICE recommends that primary health care detects people with HIV through offering testing to people at risk, including those with suggestive symptoms, those from high prevalence countries and those at risk from sex or injecting drugs.41 In areas of the country with high prevalence (defined as over 0.2% of the population affected), testing should be offered to everyone not previously diagnosed who joins the general practice. In areas of extremely high prevalence, general practitioners should consider HIV testing opportunistically at each consultation based on clinical judgement. Despite these recommendations, opportunities to offer testing are often missed and testing rates declined between 2010 and 2015.42 Systematic screening may therefore have a role to play, a randomised trial demonstrating that opt-out screening incorporated into the health check of people newly registering with a general practice in Hackney, London, can be cost-effective in improving detection and reducing longterm ill health in areas of relatively high prevalence.43

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The COVID-19 pandemic A pandemic is an epidemic that has spread to several countries or continents. An influenza pandemic had been expected for some years, but in the event the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was the cause of the major pandemic that began in 2019. COVID-19 was declared by WHO to be a pandemic on 11 March 2020. Pandemics are usually of limited duration, with declines in the number of people becoming infected as herd immunity develops or preventive measures become widely implemented. The effect on mortality rates is therefore temporary or, as with influenza, intermittent as new variants of the virus enter circulation. The effect will also usually be inequitable; COVID-19 has had greater impact on people of low socio-economic status. The death rate from COVID-19 in England was higher among people from a Black, Indian or Bangladeshi background compared to White individuals.44 The pandemic has exhausted national health systems, impairing their ability to deliver timely health care for conditions other than COVID-19, such as cancer or cardiovascular disease. A hangover effect may therefore be seen in countries with the most damaged health systems, all-cause mortality rates in these countries remaining elevated for some years. Not only do countries have variable access to tests for COVID19 and different ways of classifying and recording deaths related the infection but weak registration systems and delays in compiling data mean that comparison of mortality rates between countries should be viewed with circumspection. Reliance on excess all-cause mortality reduces the effect of different ways of classifying causes of death. This is illustrated by mortality data from the first weeks of the pandemic. In Wuhan disease surveillance districts between January and March 2020, the all-cause mortality rate was 56% higher than expected, the rate per 100,000 population being 1147 in comparison with an expected rate of 735, much of the increase being of deaths certified as due to pneumonia although COVID-19 was almost certainly the cause of many of these deaths.45 Over the same period, there was no increase in overall mortality in other parts of China. Comparisons of COVID-19 mortality rates between countries should therefore be regarded as provisional, definitive judgement being delayed until accurate data can be compiled. The data currently available indicate that national mortality rates have been influenced by the decisions of governments. Irresponsible leadership gave rise to a major outbreak in Brazil, but careful planning

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contained the initial waves of COVID-19 in South Korea and New Zealand. A report of the UK government’s Health Committee published in the autumn of 2021 identified a catalogue of failures that led to a higher than necessary death toll, including lack of preparation, an initial dalliance with the idea of herd immunity, inadequate testing capacity, ineffective systems for tracing people who had been in contact with infected individuals, delay over initiating lockdowns and failure to protect vulnerable groups, including people in social care settings.46 An analysis of excess deaths during 2020 in 79 low-, medium- and high-income countries has thrown light onto the characteristics of health systems associated with low mortality during this pandemic year.47 After taking account of population variables such as age and poverty, countries with higher spending on health care and smaller reductions in spending between 2008 and 2018 experienced lower excess mortality. Higher expenditure on primary health care specifically was associated with lower mortality, and countries with higher proportions of the population covered by forms of health insurance also experienced lower mortality. These findings suggest that better access to primary health care enabled more patients to be managed in the community and prevented hospitals from becoming overwhelmed. The risk of dying from COVID-19 increases with age, is higher among males than females and in those living in more deprived areas.48 Within countries, the unerring ability of COVID-19 to target the most socio-economically disadvantaged can be mapped to mortality rates in different regions. In England, for example, the north of the country has suffered more than the south.49 It is also higher in Black, Asian and other minority ethnic groups than among White groups even after accounting for clinical comorbidities. 50 In the United States, mortality has been higher among African Americans. 51 People with chronic mental disorders or intellectual disabilities also have an increased mortality risk. 52 In many countries, primary health care services have concentrated on preserving care for people with acute and chronic conditions other than COVID-19 and support of vaccination programmes. The strain imposed on health systems during the pandemic may have led to delays in the diagnosis and treatment of life shortening conditions including cancer. The NHS standard operating procedures for general practice in England prioritised care for those with urgent health care needs, with access to face to face consultations being restricted, depending on clinical need. The number of patients starting treatment for cancer in the UK

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fell by 26% between April and July 2020 compared to the same period in 2019.53 The impact on population mortality will not be known for a few years but it is possible the changes in access to general practice will provide further evidence of the importance of easy access to primary health care. VACCINATION Vaccination is a low-cost and effective intervention and is therefore a priority in low- and middle- as well as in high-income countries. Vaccines are available for many infectious diseases, and the routine schedule in England includes vaccines against 18 different infections, including measles, tetanus, polio, diphtheria, rotavirus, hepatitis B, meningitis B, influenza and human papilloma virus. Other vaccines advised for overseas travellers or used in specific regions include rabies, yellow fever, tickborne encephalitis, typhoid and malaria. Despite the progress that has been made in making vaccinations available to the citizens of all countries, Global Vaccine Action Plan targets for 2020 were not achieved.54 The new strategy of GAVI, the global alliance of agencies supporting vaccination, retains the ambition of achieving vaccination for all children but now acknowledges the importance of primary health care.55 It commits to promoting the resourcing of primary health care and admits that vaccination reaches more children when embedded into primary health care. A review of 78 studies of the determinants of vaccination in low- and middle-income countries put forward a three-element framework for understanding vaccine uptake.56 The first element is the intent to vaccinate, namely a parent’s demand for vaccination for their child that would result in vaccines being administered in the absence of other barriers. The second element is the readiness of the facilities, that is, the consistent supply of vaccines and the human resources to deliver them. The third element is community access, that is access that minimises barriers and maximises facilitators to transforming the intent to vaccinate into vaccines given. Primary health care is the principal service providing vaccination in high-income and many middle-income countries. In many low- and some middle-income countries vaccines are administered through specific programmes, and in countries with no or poorly developed primary health care services this might be the only option. The WHO’s review of the Global Vaccine Plan recognised the advantages of coordination between immunisation programmes, integrated primary health

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care being able to promote demand for vaccines within communities and address inequities. 57 The idea of an integrated service that delivers vaccination in the context of universal primary health care will be attractive to proponents of primary health care, and there is some low-certainty evidence from a review of randomised controlled trials that integration of vaccination with other primary health care services such as malaria prevention improves uptake of diphtheria, tetanus and polio vaccine. 58 The importance of vaccination in reducing morality can be illustrated by a few examples.

Measles A relationship between vaccination and the decline in mortality is not always easy to detect in high-income countries. Much of the decline predates the introduction of vaccines, improvements in living conditions being more important in explaining the historical fall in mortality. As Figure 5.1 shows, mortality due to diphtheria and measles in England and Wales fell sharply before the introduction of vaccines for diphtheria in 1942 and measles in 1968. Evidence about the value of vaccination in high-income countries is available, however, from the experience of periods of low vaccine uptake. A small number of deaths due to measles continue and vaccination remains an important preventive strategy. In one of the outbreaks of measles in the wake of the subsequently retracted publication by Andrew Wakefield,60 an outbreak of

FIGURE 5.1  Number of deaths caused by diphtheria and measles in children under

aged 16 years, England and Wales, 1915–1975.59

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measles between November 2012 and July 2013 in southwest and midWales led to 1202 disease notifications for measles, 88 hospital admissions and one death.61 Prior to the outbreak one in six children aged 11 had not received the MMR vaccine, but by August 2013, 77,805 catch-up doses had been given in Wales, 47,988 of which had been administered by general practices, the outbreak being declared over in July 2013. Outbreaks of measles related to falls in vaccination rates have been reported in the Philippines in 2019,62 and New York City between 2018 and 2019.63 In 2018, a crisis in the measles vaccination programme occurred in Samoa. Two babies died following routine measles, mumps and rubella vaccinations because of an error in administration, expired anaesthetic being mixed with the vaccine instead of water.64 Distrust of the injections rapidly spread through the community and vaccination rates fell and the programme was temporarily suspended. In 2019, 5,705 children contracted measles, 1,868 were admitted to hospital and 83 died. A retrospective review of global surveillance data of WHO member states identified 626,289 cases of measles reported in the period 2013 to 2017, 87% of cases being in people who had either not been vaccinated or their vaccination status was unknown.65 This finding together with the continued outbreaks associated with low vaccination rates provides evidence of the efficacy of vaccination in controlling measles infections. There is some variation in the number of cases of measles worldwide each year although the trend has been downwards, a 73% drop between 2000 and 2018 being associated by WHO with a 72% increase in the percentage of children being vaccinated over the same period.66 Despite this progress, there was a steep increase in cases and deaths in 2019–2020 linked to a pause in vaccination programmes while communities and health systems adjusted to COVID-19. The latest data suggest that the number of cases is now declining again as vaccination programmes resume.

Polio In 1988, the World Health Assembly committed to the eradication of polio by the year 2000, and although not achieved, there has been a 99% fall in cases. Cases of polio continue to occur in Pakistan and Afghanistan, and occasional outbreaks also occur in war-torn districts elsewhere. Africa was declared free of wild polio on 25 August 2020, four years after the last recorded case on the continent. In 1996, Nelson

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Mandela had launched the Kick Polio out of Africa campaign with the support of Rotary International. There followed programmes to bring vaccines to children throughout Africa, including those in remote places or locations experiencing war or unrest. Inactivated polio vaccine was introduced in the UK in 1956 although supply problems meant that the vaccination of all children took some time to achieve. The oral vaccine was introduced from 1962. During the first half of the 20th century in England and Wales, the number of notified cases varied widely from year to year, from fewer than a hundred to several thousand. However, the trend was consistently downwards from the introduction of vaccination, with 3,712 cases of paralytic polio being recorded in 1955 falling to a mean of 5.6 cases a year between 1971 and 1980.59 Sometimes called infantile paralysis, it was a feared disease because of the disability it could inflict on children, a factor that may help explain why the vaccine was in much demand among the public when it was first introduced.

Whooping cough Routine whooping cough vaccination with diphtheria and tetanus was introduced in the UK in 1957. A decline in whooping cough vaccination in the 1970s and 1980s followed publication of research purporting to show neurological complications. Whooping cough vaccination rates dropped in England from 79% in 1972 to 31% in 1978 and in the ensuing epidemic there were an estimated 5,000 hospital admissions, 200 cases of pneumonia, 83 cases of convulsions and 38 deaths. 67

Influenza A review of randomised controlled trials found that influenza vaccination reduced the risk of influenza in a single season from 6.0% to 2.4% in people aged 65 or older,68 but the trials did not provide evidence about reductions in hospital admissions or deaths. Observational studies that have accounted for differences between individuals related to acceptance of vaccination tend to show worthwhile reductions in mortality and influenza vaccination remains firmly recommended for older people and those with long-term health conditions including respiratory and cardiovascular diseases.69 There is inequity in vaccination rates. Uptake of the vaccine tends to be lower among more deprived groups,70 and in the first season of

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childhood vaccination in England, uptake was lower in areas of greater deprivation and among ethnic minority groups.71 In the United States, influenza vaccination is recommended for adults with heart disease but a recent study demonstrated that 32.7% of people aged 40 or over with atherosclerotic cardiovascular disease had not been vaccinated.72 Lack of vaccination was more likely among those aged 40 to 64 compared with older age groups, those without a usual source of health care, those without health insurance, those with a lower educational level and those of non-Hispanic Black ethnicity.

COVID-19 The creation and manufacture of the COVID-19 vaccines at unprecedented speed was achieved through the collaborative work of scientists, policymakers and pharmaceutical companies. In most countries, the administration of the vaccines to most people was achieved by primary health care teams. With the help of many volunteers, primary health care professionals adjusted and extended their working patterns to find time for this enormous emergency vaccination programme. As levels of vaccination rose in the spring of 2021, in that year mortality in the UK due to COVID-19 fell (Figure 5.2). Social distancing measures will have played a vital role as well. Gradual easing of the lockdown restrictions commenced in England on 8 March 2021 (when children returned to

FIGURE 5.2 First doses of vaccination against COVID-19 and daily deaths due to

COVID-19, UK, 10/01/21 to 30/04/21.73

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school) with further steps on 29 March 2021 (outdoor sports open), 12 April 2021 (non-essential shops open), 17 May 2021 (restaurants open for indoor meals) and 21 June 2021 (all remaining rules removed), but vaccination contributed to the decline and has been critical to maintaining control of the pandemic after the level of new cases and deaths were reduced to a minimum. VACCINE UPTAKE To be effective in reducing mortality, vaccines must be administered to the majority of the population. Two broad factors influence vaccine uptake, the first being the success of the health system in offering vaccines to every eligible individual and the second the willingness of people to take up the offer of vaccination. Primary health care is key to both. The vaccination of populations at risk of communicable disease depends on a system for identifying those people eligible for specific vaccines, providing them with information, offering the vaccines and recording who has had which vaccines to facilitate monitoring, and recall for subsequent doses if required. Primary health care provides a system for achieving these tasks, but it also provides a familiar, trusted source of care that builds confidence among patients in the value of vaccination. An EU report prepared in the aftermath of several outbreaks of vaccine preventable diseases found that family physicians and nurses do not have to be the exclusive providers of vaccines, but they are well positioned to improve vaccination rates through their frequent contact with families.74 Barriers to uptake identified by the EU panel included parental fears about safety, lack of trust, social norms, myths that undermine confidence and failure of some health professionals to counter the myths with evidence, as well as access barriers such as co-payments. Enablers include making reliable information available, building trust in providers and confidence in vaccines, and easy access to services. A report in England75 reached similar conclusions, finding that convenient access and trust in health professionals helped improve uptake, but concerns about side effects and misinformation on social media reduced it. Vaccine hesitancy is the term used to describe the reluctance to accept vaccinations. A WHO working group has reported that it is influenced by trust in (1) the effectiveness and safety of vaccines, (2) the system that delivers them, including the reliability and competence of the health services and health professionals and (3) the motivations of the policymakers who decide on the needed vaccines.76

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Research on the effectiveness of strategies to overcome hesitancy is at an early stage. Interventions that have been explored include reminder and recall schemes, parent, provider and community education and incentives, and legal requirements for vaccination, but in one systematic review of studies to address parental refusal to childhood vaccinations, the quality of studies was too poor to allow firm conclusions about the relative merits of the different methods.77 Finding the uptake of vaccines against coronavirus among his patients was low, one weekend Leicester general practitioner Azhar Farooqi set about telephoning those who had declined vaccination. Of those contacted, 70% agreed to vaccination, of whom 95% eventually received the vaccine.78 The success of this approach, relying on a local general practitioner to contact patients who had not taken up the offer of vaccination, was extended across the city. For more than 20 years, I was a part-time general practitioner in Professor Farooqi’s practice and know the community well. In the preceding 30 years of reliable and stable service to the deprived and ethnically diverse community, he had established a relationship with most patients in which his health advice was trusted above all other sources of information.79 THREE MECHANISMS We can now add three further mechanisms to the first one set out in the previous chapter. Mechanism II concerns the prevention and management of communicable diseases in general and Mechanism III is concerned specifically with vaccination. Mechanism IV highlights the key role of primary health care in reducing communicable disease mortality in children.

Mechanism II To reduce mortality from communicable diseases, primary health makes diagnoses and delivers effective preventive and therapeutic interventions in the setting of a broader service that provides advice and education for individuals and communities. Level of Evidence – Strong COMMENTARY The diagnosis of communicable diseases commonly takes place in primary health care, and early diagnosis can reduce mortality rates. Primary health care also delivers treatments shown in randomised trials to be

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effective, for example antibiotics for bacterial lower respiratory infections, oral rehydration solution for diarrhoeal infections or antiretrovirals for HIV. The incidence of communicable diseases is determined by environmental, social and economic factors and primary health care also has a part to play in addressing these although the available evidence is largely limited to observational, non-experimental studies. Primary health care addresses the prevention of communicable diseases as well as their treatment. It can provide information to both individuals and communities on the steps they can take to reduce the risk of infections, for example, by advising patients about handwashing and the use of clean drinking water and educating local leaders on the need for sanitation and sources of clean water. It can also advise individuals about the avoidance of smoking, and press governments to introduce policies on cigarette advertising and taxation. Primary health care also advises families how they can care for minor illnesses themselves and when to seek help. The importance attached to prevention has potential to reduce health inequalities but most health systems have yet to develop policies that routinely maximise the impact for marginalised or disadvantaged groups.

Mechanism III By both covering the whole population and building relationships with individuals, vaccination programmes delivered by primary health care reduce mortality caused by communicable diseases. Level of Evidence – Strong COMMENTARY Randomised controlled trial evidence is available about the effectiveness of some vaccines, but evidence is also available from the control of the targeted infectious diseases that return if the level of vaccination in the population declines. Primary health care can provide population registers that form essential building blocks for vaccination programmes. It can also administer vaccines, but primary health care has a much wider role as well. It provides information from a familiar and trusted source that builds confidence among communities, enabling high levels of vaccination to be achieved. Disadvantaged groups often have lower vaccine uptake rates. Primary health care, through its regular contact with individuals, has opportunities to reduce this inequity but the evidence that it routinely does so is limited.

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Mechanism IV By delivering interventions to treat or prevent the communicable diseases of childhood, the care of children by primary health care reduces population mortality. Level of Evidence – Strong COMMENTARY Reductions in childhood mortality can have large effects on life expectancy. The benefits of the prevention and cure of communicable disease in childhood is evident in low-income countries where the toll of childhood mortality has been gradually reduced. Socio-economic and environmental factors are also major influences on mortality rates, but even in high-income countries, primary health care has played its part in containing childhood mortality from communicable disease to a low level. NEXT Our exploration of the prevention and management of communicable diseases has revealed three of the mechanisms by which primary health care reduces population mortality, but it has also touched on other features of practice such as access and population coverage that may also be important. These will re-emerge in the next two chapters that consider non-communicable diseases and the succeeding chapters that deal with the organisation of primary health care and the relationship between patients and professionals. REFERENCES 1. GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1736–88 2. GBD 2016 Lower Respiratory Infections Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis 2018;18:1191–210 3. GBD 2017 Lower Respiratory Infections Collaborators. Quantifying risks and interventions that have affected the burden of lower respiratory infections among children younger than 5 years: An analysis for the Global Burden of Disease Study 2017. Lancet Infect Dis 2020;20:60–79 4. WHO. Integrated Management of Childhood Illness global survey report. Geneva: WHO, 2017

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5. Boschi-Pinto C, Labadie G, et al. Global implementation survey of Integrated Management of Childhood Illness (IMCI): 20 years on. BMJ Open 2018;8:e019079 6. Gera T, Shah D, et al. Integrated Management of Childhood Illness (IMCI) strategy for children under five. Cochrane Database Syst Rev 2016;22(6):CD010123 7. Ardura-Garcia C, Kuehni CE. Reducing childhood respiratory morbidity and mortality in low and middle income countries: A current challenge. Eur Respir J 2019;54:1900987 8. Sazawal S, Black RE, et al. Effect of pneumonia case management on mortality in neonates, infants, and preschool children: A meta-analysis of community-based trials. Lancet Infect Dis 2003;3:547–56 9. Dalglish SL, Vogel JJ, et al. Future directions for reducing inequity and maximising impact of child health strategies. BMJ 2018;362:k2684 10. Seidu A-A, Dickson KS, et al. Prevalence and determinants of acute lower respiratory infections among children under-five years in sub–Saharan Africa: Evidence from demographic and health surveys. SSM Popul Health 2019;8:100443 11. Ieven M, Coenen S, et al. Aetiology of lower respiratory tract infection in adults in primary care: A prospective study in 11 European countries. Clin Microbiol Infect 2018;24:1158–63 12. Pouwels KB, Dolk CK, et al. Actual versus ‘ideal’ antibiotic prescribing for common conditions in English primary care. J Antimicrob Chemother 2018;73(suppl 2):ii19–ii26 13. Salciccioli JD, Marshall DC, et al. Respiratory disease mortality in the United Kingdom compared with EU15+ countries in 1985–2015: Observational study. BMJ 2018;363:k4680 14. Steel N, Ford JA, et al. Changes in health in the countries of the UK and 150 English Local Authority areas 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2018;392:1647–61 15. British Lung Foundation. The Battle for breath. The impact of lung disease in the UK. London: British Lung Foundation, 2017 16. Local Burden of Disease Diarrhoea Collaborators. Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000–17: Analysis for the Global Burden of Disease Study 2017. Lancet 2020;395:1779–801 17. Munos MK, Walker CLF, et al. The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality. Int J Epidemiol 2010;39:i75–i87 18. Walker CLF, Rudan I, et al. Global burden of childhood pneumonia and diarrhoea. Lancet 2013;381:1405–16 19. WHO/UNICEF. Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025. Geneva: WHO, 2013 20. WHO. Integrated Management of Childhood Illness. Chart Booklet. Geneva: WHO, 2014 21. Tam CC, Rodrigues LC, et al. Longitudinal study of infectious intestinal disease in the UK (IID2 study): Incidence in the community and presenting to general practice. Gut 2012;61:69–77

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22. GBD Tuberculosis Collaborators. The global burden of tuberculosis: Results from the Global Burden of Disease Study 2015. Lancet Infect Dis 2018;18:261–84 23. PHE. Tuberculosis in England. London: Public Health England, 2019 24. Pedrazzoli D, Kranzer K, et al. Trends and risk factors for death and excess all-cause mortality among notified tuberculosis patients in the UK: An analysis of surveillance data. ERJ Open Res 2019;5:00125-2019 25. Loutet MG, Sinclair C, et al. Delay from symptom onset to treatment start among tuberculosis patients in England, 2012–2015. Epidemiol Infect 2018;146:1511–18 26. de Vries SG, Cremers AL, et al. Barriers and facilitators to the uptake of tuberculosis diagnostic and treatment services by hard-to-reach populations in countries of low and medium tuberculosis incidence: A systematic review of qualitative literature. Lancet Infect Dis 2017;17:e128–43 27. Getnet F, Demissie M, et al. Delay in diagnosis of pulmonary tuberculosis in low- and middle-income settings: Systematic review and meta-analysis. BMC Pulm Med 2017;17:202 28. Teo AKJ, Singh SR, et al. Duration and determinants of delayed diagnosis and treatment of tuberculosis in high-burden countries: A mixed methods systematic review and meta-analysis. Respir Res 2021;22:251 29. GBD 2017 HIV Collaborators. Global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2017, and forecasts to 2030, for 195 countries and territories: A systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017. Lancet HIV 2019;6:e831–59 30. UNAIDS. Progress towards the Start Free, Stay Free, AIDS Free targets. 2020 report. Geneva: Joint United Nations, Programme on HIV/AIDS, 2020 31. Rice BD, Yin Z, et al. Monitoring of the HIV epidemic using routinely collected data: The case of the United Kingdom. AIDS Behav 2017; 21:S83–S90 32. Kirwan PD, Chau C, et al. HIV in the UK – 2016 report. Public Health England, London, 2016 33. Rubin MS, Colen CG, et al. Examination of inequalities in HIV/AIDS mortality in the United States from a fundamental cause perspective. Am J Public Health 2010;100:1053–59 34. ActionAid. Primary concern: Why primary healthcare is key to tackling HIV and AIDS. London: ActionAid, 2009 35. UNAIDS. The AIDS response and primary health care: Linkages and opportunities. WHO/HIS/SDS/2018.41, Joint United Nations Programme on HIV/AIDS (UNAIDS), 2018 36. Odeny TA, Penner J, et al. Integration of HIV care with primary health care services: Effect on patient satisfaction and stigma in rural Kenya. AIDS Res Treat 2013;2013:485715 37. Crowley T, Stellenberg EL. Integrating HIV care and treatment into primary healthcare: Are clinics equipped? Afr J Prim Health Care Fam Med 2014;6:a616 38. Wirth KE, Gaolathe T, et al. Population uptake of HIV testing, treatment, viral suppression, and male circumcision following a community-based

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intervention in Botswana (Ya Tsie/BCPP): A cluster-randomised trial. Lancet HIV 2020;7:e422–33 39. Rai T, Bruton J, et al. Experience of primary care for people with HIV: A mixed-method analysis. BJGP Open 2019;3(4):bjgpopen19X101665 40. Matthews P, Madge S, et al. HIV in Primary Care. Third edition. London: MEDFASH and JUSTRI, 2016 41. NICE. HIV testing: Increasing uptake among people who may have undiagnosed HIV. Guideline NG60. London: NICE, 2016 42. Gompels M, Michael S, et al. Trends in HIV testing in the UK primary care setting: A 15-year retrospective cohort study from 2000 to 2015. BMJ Open 2019;9:e027744 43. Baggaley RF, Irvine MA, et al. Cost-effectiveness of screening for HIV in primary care: A health economics modelling analysis. Lancet HIV 2017;4: e465–74 4 4. ONS. Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England: 24 January 2020 to 31 March 2021. London: Office for National Statistics, 2021 45. Liu J, Zhang L, et al. Excess mortality in Wuhan city and other parts of China during the three months of the covid-19 outbreak: Findings from nationwide mortality registries. BMJ 2021;372:n415 46. Health and Social Care, and Science and Technology Committees. Coronavirus: Lessons learned to date. HC92. London: House of Commons, 2021 47. Kapitsinis N. The underlying factors of excess mortality in 2020: A crosscountry analysis of pre-pandemic healthcare conditions and strategies to cope with Covid-19. BMC Health Serv Res 2021;21:1197 48. PHE. Disparities in the risk and outcomes of COVID-19. London: Public Health England, 2020 49. Munford L, Khavandi S, et al. A year of COVID-19 in the North: Regional inequalities in health and economic outcomes. Newcastle: Northern Health Science Alliance, 2021 50. Mathur R, Rentsch CT, et al. Ethnic differences in SARS-CoV-2 infection and COVID-19-related hospitalisation, intensive care unit admission, and death in 17 million adults in England: An observational cohort study using the OpenSAFELY platform. Lancet 2021;397:1711–24 51. van Dorn A, Cooney RE, et al. COVID-19 exacerbating inequalities in the US. Lancet 2020;395:1243–4 52. Das-Munshi J, Changa CK, et al. All-cause and cause-specific mortality in people with mental disorders and intellectual disabilities, before and during the COVID-19 pandemic: Cohort study. Lancet Reg Health Eur 2021;11:100228 53. Mahase E. Cancer treatments fall as referrals are slow to recover, show figures. BMJ 2020;371:m3958 54. Global Vaccine Action Plan. 2019 Regional Reports on Progress towards GVAP-RVAP Goals. Annex to the GVAP review and lessons learned report. Geneva: WHO, 2019 55. GAVI. The sustainability goal. The Vaccine Alliance, 2020. www.gavi.org/ our-alliance/strategy/phase-5-2021-2025/sustainability-goal 56. Phillips DE, Dieleman JL, et al. Determinants of effective vaccine coverage in low and middle-income countries: A systematic review and interpretive synthesis. BMC Health Serv Res 2017;17:681

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57. Strategic Advisory Group of Experts on Immunization. The Global Vaccine Action Plan 2011–2020. Review and lessons learned. Geneva: WHO, 2019 58. Oyo-Ita A, Wiysonge CS, et al. Interventions for improving coverage of childhood immunisation in low- and middle-income countries. Cochrane Database Syst Rev 2016;7:CD008145 59. ONS. Notifiable diseases: Historic annual totals. London: Office for National Statistics, 2021 60. Deer B. How the case against the MMR vaccine was fixed. BMJ 2011;342:c5347 61. Abertawe Bro Morgannwg University Health Board, Powys Health Board, Hywel Dda Health Board and Public Health Wales. Report of the agencies which responded to the outbreak. 2013. www.wales.nhs.uk/sitesplus/888/ page/66425 62. Dyer O. Philippines measles outbreak is deadliest yet as vaccine scepticism spurs disease comeback. BMJ 2019;364:l739 63. Zucker JR, Rosen JB, et al. Consequences of undervaccination – Measles outbreak, New York City, 2018–2019. N Engl J Med 2020;382:1009–17 6 4. Thornton J. It’s broken me into a million pieces: Six months on from Samoa’s deadly measles outbreak. Guardian, 5th July 2020 65. Patel MK, Orenstein WA. Classification of global measles cases in 2013–17 as due to policy or vaccination failure: A retrospective review of global surveillance data. Lancet Glob Health 2019;7:e313–20 66. WHO. Measles factsheet. WHO, 2019. 67. Amirthalingam G, Gupta S, et al. Pertussis immunisation and control in England and Wales, 1957 to 2012: A historical review. Euro Surveill 2013;18:20587 68 Demicheli V, Jefferson T, et al. Vaccines for preventing influenza in the elderly. Cochrane Database Syst Rev 2018;2:CD004876 69. Ulyte A, Wei W, et al. Insights into the protective effects of influenza vaccination: More hospitalizations but lower follow-up mortality during the 2014/15 influenza season in a Swiss cohort. Vaccine 2020;38:5187–93 70. Sammon CJ, McGrogan A, et al. Factors associated with uptake of seasonal and pandemic influenza vaccine among clinical risk groups in the UK: An analysis using the General Practice Research Database. Vaccine 2012;30:2483–89 71. Green HK, Andrews N, et al. Phased introduction of a universal childhood influenza vaccination programme in England: Population-level factors predicting variation in national uptake during the first year, 2013/14. Vaccine 2015;33:2620–28 72. Grandhi GR, Mszar R, et al. Sociodemographic disparities in influenza vaccination among adults with atherosclerotic cardiovascular disease in the United States. JAMA Cardiol 2021;6:87–91 73. UK Government. Coronavirus cases in England. https://coronavirus.data. gov.uk/details/cases 74. Expert Panel on effective ways of investing in Health. Preliminary report on Vaccination Programmes and Health Systems in Europe. European Union, 2018 75. Royal Society for Public Health. Moving the needle. Promoting vaccination uptake across the life course. London: Royal Society for Public Health, 2019

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76. WHO. Report of the SAGE Working Group on Vaccine Hesitancy. WHO, 2014 77. Sadaf A, Richards JL, et al. A systematic review of interventions for reducing parental vaccine refusal and vaccine hesitancy. Vaccine 2013;31:4293–304 78. Blackburn P. Patient by patient. Doctor, 2021;April:24–27 79. Tarrant C, Dixon-Woods M, et al. Continuity and trust in primary care: A qualitative study informed by game theory. Ann Fam Med 2010;8:440–46

CHAPTER 6

Non-communicable diseases 1 Cardiovascular disease and cancer

This chapter will concentrate on cardiovascular disease and cancers, and the identification and management of risk factors for these conditions. The next chapter will consider respiratory disease and mental health. It will also present seven mechanisms identified from consideration of noncommunicable diseases. They include care being available to the whole population, care throughout the life cycle, care for the common noncommunicable diseases, prevention of ill-health, early diagnosis, care for the whole person and thoughtful use of medication. Non-communicable diseases are the most common causes of death in upper-middle- and high-income countries, but even in low-income countries ischaemic heart disease and stroke are among the top five causes of death (Table 3.3). Progress in reducing the death toll caused by non-­ communicable diseases is stalling; the UN’s Sustainable Development Goal # 3.4. requires a fall by one-third in premature deaths (i.e. deaths between the ages of 30 and 70 years) due to non-communicable diseases by 2030, but many countries are off-track for achieving the target.1 IDENTIFYING AND MANAGING RISK FACTORS Primary health care has a major role in advising people on reducing the risk of cardiovascular disease or cancer, including offering help and advice about smoking, diet and exercise. Primary health care should do whatever it can to address the underlying determinants of health, but a life-course approach to prevention, beginning in childhood (primordial prevention) and involving the support of families, education and the DOI: 10.1201/9781003355380-6

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promotion of positive lifestyles has yet to be fully implemented by health systems or policymakers. 2 This will change in the years ahead, but for now, most evidence relates to the benefits of identifying and managing lifestyle risks, for example, obesity, smoking and a lack of exercise. High systolic blood pressure was estimated to be responsible for 10.4 million deaths worldwide in 2017, smoking for 7.1 million deaths, high fasting plasma glucose for 6.5 million deaths, and high body mass index for 4.7 million deaths.3 It is not surprising that interventions to address these risk factors are seen as key for reducing the burden of cardiovascular disease and cancer. A landmark study undertaken in a small general practice in a village in the Afan valley in south Wales throws some light on how primary health care has its effect.4 Throughout the period of the study, the population was characterised by high levels of deprivation, unemployment, sickness and disability. Beginning in 1968, the general practitioner, Julian Tudor Hart, single-handedly screened the practice population aged 20–64 for hypertension mainly by case finding during consultations for other conditions. This was supplemented by calling patients in for review and home visits to those most difficult to engage. The same approach was adopted for other risk factors: Smoking, cholesterol levels, obesity, diabetes, airway obstruction and alcohol consumption. Some evidence of the effect of this rigorous approach in routine primary health care can be found in a comparison of all-cause mortality between Hart’s practice and a neighbouring practice. The all-cause standardised mortality ratio for the 1981 to 1986 period in Hart’s practice was 97.6 for all ages and 93.5 for those under aged 65, but in the local comparison practice with a similarly deprived population the ratios were 135.6 and 160.1, respectively. This is a non-experimental study from a single general practice, but the observations on how the apparent lower mortality was achieved are revealing. The practice team found that (1) providing objective data to patients such as blood pressure, weight or cholesterol levels was more effective than exhorting people to change their behaviour, (2) continuity enabled the development of a relationship of working together between professional and patient, (3) clinical audits provided information on progress and (4) detecting and managing risk factors were facilitated by patients having easy access health care, no matter how minor their problems initially appeared to be. More recent non-experimental studies from several countries reflect Hart’s findings. A study from Sweden compared the effect of a primary health care prevention programme delivered to 5,761 people in one municipality with a randomly selected sample from a different municipality.5 The programme involved people aged under 60 who visited

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their health care centre. At their visit, those with a risk factor identified through completion of a questionnaire were offered an examination of weight, height and blood pressure, and blood tests. In addition to any treatment, individuals were given detailed lifestyle advice with an emphasis on physical activity. At follow-up after 22 years, a reduction of 21% in cardiovascular deaths and 17% for all-cause deaths was observed in the intervention group. A project undertaken in Tower Hamlets, a deprived inner-city community in London, grouped general practices into networks serving 30–50,000 patients each. Each network was provided with a manager, an educational budget and financial incentives with locally agreed performance targets, a cardiovascular disease package including care for hypertension, stroke or transient ischaemic attack, coronary heart disease and health checks.6 Local guidelines, educational meetings, clinical case discussions and progress review meetings were used to support the programme. A key factor was the extensive use of an electronic information system to monitor population health indicators.7 Over the period 2000 to 2011, improvements were recorded in processes of care, for example statin prescribing and blood pressure control for people with coronary heart disease, and there was some evidence of a reduction in coronary heart disease mortality, a drop of 43% being reported among males in a three-year period. A comparison using national data tends to support the findings. In Tower Hamlets, the age and sex standardised mortality rate from cardiovascular disease among people aged under 75 years in 2016 was 117.7 per 100,000 registered patients, but it fell to 75.3 in 2019, a drop of 42.4. Over the same period, the decline in England as a whole was from 71.2 to 66.4, a drop of only 4.8.8 Is systematic screening of populations as effective as opportunistic approaches by primary health care teams? A review of randomised trials is not encouraging,9 and the experience of one large screening scheme helps to explain why. In 1974, an institute of preventive medicine was established in the medical department of Malmö General Hospital and it began a long series of studies of the epidemiology and prevention of cardiovascular diseases.10 With a relatively stable population, established record linkage for patient identification and follow-up, and a virtually complete autopsy rate, the setting was almost ideal for long-term epidemiological studies. The first stages of the Malmö prevention project involved invitations to adults to attend screening examinations, with five thousand people being screened each year. Of those invited to attend 70–75% agreed. Those with risk factors were assessed further and offered treatment in the clinics of the institute, although some of those with raised blood

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pressure were returned to their primary health care doctor if they had one. Early in the course of the project, a control group who were not invited for screening was identified to enable an evaluation of the outcomes. Both intervention and control groups were followed-up until 1995 for total mortality, cause-specific mortality, nonfatal ischaemic heart disease and nonfatal stroke.11 The findings of the evaluation were disappointing; there was no difference in total mortality between the intervention and control groups, and the only differences in causespecific deaths were fewer deaths in men under aged 40 from suicide or alcohol-related deaths, and in women under aged 40 from cancer. Nonfatal myocardial infarction and stroke did not differ between study groups in either sex. The Malmö scheme was systematic, but it was not based on primary health care services that had already established continuing relationships with patients. A Cochrane Systematic Review of randomised controlled trials of systematic versus opportunistic risk assessment to prevent cardiovascular disease found no difference for all-cause or cardiovascular mortality, although the number and quality of the trials that could be included was limited.12 In another Cochrane review, this time of health checks, (defined as multiple tests in a person who does not feel ill in order to find disease early or prevent disease from developing), 11 of 17 randomised trials investigated death rates.13 The review reported with a high level of certainty that there was no benefit on total or cancer mortality or fatal and nonfatal ischaemic heart disease, and moderate certainty of no benefit for cardiovascular mortality or fatal or nonfatal strokes. The authors of this review suggested that primary health care services identified and treated risk factors when they were found during routine consultations, and that additional health checks added little. They also thought it possible that people at high risk of developing disease declined health checks. From 2009, a programme for health checks delivered by general practices was introduced in England, offering adults aged 40 to 74 an assessment intended to spot early signs of heart disease, type 2 diabetes, kidney disease or dementia. The benefits appear to have been modest. A review has concluded that slightly less than half of those invited for a health check take up the offer, uptake being higher in older people and females but lower among people living in deprived areas.14 Attendance for a check does lead to small increases in disease detection, statin and antihypertensive prescribing, and modelling of cardiovascular risk does suggest the possibility of an impact on cardiovascular mortality, one such study suggesting that the scheme may prevent approximately 300 deaths annually in England in people under the age of 80 years,

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with benefits being slightly greater in the most deprived populations in comparison with the least deprived.15 Type 2 diabetes increases the risk of death from cardiovascular disease. Obesity and sedentary lifestyles increase the incidence and prevalence of diabetes. Addressing these risk factors has the potential to prevent or delay the onset of the condition. Early diagnosis followed by lifestyle improvements and the intensive control of glucose, lipids and blood pressure can reduce complications should diabetes develop. The detection and management of type 2 diabetes is undertaken by primary health care teams and therefore the effective care of people at risk of, or who have, diabetes contributes to primary health care’s impact on cardiovascular mortality. Diabetes also increases the risk of death from a wide variety of other causes, including some cancers, pneumonia and other infections16 including COVID-19.17 The impact of primary health care on mortality related to diabetes is demonstrated by a study from Sweden. In a study of 187,000 people with diabetes, the association of organisational characteristics of primary health care with all-cause mortality was investigated after accounting for co-morbidity and clinical and socio-economic factors.18 The amount of working time devoted to care for people with diabetes by general practitioners was significantly associated with mortality, with more time being associated with lower mortality. The effect on mortality of time nurses devoted to care of people with diabetes did not quite reach significance, and there was no association with the education of health professionals about diabetes or length of appointments in primary health care clinics.

Obesity Regulations on food quality, physical education in schools, and the advertising of food, drink and snacks are essential elements of national programmes to help reduce overweight and obesity in the population. Primary health care also plays a role by providing information and education, and by helping people who wish to do so to lose weight. Management generally involves a multi-component intervention that includes reduced calorie intake, increased physical activity and help in behaviour change.19 A team of health professionals is often needed to deliver each of these components. A systematic review of 15 randomised trials of lifestyle weight loss interventions concluded that all-cause mortality was 15% lower among people who had received the intervention.20 In people with type 2 diabetes, however, the effect of intentional weight loss on mortality is not entirely clear and more research is required. 21 Bariatric surgery may be offered to people referred to specialist care with

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severe obesity and a recent review reported that it was followed by large reductions in all-cause mortality and cardiovascular mortality.22

Physical activity It has been estimated that 7.2% of all-cause deaths globally are related to physical inactivity. 23 Primary health care can encourage increased physical activity among adults, and among those with specific risk factors. A systematic review of 46 randomised trials of interventions to promote physical activity delivered in primary health care without referral to external agencies concluded that exercise levels increased, especially when the intervention involved multiple contacts with the health care team. 24 Selected patients may be referred on within the health system or to community agencies to access staff with the skills to promote sustained change in exercise behaviour.

Tobacco Global estimates suggest that 32.7% of males and 6.6% of females aged over 15 years are smokers, amounting to over one billion smokers worldwide, and in consequence in 2019, 20% of deaths among males and 5.8% of deaths among females were related to smoking.25 National tobacco control policies, including regulations on sales and advertising, bans on smoking in public places and steep taxation have done much to reduce the prevalence of smoking. Cost-effective smoking cessation interventions can be delivered in primary health care, including brief advice only, 26 nicotine replacement therapy, 27 behavioural support by nurses28 and the use of different interventions in combination. 29 People who quit smoking gain in life expectancy, 30 the risk of developing cardiovascular disease declining over a period of several years. TWO INTERVENTIONS FOR CARDIOVASCULAR DISEASE Primary health care has a central role in the detection and treatment of hypertension and use of statins in those with elevated risk of death from cardiovascular disease.

Hypertension One problem in reducing cardiovascular mortality is that many of those with hypertension are not aware that they have the condition. In an analysis involving 44 low- and middle-income countries, 73.6% of those

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with hypertension had at some time had their blood pressure measured, 39.2% had been diagnosed with hypertension, 29.9% had received some treatment, and as few as 10.3% had achieved control of their blood pressure.31 Being older, female, more educated, wealthier and a non-smoker were all positively associated with achieving beneficial aspects of care. In relation to their GDP, three countries performed particularly well in detecting and managing hypertension – Costa Rica, Kyrgyzstan and Bangladesh. All these countries have established primary health care services that include community outreach and community involvement. In addition, antihypertensive medications are generally available and affordable. Performance was also better in the South American countries of Brazil, Ecuador and Peru. There have been improvements in the detection and management of hypertension in England in recent years, as shown in Table 6.1 but 19% of men and 16% of women aged 16 and over still have either untreated or uncontrolled hypertension. Of course, some people may not want to know whether they have hypertension and will decline a blood pressure reading, but the number of people that adopt this position are very few. The principal reason that hypertension remains untreated in 13% of men and 10% of women is that the health system has failed to detect their condition. Low levels of detection and control of hypertension occur in almost all countries, including the United States where the proportion aware of their hypertension increased from 69.9% in 1999/2000 to 84.7% in 2013/2014 but then declined to 77.0% in 2017–2018.33 People with hypertension who had a usual source of care or had visited their provider in the preceding year were more likely to have controlled blood pressure than those who did not have these features of care. In China

TABLE 6.1 Percentages of adults aged 16 and over with hypertension controlled, uncontrolled or not treated, in 2003 and 2018, England32

2003 Males % Normotensive, untreated Hypertensive controlled Hypertensive uncontrolled Hypertension, untreated Total

2018

Females %

Males %

Females %

68 5 6 20

71 6 8 16

70 11 6 13

74 10 6 10

100

100

100

100

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the proportion of people with hypertension who were aware of their condition increased from 31.7% in 1991 to 51.1% in 2009.34 Trends in 12 high-income countries (Australia, Canada, Finland, Germany, Ireland, Italy, Japan, New Zealand, South Korea, Spain, the United Kingdom and the United States) in detection and treatment of hypertension show improvements although the rate of improvement has slowed in most countries in the past decade.35 Even in the best performing countries, only 80% of those with hypertension were on treatment and less than 70% had their blood pressure controlled. A review of studies of hypertension detection reported that older people, women and people with a physical health condition were more likely than others to have their hypertension identified.36 Living alone was associated with lower detection although there was no consistent relationship with socio-economic factors or ethnic groups. Access to care also influences hypertension detection. In the United States, younger adult males without access to care or infrequent users of preventive care have low detection levels.37 Lack of health insurance is a barrier to detection in Ghana38 and a barrier to treatment in China. 25 Failure to detect hypertension increases the risk of future cardiovascular events and mortality. In England, the number of people on general practice hypertension registers has been shown to predict mortality in several studies. In an ecological study at primary care trust level using counts of deaths in the years 2008 and 2009, a 1% increase in the percentage of patients on general practice hypertension registers was associated with a 3% decline in coronary heart disease mortality and a 6% decline in stroke mortality.39 In a study at the level of general practices using under aged 75 all-cause standardised mortality ratios, the percentage of the practice population included on practice hypertension registers again predicted mortality, with more patients diagnosed with hypertension being associated with lower mortality.40 These findings suggest that the diagnosis of hypertension leads on to the management of the raised blood pressure and a reduction in the risk of cardiovascular disease. Can primary health care professionals, despite the limitations on their time and resources, be assisted to help increase the number of patients who have a blood pressure check and initiate diagnostic investigations in those with raised blood pressure? Although there are many randomised trials of interventions to improve blood pressure control among people already diagnosed with hypertension, there are fewer trials of interventions to improve hypertension detection. Reminders from health professionals can help,41 as can quality improvement strategies that use a mix of interventions including education and changes to workflows.42 Blood pressure checks by pharmacists, dentists or emergency departments may

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be a useful addition to opportunistic screening in primary health care as long as systems are in place to communicate blood pressure readings to the clinician responsible for managing the patient’s hypertension, but research studies are needed to confirm the benefits.

Statins Statins reduce mortality in those at risk of cardiovascular disease. There are, of course, contraindications to statin therapy, some patients experience side effects, and some people refuse them when they are offered. However, their role in reducing mortality when used in primary or secondary prevention is well established. Evidence can be found from the use of statins in routine practice outside randomised trials. An example is a US study of almost 100,000 people aged at least 65 years, all assessed as clinically eligible for statin therapy for secondary prevention of cardiovascular disease.43 Five categories of statin users were identified: Adherent to high-, moderate- or low-dose treatment, non-adherent, and not treated. Only 20% of males and 12% of females eligible for treatment were in the adherent high-dose category. Among men, 18% received no statins and among women 29% received no statins. Allcause mortality rates increased as treatment intensity decreased. In the high-dose group, 8.9% died during the two and half years of follow-up, 10.4% died in the moderate-dose group, 10.7% died in the low-dose group, 13.5% died in the non-adherent group, and 14.7% died in those not treated with statins. In a study involving 174 general practices in Denmark that included 1,533 screen-detected people with type 2 diabetes aged 40–69 years, 130 of the included patients died during the 6.5 years of follow-up.44 There were wide variations in statin prescribing between practices, but after accounting for clinical variables, all-cause mortality was lower in those practices with higher prescribing. Thus, in a similar way to primary health care teams’ reducing mortality through detecting hypertension, their use of statins also has an influence on population mortality. But many patients who could benefit from statin treatment do not receive them. Among 29,043 adults aged 18 or over in the United Kingdom who had a stroke or a transient ischaemic attack, of those in whom lipid lowering medication had been indicated only 51% had been receiving them.45 In Hungary, deaths due to circulatory diseases are higher in more deprived than in advantaged communities, but the number of general practitioner prescriptions for statins show the opposite relationship, being higher in advantaged and lower in deprived communities.46 In New Zealand, statin prescribing has been shown to be higher in the most

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socio-economically deprived districts, with use of statins being higher among Māori compared to non-Māori communities.47 Thus, primary health care can either reduce inequities with the use of statins as in New Zealand, or increase them, as in Hungary. Features of health systems including access, financial burdens and policies designed to improve health equity are likely to influence whether primary health care reduces or increases health inequities. A study in 98 general practices in East London in 2010 identified small differences in levels of prescribing of lipid-modifying drugs between groups, rates of prescribing being lower in women than in men and lower in Black African/Caribbean patients when compared to White patients, but there were no differences related to social deprivation.48 In England as a whole, statin prescribing increases as levels of deprivation in the community increases. The percentage of people in 2019–2020 with a new diagnosis of hypertension and a cardiovascular risk assessment of 20% or greater who had been prescribed a statin varied from 52.8% in one commissioning group to 83.3% in the best performing group. The variation for people with diabetes and a history of cardiovascular disease was from 74.9% to 91.2% but rates of prescribing tended to be a little higher in commissioning groups with greater deprivation as measured by IMD (Table 6.2). Prescribing rates were higher in commissioning groups with

TABLE 6.2  Percentage of newly diagnosed patients with hypertension and people with diabetes and a history of cardiovascular disease prescribed statins in clinical commissioning groups (CCGs) in England, 2019–2020, related to deciles of the index of multiple deprivation (IMD)49

IMD deciles (CCGs ranked by IMD and divided into 10 equally sized groups)

Mean IMD

1 – lowest IMD 2 3 4 5 6 7 8 9 10 – highest IMD

11.2 14.3 16.9 18.8 21.4 22.8 25.8 29.3 31.9 38.2

% of new % of people with CHD mortality hypertensives diabetes and a history with CVD rate under aged of CVD (excluding risk > = 20% 75, directly prescribed a haemorrhagic stroke) standardised prescribed a statin statin per 100,000 26.0 32.3 34.3 35.8 39.7 37.6 43.9 48.6 53.8 59.7

65.5 66.5 65.3 65.8 63.8 62.4 68.8 69.0 69.9 68.1

80.5 81.8 81.5 81.3 82.6 82.6 84.0 85.8 84.7 84.7

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higher coronary heart disease (CHD) mortality rates in people under aged 75 years but even so, in all commissioning groups, over 30% of people with hypertension with a cardiovascular risk of 20% or over were not prescribed a statin. CANCERS Primary health care generally has limited roles in the detailed investigation and treatment of cancers. Nonetheless, it does have roles in promoting and in some cases conducting screening, in the initial stages of diagnosis, and in the support and follow-up of people during and after treatment. Survival rates in the United Kingdom tend to be lower than in comparable countries, a situation that has given rise to research studies of the role of primary health care in the initial stages of diagnosis.50

Screening There is sufficient evidence of the benefits to health for the US Centers for Disease Control and Prevention to recommend screening for breast, cervical, colorectal and lung cancers, 51 and most high-income countries have similar policies although the benefits of lung cancer screening remain under evaluation by some countries. Primary health care professionals may not administer all screening tests themselves, but they are in a position to advise patients about what screening involves and to encourage them to take part. In the United Kingdom, people who have consulted a general practitioner are more likely than those who have not to agree to screening for breast or cervical cancer in the following 12 months.52 Cervical cancer is globally the fourth most common cancer in women53 and in many countries primary health care professionals have a central role in screening for cervical cancer, through visual inspection with ascetic acid, cytology or increasingly HPV testing. Cervical screening does reduce mortality from cervical cancer; a review of ten screening programmes in Europe reported reductions in mortality from cervical cancer of between 41% and 92% when comparing attenders for screening with non-attenders.54 HPV vaccination alone is expected to be able to eliminate cervical cancer by the end of the century, but the widespread roll out of screening would bring forward the achievement of that target by between 11 and 31 years.55 The contribution of primary health care is illustrated by findings from Brazil showing, after accounting for other demographic and socio-economic factors, that states with higher funding for primary health care services had lower mortality from cervical

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cancer.56 However, services for screening and treatment remain poor in many low- and middle-income countries. In the United Kingdom, participants in screening for colorectal cancer had a 27% lower risk of death from colorectal cancer during the follow up of up to 10 years.57 Socio-economic disadvantage tends to be associated with lower levels of participation and poor health literacy can also be a barrier, 58 and ethnicity may also be associated with uptake, with participation tending to be higher among groups classified as White.59 The recommendation of a primary health care doctor is one factor that can encourage people to take part.60 In England, uptake of cervical screening by eligible patients is about 70% but has been declining and is lower among socio-economically deprived communities and some Black and other ethnic minority groups. Endorsement of screening by the patient’s primary health care doctor can increase uptake; text reminders and links with community leaders can also be helpful.61 In contrast with other cancer screening programmes, the evidence of the benefit from screening mammography on breast cancer mortality is contested. A Cochrane review of randomised trials selected because they were at low risk of bias did not suggest an effect of screening on total cancer mortality.62 Mortality from breast cancer has been falling, but the extent to which mammography is responsible is uncertain. The decline has been similar among populations where screening has been available for a long time and in populations where it has been introduced only recently.63 The difficulty of demonstrating convincing evidence of a substantial mortality reduction almost certainly means that if there is any effect it is not a large one.

Suspecting cancer in primary health care The diagnosis of cancer at an early stage improves survival from many cancers. The first suspicion a patient may have cancer can occur either in primary health care, in a specialist outpatient department, in an emergency department or during a hospital admission, but first presentation at services other than primary health care may be at later stages of the disease. It follows that primary health care professionals should be ready to suspect cancer as the possible cause of the patient’s symptoms or signs and to instigate speedy investigation or referral to specialist cancer services. In a study of people aged 65 or older enrolled in the Medicare health insurance programme in the United States, in the period 4 to 27 months before the diagnosis of colorectal cancer, people who made five to ten visits to primary health care services had a 22% lower

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mortality from colorectal cancer than people who made no visits or only one visit.64 The diagnosis was more likely to be at an early stage in those who had more primary health care visits. A companion study investigated the association of visits to primary health care services before a diagnosis of breast cancer on breast cancer mortality.65 The risk of breast cancer mortality among people who had five to ten visits was only twothirds that of the risk among those who had no visits or only one visit, the difference being only partly explained by greater use of mammography in those with more visits. Several high-income countries have introduced fast track referral schemes for people with features suggestive of cancer to shorten the interval between first presentation to primary health care and initiation of treatment. In England, the maximum waiting time target for the suspected cancer fast track scheme is two weeks from the day an appointment is electronically booked by primary health care, or when the hospital or service receives the referral letter. Even before the pandemic, however, the proportion of referrals that exceeded the two-week target was increasing. A recent study of 1.4 million people with a new cancer diagnosis followed up for five years found that a greater use of the two-week referral scheme was associated with lower mortality for all cancers combined and for the four most common cancers individually (colorectal, lung, breast and prostate).66 An analysis of the primary health care records confirmed that a delay in the referral of patients with colorectal cancer is associated with worse survival, with patients with non-specific symptoms experiencing longer delays.67 The investigation of the effect of delays between first presenting with a symptom that might be due to cancer and referral from primary to secondary care is complicated by the fact that more advanced cancers often present with easily recognised features whereas cancers at an earlier stage present with fewer or less obvious features. Thus, referrals through the urgent two-week wait scheme may be more likely than non-urgent referrals to be of more advanced cancers that will consequently have a poorer prognosis. This issue is well-demonstrated by a study undertaken in general practices in Denmark and the United Kingdom that investigated delay and survival from colorectal cancer.68 The findings showed a U-shaped association between delay and survival; that is, those with a very short or a very long diagnostic delay had worse survival. A similar U-shaped association was found in a later study that included colorectal, lung, melanoma skin, breast or prostate cancers.69 Reducing the delay has the potential to improve survival; strategies to encourage patients to recognise and report symptoms as early as possible are needed as well as ways to help practitioners suspect cancer at an early stage.

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Access to primary health care appears to influence delays in diagnosis. A study from England related diagnoses of breast, lung, colorectal and prostate cancer to practice characteristics and performance.70 Practices that had higher rates of referral through the two-week wait scheme had a lower proportions of breast cancers diagnosed late; a higher proportion were diagnosed late if more patients reported difficulty getting an appointment. For lung cancer, higher two-week wait referral rates were associated with lower proportions of late diagnoses but practices with fewer general practitioners per unit of patient population were associated with higher proportions of late diagnoses. An emergency, unplanned hospital admission may be the mode of first presentation of cancers in some patients and in some of these, prior interaction with primary health care services may have been missed opportunities for earlier diagnosis. In one study involving patients from 7,957 practices in England, 21.8% of first admissions for cancer were unplanned.71 The most powerful predictor of unplanned admission rates was the level of deprivation of the area of the patient’s residence. In addition, practices that patients reported as having worse access tended to have higher rates of unplanned hospital admissions, although higher overall performance as measured by the pay-for-performance indicators of the quality and outcomes framework was associated with lower unplanned admission rates. In England, patient awareness – recognising symptoms of cancer early followed by seeking medical help – is lower in socio-economically deprived areas of the country72 and lower among ethnic minority groups in comparison with White groups.73 Differences in outcomes among different ethnic and socio-economic groups can also be found in the United States. Factors involved include access to health care, and risk factors such as lifestyle and tobacco use.74 In addition to improving access to health care, therefore, policies to tackle risk factors and to raise awareness of cancer and promote earlier use of health services are required. Primary health care has the potential to reduce mortality rates through improved earlier diagnosis of cancer in socio-economic, ethnic and, other groups currently at increased risk of experiencing delays, but there is little evidence of either the existence or success of concerted programmes to achieve this. Although survival rates in England have improved, the gap between socio-economically advantaged and disadvantaged groups remains.75 Further evidence on the impact of detection and referral of people with suspected cancer by primary health care teams will emerge from the debris of the COVID-19 pandemic. Delays in referrals caused either by patients’ reluctance to seek help from an over-burdened health system or by the inability of primary health care to provide the access required may translate into lower cancer survival rates.76 The resulting

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harms to health are likely to fall on disadvantaged groups and others who have difficulty in obtaining access to care. It is not only late diagnosis that can be a problem, the referral of large numbers of patients with few features of cancer or of patients with false positive findings in screening schemes causes problems as well. The consequence can be unnecessary investigations and over-treatment causing avoidable harm to patients and depression and anxiety provoked by investigation for cancer.77 The challenges of delayed diagnosis and over-diagnosis reflect how difficult it can sometimes be to decide on the cause of a patient’s symptoms. Work is underway to develop ways to help professionals improve their diagnostic precision, a topic that will be discussed further when considering the role of the clinical method (Chapter 9).

NEXT This overview of cardiovascular disease and cancer will have begun to suggest some of the mechanisms of primary health care, but before these are introduced, other non-communicable conditions must be considered. The next chapter addresses respiratory diseases and mental health, the discussion of mental health leading on to the importance of prescribing as an additional influence on mortality. The mechanisms emerging from this overview of non-communicable diseases will then be set out. REFERENCES 1. NCD Countdown 2030 Collaborators. NCD Countdown 2030: Efficient pathways and strategic investments to accelerate progress towards the Sustainable Development Goal target 3.4 in low-income and middle-income countries. Lancet 2022;399:1266–78 2. Williams TC, Drake AJ. What a general paediatrician needs to know about early life programming. Arch Dis Child 2015;100:1058–63 3. GBD 2017 Risk Factor Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1923–94 4. Hart JT, Thomas C, et al. Twenty-five years of case finding and audit in a socially deprived community. BMJ 1991;302:1509–13 5. Journath G, Hammar N, et al. A Swedish primary healthcare prevention programme focusing on promotion of physical activity and a healthy lifestyle reduced cardiovascular events and mortality: 22-year follow-up of 5761 study participants and a reference group. Br J Sports Med 2020;0:1–6 6. Robson J, Hull S, et al. Improving cardiovascular disease using managed networks in general practice. An observational study in inner London. Br J Gen Pract 2014;64:e268–74

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7. Robson J, Boomla K, et al. Learning Health Systems. Chapter 10 in: The Exceptional Potential of General Practice. Making a Difference in Primary Care. Boca Raton: CRC Press, 2019 8. NHS Digital. 1.2 Under 75 mortality from cardiovascular disease. Data set, Part of CCG Outcomes Indicator Set–October 2020. https://digital.nhs.uk/ data-and-information/publications/statistical/ccg-outcomes-indicator-set/ october-2020/domain-1-preventing-people-from-dying-prematurely-ccg/ 1-2-under-75-mortality-from-cardiovascular-disease 9. Schmidt B-M, Durao S, et al. Screening strategies for hypertension. Cochrane Database Syst Rev 2020;5:CD013212 10. Trell E. Community-based preventive medical department for individual risk factor assessment and intervention in an urban population. Prev Med 1983;12:397–402 11. Berglund G, Nilsson P, et al. Long-term outcome of the Malmö Preventive Project: Mortality and cardiovascular morbidity. J Intern Med 2000;247:19–29 12. Dyakova M, Shantikumar S, et al. Systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2016;1:CD010411 13. Krogsbøll LT, Jørgensen KJ, et al. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database Syst Rev 2019;1:CD009009 14. Martin A, Saunders CL, et al. Delivery and impact of the NHS Health Check in the first 8 years: A systematic review. Br J Gen Pract 2018; 68:e449–59 15. Mytton OT, Jackson C, et al. The current and potential health benefits of the National Health Service Health Check cardiovascular disease prevention programme in England: A microsimulation study. PLoS Med 2018;15:e1002517 16. The Emerging Risk Factors Collaboration. Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med 2011;364:829–41 17. Barron E, Bakhai C, et al. Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: A whole-population study. Lancet Diabetes Endocrinol 2020;8:813–22 18. Husdal R, Adolfsson ET, et al. Organisation of primary diabetes care in people with type 2 diabetes in relation to all-cause mortality: A nationwide register-based cohort study. Diabetes Res and Clin Prac 2020; 167:108352 19. Semlitsch T, Stigler FL, et al. Management of overweight and obesity in primary care – A systematic overview of international evidence-based guidelines. Obes Rev 2019;20:1218–1230 20. Kritchevsky SB, Beavers KM, et al. Intentional weight loss and all-cause mortality: A meta-analysis of randomized clinical trials. PLoS One 2015;10(3):e0121993 21. Strelitz J, Lawlor ER, et al. Association between weight change and incidence of cardiovascular disease events and mortality among adults with type 2 diabetes: A systematic review of observational studies and behavioural intervention trials. Diabetologia 2022;65:424–439 22. Wiggins T, Guidozzi N, et al. Association of bariatric surgery with all-cause mortality and incidence of obesity-related disease at a population level: A systematic review and meta-analysis. PLoS Med 2020;17(7):e1003206 23. Katzmarzyk PT, Friedenreich C, et al. Physical inactivity and non-communicable disease burden in low-, middle-, and high-income countries. Br J Sports Med 2022;56(2):101–106

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24. Kettle VE, Madigan CD, et al. Effectiveness of physical activity interventions delivered or prompted by health professionals in primary care settings: Systematic review and meta-analysis of randomised controlled trials. BMJ 2022;376:e068465 25. GBD 2019 Tobacco Collaborators. Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990–2019: A systematic analysis from the Global Burden of Disease Study 2019. Lancet 2021;397:2337–60 26. Stead LF, Buitrago D, et al. Physician advice for smoking cessation. Cochrane Database Syst Rev 2013;5:CD000165 27. Hartmann-Boyce J, Chepkin SC, et al. Nicotine replacement therapy versus control for smoking cessation. Cochrane Database Sys Rev 2018;5:CD000146 28. Rice VH, Heath L, et al. Nursing interventions for smoking cessation. Cochrane Database Syst Rev 2017;12:CD001188 29. Martín Cantera C, Puigdomènech E, et al. Effectiveness of multicomponent interventions in primary healthcare settings to promote continuous smoking cessation in adults: A systematic review. BMJ Open 2015;5:e008807 30. Taylor DH Jr, Hasselblad V, et al. Benefits of smoking cessation for longevity. Am J Public Health 2002;92:990–996 31. Geldsetzer P, Manne-Goehler J, et al. The state of hypertension care in 44 low-income and middle-income countries: A cross-sectional study of nationally representative individual-level data from 1·1 million adults. Lancet 2019;394:652–62 32. NHS Digital. Health Survey for England 2018: Data tables. Adults’ health. https://digital.nhs.uk /data-and-information /publications/statistical/ health-su r vey-for- england /2018/ health-su r vey-for- england-2018 data-tables 33. Muntner P, Hardy ST, et al. Trends in blood pressure control among US adults with hypertension, 1999–2000 to 2017–2018. JAMA 2020;324:1190–1200 34. Liao Y, Gilmour S, et al. Health insurance coverage and hypertension control in China: Results from the China health and nutrition survey. PLoS One 2016;11:e0152091 35. NCD Risk Factor Collaboration (NCD-RisC). Long-term and recent trends in hypertension awareness, treatment, and control in 12 high-income countries: An analysis of 123 nationally representative surveys. Lancet 2019;394:639–51 36. Baker R, Wilson A, et al. Levels of detection of hypertension in primary medical care and interventions to improve detection: A systematic review of the evidence since 2000. BMJ Open 2018;8:e019965 37. Zhang Y, Moran AE. Trends in the prevalence, awareness, treatment, and control of hypertension among young adults in the United States, 1999 to 2014. Hypertension. 2017;70:736–742 38. Sanuade OA, Boatemaa S, et al. Hypertension prevalence, awareness, treatment and control in Ghanaian population: Evidence from the Ghana demographic and health survey. PLoS One 2018;13:e0205985 39. Levene LS, Bankart J, et al. Association of primary care characteristics with variations in mortality rates in England: An observational study. PLoS One 2012;7:e47800 40. Baker R, Honeyford K, et al. Population characteristics, mechanisms of primary care and premature mortality in England: A cross-sectional study. BMJ Open 2016;6:e009981 41. McDowell I, Newell C, et al. A randomized trial of computerized reminders for blood pressure screening in primary care. Medical Care 1989;27:297–305

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42. Shaikh U, Petray J, et al. Improving blood pressure screening and control at an academic health system. BMJ Open Quality 2020;9:e000614 43. Musich S, Wang SS, et al. Underutilization of statin therapy for secondary prevention of cardiovascular disease among older adults. Population Health Management 2019;22:74–82 44. Simmons RK, Carlsen AH, et al. Variation in prescribing of lipid-lowering medication in primary care is associated with incidence of cardiovascular disease and all-cause mortality in people with screen-detected diabetes: Findings from the ADDITION-Denmark trial. Diabet Med 2014;31:1577–1585 45. Turner GM, Calvert M, et al. Under-prescribing of prevention drugs and primary prevention of stroke and transient ischaemic attack in UK general practice: A retrospective analysis. PLoS Med 2016;13:e1002169 46. Boruzs K, Juhász A, et al. Relationship between statin utilization and socioeconomic deprivation in Hungary. Front Pharmacol 2016;7:66 47. Norris P, Horsburgh S, et al. Equity in statin use in New Zealand. J Prim Health Care 2014;6:17–22 48. Mathur R, Badrick I, et al. Prescribing in general practice for people with coronary heart disease; equity by age, sex, ethnic group and deprivation. Ethnicity & Health 2011;16:107–123 49. Office for Health Improvement and Disparities. National General Practice Profiles, 2021. https://fingertips.phe.org.uk/profile/general-practice 50. Allemani C, Matsuda T, et al. Global surveillance of trends in cancer survival 2000–14 (CONCORD-3): Analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries. Lancet 2018;391:1023–75 51. Centers for Disease Control and Prevention. Screening Tests. CDC, 2021. https://www.cdc.gov/cancer/dcpc/prevention/screening.htm 52. Labeit A, Peinemann F, et al. Utilisation of preventative health check-ups in the UK: Findings from individual-level repeated cross-sectional data from 1992 to 2008. BMJ Open 2013;3:e003387 53. Small W Jr, Bacon MA, et al. Cervical cancer: A global health crisis. Cancer 2017;123:2404–12 54. Jansen EEL, Zielonke N, et al. Effect of organised cervical cancer screening on cervical cancer mortality in Europe: A systematic review. European Journal of Cancer 2020;127:207–23 55. Brisson M, Kim JJ, et al. Impact of HPV vaccination and cervical screening on cervical cancer elimination: A comparative modelling analysis in 78 lowincome and lower-middle-income countries. Lancet 2020;395: 575–90 56. Rocha TAH, da Silva NC, et al. Primary health care and cervical cancer mortality rates in Brazil. A longitudinal ecological study. J Ambulatory Care Manage 2017;40:supp. S24–S34 57. Libby G, Brewster DH, et al. The impact of population-based faecal occult blood test screening on colorectal cancer mortality: A matched cohort study. British Journal of Cancer 2012;107:255–259 58. Dharni N, Armstrong D, et al. Factors influencing participation in colorectal cancer screening – A qualitative study in an ethnic and socio- economically diverse inner city population. Health Expectations 2017;20:608–617 59. de Klerk CM, Gupta S, et al. Socioeconomic and ethnic inequities within organised colorectal cancer screening programmes worldwide. Gut 2918;67:679–687 60. Honein-AbouHaidar GN, Kastner M, et al. Systematic review and metastudy synthesis of qualitative studies evaluating facilitators and barriers to participation in colorectal cancer screening. Cancer Epidemiol Biomarkers Prev 2016;25:907–917

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61. NHS England. The Independent Review of Adult Screening Programmes in England. London: NHS England, 2019 62. Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2013;6:CD001877 63. Autier P, Boniol M. Mammography screening: A major issue in medicine. Euro of Cancer 2018;90:34–62 64. Ferrante JM, Lee J-H, et al. Primary care utilization and colorectal cancer incidence and mortality among Medicare beneficiaries. A population-based, case–control study. Ann Intern Med 2013;159:437–446 65. Fisher KJ, Lee J-H, et al. The effects of primary care on breast cancer mortality and incidence among Medicare beneficiaries. Cancer 2013;119:2964–72 66. Round T, Gildea C, et al. Association between use of urgent suspected cancer referral and mortality and stage at diagnosis: A 5-year national cohort study. Br J Gen Pract 2020;70:e389–98 67. Arhi CS, Burns EM, et al. Delays in referral from primary care worsen survival for patients with colorectal cancer: A retrospective cohort study. Br J Gen Pract 2020;70(696):e463–71 68. Tørring ML, Frydenberg M, et al. Diagnostic interval and mortality in colorectal cancer: U-shaped association demonstrated for three different datasets. J Clin Epidemiol 2012;65:669–78 69. Tørring ML, Frydenberg M, et al. Evidence of increasing mortality with longer diagnostic intervals for five common cancers: A cohort study in primary care. Eur J Cancer 2013;49:2187–98 70. Maclean R, Jeffreys M, et al. Primary care characteristics and stage of cancer at diagnosis using data from the National Cancer Registration Service, quality outcomes framework and general practice information. BMC Cancer 2015;15:500 71. Bottle A, Tsang C, et al. Association between patient and general practice characteristics and unplanned first-time admissions for cancer: Observational study. Br J Cancer 2012;107:1213–19 72. Niksic M, Rachet B, et al. Is cancer survival associated with cancer symptom awareness and barriers to seeking medical help in England? An ecological study. Br J Cancer 2016;115:876–86 73. Niksic M, Rachet B, et al. Ethnic differences in cancer symptom awareness and barriers to seeking medical help in England. Br J Cancer 2016;115:136–44 74. Zavala VA, Bracci P, et al. Cancer health disparities in racial/ethnic minorities in the United States. Br J Cancer 2021;124:315–32 75. Exarchakou A, Rachet B, et al. Impact of national cancer policies on cancer survival trends and socioeconomic inequalities in England, 1996–2013: Population based study. BMJ 2018;360:k764 76. Sud A, Torr B, Jones ME, et al. Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: A modelling study. Lancet Oncol 2020;21:1035–44 77. Kale MS, Korenstein D. Overdiagnosis in primary care: Framing the problem and finding solutions. BMJ 2018;362:k2820

CHAPTER 7

Non-communicable diseases 2 Respiratory disorders and mental health

Before the mechanisms arising from this review of non-communicable diseases are set out, two further groups of conditions, chronic respiratory disorders and mental health conditions must be given some attention. The evidence uncovered leads to the consideration of aspects of prescribing. At the end of the chapter, seven mechanisms are set out, relating to the availability of primary health care to the whole population, care throughout the lifecycle, management of diseases or conditions causing the most deaths, illness prevention, making early diagnoses, caring for the whole person and avoiding harms when prescribing medication. CHRONIC RESPIRATORY DISORDERS

Asthma The most common chronic non-communicable respiratory diseases are asthma, COPD and occupational lung disease. Together, they were the third leading cause of death worldwide in 2017, behind cardiovascular disease and cancers, and accounted for 7% of all deaths in that year.1 Asthma accounted for 0.9% of all deaths, a rate of 6.5 deaths per year per 100,000 people globally. The majority of continuing care for people with asthma or COPD is provided by primary health care, a responsibility that can be a challenge for the health systems of low- and middle-income countries. In both Sub-Saharan Africa, North Africa and the Middle East, asthma and COPD are under-diagnosed, under-treated and poorly prevented.2 DOI: 10.1201/9781003355380-7

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International organisations and non-governmental agencies have often focused on infectious diseases, leaving many low- and middle-income countries unable to adequately manage chronic conditions. The absence or weakness of primary health care services is exacerbated by the difficulty of funding long-term medication.3 WHO’s Global Alliance against Respiratory Diseases (GARD) seeks to encourage improved access to care for asthma and COPD but progress is slow, although there is some evidence that countries taking part in the GARD programme have achieved reductions in mortality from asthma and COPD.4 Improving access to health care in Brazil for people with asthma has had beneficial results; in an analysis of trends between two threeyear periods, 1999–2001 and 2009–2011, declines in mortality from asthma were greater in municipalities that experienced bigger increases in the number of doctors per 10,000 inhabitants. 5 The national decline in asthma mortality in Brazil may also be related to the introduction of cost-free access to beclomethasone and albuterol medications in 2009.6 In South Africa, a multifaceted intervention primarily for primary health care nurses and consisting of a clinical decision support tool and additional training was developed to build on the WHO’s Integrated Management of Childhood Illness programme.7 The intervention, called the Practical Approach to Care Kit (PACK), covers the care of children up to 13 years old and is being trialled in South Africa, Botswana, Brazil, Nigeria and Ethiopia. The intervention targets the primary health care facility as a unit, enabling shared learning, re-organising pathways of care, clarifying tasks and building teamwork. Approaches such as the PACK intervention offer routes for transitioning from a narrowly based prevention plus acute treatment service to one that incorporates the chronic disease management that is increasingly needed as noncommunicable diseases become more prevalent. Reducing asthma mortality is just as much a challenge for highincome countries. In England and Wales, the total number of deaths with asthma as the underlying cause fell from 1,269 in 2001 to 997 in 2009 but since then a gradual increase in deaths has taken place, with 1,392 people dying from asthma in 2018.8 A national review investigated the deaths of 195 people from asthma between February 2012 to January 2013, of whom 87 (45%) had died without seeking medical assistance or before emergency care could be provided.9 Only 83 of the 195 (43%) had been managed in secondary or tertiary care and failure to apply the recommendations of asthma guidelines contributed to the deaths of 89 (46%) patients. Only 43% had had an asthma review in general practice in the year before death; 42% of these annual reviews had deficiencies, including failure to provide written management plans,

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or check inhaler technique or assess medication adherence, and in those who had accessed medical treatment during the asthma exacerbation, failures by primary health care occurred in 32% of cases including delay in initiating treatment. Among those who died, contributory psychosocial factors were identified in 26%, including depression and substance misuse. Concerted programmes concentrating on primary health care appear to have potential in reducing asthma mortality. In Finland, a country with a population of around 5.5 million people, a national asthma programme was implemented from 1994. It focused on (1) early diagnosis, (2) active anti-inflammatory treatment from the outset, (3) guided selfmanagement and (4) effective networking between general practitioners and pharmacies.10 Prior to the national programme, patients with asthma had been cared for mostly by pulmonary physicians and paediatricians but to enable a transfer to primary health care, training was provided for one general practitioner and one nurse per health centre to help them coordinate local activities and lead the delivery of care.11 From 1997, pharmacies were required to designate a member of staff as asthma contact person and to deliver patient education. There is some evidence to suggest the programme was associated with declines in asthma mortality, no pre-school or school-age children dying of asthma from 1999 to 2015, and over this period among all children there were only four deaths due to asthma.12 The total number of deaths, all ages combined, fell from 123 in 1993 to 85 in 2003, with the death rate among people with diagnosed asthma falling from 0.91/1,000 to 0.41/1,000 over this period.13 The Finland programme has served as a model for other national asthma programmes. A review of such programmes in eight European countries (Finland, France, Ireland, Italy, the Netherlands, Poland, Portugal and Turkey) found improvements in patient management and highlighted features contributing to success, including early diagnosis, improved long-term control, self-management and education, and networking for general practitioners, nurses and pharmacists.14 Inequities in mortality can be found for asthma as for many other conditions, but the effect of primary health care in reducing these inequities is not clear. In a quantitative study of asthma deaths in North Carolina over the period 1999–2016, the age-adjusted deaths rates were 9.6 per million among males and 14.6 among females; the ethnic group with the highest death rate was African Americans at 24.7 per million, with the lowest being Hispanics at 5.5 per million.15 Variations in the care of people with asthma in Wales have been identified in a study following patients from 2013 to 2017.16 A clear pattern of worse care and worse outcomes were observed among the more socio-economically deprived.

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The most deprived had fewer primary health care consultations for asthma, lower use of preventive medication, more asthma-related emergency department attendances and more hospital admissions; those admitted also had longer in-patient stays. They were also at greater risk of death. Deprived populations are disadvantaged by where they live in addition to the health care they receive. Since levels of nitrogen dioxide and particulates tend to be higher in poor neighbourhoods, disadvantaged and ethnic minority children are more exposed to environmental air pollution and therefore at increased risk of developing asthma.17

Chronic obstructive pulmonary disease (COPD) In 2017, COPD accounted for 5.7% of all deaths worldwide, a rate of 41·9 deaths per year per 100,000 individuals.1 Most patients with COPD most of the time are managed in primary health care, but the extent of that care varies between countries, with those with more developed primary health care tending to provide more comprehensive care than countries with less developed systems. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) was launched in 1998 to provide international recommendations for the management of COPD.18 The recommendations are updated annually and cover diagnosis and initial assessment, smoking cessation, air pollution, vaccination against influenza and pneumococcal infection, medication, rehabilitation, patient education and self-management, and treatment of exacerbations. Most of these aspects of care are delivered by primary health care teams, with referrals to specialist services being reserved for selected cases. China accounts for around one-third of all deaths from COPD worldwide, with the country’s age-standardised death rate in 2016 in men being 55.3 per 100,000 per year and a corresponding 33.1 per 100,000 per year in women.19 Smoking and air pollution are important risk factors, with the use of solid fuels for cooking and heating contributing to prevalence, particularly among those with lower household incomes. 20 Health system reforms in China still have much to do to improve the delivery and equity of effective health care to people with COPD. Evidence from a systematic survey of a national sample has identified poor detection and management of COPD, including poor awareness among patients that they had COPD, infrequent use of appropriate medication, and low use of influenza and pneumococcal vaccines. 21 Under-diagnosis is a problem not confined to China. A study of four Latin American countries (Argentina, Colombia, Venezuela and Uruguay) revealed that only one-third of patients found to have COPD at a screening examination had previously been told they had the

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condition, with under-diagnosis being associated with being overweight (BMI 30 kg/m 2 or more), Black ethnicity, milder airways obstruction or less recent use of health care. 22 Primary health care can manage COPD effectively. In Finland a national programme for COPD was implemented in 1998. It built on the nation’s asthma programme and involved the nurses and doctors leading the asthma programme taking on the same role for COPD.23 Guidelines and educational events that brought together both primary and secondary care were used to improve care delivery, and in subsequent years decreases in smoking rates were observed, the quality of spirometry improved, and hospital admission rates for COPD declined. COPD mortality among Finnish males dropped sharply between 1995 and 2015, although mortality remained stable at a much lower level among women. 24 In England and Wales, the annual number of deaths caused by COPD rose from 24,432 in 2001 to 36,440 in 2018.8 It is more common in men than women and more common in deprived patient populations.25 In those with COPD, all-cause mortality is higher in deprived compared to affluent groups, 26 and comorbidity, especially cardiovascular disease, is an important risk factor for mortality.27 Prevalence is higher in Scotland and the North of England than in the south of the country. One role of primary health care is to encourage smoking cessation, and the evidence of benefit of this on mortality is encouraging. In an investigation in one English county, 91.3% of patients with COPD had a note of their smoking status in their primary health care records, 38.5% being current smokers and 59.4% ex-smokers suggesting some success in promoting cessation. The findings also showed that smokers who stopped had a lower risk of death from any cause during three years of follow-up.28 Nevertheless, some patients are over-treated, especially with inhaled steroids, 29 and they often lack advice on self-management or written plans to help them recognise exacerbations.30 Some features of primary health care have been shown to be associated with reduced mortality rates in people with COPD. In a study of all 152 English primary care trusts, the administrative bodies governing primary care in place at that time, predictors of mortality due to COPD were primarily population characteristics.31 Primary care trusts had higher mortality rates from COPD if they had higher levels of deprivation, a higher proportion of the population of White ethnicity, a higher proportion who were males, or a higher proportion aged 65 years or older. The only service characteristic that predicted lower mortality was greater relationship continuity as measured by a question in the national general practice patient survey asking respondents whether they were

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able to see their preferred general practitioner. Among patients admitted to hospital with COPD, the number of general practitioners per 1,000 patients was identified in an analysis of patients in England to be one of several clinical and organisational factors significantly associated with mortality in the year after admission, with more general practitioners being associated with lower all-cause mortality.32 In a study undertaken in Australia, patients with COPD, asthma or emphysema who had regularly scheduled visits with their primary health care doctor for planned reviews, in comparison with patients who did not, had lower all-cause mortality during 11 years of follow-up.33

MENTAL HEALTH

Mental health, physical conditions and multimorbidity Chronic conditions including diabetes, COPD, chronic pain, cancer or cardiovascular disease can give rise to anxiety and depression. Depression in turn can aggravate the physical problem. In people with diabetes, for example, depression can increase the risk of all-cause mortality. A systematic review of nine studies of this association concluded that comorbid depression in people with diabetes was associated with a 47.9% increase in cardiovascular mortality. 34 Early evidence is emerging to suggest that treating depression could lead to improved outcomes, although further research to confirm this is needed. A randomised trial of the addition of cognitive behaviour therapy to antidepressant medication in people with diabetes showed improvements in depression, adherence to medication and control of blood sugar. 35 An observational study from Taiwan in which people with both diabetes and depression were followed up for a mean of nine years demonstrated, after accounting for confounding variables, that treatment with antidepressants was associated with lower all-cause mortality. 36 There were 1,964 deaths per 100,000 person years in the group that had received little or no antidepressant treatment but only 1,114 per 100,000 person years among those who had received the highest doses of antidepressants. In the case of COPD, depression also increases the risk of death. After adjusting for the severity of COPD, age, BMI, level of physical activity, functional limitations and level of education, the presence of depression in Norwegian patients with COPD was associated with a 21% increase in all-cause mortality.37 However, if the symptoms of depression improved, the risk of mortality decreased. Despite this finding, a review of randomised trials found too little evidence about the effects of

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antidepressant medication in people with COPD to enable conclusions to be drawn on whether any benefits outweighed the potential harms.38 England’s National Institute for Health and Care Excellence (NICE) has defined multimorbidity as the presence of two or more long-term health conditions, which can include defined physical and mental health conditions such as diabetes or schizophrenia, ongoing conditions such as a learning disability, symptom complexes such as frailty or chronic pain, sensory impairment such as sight or hearing loss, and alcohol and substance misuse.39 The occurrence of depression with diabetes, COPD or another chronic conditions therefore complies with this definition.40 Multimorbidity and the social determinants of health work together to shorten lives.41 The Whitehall programme of research that has followed up British civil servants from 1985 collected data on social determinants and conducted clinical examinations at regular intervals.42 Multimorbidity was associated with a fourfold increase in mortality risk and was a more powerful predictor of mortality than either frailty or disability. As the social determinants of health accumulated, the likelihood of multimorbidity increased. A variety of measures of multimorbidity have been developed drawing on either information about the conditions affecting patients, broad diagnostic categories or use of medications. As yet, however, only limited progress has been made in the routine use of a standard measure in clinical practice to guide the management of services or inform the care of individuals. Data on multimorbidity have been used in administrative contexts such as in health insurance databases and in models to predict the risk of hospital admission.43 The required information lies in electronic health records and therefore levels of multimorbidity in practice populations can be readily estimated for use in planning and monitoring services. Practical methods for reducing mortality among people with established multimorbidity need further development, however. One randomised trial provides preliminary evidence that effective management of depression in people with multimorbidity can reduce mortality rates. It took place in 20 primary health care practices in New York and involved people aged 60 or over who received either the usual primary health care or health care enhanced by the addition of a depression care manager who offered psychotherapy, adjusted antidepressant medication and monitored progress.44 Depressed patients with comorbidity were at increased risk of death during follow up in the practices offering the usual care only, but this effect was not found in practices offering the enhanced service. In contrast, a UK randomised trial of patients with multimorbidity receiving a less intensive intervention consisting of a six-monthly comprehensive multidisciplinary review by a

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nurse, pharmacist and physician that included screening for depression found no effect on the study’s primary outcome, quality of life.45 There was also no evidence of a difference between the intervention and control groups in the number of deaths. The care of people with multimorbidity will be studied intensively in the next few years and it must be hoped that interventions that do reduce mortality rates and improve health status can be identified. Although people with chronic physical conditions are at increased risk of depression, people with chronic mental illness are also at increased risk of physical diseases. For example, schizophrenia is associated with increased risk of death from cardiovascular disease in comparison with people without schizophrenia,46 and the risk death from COVID-19 is higher among people with, compared to people without, mental health disorders.47 Primary health care in many countries can fail to adequately manage cardiovascular risk in people with severe mental illness. For example, in Norway, people with schizophrenia or bipolar disorder compared to people without these conditions were found to be at increased risk of death caused by cardiovascular diseases that had not been diagnosed for a large portion of their lives although almost all patients had visited primary health care services.48 Under-treatment of cardiovascular disorders in people with serious mental illness has been documented in England as well.49 In England, the payment for the performance scheme known as the quality and outcomes framework includes indicators for the management of a variety of chronic conditions, among which is serious mental illness. The actions primary health care teams are incentivised to take include an annual review of health needs and recording a care plan. Using patient-level data from the electronic records of around 200 general practices in a retrospective observational study, almost 20,000 patients with serious mental illness were followed up to investigate any associations between annual health reviews and care plans and subsequent outcomes. 50 Patients who had a care plan and those who had annual reviews were associated with fewer emergency department attendances and fewer admissions for serious mental illness and for ambulatory care sensitive conditions. An additional finding was that higher continuity of care with a general practitioner was associated with fewer admissions for ambulatory care sensitive conditions. These findings support the case for promoting health reviews and care plans in primary health care for people with serious mental illness although the effect on mortality is not yet clear.

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Preventing suicide Suicide accounts for 1.4% of all deaths worldwide. In 2019, there were a total of 5,691 suicides in England and Wales, an age-standardised rate of 11.0 per 100,000 population.51 Rates were three times higher among men (16.9 deaths per 100,000) than among women (5.3 deaths per 100,000), and two to three times higher in the most compared to the least deprived neighbourhoods. 52 Information limited to patients who had been in contact with mental health services in the preceding 12 months indicates that suicide rates tend to be lower in ethnic minority groups compared to Whites.53 In the last decade, overall suicide rates in England and Wales have remained fairly stable but rises appear to be underway among younger females (10 to 24 and 25 to 44 age groups) and middle-aged men (25–44 and 45 to 64 age groups). NICE guidance advises primary health care professionals to always ask about suicidal ideation and intent when assessing a patient’s mental health, and if there is a risk of self-harm or suicide. In addition, access to social support or other sources of help should be checked, help should be arranged according to the level of risk, and further help should be offered if the situation deteriorates.54 If there is a high risk of suicide, referral to specialist services should be arranged, urgently if necessary, and the family or carers informed when appropriate. The most recent National Confidential Inquiry into Suicide and Safety in Mental Health55 gives little attention to the role of primary health care but does encourage safer prescribing, particularly of opiates in long-term illness. Contact with primary health care among those who go on to commit suicide is common; a review of studies of contacts before suicide concluded that approximately 80% had been in contact with primary health care in the 12 months before suicide and as many as 44% had been in contact one month prior to suicide.56 A systematic review of studies of the implementation of mental health care programmes in primary health care in low- and middle-income countries found many barriers to success and concluded that strengthening health systems was necessary, including greater funding, adequate staff numbers and improvement of specialist mental health support.57 Does primary health care reduce the number of suicides? Although the training of primary health care professionals is often included in national suicide prevention strategies, evidence of the effect is difficult to find. A review of 14 studies of suicide prevention activities delivered by primary health care doctors concluded that the evidence of any benefits was equivocal resulting in a reluctance to by the authors recommend the roll out of these initiatives.58 In a review of studies of prevention strategies,

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restricting access to lethal means including analgesic drugs and jumping hotspots, school awareness programmes and effective pharmacological and psychological treatment of depression were found to have evidence in support of their effectiveness.59 However, there was insufficient evidence on the benefits or otherwise of screening in primary health care, or physician training, or general public education. Collaboration between primary health care teams and mental health professionals may be a more promising approach. A review that included studies of interventions delivered by multidisciplinary teams concluded that a collaborative approach had the potential to reduce suicide attempts.60 The primary health care teams in the studies of this review included professionals with special expertise in mental health, psychological therapies, and management of suicide risk. The supporting interventions combined education of practitioners, screening for suicide risk, managing depression symptoms, and assessing and managing suicide risk. In the United Kingdom, the charities Samaritans and the Centre for Mental Health have reviewed the evidence on the role of primary health care in suicide prevention, concluding that the sector plays a key role but identified five areas in need of improvement: (1) Continuing training for primary health care staff is required; (2) the therapeutic relationship between staff and patients is being impaired through short appointment times and the growing pressure on services; (3) primary health care staff need emotional support including after a patient has died by suicide; (4) effective pathways between primary health care and other clinical and social support services are required and (5) primary health care is confronted by too difficult or too many hurdles in obtaining referrals to other sources of support.61 The report also highlighted the role of the network of services and the local community in working together; poor coordination between services can lead to loss of confidence by primary health care professionals in the accessibility and willingness of local services to help. The Zero Suicide programme launched in the United States focused on health care and brings together leadership within health care, training for staff, screening and assessment using evaluated tools, a care protocol tailored to the individual patient found to be at risk, evidencebased treatments such as cognitive behavioural therapy to address suicidal thoughts, support during transitions between different care sectors (e.g. referral to primary and secondary care and discharge back again), and measuring outcomes and conducting quality improvement.62 The programme is being introduced in other countries including the United Kingdom. The effect of the Zero Suicide programme is not yet known,

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although a recent evaluation from Australia suggests a reduction in repeated suicide attempts.63 The social and psychological environment can affect the risk of suicide. For example, suicide rates are often higher in marginalised Indigenous populations compared to non-indigenous populations.64 Reducing isolation and enabling people to connect with their communities and peers are key components of primary prevention.65 A suggested framework for suicide prevention programmes has four levels – society as the first level, the community as the second level, relationships as the third level and the individual as the final level.66 Society can contribute to national policies such as gun laws, and allocate funds for education and mental health provision. The community can contribute to school-based support, community groups and local leadership. Relationships can contribute social support and the human contact everyone needs. The individual in distress can seek help to prevent thoughts of self-harm. It is clear, then, that our current level of knowledge of what works is incomplete. Definitive evidence of effect is not available, but the involvement of multidisciplinary teams with mental health expertise and community links appears to be important, but since many patients who are at risk of suicide present to primary health care, this part of the health system must be included in strategies to reduce suicides.

Prescribing Treatment for mental health conditions and multimorbidity often includes medication, but drugs themselves can impair mental or physical health. Sometimes patients are given drugs that they should not have, for example because they have impaired kidney or liver function. Sometimes they are already taking other drugs and the new drug may interact with medication with dangerous consequences. Sometimes, the new drugs cause addictions to develop. Barbiturates were first used in clinical practice in 1903 but it took 50 years for the medical profession to fully accept the highly addictive nature of this class of drugs.67 They were widely used as sedatives to help people sleep, leading many patients to become addicted to them. Barbiturates became a common cause of deaths by overdose but by the mid-1970s general practitioners were switching to the prescribing of benzodiazepines, which were safer in overdose. Life expectancy of middle-aged White and Native American men and women has declined in recent years, a fall that partly explains the decline in overall US life expectancy between 2015 and 2017.68 Increases in drugpoisoning, suicide and alcohol-related deaths were largely responsible.

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Drug-poisoning rates were highest among the 35–49-year-old age group, whereas suicide and alcohol-related deaths were highest in the 50–64 age group. Drug-poisoning and alcohol-related deaths were highest in US counties with the highest unemployment and socio-economic deprivation and lowest in counties with the lowest unemployment and deprivation. Higher rates of opioid prescribing and more deaths from drug overdoses are found in counties with greater levels of deprivation.69 The risk of someone having a prescription for an opioid was 72% higher in the most deprived counties compared to the least deprived. Between 2000 and 2010, opioid prescribing for non-cancer pain rose by 73% in the United States and a rise in deaths from drug overdoses ensued.70 In 2017, prescription opioids were involved in 24.2% of fatal drug overdoses in the United States.71 After a period in which prescribing increased, prescriptions from primary health care began to decline from 2016 after the publication of new guidance on prescribing for chronic pain from the Centers for Disease Control and Prevention. Drug overdose deaths continue, however, largely through the use of heroin or illicitly manufactured fentanyl. The role of the Sackler family in the opioid epidemic in the United States has been carefully researched by Patrick Keefe.72 Purdue Frederick was a small pharmaceutical company run by the Sackler family that marketed OxyContin in the 1990s, a controlled release version of the opiate drug oxycodone. Purdue used nefarious methods to persuade the Federal Drug Administration to allow the company to say in the absence of evidence that delayed absorption of the drug was believed to reduce the risk of abuse of the drug. The network of political lobbying, legal machinations and other shenanigans that enabled the opioid crisis to develop are shocking. Pharmaceutical companies other than Purdue were also involved in marketing addictive opiate drugs, fentanyl being one example. Once prescribed for chronic pain, an addiction develops that compels some patients to seek illicit supplies, creating a market for street drugs. It is true that primary health care doctors were misled by pharmaceutical companies about the addictive potential of these drugs. It is also true that some doctors urged caution in their use and demanded evidence about their effects. Specialists also prescribed these opiates, but it cannot be denied that the medical profession as a whole failed to protect patients from these harmful substances. The opioid epidemic has been most severe in the United States but although prescribing rates are lower in Europe, they are rising.73 In England, between 1998 and 2016, in terms of morphine equivalent dosage, prescribing by general practices increased from 190,000 mg to

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431,000 mg per 1,000 persons per year.74 Higher prescribing was associated with practices with larger list sizes, rural locations and more deprivation. The increase in opioid prescribing has been matched by an increase in opiate-related deaths.75 The problem varies between areas of the United Kingdom, Scotland being particularly affected. In a study of UK general practice clinical records over the period 2006 to 2017 that included almost 2 million adult patients without cancer who commenced a prescription opioid, 14.6% became long-term users in the first year.76 Socioeconomic deprivation, individuals aged 75 or over, and the presence of conditions including fibromyalgia, rheumatological conditions, recent major surgery and a history of substance abuse, alcohol abuse and selfharm or suicide attempts were associated with long-term opioid use. Lives may be shortened by prescribing problems other than the excessive recourse to potentially addictive drugs. Prescribing the wrong drug, the wrong dose, a contraindicated drug or a drug that interacts with other medication are the second most common cause of significant avoidable harm to patients, with failures in diagnosis being the most common cause.77 A recent review reported that 1% of primary health care patients experienced avoidable medication harm, a percentage lower than intensive care or elderly care settings but nevertheless important because of the large number of people who attend primary health care.78 Approaches for improving the safety of prescribing are clearly needed. The involvement of pharmacists in using electronic communication with prescribers, combined with support, educational outreach and feedback of information on prescribing performance has been shown in a randomised trial to reduce medication errors in primary health care.79 The prescribing of antibiotics or antivirals when they are not needed is another problem in prescribing that has the potential to increase mortality rates by promoting the emergence of resistant organisms. An estimated 50,000 deaths annually in Europe and the United States are due to antibiotic resistance.80 Primary health care professionals must balance the temptation to offer their patients an antibiotic even when they know the chance of benefit is very low against the risk of increased antimicrobial resistance in the community.81 Resistance to antivirals is also a concern; resistance to drugs used to treat HIV is on the rise and there is a risk that COVID-19 will develop resistance to the antivirals now being used. MECHANISMS Seven mechanisms uncovered by the discussion of non-communicable diseases now follow.

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Mechanism V The extent to which primary health care reduces population mortality is dependent on the extent to which the whole population is covered by the service. Level of Evidence – Moderate COMMENTARY No randomised controlled trial has been found that compared the effect of care for a whole population to a partial population in reducing whole population mortality and it is difficult to imagine that such a trial would be regarded as ethical. It is self-evident that the population effect of a clinical intervention will be reduced if it is not available to all those who might benefit from it. Observational studies on the prevention or management of both communicable and non-communicable diseases all support the case for extending primary health care to the entire population.

Mechanism VI Primary health care is concerned with the current and future health of individuals and groups, at all stages of the lifecycle from conception to old age. Care of the person throughout life enables primary health care to reduce population mortality more than fragmented care of episodic illnesses. Level of Evidence – Moderate COMMENTARY The care of patients throughout life is shared between primary health care and specialist care, but whereas specialist care is concentrated on discrete episodes, on conditions that need special technical expertise, or on specific periods of life such as childhood or old age, primary health care is continuous and lifelong. Even when specialists are providing the overwhelming majority of a patient’s care, there are few occasions when primary health care has no role to play at all. It provides health care over the life-course. Randomised controlled trials provide evidence about the effectiveness of specific preventive interventions appropriate for different stages of life but studies that compare longitudinal care over the life-course with care for selected life stages are not available. Despite this, evidence is growing about the importance of early life on future health. The theory of early life programming and the life-course approach to explaining health inequalities

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underline the importance of the lifelong perspective of primary health care. Interventions based on these theories are beginning to be explored in primary health care but studies of the outcomes have yet to be completed. Perhaps eventually we will be able to track the effect of early life clinical and social interventions on the health of adults 20 to 40 years later.

Mechanism VII The management by primary health care of those non-communicable diseases that are responsible for many deaths reduces population mortality. Level of Evidence – Strong COMMENTARY Randomised controlled trials confirm the efficacy of treatments for cardiovascular and respiratory disorders that are routinely delivered in primary health care. The management of several other conditions has not been discussed, including diabetes or neurological diseases, and it is possible that more evidence to support this mechanism would be found if they had been investigated, but it was essential to be selective in order to keep the task of seeking evidence within manageable limits.

Mechanism VIII Illness prevention delivered in primary health care reduces population mortality. Level of Evidence – Strong COMMENTARY There is good evidence that prevention can reduce mortality, for example, recommending and offering help with smoking cessation and in treating raised blood pressure. Primary health care can make these effective interventions available to all in the population, an essential step in maximising the effect on population mortality.

Mechanism IX By making early diagnoses, primary health care reduces mortality caused by those conditions in which late diagnosis leads to worse outcomes. Level of Evidence – Moderate

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COMMENTARY For some conditions, delay in diagnosis and subsequent treatment increases the likelihood of poor outcomes. Observational studies provide evidence to show the consequences of delayed diagnosis for some cancers, for example. By being accessible to all in the population, primary health care makes early diagnosis possible for many patients. Despite the advantage of universal access in comparison with secondary care, primary health care is not always successful in making early diagnoses and therefore research continues to identify new approaches whilst quality improvement initiatives try to achieve consistent and effective use of the approaches now in use.

Mechanism X By caring for the patient as a whole person, primary health care addresses most of the common causes of population mortality, whether they are traditionally classified as physical or mental health conditions. Level of Evidence – Weak COMMENTARY I am not aware of randomised trials of primary health care in which managing both mental and physical illnesses were compared with services managing only one or the other. It should also be remembered that the physical health of people with chronic mental illness is sometimes neglected, but systematic efforts can improve general health, for example, by reducing cardiovascular risk. Evidence about the effect of primary health care in reducing suicides is mixed but does suggest that the combination of access to help and the support of multidisciplinary teams are important ingredients.

Mechanism XI Primary health care can increase population mortality by prescribing • • •

Medications that lead to drug addiction Antibiotics or antivirals when they are not necessary, leading to the emergence of drug resistant organisms Inappropriately, including selecting the wrong drug or dose, or unsuitably introducing a drug that causes a dangerous interaction with other medication

Level of Evidence – Moderate

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COMMENTARY It is impossible to deny the part that the prescribing of barbiturates and opiates has played in creating addiction to these drugs and to causing deaths through overdoses that have followed. It is also true that antibiotics are sometimes prescribed when they could be avoided and that errors in prescribing are not uncommon. The supporting evidence is variable in quality, being predominantly observational although there are randomised trials of interventions to improve prescribing safety. There is also ample evidence that errors in prescribing can be followed by serious harm to patients. Eleven mechanisms have now been identified, and it is time to turn to the organisational features of primary health care and ask whether they influence population mortality. REFERENCES 1. GBD Chronic Respiratory Disease Collaborators. Prevalence and attributable health burden of chronic respiratory diseases, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet Respir Med 2020;8:585–96 2. Ahmed R, Robinson R, et al. The epidemiology of noncommunicable respiratory disease in sub-Saharan Africa, the Middle East, and North Africa. Malawi Med Jo 2017;29:203–11 3. Beran D, Zar HJ, et al. Burden of asthma and chronic obstructive pulmonary disease and access to essential medicines in low-income and middleincome countries. Lancet Respir Med 2015;3:159–70 4. Khaltaev N. GARD, a new way to battle with chronic respiratory diseases, from disease oriented programmes to global partnership. J Thorac Dis 2017;9:4676–89 5. Ponte EV, Cruz AA, et al. Urbanization is associated with increased asthma morbidity and mortality in Brazil. Clin Respir J. 2018;12:410–17. https:// doi.org/10.1111/crj.12530 6. Cardoso T de A, Roncada C, et al. The impact of asthma in Brazil: A longitudinal analysis of data from a Brazilian national database system. J Bras Pneumol 2017;43:163–68 7. Picken S, Hannington J, et al. PACK Child: The development of a practical guide to extend the scope of integrated primary care for children and young adolescents. BMJ Glob Health 2018;3:e000957 8. ONS. Deaths from asthma, respiratory disease, chronic obstructive pulmonary disease and flu, England and Wales, 2001–2018 occurrences. London: Office for National Statistics, 2020 9. Royal College of Physicians. Why asthma still kills: The National Review of Asthma Deaths (NRAD) Confidential Enquiry Report. London: RCP, 2014 10. Haahtela T, Selroos O. Chapter One. A population management model of asthma and allergy: Case Finland. P 1–10. In: Szefler SS, Holguin F, Wechsler ME Personalising Asthma Management for the Clinician. St Louis: Elsevier, 2018 11. Haahtela T, Klaukka T, et al. Asthma programme in Finland: A community problem needs community solutions. Thorax 2001;56:806–14

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12. Kivistö JE, Karjalainen J, et al. Very low asthma death incidence among Finnish children from 1999 to 2015. Pediatr Pulmonol 2018;53:1009–13 13. Haahtela T, Tuomisto LE, et al. A 10 year asthma programme in Finland: Major change for the better. Thorax 2006;61:663–70 14. Selroos O, Kupczyk M, et al. National and regional asthma programmes in Europe. Eur Respir Rev 2015;24:474–83 15. Kearney GD, Wooten W, et al. Asthma deaths in North Carolina: 1999–2016, J Asthma 2020;57:478–86 16. Alsallakh MA, Rodgers SE, et al. Association of socioeconomic deprivation with asthma care, outcomes, and deaths in Wales: A 5-year national linked primary and secondary care cohort study. PLoS Med 2021;18:e1003497 17. Kravitz-Wirtz N, Teixeira S, et al. Early-life air pollution exposure, neighborhood poverty, and childhood asthma in the United States, 1990–2014. Int J Environ Res Public Health 2018;15:1114 18. GOLD. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2020 Report. Global Initiative for Chronic Obstructive Lung Disease, 2020. https://goldcopd.org/wp-content/ uploads/2019/11/GOLD-2020-REPORT-ver1.1wms.pdf 19. Zhu J, Cui L, et al. Mortality pattern trends and disparities among Chinese from 2004 to 2016. BMC Public Health 2019;19:780 20. Li J, Qin C, et al. Solid fuel use and incident COPD in Chinese adults: Findings from the China Kadoorie Biobank. Environ Health Perspect 2019;127:057008-1 to 10 21. Kurmi OP, Davis KJ, et al. Patterns and management of chronic obstructive pulmonary disease in urban and rural China: A community-based survey of 25 000 adults across 10 regions. BMJ Open Resp Res 2018;5:e000267 22. Casas Herrera A, Montes de Oca M, et al. COPD underdiagnosis and misdiagnosis in a high-risk primary care population in four Latin American countries. A key to enhance disease diagnosis: The PUMA Study. PLoS One 2016;11:e0152266 23. Kinnula VL, Vasankari T, et al. The 10-year COPD Programme in Finland: Effects on quality of diagnosis, smoking, prevalence, hospital admissions and mortality. Prim Care Respir J 2011;20:178–183 24. Lortet-Tieulent J, Soerjomataram I, et al. International trends in COPD mortality, 1995–2017. Eur Respir J 2019;54:1901791 25. Snell N, Strachan D, et al. Epidemiology of chronic obstructive pulmonary disease (COPD) in the UK: Findings from the British Lung Foundation’s ‘respiratory health of the nation’ project. Thorax 2016;71(Suppl 3):A20 26. Collins PF, Stratton RJ, et al. Influence of deprivation on health care use, health care costs, and mortality in COPD. Int J Chron Obstruct Pulmon Dis 2018;13:1289–96 27. Ellingsen J, Johansson G, et al. Impact of comorbidities and commonly used drugs on mortality in COPD – Real-world data from a primary care setting. Int J Chron Obstruct Pulmon Dis 2020:15 235–45 28. Josephs L, Culliford D, et al. Improved outcomes in ex-smokers with COPD: A UK primary care observational cohort study. Eur Respir J 2017;49:1602114 29. Halpin DMG, de Jong HJI, et al. Distribution, temporal stability and appropriateness of therapy of patients with COPD in the UK in relation to GOLD 2019. eClinicalMedicine 2019;14:3241 30. Philip K, Gaduzo S, et al. Patient experience of COPD care: Outcomes from the British Lung Foundation Patient Passport. BMJ Open Resp Res 2019;6:e000478 31. Levene LS, Bankart J, et al. Association of primary care characteristics with variations in mortality rates in England: An observational study. PLoS One 2021;7:e47800

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32. Bottle A, Honeyford K, et al. Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: A national observational study. Health Serv Deliv Res 2018;6:26 33. Einarsdóttir K, Preen DB, et al. Regular primary care lowers hospitalisation risk and mortality in seniors with chronic respiratory diseases. J Gen Intern Med 2010;25:766–73 34. Farooqi A, Khunti K, et al. Comorbid depression and risk of cardiac events and cardiac mortality in people with diabetes: A systematic review and meta-analysis. Diabetes Res Clin Pract 2018;156:107816 35. Safren SA, Gonzalez JS, et al. A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBTAD) in patients with uncontrolled type 2 diabetes. Diabetes Care 2014;37:625–33 36. Chen H-M, Yang Y-H, et al. Antidepressants reduced risk of mortality in patients with diabetes mellitus: A population-based cohort study in Taiwan. J Clin Endocrinol Metab 2019;104:4619–25 37. Vikjord SAA, Brumpton BM, et al. The association of anxiety and depression with mortality in a COPD cohort. The HUNT study, Norway. Respir Med 2020;171:106089 38. Pollok J, van Agteren JEM, et al. Pharmacological interventions for the treatment of depression in chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2018;12:CD012346 39. NICE. Multimorbidity: Clinical assessment and management. NICE guideline [NG56]. London: National Institute for Health and Care Excellence, 2016 40. Read JR, Sharpe L, et al. Multimorbidity and depression: A systematic review and meta-analysis. J Affect Disord 2017;221:36–46 41. Mercer SW, Zhou Y, et al. Multimorbidity and socioeconomic deprivation in primary care consultations. Ann Fam Med 2018;16:127–31 42. Dugravot A, Fayosse A, et al. Social inequalities in multimorbidity, frailty, disability, and transitions to mortality: A 24-year follow-up of the Whitehall II Cohort Study. Lancet Public Health 2020;5:e42–50 43. Wallace E, Stuart E, et al. Risk prediction models to predict emergency hospital admission in community-dwelling adults. A systematic review. Med Care 2014;52:751–65 4 4. Gallo JJ, Hwang S, et al. Multimorbidity, depression, and mortality in primary care: Randomized clinical trial of an evidence-based depression care management program on mortality risk. J Gen Intern Med 2015;31: 380–6 45. Salisbury C, Man M-S, et al. Management of multimorbidity using a patient-centred care model: A pragmatic cluster-randomised trial of the 3D approach. Lancet 2018;392:41–50 46. Westman J, Eriksson SV, et al. Increased cardiovascular mortality in people with schizophrenia: A 24-year National Register Study. Epidemiol Psychiatr Sci 2018;27:519–27 47. Fond G, Nemani K, et al. Association between mental health disorders and mortality among patients with COVID-19 in 7 countries. A systematic review and meta-analysis. JAMA Psychiatry 2021;78:1208–17 48. Heiberg IH, Jacobsen BK, et al. Undiagnosed cardiovascular disease prior to cardiovascular death in individuals with severe mental illness. Acta Psychiatr Scand 2019:139:558–71 49. Woodhead C, Ashworth M, et al. Cardiovascular disease treatment among patients with severe mental illness: A data linkage study between primary and secondary care. Br J Gen Pract 2016;66:e374–81

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50. Jacobs R, Aylott L, et al. The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: A retrospective observational study. Southampton (UK): NIHR Journals Library; 2020 Jun. PMID: 32550675 51. ONS. Suicides in England and Wales: 2019 registrations. London: Office for National Statistics, 2020 52. Samaritans. Dying from inequality. Socioeconomic disadvantage and suicidal behaviour. Samaritans: Ewell, Surrey, 2017 53. Hunt IM, Richards N, et al. Suicide rates by ethnic group among patients in contact with mental health services: An observational cohort study in England and Wales. Lancet Psychiatry 2021;8:1083–93 54. NICE. Depression. The NICE guideline on the treatment and management of depression in adults. Updated edition. London: National Collaborating Centre for Mental Health, 2020 55. HQIP. National Confidential Inquiry into Suicides and Safety in Mental Health. Annual Report: England, Northern Ireland, Scotland and Wales, 2019. University of Manchester, 2019 56. Stene-Larsen K, Reneflot A. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health 2019;47:9–17 57. Esponda GM, Hartman S, et al. Barriers and facilitators of mental health programmes in primary care in low-income and middle-income countries. Lancet Psychiatry 2020;7:78–92 58. Milner A, Witt K, et al. The effectiveness of suicide prevention delivered by GPs: A systematic review and meta-analysis. J Affect Disord 2017; 210:294–302 59. Zalsman G, Hawton K, et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry 2016;3:646–59 60. Dueweke AR, Bridges AJ. Suicide interventions in primary care: A elective review of the evidence. Fam Syst Health 2018;36:289–302 61. Centre for Mental Health. Strengthening the Frontline: Investing in primary care for effective suicide prevention. Centre for Mental Health and The Samaritans, London, 2019 62. Hogan MF, Grumet JG. Suicide prevention: An emerging priority for health care. Health Aff 2016;35:1084–90 63. Stapelberg NJC, Sveticic J, et al. Efficacy of the Zero Suicide framework in reducing recurrent suicide attempts: Cross-sectional and time-to-recurrentevent analyses. Br J Psychiatry 2021;219:427–36 64. Pollock NJ, Naicker K, et al. Global incidence of suicide among Indigenous peoples: A systematic review. BMC Med 2018;16:145 65. Horowitz L, Tipton MV, et al. Primary and secondary prevention of youth suicide. Pediatrics 2020;145:S195-S203 66. Cramer RJ, Kapusta ND. A social-ecological framework of theory, assessment, and prevention of suicide. Front Psychol 2017;8:1756 67. d’Orban PT. Barbiturate abuse. J Med Ethics 1976;2:63–7 68. Shiels MS, Tatalovich Z, et al. Trends in mortality from drug poisonings, suicide, and alcohol-induced deaths in the United States from 2000 to 2017. JAMA Netw Open 2020;3:e2016217 69. Kurani S, McCoy RG, et al. Place, poverty and prescriptions: A cross-sectional study using Area Deprivation Index to assess opioid use and drug-poisoning mortality in the USA from 2012 to 2017. BMJ Open 2020;10:e035376 70. James JR, Scott JAM, et al. Mortality after discontinuation of primary care–based chronic opioid therapy for pain: A retrospective cohort study. J Gen Intern Med 2019;34:2749–55

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71. García MC, Heilig CM, et al. Opioid prescribing rates in nonmetropolitan and metropolitan counties among primary care providers using an electronic health record system – United States, 2014–2017. MMWR Morb Mortal Wkly Rep 2019;68(2):25–30 72. Keefe, PR. Empire of Pain. The Secret History of the Sackler Dynasty. London: Picador, 2021 73. Helmerhorst GTT, Teunis T, et al. An epidemic of the use, misuse and overdose of opioids and deaths due to overdose, in the United States and Canada. Is Europe next? Bone Joint J 2017;99-B:856–64 74. Curtis HJ, Croker R, et al. Opioid prescribing trends and geographical variation in England, 1998–2018: A retrospective database study. Lancet Psychiatry 2019;6:140–50 75. Alenezi A, Yahyouche A, et al. Current status of opioid epidemic in the United Kingdom and strategies for treatment optimisation in chronic pain. Int J Clin Pharm 2021;43:318–22 76. Jani M, Birlie Yimer B, et al. Time trends and prescribing patterns of opioid drugs in UK primary care patients with non-cancer pain: A retrospective cohort study. PLoS Med 2020;17:e1003270 77. Avery AJ, Sheehan C, et al. Incidence, nature and causes of avoidable significant harm in primary care in England: Retrospective case note review. BMJ Qual Saf 2021;30:961–76 78. Hodkinson A, Tyler N, et al. Preventable medication harm across health care settings: A systematic review and meta-analysis. BMC Med 2020;18:313 79. Avery AJ, Rodgers S, et al. A pharmacist-led information technology intervention for medication errors (PINCER): A multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet 2012;379:1310–19 80. Institute and Faculty of Actuaries. Longevity Bulletin Issue 8. Antimicrobial Resistance. London: Institute and Faculty of Actuaries, 2016 81. Tarrant C, Colman AM, et al. Optimizing antibiotic prescribing: Collective approaches to managing a common-pool resource. Clin Microbiol Infect 2019;25:1356–63

CHAPTER 8

Organisational features of primary health care

We now turn to the question of whether the organisation of primary health care influences mortality. Do funding or staffing levels make a difference? What about access or gatekeeping? After reviewing the evidence on these and other aspects of organisation, six mechanisms that influence mortality are described at the end of the chapter – levels of funding, the range of health professionals who contribute a mix of expertise, access, outreach, a comprehensive service, and responding to the health and social care needs of mothers and children in partnership with other agencies. EXPENDITURE ON PRIMARY HEALTH CARE In 2017, the mean spent on health care of 190 countries was US $1,080 per capita, or around 10% of their GDPs.1 In low-income countries the amount spent was typically $41 per person in 2017 compared to $2,937 in high-income countries. Donor funding accounted for 27% of funding in low-income countries and 3% in lower-middle-income countries. Of 88 countries able to provide data on spending on primary health care, Switzerland spent the most per person per year, $3,884, and the Democratic Republic of the Congo the least, a meagre $11 per person per year. The relationship between health care spending and population mortality tends to be more obvious among low-income than among highincome nations. In order to meet the Sustainable Development Goals for 2030 that include reductions in mortality set by the United Nations DOI: 10.1201/9781003355380-8

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General Assembly, it has been estimated in a modelling study that a group of 67 low- and middle-income countries would need between them an additional amount spent per year of $200 billion to provide a core set of primary health care interventions and $328 billion to create a model of primary health care as set out in the Declaration of Astana.2 Even if only the less ambitious of these two options were to be implemented, it was predicted that 60 million deaths a year would be avoided and life expectancy in low-income countries would increase by 6.7 years, in lower-middle-income countries by 4.0 years, and in upper-middleincome countries by 2.3 years. High-income countries can afford to pay for more than a basic service and are often pressed to do so by public demand. A study of 27 EU states plus four other countries explored the links between strong primary health care and various outcomes including potential years of life lost due to diabetes, ischaemic heart disease, cerebrovascular disease and asthma, bronchitis and emphysema.3 After accounting for confounding variables, stronger primary health care was associated with higher overall health expenditure but lower potential years of life lost due to ischaemic heart disease, cerebrovascular disease and asthma, bronchitis and emphysema. In investigating the effects of health care spending, a wide range of additional factors must be taken into account, including overall national economic performance, the extent of socio-economic inequality in the population, investment in social welfare and education, policies to limit smoking and alcohol use, and road safety and other preventive measures. The effect of health care expenditure on health is also modified by the way funds are used and how services are paid for. Payment systems influence how and whether people who are ill can afford to access services and also the decisions health professionals make about clinical investigations or referrals. They include fee-for-service, private health insurance systems run for profit, social insurance in which employers and employees make contributions, general taxation, or through a mix of these. The transition from predominantly communicable to non-communicable diseases in the population is an additional factor, with the costs of managing long-term chronic conditions being different from those of managing many infectious diseases. It should not be surprising, therefore, that the relationship between funding and mortality becomes more difficult to identify as countries become more wealthy and long-term chronic conditions become more common. It is therefore likely that the effect of additional money for primary health care is greater when the starting level of funding is low rather than when funding is already generous. At some stage, further health care

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expenditure is likely to have no benefit on mortality and it is theoretically possible that continued growth in spending could lead to increases in mortality through the iatrogenic harms of over-medicalisation and the diversion of funds to health care from more beneficial fields such as education or the reduction of environmental pollution. But no country has yet provided evidence of such an effect and this possibility should be regarded as speculative. Among OECD countries in 2016, around 14% of total health spending was devoted to primary health care, equivalent to around $500 per person per year.4 Various ways of finding the money to pay for health care are used in different countries, and the money is allocated to health care providers through different mechanisms. This diversity is complicated by the way in which the different payment approaches direct care to marginalised groups and those most in need. Evidence of the effect of extending health insurance is provided by the Affordable Care Act implemented in 2014 in the United States. The principal goal of the Affordable Care Act was to extend health insurance coverage to more of the population, but it was also intended to increase access to preventive care through wider use of electronic health records and community health workers in primary health care teams. 5 The approach had the potential to improve the health care of previously underserved groups, and available evidence does point to potential reductions in mortality. Although greater access to specialist care would have occurred, greater access to primary health care was also expected to play a role. The Affordable Care Act was associated with lower mortality among people with newly diagnosed breast, colorectal or lung cancer, an effect largely explained in the analysis by earlier diagnosis.6 On average, funding for the NHS in the United Kingdom has grown at a rate of 3.7% a year since its creation in 1948, but between 2009 and 2019 the rate was only 2.1%.7 In 2005/2006 general practice received around 9.6% of the NHS budget, in 2017 the percentage was 8.1%.8 The effect of such restricted funding on population mortality is difficult to estimate; a slowdown in the rate at which life expectancy has improved has occurred in other countries, not just the United Kingdom, and it is likely that a mix of factors is responsible. The spending constraints placed on both health and social care between 2010 and 2014 were associated with a higher-than-expected number of deaths, although the contribution of the funding constraints on primary health care to the excess deaths is difficult to quantify. One analysis suggested that a 1% increase in total health care spending would be associated with a 0.5% reduction in mortality as measured by years of life lost under the age of 75 years.9

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Another analysis suggested that funding constraints in social and health care in England had been associated with 120,000 more deaths than would have been expected over the years 2010 to 2017.10 In an early warning of what was to happen in the pandemic, this time trend analysis found that the population groups most vulnerable to the effects of funding constraints were the elderly and those in care homes. In addition to the overall level of funding, policies are needed to distribute resources to meet the health care needs of poorer neighbourhoods. In England, a funding formula is used to account for primary health care workload and the costs of delivering care to local populations. The formula takes account of population age and sex structure, morbidity and mortality measures, but ethnicity and levels of deprivation are not accounted for. In an analysis of increases in payments for general practices between 2013 and 2017, a 10% higher practice IMD score was associated with an increase of only 0.06% in a practice’s NHS payments.11 People in poor communities are more likely to have a chronic condition, more likely to have multimorbidity, more likely to have undetected conditions, and more likely to have a mental health condition or social problems that make both detection of health problems in the first place and their management in the long-term more challenging and therefore more costly. It is not easy to develop a formula for allocating funds that takes account of these disadvantages, but absence of such a formula is likely to mean that inequities amenable to health care persist. I have not found a study of the effect if any of increased funding for general practices on the mortality rate of practice populations, but there are studies of associations of funding with other features of practice performance. In one study, practices in receipt of a supplement to the capitation payments achieved fewer emergency department attendances, emergency admissions and admissions for ambulatory care sensitive conditions.12 Another study related funding to the quality ratings awarded to 7,310 general practices after external inspections by the regulator of health care quality, the Care Quality Commission.13 Adjusting for known confounders, higher capitation funding per patient was associated with higher ratings in all of the assessed domains of quality as well as the overall quality rating. Greater funding of primary health care, therefore, is associated with lower population mortality in low- and middle-income countries and evidence relating to high-income countries supports an association as well. However, the distribution of funds does not always account for the needs of disadvantaged populations.

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STAFFING The number of staff is one of several measures of the quantity of primary health care available but most of the evidence relates to doctors. The evidence of an association between the number of doctors and mortality has been laid out in Chapter 4, but primary health care is delivered by a variety of health professionals. The effect of staff on mortality will depend not only on the number of staff per unit of population but also on the roles of the staff, the patient groups that they care for, their support and training, and the community and health system context in which they are deployed. In almost all countries, nurses are critical to the delivery of primary health care services. Their roles vary from being the principal providers of care to team members working alongside other professionals. Task shifting in which nurses take over some of the functions of doctors is increasingly common in high-income countries. Since nurses are frequently the professionals who deliver preventive health care or manage the routine care of chronic conditions, it may be supposed that greater access to primary health care nurses would be associated with lower population mortality. Unfortunately, there has been relatively little research of the impact on mortality of nurses in primary health care (in contrast to research on numbers of doctors), but the evidence that is available tends to support an effect. In a study of the effect of funding in England, failure to employ sufficient nurses in health and social care was found to be associated with stalling mortality rates.11 A recent overview of 61 reviews of the effect on outcomes of various nursing interventions concluded that in many low-income countries, nurses are critical to reducing mortality through the management of acute conditions and the prevention of disease.14 For example, the effectiveness of health promotion and vaccination is wellestablished, and nurses are often responsible for these aspects of care. The substitution of doctors by nurses in primary health care has been investigated in randomised controlled trials. A systematic review of 18 of these trials, 17 of which were conducted in high-income countries, provides encouragement in some groups of patients.15 Eight trials investigated the effect on mortality and a meta-analysis suggested that nurseled care might lead to slightly fewer deaths (6 deaths per 1,000 people at risk for doctor-led care, and between 4 and 6 for nurse-led care), but the finding was graded as of low certainty since the range of effect identified in the statistical analysis included the possibility of no difference. Another reason for caution in interpreting this finding is that the patients in these trials were limited to those with a specific chronic condition in need of continuing care such as HIV or rheumatoid arthritis,

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or minor illnesses with high-risk cases diverted to doctors. Other clinical outcomes were similar for both nurse and doctor consultations. However, nurse consultations were probably longer, and the review also concluded that patient satisfaction was probably slightly higher for nurse consultations. However, this is an ‘apples and oranges’ comparison.16 An apple (a consultation with a nurse) may be a very satisfactory apple, but it is not an orange (a consultation with a doctor). In past years in highincome countries, patients could insist on consulting a doctor but in the face of growing demand and failure to build up the medical workforce, this principle has been undermined by triage systems that disempower patients and direct them to other practitioners. This is a policy borne of necessity rather than one arising from evidence. There has been little or no research of the relationship between the number of primary health care nurses and population mortality in high-income countries. In view of the number of nurses working in primary health care and the wide range of roles they perform, it is surprising that the research evidence of their impact is so limited. On the basis of what is known, however, nurses are key primary health care professionals. It is also evident that teams of doctors and nurses, and probably other groups of professionals, are essential to the delivery of effective services. Indeed, almost no country any longer has a doctor-only delivered primary health care system. Receptionists, managers and other non-clinical staff also work in primary health care. These groups are also under-investigated and may crucially modify factors such as access to care by socially disadvantaged patients, but it is not possible to quantify their potential impact on patient health. Community health workers are the foundation of primary health care teams in many low-income countries. In middle-income countries, community health workers are often joined by nurses in providing the point of access to health care. Community health workers can also be found in highincome countries where they tend to focus on providing care to underserved groups or for selected non-communicable diseases. A systematic review of reviews of the impact of community health workers in low-, middle- and some high-income countries identified several factors that influenced their success.17 Their effect was greater when they had clear roles with a limited number of tasks, training that covered not only technical issues but also skills in communication and counselling, supportive supervision, reliable provision of supplies and remuneration, a location within the community to help local acceptance, and integration with the local health system. Community health workers can potentially help low- and middleincome countries manage the growing burden of chronic disease. In a cluster-randomised controlled trial undertaken in Bangladesh, Pakistan and Sri Lanka, trained community health workers made home visits to

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manage the care of people with hypertension.18 They delivered health education to patients and families, and could refer people with poorly controlled blood pressure or at high risk of cardiovascular disease to a primary health care facility. At the end of two years follow-up, blood pressure control and health status were better in the intervention group; the number of cardiovascular deaths in the intervention group was 8 compared to 23 in the control group, a statistically significant difference. The effect of community health workers in reducing health inequities is inconsistent.19 In a project in northern Ghana, community teams consisting of a nurse with volunteer community health workers undertook home visits and facilitated participatory women’s groups that involved learning and taking practical action. The nurse and community health worker teams were more successful than either community health workers or nurses alone in reducing inequity in mortality rates between children of wealthier or more educated families and those of disadvantaged families. 20 A review of evidence on the impact on neonatal mortality and other outcomes related to childbirth concluded that community based primary health care built around community health workers often did have the greatest benefit for the poorest segment of the population. 21 However, only 10 of the 93 included studies investigated the effect on equity and of these ten, there were reductions in inequity in neonatal outcomes in seven, no effect on one, and increased inequity in two. It would seem that services based on community health workers must be explicitly designed and delivered to affect health equity if they are to make a difference to outcomes between the rich and the poor. A review of the impact of community health workers in US health care concluded they can be effective in delivering care for chronic diseases, including to marginalised groups, especially when thoroughly trained and supported, and included as part of health care teams.22 However, even in such a rich country as the United States, community health workers serving undocumented Latin American immigrants, African American refugees or people with drug addictions or mental health problems, have reported facing challenges in accessing resources including the availability of health and social services for their patients, and lack of awareness of their roles among health professionals. 23 Several other groups of professionals contribute to primary health care. These can include physiotherapists, advanced nurse practitioners, social workers, physician associates and pharmacists. There are also mental health professionals such as community psychiatric nurses, clinical psychologists and behavioural health practitioners. Although they may benefit care in a variety of ways, evidence that they reduce population mortality is limited or absent. Evidence about the effect of

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pharmacists is mixed. In a systematic review of randomised trials, medication reviews by a pharmacist of a specific group of patients – those in nursing homes – were not found to lead to reduced deaths or hospital admissions. 24 However, in a randomised trial in a US health maintenance organisation having a pharmacist review in ambulatory care led to reduced mortality and fewer hospital admissions. 25 A major UK trial in primary health care demonstrated how pharmacists can reduce prescribing errors that could have the potential to cause serious harm. 26 A review of 38 randomised trials of pharmacists located in general practices reported positive effects on at least one outcome in 25 of the trials, including improvements in blood pressure, cholesterol and glycated haemoglobin control. 27 However, large, long duration trials are needed to test the effect on mortality.

Teamwork Failure of communication within the team, lack of leadership in developing plans and priorities, poor staff development and support, and failing relationships all have the potential to impair the delivery of care. Models of teamwork in primary health care suggest that teamwork does affect population outcomes although evidence relating to mortality is lacking.28 A recent review of team characteristics and outcomes included 77 articles and concluded that the addition of new professionals to teams, the adoption of new models of care, and new approaches to planning can improve aspects of the management of chronic disease, but there was insufficient evidence to make statements about the impact on health outcomes. 29 The effectiveness of teamwork can be related to the agreement of objectives, the participation of all team members, and support for innovation.30 These processes were incorporated into a team climate questionnaire about how teams function, enabling the relationship between climate and team effectiveness to be explored in several studies. A review of studies of team climate in primary health care has concluded that insufficient information is currently available to allow firm conclusions about a relationship with outcomes, and there is as yet, no evidence about any effect on population mortality.31 FIRST-CONTACT CARE AND GATEKEEPING Starfield defined first-contact care as accessibility to and use of services for each new problem for which people seek health care. 32 There are occasions, however, in which people seek care for new problems from services other than primary health care, for example, injuries or sudden

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medical crises. Therefore, it is probably more accurate to regard primary health care as the first point of contact with services for the majority, but not all, of the health problems for which people seek help. The provision of first-contact care for most health problems equips health systems with a clear point of access for patients, but evidence of an impact on population mortality is lacking. It is not always welcomed by patients, a survey of the general public in one province of China showing that 70% of respondents preferred hospital services for first contact care. 33 Distrust in the competence of primary health care staff lay behind this finding, with acceptance of the first-contact role for primary health care depending on perceptions of the quality of care offered. Gatekeeping, in which access to specialists is allowed only through the first point of contact with the health system, is indeed a form of restriction on patient access to care, and can sometimes have a negative effect on mortality. For example, gatekeeping has been shown in some studies to be associated with lower cancer survival rates, perhaps because of delays in diagnosis.34 On the other hand, gatekeeping may help coordinate the care of people with multimorbidity and also reduce unnecessary use of expensive secondary care. By reserving access to specialist services for those who genuinely need it, it may prevent specialist care becoming overwhelmed and thereby improve overall mortality rates. A review of studies of the impact of gatekeeping by primary health care doctors found 25 relevant studies, 21 of which were observational in design; one was a randomised trial, one a review, and two studies of care before and after the introduction of gatekeeping.35 Almost all the studies were from high-income countries. The findings confirmed lower cancer survival rates in gatekeeping systems and patient satisfaction was also lower, but health care use and expenditure were lower and other aspects of quality of care were better. More educated people tend to have greater use of specialist services in European countries including the United Kingdom even when the need for care in more or less educated people is the same.36 Gatekeeping does not appear to correct this inequity. Gatekeeping could help to reduce inequalities in access to care by limiting the role of individuals and allowing primary health care professionals to act as advocates for less privileged patients. However, it appears to increase inequities since wealthy or better educated patients are more successful in negotiating their way through the health system. Wealthy patients can also choose to use private specialist care if this is available. A survey of 40,000 people in the 27 European Union countries reported that 6% of people had paid a bribe for health care and 29% had used personal connections to receive care.37 In a study from the United Kingdom general practice, the likelihood

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of referral of symptomatic patients presenting with hip pain aged 85 or over or with dyspepsia in people aged 55 or over decreased as socioeconomic deprivation increased, although there was no such association for postmenopausal bleeding.38 Since more countries are developing systems of gatekeeping, research into the consequences is needed for high-, middle- and low-income countries. In summary, then, do the benefits of first-contact care and gatekeeping outweigh the potential harms? Unfortunately, the evidence is incomplete. Even if gatekeeping turns out to have advantages, its effect in increasing inequities in access to specialist care needs addressing. ACCESS Access is a prerequisite to receiving health care and therefore better access to interventions known to be effective should lead to lower mortality. The evidence bears this out. In a study of 7,856 general practices in England, an association was found between patient reports of being able to get an appointment within 48 hours and mortality; better reported access was associated with lower all-cause mortality for people under 75 years.39 In a study in Washington State in the United States, a measure of access to primary health care was constructed from data on population dispersion and travel time to primary health care to create a primary health care access score.40 Higher scores indicated better access and were associated with lower all-cause mortality and lower mortality due to heart disease and cancers. Access, the ability of a health system to offer consultations for people with health problems, is to some extent another measure of the quantity of primary health care, although modulated by the way it is deployed to meet the needs of the population. In an efficient health care system, if more primary health care is made available, access should improve. Other factors also influence access, however, such as financial barriers and travelling time to health care facilities. A review of studies of access to care and under-five mortality in Sub-Saharan Africa found that distance to health facilities and costs for services could influence access.41 Other factors were also relevant. Social status, levels of domestic help and social support, health knowledge and caregiver authority over spending could all influence whether mothers accessed services. Female autonomy also played a role in decisions about accessing care, the need to seek permission from a male household member being a factor that could cause delays and increase the risk of child death. Some groups face particular challenges in access to health care. Migrants, asylum seekers, travellers, the homeless, LGBTQ+ people,

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and some Indigenous and other minority ethnic groups can face difficulties, as can people with hearing or visual loss. Access to primary health care services for people in prisons is often inadequate. This problem, related to increased death rates in both the United Kingdom and United States, disproportionately affects Black and ethnic minority inmates.42,43 National policies on health care funding, plans to achieve universal health coverage, whether populations are geographically widely dispersed or concentrated, and attitudes towards achieving equity in health and health care, all affect the levels of access different countries offer their citizens. Candidacy is a theory that has been proposed to explain the difficulties some patients encounter in accessing health care. The theory argues that a patient’s eligibility for access to health care – whether they can be regarded as a candidate for care – is determined by the individual, their social context and the family or people who support or advise them, and the health system that decides which health problems merit attention.44 The interaction between the system’s and the patient’s views on eligibility lead to the patient being recognised, or not, as a suitable candidate for health care. The theory of candidacy has been used in numerous studies to understand access to care. The general message is that gaining recognition as a candidate for care can sometimes be a challenge, but it is particularly difficult for some ethnic, social or disease groups. The influence of candidacy is illustrated by a study using simulated patients undertaken in Texas in the United States.45 The people acting the role of patients represented different ethnic groups and genders, including adopting names associated with different groups. They were asked to telephone a sample of primary health care offices as new patients requesting an appointment. If asked about health insurance, the simulated patients reported that they did not have insurance but would pay for care themselves. The health problems assigned to the simulated patients were chosen to be typical of the range of problems seen in each clinic but excluding emergencies that would demand an urgent assessment. Black and Hispanic callers were more likely to be asked about their health insurance than White callers, and the mean wait for appointments for White patients was 8.6 days, but 11.2 for Hispanic patients and 12.2 days for Black patients. In an analysis of data from the general practice patient survey in England, South Asian and Chinese patients, younger patients and those in poor health reported a less positive primary care experience than White patients, older patients and those in better health.46 This is not fully explained by different interpretations of survey questions being made by different groups. The low scores of most South

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Asian and Chinese patients were partly explained by receiving care from practices in which most patients, regardless of ethnicity, reported worse experience. In a review involving 38 countries focused on the homeless, people with substance use disorders, sex workers and people in prison (marginalised people who may not always be judged as candidates for care), rates of mortality were up to 10 times higher than the population as a whole.47 Within these groups, women tended to suffer higher mortality. The factors that lead to marginalisation in the first place – housing, poverty and other social determinants of health – need to be addressed but so does access. A navigator or advocate may help, that is someone who accompanies the marginalised person with multiple disadvantages to primary health care and helps them gain access to the services required. 48 Of the homeless in England, rough sleepers have the greatest barriers to access, with low rates of registration with general practitioners and consequent reduced use of hospitals. In a survey of 2,505 homeless people, as many as a quarter reported being refused registration with a GP or dentist.49 Services that include outreach activities, involve multidisciplinary teams with public health nurses, and allow for close integration with mental health services can improve outcomes.50 Access is also a problem for LGBT+ people. Stonewall’s survey of 5,375 LGBT+ people in England, Scotland and Wales reported that one in seven had avoided treatment because of fear of discrimination and one in four reported a lack of understanding by health care staff.51 Roma and travellers can also face difficulties in access to primary health care. Roma in Eastern Europe have less knowledge of the health care facilities available and are met with poorly responsive services when they do seek help.52 The costs of care, distance to health care facilities and the prejudice of health care staff are additional barriers, but when primary health care adjusts its policies to accommodate the local population, effective care can be provided.53 Examples of the beneficial adjustments include training about Roma culture, the provision of translation services, and the use of a mediator between primary health care and the Roma population to build confidence and understanding. COMPREHENSIVENESS Comprehensiveness is commonly regarded as care throughout life of the majority of the health care needs of the majority of patients. Whether the patient is an infant, an adolescent, a middle-aged adult or frail old person, primary health care deals with most clinical problems. It may also help with some social problems. Evidence from low-income countries of

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the benefits of advancing beyond isolated disease programmes towards the creation of services caring for mothers and children, and onwards to the care of all citizens, demonstrates how comprehensive primary health care leads to reductions in mortality. Countries with higher total health care expenditure tend to provide more comprehensive primary health care than countries with lower expenditure.54 Although the care of children has been a priority in lowand lower-middle-income countries and has been responsible for substantial reductions in mortality, the preoccupation of health systems in high-income countries further advanced in the epidemiological transition has turned from children to older people with chronic conditions. The priority appears to have become the avalanche of chronic disease, with the primary health care of children becoming comparatively neglected. The profound effect of environmental, social and economic factors on health inequities in childhood have been summarised by England’s Children’s Commissioner.55 In addition to increased mortality, greater deprivation is associated with the failure to reach the expected levels of physical, emotional and mental development. Meanwhile, the proportion of children living in poverty has been rising. The Commissioner called on the NHS to commit to identifying vulnerable children who have specific health needs or other issues likely to impact healthy development. Adversity in childhood is not only a risk factor for childhood mortality; the impact can persist and lead to an increased risk of adult premature mortality. Recommendations to government made in a report from the Royal College of Paediatrics and Child Health included provision of effective preventive and clinical services with a particular focus on primary health care and overcoming the adverse health effects of poverty.56 The report recommended that more GPs be supported to access child health training opportunities by extending their training, and that all child health professionals should be trained in dealing with children and young people presenting with mental health problems. Three models of primary health care for children can be found in Europe: (1) The provision of services for children by paediatricians, (2) delivery shared by paediatricians and primary health care professionals in collaboration and (3) delivery by primary health care professionals with referral of selected cases, as in the United Kingdom. The best approach is not clear but several countries, including the United Kingdom, need to take action to improve outcomes.57 Close collaboration between primary health and specialist care is important, whichever organisational form is chosen. In England, child health general practice hubs offer one approach, in which paediatricians and general practitioners participate in joint clinics and multidisciplinary meetings.58 Integrated and shared

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record systems and the use of data for the analysis of population health may be another.59 In different countries or regions, depending on local circumstances, primary health care may provide obstetric care, surgical operations, or health education delivered to communities. In many high-income countries, however, primary health care has withdrawn from much of maternity care. Reconnection with the family doctor’s role might help. In addition to a regular review of the general health of pregnant women, this should include preconception advice. Good health prior to conception is more likely to be followed by the birth of a healthy child, and primary health care is the principal service for helping women improve their lifestyles and for detecting and managing conditions that put health at risk.60 It can also assess the social determinants of the health of the mother and the anticipated child, and can offer tailored support. Out-of-hours care is care provided when clinics are closed in the evening and night, on weekends and on public holidays, and is one element of a comprehensive service. Having been the norm, direct provision of out-of-hours care by individual general practices has become uncommon in many countries. A survey of 27 OECD countries reported that out-ofhours services in most health systems were facing challenges, including the reluctance of primary health care physicians to participate because of the high workload and poor remuneration, with variations in access to services within countries leading to over-use of hospital emergency departments. In response to these pressures, services are increasingly provided by a range of providers, including groups of professionals operating a rota to provide cover over a geographical area, practice-based services and primary care centres of various types. The impact of these different services on population mortality is unclear. OUTREACH AND COMMUNITY ENGAGEMENT The value of outreach, of taking health professionals and services into local communities to bring health care to people not otherwise routinely in contact with it, was demonstrated by initiatives to increase uptake of COVID-19 vaccination. It was common throughout Europe to find pop-up clinics in places of worship or hostels serving homeless people or a vaccine bus that visited areas of high deprivation.61 Communitybased primary health care involves health services and communities working together to improve health. It can include health promotion for households as well as the provision of health care in the community and beyond health facilities. It is an approach implemented in low- and middle-income countries by governments, non-governmental

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organisations, community health workers, private or research organisations and others. Reviews have claimed reductions in maternal62 and neonatal mortality63 and child mortality.64 It appears to be more likely to be effective if it includes comprehensive primary health care with an emphasis on maternal, child health and family planning services, secure systems for referral of patients to more intensive health services, and high levels of community engagement.65 A meta-analysis of seven trials of community engagement built on women’s groups reported an estimated 49% reduction in maternal mortality and 33% reduction in neonatal mortality.66 Experience of community engagement and outreach is developing in high-income countries. In the United States, there are examples of communities working together to improve population health.67 Outreach activities in high-income countries have also focused on marginalised groups who suffer high mortality rates such as the homeless, sex-workers and people addicted to drugs.48 The process of bringing health and social care together in a service that takes tailored actions to contact people in these groups is increasingly being referred to as inclusion health. Reviews of studies of programmes to reach and support marginalised groups confirm that services designed to meet their needs can improve health and reduce mortality.51,68,69 Social prescribing is a recent development in the tradition of community engagement. It involves non-medical interventions intended to help patients improve their health behaviours and to address social and other determinants of health.70 A social prescription is a referral for a patient to an activity within the local community, for example, physical activities at a gym or exercise classes, weight management, support in applying for welfare benefits, employment advice or volunteering activities and others. The Glasgow Deep End Link Worker Programme shared some features of social prescribing and involved the appointment of link workers to general practices serving deprived patient populations.71 General practitioners could refer patients to the link worker who would then arrange access to community organisations such as walking groups, debt management support, welfare rights, drug and alcohol management support and befriending schemes. Although uptake of community services increased among those patients referred to the link worker, outcomes were not improved in comparison with patients of practices without a link worker. Evidence from studies to evaluate social prescribing suggests there may be some reduction of demand for general practice services but the available evidence has not yet confirmed benefits in health

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outcomes.72 Two systematic reviews reached similar conclusions, finding insufficient evidence to judge whether they were effective or value for money.73,74 MECHANISMS

Mechanism XII Increases in funding for primary health care that are used to provide more care to more patients lead to reduced population mortality, although: • •

The incremental benefits diminish when funding is already at a high level And formulae for allocating funds to reduce inequity in outcomes are poorly developed

Level of Evidence – Strong COMMENTARY It is of course true that much depends on what is done with money for primary health care services; imprudent use of large sums of money will not necessarily be more effective in improving health than the more considered use of smaller sums. However, the available evidence confirms a broadly consistent relationship between funding and measures of health, including mortality. Randomised trials of different levels of funding are not available, but international evaluations of health services do indicate that more funding enables the provision of more health care facilities, the employment of more staff, and the treatment of more patients. Funding may therefore be regarded as another measure of the quantity of primary health care available to a population but the effect of increased funding on health is moderated by the choices made in the use of the additional funds and the amount of funding already in place. If funding is already at a high level, there may be little or no reductions in population mortality. Even so, in almost all health systems in the world the demand for care exceeds its supply and increases in funding that increase supply can be expected to reduce population mortality. Increased funding does not guarantee reductions in inequities. Again, this depends on how the money is spent. Funding should be allocated to enable the needs of disadvantaged populations to be met, but a fair and effective allocation formula is not yet available. Funding that allows people to eat a healthy diet, heat their homes and nurture their children are necessary too.

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Mechanism XIII A blend of different professionals in primary health care, tailored to local needs reduces population mortality by • • •

Broadening the expertise available to patients Increasing access to care, including for those from disadvantaged groups Improving management of some conditions

There is more evidence about the effects of nurses and community health workers than other professional groups. Level of Evidence – Moderate COMMENTARY There is as yet little experimental evidence of the benefits of a multi-professional in comparison with a uni-professional workforce. On the other hand, there is wide acceptance that the delivery of cost-effective care to diverse populations requires a mix of staff, the proportions of different staff being dictated by the needs of those served, and there is evidence of the beneficial effects of nurses and community health workers in various settings. The employment of a variety of staff not only brings a mix of expertise better able to manage different health problems but it also enables contact with a wider range of people in the population, for example mothers with young children, those housebound because of disease or disability, and the homeless or marginalised. A lone doctor in an office cannot meet the needs of all these different groups.

Mechanism XIV Access to primary health care and the access it controls to specialist care (gatekeeping) affect population mortality and inequity in mortality between disadvantaged and privileged groups. Level of Evidence – Strong COMMENTARY There is a large body of consistent evidence to show that access to primary health care can be difficult for many patients, including ethnic minorities, the socio-economically deprived, LGBT+ people, the homeless, travellers, individuals who are hearing and/or vision impaired and others. There is

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also evidence to show that reduced access is associated with higher mortality rates and there are examples of initiatives to improve access that achieved improved outcomes. However, unless specific policies are routinely implemented to eliminate the barriers faced by specific groups, there is a risk that inequity becomes built into the way access systems work. Having managed to gain access to primary health care, patients can encounter barriers to onward referral to specialist care in health systems with gatekeeping. In general, it is the same groups that face the most barriers. The idea of candidacy, in which both patients and services can be the source of barriers, is useful for understanding how these groups come to be disadvantaged by access systems, but it has not yet been extensively used to investigate gatekeeping.

Mechanism XV By actively engaging with communities through outreach activities, primary health care can reduce mortality among underserved or marginalised groups. Level of Evidence – Strong COMMENTARY The evidence of impact on mortality for outreach and community engagement activities largely rests on studies conducted in low- and middleincome countries. There is some supporting evidence from high-income countries in relation to marginalised groups, especially the homeless and those addicted to drugs. The inclusion not only of primary health care staff but also health professionals with expertise in mental health and drug misuse combined with partnership with social care services appears to be key to effectiveness.

Mechanism XVI Primary health care reduces population mortality by providing a comprehensive service that meets the needs of most patients. Level of Evidence – Moderate COMMENTARY Although there is little or no experimental evidence, the benefits of comprehensive care are demonstrated by the development of primary health care as countries progress through the demographic transition.

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When care is extended beyond single disease programmes to focus on the health problems of groups of people, specifically mothers and young children, mortality rates decline. By caring for people rather than specific diseases, primary health care improves population health.

Mechanisms XVII Primary health care can reduce population mortality by • •

Supporting the health and welfare of mothers Acting to avoid or mitigate the effect of adverse childhood experiences

These interventions often involve partnership with other health or social care agencies. Level of Evidence – Moderate COMMENTARY The effect of primary health care for mothers and children on mortality in low- and middle-income countries is substantial. There is less evidence from high-income countries, and there is diversity among them in the structure of services for children, suggesting a lack of consensus about the role of primary health care in children’s health. There are no randomised controlled trials of the long-term effects on mortality of primary health care interventions to address adverse childhood experiences but there is an abundance of evidence of the importance of prenatal, infant and childhood experiences on future health. Attempts to improve the primary health care of children have to contend with the unavoidable preoccupation of policymakers in high-income countries with services for non-communicable disease in adults. This has occurred following a retreat of primary health care from aspects of maternity care. The direction of change has therefore been away from the old idea of family medicine and towards systems of care for chronic conditions. The consequence for mortality rates in infants and children is difficult to estimate, but a negative effect cannot be ruled out. In some countries, the importance attached to child health in primary health care needs to be restored. REFERENCES 1. WHO. Global spending on health: A world in transition. Geneva: WHO, 2019 2. Stenberg K, Hanssen O, et al. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: A modelling study. Lancet Glob Health 2019;7:e1500–10

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3. Kringos DS, Boerma W, et al. Europe’s strong primary care systems are linked to better population health but also to higher health spending. Health Aff 2013;32:686–94 4. OECD. Spending on primary care: First estimates. Paris: Organisation for Economic Co-operation and Development, 2018 5. Gore R, Dhar R, et al. Changing clinic-community social ties in immigrantserving primary care practices in New York City: Social and organizational implications of the Affordable Care Act’s population-health-related provisions. The Russell Sage Foundation Journal of the Social Sciences 2020;264–87 6. Lam MB, Phelan J, et al. Medicaid expansion and mortality among patients with breast, lung, and colorectal cancer. JAMA Netw Open 2020;3(11):e2024366 7. Charlesworth A, Gershlick B, et al. Briefing: Investing in The NHS long term plan. London: The Health Foundation, 2019 8. BMA. Investment in general practice. London: British Medical Association, 2020 9. Martin S, Longo F, et al. Causal impact of social care, public health and healthcare expenditure on mortality in England: Cross-sectional evidence for 2013/2014. BMJ Open 2021;11:e046417 10. Watkins J, Wulaningsih W, et al. Effects of health and social care spending constraints on mortality in England: A time trend analysis. BMJ Open 2017;7:e017722 11. Levene LS, Baker R, et al. Socioeconomic deprivation scores as predictors of variations in NHS practice payments: A longitudinal study of English general practices 2013–2017. Br J Gen Pract 2019. DOI:https://doi.org/10.3399/ bjgp19X704549 12. L’Esperance V, Sutton M, et al. Impact of primary care funding on secondary care utilisation and patient outcomes: A retrospective cross-sectional study of English general practice. Br J Gen Pract 2017;67:e10-e19 13. L’Esperance V, Gravelle H, et al. Relationship between general practice capitation funding and the quality of primary care in England: A crosssectional, 3-year study. Br J Gen Pract 2019;9:e030624 14. Coster S, Watkins M, et al. What is the impact of professional nursing on patients’ outcomes globally? An overview of research evidence. Int J Nurs Stud 2018;78:76–83 15. Laurant M, van der Biezen M, et al. Nurses as substitutes for doctors in primary care. Cochrane Database Syst Rev 2018;7:CD001271 16. Redsell S, Jackson C, et al. Patients’ accounts of the differences in nurses’ and general practitioners’ role in primary care. J Adv Nurs 2007;57: 172–80 17. Scott K, Beckham SW, et al. What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers. Human Resources for Health 2018;16:39 18. Jafar TH, Gandhi M, et al. A community-based intervention for managing hypertension in rural South Asia. N Engl J Med 2020;382:717–26 19. Blanchard AK, Prost A, et al. Effects of community health worker interventions on socioeconomic inequities in maternal and newborn health in lowincome and middle-income countries: A mixed-methods systematic review. BMJ Global Health 2019;4:e001308 20. Bawaha AA, Phillips JF, et al. Does the provision of community health services offset the effects of poverty and low maternal educational attainment on childhood mortality? An analysis of the equity effect of the Navrongo experiment in Northern Ghana. SSM Popul Health 2019;7:100335

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21. Sacks E, Freeman PA, et al. Comprehensive review of the evidence regarding the effectiveness of community–based primary health care in improving maternal, neonatal and child health: 3. neonatal health findings. J Glob Health 2017;7:010903 22. CDC. Policy evidence assessment report: Community health worker policy components. Atlanta: Centers for Disease Control and Prevention, 2014 23. Logan R. ‘A poverty in understanding’: Assessing the structural challenges experienced by community health workers and their clients. Glob Public Health 2020;15:137–50 24. Wallerstedt SM, Kindblom JM, et al. Medication reviews for nursing home residents to reduce mortality and hospitalization: Systematic review and meta-analysis. Br J Clin Pharmacol 2014;78:488–97 25. Yuan Y, Hay JW, et al. Effects of ambulatory-care pharmacist consultation on mortality and hospitalization. Am J Manag Care 2003;9:45–56 26. Avery AJ, Rodgers S, et al. A pharmacist-led information technology intervention for medication errors (PINCER): A multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet 2012;379:1310–19 27. Tan ECK, Stewart K, et al. Pharmacist services provided in general practice clinics: A systematic review and meta-analysis. Res Social Adm Pharm 2014;10:608–22 28. Warde CM, Giannitrapani KF, et al. Teaching primary care teamwork: A conceptual model of primary care team performance. Clin Teach 2020;17:249–54 29. Wranik WD, Price S, et al. Implications of interprofessional primary care team characteristics for health services and patient health outcomes: A systematic review with narrative synthesis. Health Policy 2019;123:550–63 30. Poulton BC, West MA. The determinants of effectiveness in primary health care teams. J Interprof Care 1999;13:7–18 31. Goh TT, Eccles MP. Team climate and quality of care in primary health care: A review of studies using the Team Climate Inventory in the United Kingdom. BMC Res Notes 2009;2:222 32. Starfield B. Primary Care, Balancing Health Needs, Services and Technology. Oxford: Oxford University Press, 1998 33. Wu D, Lam TP, et al. Health reforms in China: The public’s choices for firstcontact care in urban areas. Fam Pract 2017;34:194–200 34. Greenfield G, Foley K, et al. Rethinking primary care’s gatekeeper role. BMJ 2016;354:i4803 35. Sripa P, Hayhoe B, et al. Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: A systematic review. Br J Gen Pract 2019;69:e294–303 36. Fjær EL, Balaj M, et al. Exploring the differences in general practitioner and health care specialist utilization according to education, occupation, income and social networks across Europe: Findings from the European Social Survey (2014) Special Module on the Social Determinants of Health. Eur J Public Health 2017;27(sup. 1):73–81 37. Transparency International. Global Corruption Barometer EU: People worried about unchecked abuses of power. June 2021. www.transparency. org/en/news/gcb-eu-2021-survey-people-worry-corruption-uncheckedimpunity-business-politics 38. McBride D, Hardoon S, et al. Explaining variation in referral from primary to secondary care: Cohort study. BMJ 2010;341:c6267 39. Baker R, Honeyford K, et al. Population characteristics, mechanisms of primary care and premature mortality in England: A cross-sectional study. BMJ Open 2016;6:e009981

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40. Amiri S, Espenschied JR, et al. Access to primary care physicians and mortality in Washington State: Application of a 2-step floating catchment area. J Rural Health 2019;36:292–99 41. Rutherford ME, Mulholland K, et al. How access to health care relates to under-five mortality in sub-Saharan Africa: Systematic review. Trop Med Int Health 2010;15:508–19 42 Independent Advisory Panel on Deaths in Custody and Royal College of Nursing. Avoidable natural deaths in prison custody: Putting things right. London: RCN, 2020 43. Bovell-Ammon BJ, Xuan Z, et al. Association of incarceration with mortality by race from a national longitudinal cohort study. JAMA Netw Open 2021;4:e2133083 4 4. Dixon-Woods M, Cavers D, et al. Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol 2006;6:35 45. Wisniewski JM, Walker B. Association of simulated patient race/ethnicity with scheduling of primary care appointments. JAMA Netw Open 2020;3:e1920010 46. Lyratzopoulos G, Elliott M, et al. Understanding ethnic and other sociodemographic differences in patient experience of primary care: Evidence from the English General Practice Patient Survey. BMJ Qual Saf 2012;21:21–29 47. Aldridge RW, Story A, et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: A systematic review and meta-analysis. Lancet 2018;391:241–50 48. McCarthy L, Parr S, et al. Understanding models of support for people facing multiple disadvantage: A literature review. Sheffield: Centre for Regional Economic and Social Research, Sheffield Hallam University, 2020 49. Elwell-Sutton T, Fok J, et al. Factors associated with access to care and healthcare utilization in the homeless population of England. J Public Health 2016;39:26–33 50. Jego M, Abcaya J, et al. Improving health care management in primary care for homeless people: A literature review. Int J Environ Res Public Health 2018;15:309 51. Stonewall. LGBT in Britain. Health Report. London: Stonewall, 2018 52. Muncan B. Eastern European Roma: Ethnic discrimination in the public healthcare system. J Glob Health Rep 2018;2:e2018025 53. Graaf P de, Rotar Pavlic D, et al. Primary care for the Roma in Europe: Position paper of the European Forum for Primary Care. Zdrav Var 2016;55:218–24 54. Pavlič DR, Sever M, et al. Strength of primary care service delivery: A comparative study of European countries, Australia, New Zealand, and Canada. Prim Health Care Res Dev 2018;19:277–87 55. Children’s Commissioner. Children’s Commissioner’s Briefing: Health Inequalities in Childhood. 2020. www.childrenscommissioner.gov.United kingdom/report/health-inequalities-briefing/ 56. Royal College of Paediatrics and Child Health. State of Child Health Report 2017. London: RCPCH, 2017 57. Hoey H, Pettoello-Mantovani M, et al. Diversity of child health care in Europe. Arch Dis Child 2021;106:732–33 58. Montgomery-Taylor S, Watson M, et al. Child Health General Practice Hubs: A service evaluation. Arch Dis Child 2016;101:333–37 59. Hassanzadeh R, Klaber R, et al. Data-driven, integrated primary and secondary care for children: Moving from policy to practice. J Royal Soc Med 2021;114:63–8

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60. Stephenson J, Heslehurst N, et al. Before the beginning: Nutrition and lifestyle in the preconception period and its importance for future health. Lancet 2018;391:1830–41 61. Kumpunen S, Webb E, et al. Transformations in the landscape of primary health care during Covid-19: Themes from the European region. Health Policy 2022;126:391–97 62. Jennings MC, Pradhan S, et al. A comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 2. Maternal health findings. J Glob Health 2017;7(1):010902 63. Sacks E, Freeman PA, et al. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 3. Neonatal health findings. J Glob Health 2017;7(1): 010903 64. Freeman PA, Schleiff M, et al. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 4. Child health findings. J Glob Health 2017;7(1):010904 65. Perry HB, Rassekh BM, et al. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 7. Shared characteristics of projects with evidence of long–term mortality impact. J Glob Health 2017;7(1): 010907 66. Prost A, Colbourn T, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: A systematic review and meta-analysis. Lancet 2013;381:1736–46 67. Robert Wood Johnson Foundation. From vision to action: Measures to mobilize a culture of health. 2015. Princeton: Robert Wood Johnson Foundation, 2015 68. Miler JA, Carver H, et al. What treatment and services are effective for people who are homeless and use drugs? A systematic ‘review of reviews’. PLoS One 2021;16:e0254729 69. Davies A, Wood AJ. Homeless health care: Meeting the challenges of providing primary care. Medical Journal of Australia 2018;209:230–34 70. Drinkwater C, Wildman J, et al. Social prescribing. BMJ 2019;364:l1285 71. Mercer SW, Fitzpatrick B, et al. Effectiveness of community-links practitioners in areas of high socioeconomic deprivation. Annals Fam Med 2019;17:518–25 72. Carnes D, Sohanpal R, et al. The impact of a social prescribing service on patients in primary care: A mixed methods evaluation. BMC Health Serv Res 2017;17:835 73. Bickerdike L, Booth A, et al. Social prescribing: Less rhetoric and more reality. A systematic review of the evidence. BMJ Open 2017;7:e013384 74. Pescheny JV, Randhawa G, et al. The impact of social prescribing services on service users: A systematic review of the evidence. Eur J Public Health 2019;30:664–73

CHAPTER 9

The patient–professional relationship

The outcomes of the clinical relationship are many and varied, and include emotions, attitudes to health services, access to other services, knowledge of illness and its management, acceptance of chronic problems, ways to manage symptoms, and sometimes improved health. Our focus, though, is mortality and inequities in mortality. Many related approaches, concepts, frameworks, theories and ideas have been used in studies of patient–professional interactions and it is impossible to discuss all of them here. Instead, those most likely to be relevant to mortality have been selected, and include the patient-centred clinical method, longitudinality and continuity, coordination, cultural competence and other aspects of the therapeutic relationship. Four mechanisms that influence mortality are introduced at the end of the chapter – competent use of the clinical method, relationship continuity, confidence and trust that promote adherence and specific interventions to improve adherence. CLINICAL METHOD Clinical method is the process clinicians follow to acquire information about the patient through listening, questioning, observing and examining. They then use this to generate working diagnoses and to select investigations or therapies.1 Failure to diagnose a condition when it is at a treatable stage is often a failure of the clinical method, for example, a failure to enquire in detail about symptoms or an inadequate physical examination. The interpretation of the findings from the interview or DOI: 10.1201/9781003355380-9

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examination of a patient can also give rise to diagnostic errors that may be caused by gaps in knowledge or cognitive biases. Although it is possible to find reports of diagnostic errors that have shortened lives in individual cases, evidence related to population mortality is more elusive. The WHO claims that in primary health care the most common harmful diagnostic errors involve cancer, infections and cardiovascular disease. 2 Other errors that have potential to cause harm include prescribing, poor communication between professionals and system failures.3 In a US study in Veteran Affairs centres, errors were identified through review of 1,767 patients who had attended primary health care and then had an unplanned hospital admission or an emergency department visit in the following 14 days.4 Diagnostic errors were discovered in 190 (10.8%), 68 of which involved missed diagnoses, including cases of pneumonia, congestive heart failure, acute renal failure, urinary tract infection and cancer. They were explained by failure to collect the necessary information or to synthesise it appropriately during the consultation. In a study of 1,474 primary health care consultations in Japan, diagnostic errors were identified in 57 (3.9%) of the cases. 5 The more common missed diagnoses were of relatively common rather than rare conditions, for example, cancer, dermatitis or hypertension, but diagnostic error was more common in patients with multimorbidity. A review of the primary health care records of over 14,000 patients of 12 general practices in England identified 74 cases of significant avoidable harm.6 Examples of the type of problem included a 30-week delay in diagnosing throat cancer, a 7-year delay in diagnosing prostate cancer, a 4-month delay in referring a patient with limb ischaemia to a vascular surgeon and two patients with known reduced kidney function who continued to be prescribed nephrotoxic drugs. It is clear, therefore, that failures in the clinical method do occur and that they have the potential to impair outcomes and shorten lives. The corollary is that the effective use of the clinical method avoids delay and reduces mortality. THE PATIENT-CENTRED CLINICAL METHOD The patient-centred clinical method is a development intended to take account not only of the medical formulation of the patient’s problem but also the individual’s experience of the illness.7 It involves developing an understanding of the whole person and finding common ground on how to manage the problem.

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A systematic review of 43 randomised trials of interventions to promote patient-centred consultations reported moderate beneficial effects on the consultation process, mixed effects on subsequent patient behaviour and satisfaction, and small positive effects on health status.8 Those studies that investigated health status focused on short-term outcomes and used measures of disease control such as glycated haemoglobin in people with diabetes, or measures of symptoms, pain, anxiety, quality of life or enablement. The effect, if any, on mortality is unknown. In an observational study of video-recorded consultations with patients with depression in general practices in Greater Glasgow in Scotland,9 patient-centredness was observed to be lower in practices in areas of high deprivation than in practices in affluent areas. These findings were extended in a later study in which 659 consultations were video-recorded.10 In affluent areas patients with multimorbidity received longer consultations than those without multimorbidity (12.8 versus 9.3 minutes) but their counterparts in deprived areas did not (9.9 versus 10.0 minutes). Patient-centredness observed on the video recordings and empathy as perceived by patients was higher in the affluent areas. In the United States study involving 509 patients attending a single primary health care centre and whose consultations were video-recorded, greater patient-centredness was observed with more educated patients and those who were less ill.11 Whether the patient-centred method is inadequately tailored to the needs of people in more deprived settings, or whether the gap in experience of affluent and deprived patients is entirely explained by consultations of inadequate length is not clear from the evidence. Shared decision-making may be regarded as one component of patientcentred care. Clinicians and patients are encouraged to work together to understand the patient’s problem and decide how to address it. Aids to decision-making have been developed and evaluated to help patients and their clinicians make decisions about long-term treatments such as initiating medication for diabetes, invasive therapies such as surgery or complex screening choices such as for prostate cancer. A systematic review of randomised trials of such aids used in primary or secondary care settings concluded that they may help patients make treatment choices in accordance with their values and that there were no adverse effects on outcomes.12 However, there is insufficient evidence to judge whether or not shared decision-making has an effect on mortality when used in primary health care. It needs to be reiterated, of course, that the outcome of interest is mortality; shared decision-making or the patient-centred clinical method may benefit outcomes other than mortality. The findings reported here cannot be used on their own to judge the value of these approaches.

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LONGITUDINALITY AND CONTINUITY Starfield described longitudinality as being the existence of a regular source of care and its use over time. Populations may experience longitudinality although the interest of most researchers and practitioners has concentrated on the experience of longitudinality by individuals. The classic illustration of the advantages of the longitudinal care of a population is that of general practitioner Will Pickles. He joined a general practice in Aysgarth in Wensleydale in the Yorkshire dales in 1913, the isolated villages and stable population providing an ideal setting for describing the epidemiology of many common and some fewer common diseases.13 The diseases he investigated were mostly communicable, including measles, scarlet fever, whooping cough and epidemic myalgia, the course of these conditions through the community being described using simple charts. In many ways, the argument for charting mortality in primary health care populations builds on Pickles’ early demonstration of what might be achieved. The paper and pencil charts have been replaced by electronic records and computer enabled statistical techniques, and the conditions nowadays are more often non-communicable than communicable, but the idea is the same. If we understand the disease patterns in our populations, we should be better able to preserve or restore the health of those in our care. Continuity develops over time and is therefore longitudinal, but the term is usually reserved for the longitudinal care of individuals. Three types of continuity have been defined: (1) Relationship (or personal), that is, a continuing relationship between the individual patient and caring clinician over time, (2) informational – the availability of records that ensure consistent information is available to all involved in the care of the patient and (3) management – coordination and communication between all groups involved in the individual’s care.14 Most studies of the effects of continuity have limited themselves to investigating relationship continuity. Based on predominantly observational studies of relationship continuity, an association between higher patient continuity with medical professionals and lower mortality has been identified in two recent reviews. Gray and colleagues15 included 22 studies from 9 countries that had been undertaken in primary or secondary care. Eighteen of these studies reported a statistically significant relationship with mortality, 16 with all-cause mortality. The second review was limited to studies undertaken in primary health care, finding 13 studies of which 12 measured the effect with all-cause mortality.16 Nine of the studies of all-cause mortality reported an association between higher continuity

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and lower mortality, two found no association, and in one the association varied from higher to lower mortality depending on which measure of continuity was used. The study that focused on disease-specific mortality found an association between higher continuity and lower cardiovascular mortality. Exactly how continuity produces an effect on mortality is uncertain. Potential theories include improved preventive care leading to better outcomes17 and increased trust leading to greater confidence in and adherence to treatment.15 Reduced fragmentation of care between professionals may be another, the mix-ups and communication errors caused by failures in coordination putting patient safety at risk.18 A further unresolved question is which patients benefit from continuity? A measurable reduction in mortality seems unlikely for a young and healthy population but the effect may be different for an older multimorbid population. And there may be patients who are harmed by continuity; a fresh pair of eyes may be more alert to the signs of early cancer. Therefore, although an association between relationship continuity and population mortality is likely, randomised trial evidence is needed and we need better evidence about which patients do and which do not benefit, and with this information determine how to mitigate any negative effects. COORDINATION As patients increasingly receive care from a variety of services and practitioners, especially patients with multimorbidity, it becomes increasingly important to coordinate patient management to avoid mistakes and oversights. The opportunity for duplication of tests or errors in treatment grow as the number of services involved in a patient’s care increases, and as a patient moves between different sectors of care there is a risk that the patient encounters delay or becomes lost in the system. Primary health care, with its responsibility for the whole patient and its record system with information on all the patient’s problems, is the sector of the health system most able to coordinate the patient’s voyage between settings, providers and specialists. In a survey of patients in 11 high-income countries, having an established relationship with a primary health care physician was associated with better perceived care coordination although younger patients and those with chronic conditions reported poorer care coordination.19 Interventions to improve coordination may be focused within the primary health care practice, within a specialist service or implemented by an administrative or management organisation with links to both.

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Strategies suitable for use within the primary health care unit include enhanced record systems, care coordinators, limiting the size of small primary health care teams responsible for specific patients, and involvement of the patient or carer in coordinating aspects of care. Specialist services may appoint care navigators or provide patients with detailed care plans, and administrative organisations may provide resources, incentives or schemes to improve communication between providers. Unfortunately, there is an absence of evidence about the effect if any of these interventions on mortality. CULTURAL COMPETENCE Cultural competence may be defined as the ability to work and communicate effectively and appropriately with people from culturally different backgrounds. 20 In communicating effectively, it therefore shares some features with the patient-centred clinical method but adds the obligation to ensure this for people of all cultures, whether shared with, or different from the carers. It is relevant not only to care for different ethnic groups but also for people with disabilities, 21 lesbian, gay and bisexual people22 and transgender people, 23 all of whom can experience disadvantage through cultural incompetence. Can interventions to improve cultural competence redress some of the inequities in mortality rates? Cultural competence is generally regarded as having three dimensions: Cultural awareness (the awareness of one’s own views such as ethnocentric or biased beliefs towards other cultures); cultural knowledge (the continuing acquisition of information about other cultures); and cultural skills (the communication and behavioural skills needed to interact effectively with people of different cultures). Other terms sometimes used include cultural sensitivity (awareness of cultural differences between people without assigning a value to them, either positive or negative) and cultural humility (respecting the beliefs, customs, and values of another person). A reasonable hypothesis is that lack of cultural competence on the part of services or individual providers could lead to deficient health care for people of some cultures and therefore poor outcomes. A 2003 report by the US Institute of Medicine recognised that ethnic minorities received a lower quality of care than the majority population and that professionals and health care organisations contributed to the situation. 24 Key recommendations included education during basic training and in continuing education coupled with monitoring of care and outcomes to assess progress. Progress appears to have been slow since then, however. At the time of writing, medical journals in both the

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United States and United Kingdom have contained many articles on the high mortality from COVID-19 in ethnic minority groups and vaccine hesitancy in some groups. Interventions to improve cultural competence include training for health professionals, training for patients, case-based learning, simulation, patient navigators and exchange programmes. However, it is not clear which approaches are most effective in improving competence.25 A review of studies of the effects of such interventions suggests there can be improvements in some outcomes, for example in measures of diabetes control, and in access to care and satisfaction, but the effects were inconsistent between studies and also varied between patient groups and clinical conditions. Available research does not illuminate any effects on mortality. Language is important in achieving effective communication in consultations, but some patients are not sufficiently fluent in the language of the host country. There are disadvantages to asking family members to serve as translators, but professional interpreters are increasingly available in some health systems. Some outcomes may be improved when the doctor can speak the same language as the patient. A study of general practice consultations in England found that patients who spoke South Asian languages and whose consultations were in their own language reported greater enablement than similar patients whose consultations were in English. 26 FACE-TO-FACE CONSULTING VERSUS OTHER CONSULTING MODALITIES Alternatives to face-to-face consultations include telephone, email and video consulting. They may be used to replace face-to-face consultations or to supplement them for people with significant long-term conditions or to provide access to care for people remote from health services. They may also be used to manage the demand for care or to maintain access when attending a primary health care clinic involves risk of exposure to an infectious disease. Telemedicine – the use of technology to deliver care – has been investigated in studies undertaken during the past two decades. Several technologies may be used in telemedicine, and among the most common is a live interactive audio-visual consultation between the provider and the patient using computers or mobile telephones. Mobile health (mHealth) is a variant of this approach that uses mobile phones or tablets. Another form of telehealth is the remote monitoring of patients, data being collected by patients on their asthma, hypertension or diabetes, for example, and then forwarded to the provider.

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A recent overview of 98 systematic reviews of telemedicine published between 2014 and 201927 reported that telemedicine was acceptable to patients and was of comparable effectiveness to face-to-face consultations for a variety of conditions and specialties. Reviews that had investigated the effect, if any, on mortality reported either no difference between telemedicine and the usual care or reductions in mortality with telemedicine in a specific group of patients – those with heart failure. Telemedicine can be used in low-income countries. A review of its use in Sub-Saharan Africa for maternal health care included seven articles, six of which involved mHealth. 28 Factors contributing to the successful implementation of telemedicine included good telephone network coverage, support for training and use of the technology, acceptance by health workers, continued funding and government support to deploy the service on a large scale. Before drawing conclusions about the potential role of telemedicine in primary health care, it should be recalled that the evidence rests largely on the management by specialists of groups of patients with selected conditions that have already been diagnosed. The primary health care of patients with undifferentiated health problems in need of assessment and initial diagnosis is very different. Large-scale independently funded randomised trials and qualitative studies of telemedicine in primary health care are essential before final judgement can be made about the outcomes for patients. Telephone consultations have become more common in the past 20 years, but they cannot substitute for a face-to-face consultation when clinical examination is required or when there are communication difficulties or concerns about the safety of assessing the patient by telephone. A systematic review of telephone consultations in general practice concluded that they offer an appropriate option in specific circumstances, although more evidence would be welcome about when they may be used and when they are better avoided. 29 Consultations via email (sometimes referred to as econsultations) may help professionals make efficient use of their time and improve access to care for some patients. There are clear limitations as well – the level of interaction may be reduced compared to face-to-face consultations and clinical examinations are not possible. Thus, it may be hypothesised that econsultations could improve outcomes through improved access or impair outcomes through limiting the amount of information exchanged between the patient and the professional. A Cochrane review of studies of email communication between patients or their carers and health professionals found insufficient evidence to evaluate effectiveness.30 In another review, few experimental

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studies were found, and no conclusion was possible about any effect on mortality among patients of primary health care.31 Some of the advantages and drawbacks of telemedicine have been highlighted in the pandemic. Although in many countries, telemedicine helped to preserve access, it reduced the opportunity for physical examinations, a problem only partly addressed by bringing selected patients into the clinic. The roll-out of triage systems that direct patients to different professionals and consultation modalities has also been inadequately researched. The long-term consequences have yet to be documented, but early reports give cause for concern. The senior coroner in Manchester, England, identified five deaths in which the seriousness of patients’ problems had not been recognised in telephone consultations with general practitioners.32 Despite the shortage of evidence of the effects of telemedicine, it is here to stay. In many countries, telemedicine has a continuing role in delivering primary health care to people in remote or rural areas. Elsewhere, the increased use of telemedicine that occurred during the pandemic is unlikely to be reversed in today’s stressed health systems. Nevertheless, until better evidence is available of the impact in different patient groups, it is not possible to judge whether any benefits in terms of population mortality outweigh the harms. THE THERAPEUTIC RELATIONSHIP The idea that the relationship between patient and health professional can affect the clinical outcome is made explicit in the term therapeutic relationship, an idea that has come from psychotherapy and rests on the belief that the success of therapy depends on the relationship between patient and therapist. If we are interested in the therapeutic relationship between professionals and patients, we need to ask patients about their views and experiences. We cannot rely solely on studies that investigate the experience of professionals. The next section draws on work by or about patients and their experiences that can help us explore whether the patient–professional relationship in primary health care has any effect on population mortality. Patient satisfaction is considered first. It has been studied longer than most of the other ways of thinking about patients’ views and in consequence the methodological problems are better understood.

Satisfaction/experience What is satisfaction with primary health care? More than 50 years ago, social surveys commonly asked ‘were you satisfied with your care?’ with

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‘yes’ or ‘no’ being the offered response options. Sometimes the question was ‘how satisfied were you?’ with more response options being offered, perhaps ‘very satisfied’, ‘partly satisfied’, ‘neither satisfied nor dissatisfied’, ‘partly dissatisfied’ or ‘very dissatisfied’. The problem with such questions is that the care the patient receives is made up of many different elements, including their expectations of care and whether they were met, making an appointment, waiting times, the clinical examination, decisions made about treatment, and much more. When asked, the patient must put together their observations and feelings about all these things and come up a summary answer. It’s hardly surprising, then, that the most common response is an expression of some degree of satisfaction. People’s responses to questions about their experiences of primary health care are a mixture of reports about what happened and how they felt about what happened. Patient satisfaction and patient experience are sometimes argued to be different concepts but whether it is possible to make valid distinctions between them is open to question. The proposition that patients report what happened to them (experience) without being influenced by how they felt (satisfaction) is unlikely to be true, and studies have confirmed that experience and satisfaction are overlapping entities.33,34 It is possible that services that achieve lower mortality rates are also more satisfying to use. In this case, an association between measures of satisfaction or experience and mortality might be found. It is also possible that satisfaction and experience influence other v`ariables that do have a more direct effect on mortality. For example, satisfaction or experience may increase trust and adherence, thereby leading to better health outcomes and lower mortality. There have been some investigations of associations between reported satisfaction and mortality among hospital patients but there is little evidence relating to primary health care.

Trust The recent pandemic has provided plenty of evidence of the importance of trust in the acceptance by the public of rules that restricted contact between families and friends, that closed businesses and interrupted children’s education. In a study of 150 countries during the pandemic, the most trusting societies tended to bring down cases and deaths faster than the least trusting.35 Trust was also key for the randomised trials made possible by numerous volunteers agreeing to help test new treatments and vaccines, and the effect of the absence of trust was illustrated by the wacky ideas that the virus was a hoax and the vaccines were a plot to control the populace.

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Trust is important in the day-to-day delivery of routine primary health care just as much as it was at the height of a pandemic. It cannot be taken for granted, however, and in today’s world of instant communication of both news and rumours, both individual clinicians and health care institutions need to give special attention to building and maintaining patient trust. Patients can trust individual clinicians and they can also trust health care institutions such as their local primary health care centre or hospital. The role of trust in modern health care can be found in decisions made by people in low-, middle- and high-income countries on use of care. A mother taking her baby for its first vaccination at six weeks old will inevitably have some anxiety, but this is counterbalanced by trust not only in the health professional who administers the vaccine but also the public health advice that recommends the vaccination schedule, the government health department that promotes and perhaps funds the vaccine schedule, the regulatory system that tests and approves the vaccines as safe and effective, the researchers who have developed the vaccine and those who have conducted the evaluation trials, the manufacturers who followed safe processes in making the vaccine and the staff responsible for the storage and transport of the vaccine. Almost all health care interventions depend on networks of actors that the individual patient is unable to question in person. Trust is a vital ingredient that enables health care to function.

Enablement and empathy Enablement can be thought of as the extent to which patients feel better able, as a result of their consultation with a health professional, to cope with and understand their illness, to keep themselves healthy, and to feel confident about their health. 36 Research has not investigated any links between enablement and mortality, but there is evidence relating to empathy. In a study of 867 people in England with screen-detected type 2 diabetes followed up for 10 years, patients’ perceptions of empathy were measured at the end of the first year of care using a questionnaire. 37 During follow-up, data were collected on all deaths and on fatal and non-fatal cardiovascular events (myocardial infarction, revascularization, nontraumatic amputation and stroke). In a comparison of patients whose empathy scores were in the highest third with those in the lowest third, after accounting for the effect of patient characteristics, higher empathy was associated with lower all-cause mortality. In another study that used the same measure of empathy with 659 unselected patients aged 18 years or over attending

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general practices in Scotland, the chosen outcome measure was change in severity of symptoms after one month.38 Patient perceptions of physician empathy predicted outcomes, with greater empathy being associated with better outcomes in patients from practices in both more and less socio-economically deprived areas. Information on satisfaction, experience, trust, enablement and empathy are investigated by using questionnaires or interviews to ask patients for their views. A key question is whether these are genuinely different constructs as far as patients are concerned or are they all expressions of patients’ underlying feelings of positivity or negativity towards the relationship they have with their health professionals? Patients tend to answer questions on these different concepts in the same way and therefore some caution is needed in drawing firm conclusions. Although satisfaction, experience, trust, enablement and empathy are useful and important ways of understanding the patient–professional relationship, when exploring associations with mortality, it may be wiser to make a link between the relationship as a whole rather than particular features of the relationship that we imagine we can isolate and measure with precision.

Adherence Adherence is the term used to describe whether patients have followed the advice they have been given, although an alternative that better incorporates the patient’s right to give or withhold consent would be preferrable. Unfortunately, it is used throughout the research literature and therefore has to be employed here. In the same way that satisfaction, trust or empathy can be measured by asking patients to respond to questions or surveys, patients can be asked whether they have followed professional advice. An advantage, though, is that adherence can be measured in more objective ways as well, for example, by blood or urine tests to confirm that medication has been taken. There is consistent evidence that adherence to medication for several chronic conditions is associated with mortality. In a systematic review of 66 studies of adherence in people aged 50 or over, non-adherence was associated with increased mortality; in the meta-analysis, high levels of adherence were associated with a 21% reduction in mortality. 39 Adherence to aspirin medication is associated with subsequent cardiovascular mortality,40 medication adherence is associated with all-cause mortality in heart failure41 and adherence to statin medication after a myocardial infarction has been shown to be associated with all-cause mortality.42 A meta-analysis of eight observational studies of people with

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type 2 diabetes estimated that a mean of 37.8% of patients was classified as poorly adherent.43 Three of the included studies had investigated the impact on mortality, and these showed that among patients with high adherence, the rate of all-cause mortality was 28% lower than in those with low adherence. The association between adherence and mortality can be found for other therapies as well. These examples are all of clinical interventions shown in randomised trials to improve outcomes and therefore the findings from observational studies of the effects of adherence are not unexpected. It is possible that some of the effect of adherence on mortality is explained by a healthy adherer effect, that is, adherence is a marker for other behaviours that maintain health such as eating a healthy diet and enjoying regular exercise. These factors can be partly accounted for in the statistical analysis of observational studies, but the healthy adherer effect is less of a problem in randomised trials. In an overview of systematic reviews of interventions to improve medication adherence, eight trials included in the reviews had investigated mortality.44 In four of these, the intervention was a reminder, and had no benefit on mortality. Three trials evaluated patient education and counselling and these appeared more promising, with benefits for several outcomes including mortality. Most trials of interventions to improve adherence do not include mortality as an outcome. However, they do show there are interventions available that do improve adherence. For example, a review of 771 studies reported that the most effective interventions were delivered face- toface and that technological interventions such as electronic monitoring and pill count measures could also be helpful.45 A systematic review of 35 randomised trials of interventions to improve adherence to lipid-lowering medication reported long-term reductions in cholesterol levels. The more effective interventions included pharmacist-led interventions, electronic reminders and educational activities.46 A review of 21 systematic reviews of factors that influence adherence to oral medications for chronic conditions concluded that younger and older patients were at greater risk of poor adherence; the evidence that educational attainment influenced adherence was equivocal; a lower economic situation tended to be associated with poorer adherence. Ethnicity was also associated with adherence, with White patients tending to have higher adherence than Black, Asian or Hispanic patients.47 The cost of prescriptions can affect adherence. In Australia, the Pharmaceutical Benefits Scheme has periodic increases in patient co-payments for prescriptions, with the co-payment generally increasing each year in line with inflation. A 21% increase occurred on 21 January 2005. After this cost increase, some patients stopped their statins or decreased the

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dose. In a two-year follow-up period, the risk of death from any cause increased by 61% among those who stopped their statins and by 39% among those who reduced the dose.48 Trust appears to be important for adherence. In a qualitative study of US patients who failed to collect a prescription for a new diagnosis of hypertension, the patients taking part reported that a trusting patient– provider relationship and shared decision-making that included full disclosure of potential side effects and the costs of prescriptions would increase the likelihood of them accepting the medication.49 A study of people with type 2 diabetes in Lebanon reported that adherence to insulin was higher and emotional distress caused by the diabetes was lower among people with greater trust in their physician.50 A child’s trust in their doctor is influenced by their mother’s trust in the doctor, and in a study of children with asthma, as mothers’ and children’s trust increased, the children’s adherence to asthma medication increased and their quality of life improved.51 Racial discrimination can also play a role in adherence. In a US study of 780 African American men and women with hypertension, their reported experiences of racial discrimination were captured using the Experiences of Discrimination Scale that asked about being hassled, made to feel inferior or prevented from doing something.52 After accounting for other variables (income, education, age and gender), increasing reports of discrimination were associated with declines in medication adherence. Trust in the physician reduced, but did not eliminate, the effect of discrimination on adherence. Some studies report an association between relationship continuity and adherence. For example, a longitudinal study of people with type 2 diabetes in Taiwan found that higher continuity was associated with lower risk of hospital admission during the period of follow-up and that this effect was partly mediated by adherence, that is, greater continuity was associated with higher adherence which led to lower risk of admission.53 An association between continuity and adherence among people with type 2 diabetes has also been found in Quebec, Canada,54 between relationship continuity and adherence among patients with heart failure in the Netherlands,55 and between continuity and statin adherence in Australia.56 It is possible that this observed link between relationship continuity and adherence at least partly explains the association between continuity and mortality, but this has not yet been confirmed in research studies. Measures of satisfaction, trust, enablement or perceived empathy are all concerned with patients’ responses to their relationships with professionals. Adherence too is partly a consequence of the patient–professional relationship, and this helps to explain why the relationship between

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patient and professional in primary health care merits being referred to as therapeutic. The hypothesis is that when the health professional has a deeper understanding of the patient, their preferences and beliefs, their family, their community and their socio-economic circumstances, the patient will feel better able to place trust and confidence in the professional. This is followed by clinical decisions tailored to the needs and wishes of the patient, improved adherence and better outcomes. MECHANISMS

Mechanism XVIII In primary health care, competent application of the clinical method in consultations with patients lowers population mortality. Level of Evidence – Moderate COMMENTARY There is little or no experimental evidence to support the case for the clinical method but there is no shortage of examples collected by medical defence organisations of poor clinical outcomes following failures in the application of the clinical method. The principal components of the clinical method – the history of the presenting complaint, questions to identify features that point to the diagnosis, and an appropriate clinical examination – have been the beating heart of clinical practice for millennia. The investigations available in high-income countries, the blood tests, the radiology, and the scans, are no substitute for competence in the use of the clinical method, and it would be unthinkable to exclude it as a mechanism of primary health care that influences mortality.

Mechanism XIX By reducing the risk of mix-ups in the management of individuals and facilitating the development of therapeutic relationships with patients, relationship continuity in primary health care reduces population mortality. Level of Evidence – Moderate COMMENTARY Continuity of care between a patient and professional allows a relationship to develop. It does not guarantee a relationship of trust and

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confidence, but it does prepare the ground for these to grow if the professional attends to the patient carefully. A comprehensive theory of how continuity affects outcomes by enabling greater knowledge of the patient by the professional and of the professional by the patient leading to better clinical decision-making has been proposed.57 However, although generally consistent, the evidence of an association between relationship continuity and mortality is observational only and experimental studies are needed to help us understand the role of continuity in today’s stressed primary health care systems.

Mechanism XX The development of relationships characterised by confidence and trust between patients and professionals – therapeutic relationships – encourages patients to continue to use primary health care and to adopt the advice they receive, leading to reduced mortality. Level of Evidence – Moderate COMMENTARY Various measures have been used to investigate the patient–clinician relationship and although we may not fully understand how the measures differ from each other, they tend to reveal an association between more positive responses of patients to their care and better outcomes. The search for a simple explanation, for one factor that determines whether the patient’s views of the relationship are positive or negative, is almost certainly destined for disappointment. Each person, each patient or professional, is different in habits and personality, and our moods and opinions vary from day to day. Like the spike protein on the COVID-19 virus and the complementary design of the binding antibody, perhaps it is the fit between the patient and professional that makes the difference. Nevertheless, the observational evidence available suggests that this fit does influence outcomes, including mortality.

Mechanism XXI In addition to building relationships of trust and confidence with patients, the employment by primary health care of specific interventions can also improve adherence and lead to reduced mortality. Level of Evidence – Moderate

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COMMENTARY There is both non-experimental and some limited experimental evidence that greater adherence leads to reduced mortality. Vaccine hesitancy is one example of the consequences of low adherence but the same effect of increased mortality with lower adherence can be found with medication for life-shortening conditions. Adherence is encouraged by a positive relationship but also by specific interventions, for example, discussion of adherence during consultations or the support of a pharmacist. The available evidence does not allow statements about the patient centred clinical method, cultural competence or coordination. The evidence is also limited with respect to alternatives to face-to-face consultations. This lack of evidence in relation to mortality does not mean that these features of care do not have benefits. They may improve other outcomes – mortality is not the only important outcome.

REFERENCES 1. Fraser RC. Clinical Method. A general practice approach. Oxford: Butterworth-Heinemann Ltd, 1992 2. WHO. Diagnostic Errors: Technical Series on Safer Primary Care. Geneva: WHO, 2016 3. Health Foundation. Evidence Scan. Levels of harm in primary care. London: Health Foundation, 2011 4. Singh H, Giardina TD, et al. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med 2013;173:418–425 5. Aoki T, Watanuki S. Multimorbidity and patient-reported diagnostic errors in the primary care setting: Multicentre cross-sectional study in Japan. BMJ Open 2020;10:e039040 6. Avery AJ, Sheehan C, et al. Incidence, nature and causes of avoidable significant harm in primary care in England: Retrospective case note review. BMJ Qual Saf 2021;30:961–976 7. Weston WW, Brown JB. Overview of the patient-centered clinical method. Chapter 2 in: Stewart M, Brown JB, et al. Patient-Centered Medicine. Transforming the Clinical Method. Thousand Oaks, CA: Sage, 1995 8. Dwamena F, Holmes-Rovner M, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012;12:CD003267 9. Jani B, Bikker AP, et al. Patient centredness and the outcome of primary care consultations with patients with depression in areas of high and low socioeconomic deprivation. Br J Gen Pract 2012;62(601):e576–581 10. Mercer SW, Zhou Y, et al. Multimorbidity and socioeconomic deprivation in primary care consultations. Ann Fam Med 2018;16(2):127–131 11. Bertakis KD, Azari R. Determinants and outcomes of patient-centered care. Patient Educ Couns 2011;85:46–52 12. Stacey D, Légaré F, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2017;4:CD001431 13. Pickles WN. Epidemiology in Country Practice. Torquay: The Devonshire Press Ltd, 1972 (Re-issue, originally published in 1939)

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14. Haggerty JL, Reid RJ, et al. Continuity of care: A multidisciplinary review. BMJ 2003;327: 1219–1221 15. Gray DJP, Sidaway-Lee K, et al. Continuity of care with doctors – A matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018;8:e021161 16. Baker R, Freeman GK, et al. Primary medical care continuity and patient mortality: A systematic review. Br J Gen Pract 2020;70:e600–e611 17. Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: A critical review. Ann Fam Med 2005;3:159–166 18. Tarrant C, Windridge K, et al. ‘Falling through gaps’: Primary care patients’ accounts of breakdowns in experienced continuity of care. Fam Pract 2015;32:82–87 19. Penm J, MacKinnon NJ, et al. Minding the gap: Factors associated with primary care coordination of adults in 11 countries. Ann Fam Med 2017;15:113–119 20. Alizadeh S, Chavan M. Cultural competence dimensions and outcomes: A systematic review of the literature. Health Soc Care Community 2016;24:e117–e130 21. Agaronnik N, Campbell, et al. Exploring issues relating to disability cultural competence among practicing physicians. Disabil Health J 2019;12:403–410 22. Felsenstein DR. Enhancing lesbian, gay, bisexual, and transgender cultural competence in a midwestern primary care clinic setting. J Nurses Prof Dev 2018;34:142–150 23. Vermeir E, Jackson LA, et al. Improving healthcare providers’ interactions with trans patients: Recommendations to promote cultural competence. Healthc Policy 2018;14:11–18 24. Smedley BD, Stith AY, et al (Eds). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Report of the Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press, 2003 25. Brottman MR, Char DM, et al. Toward cultural competency in health care: A scoping review of the diversity and inclusion education literature. Acad Med 2020;95:803–813 26. Freeman GK, Walker JJ, et al. Non-English speakers consulting with the GP in their own language: A cross-sectional survey. BJGP 2002;52:36–38 27. Eze ND, Mateus C, et al. Telemedicine in the OECD: An umbrella review of clinical and cost-effectiveness, patient experience and implementation. PLoS One 2020;15:e0237585 28. Ahmed MAA, Gagnon M-P, et al. A mixed methods systematic review of success factors of mHealth and telehealth for maternal health in SubSaharan Africa. mHealth 2017;3:22 29. Downes MJ, Mervin MC, et al. Telephone consultations for general practice: A systematic review. Syst Rev 2017;6:128 30. Atherton H, Sawmynaden P, et al. Email for clinical communication between patients/caregivers and healthcare professionals. Cochrane Database Syst Rev 2012;11:CD007978 31. Vimalananda VG, Orlander JD, et al. Electronic consultations (E-consults) and their outcomes: A systematic review. J Am Med Inform Assoc 2020;27:471–479 32. Rapson J, Kirton H. Concern raised over death of five patients seen remotely by GPs. Health Serv J; 9 Sept. 2021 33. Pinder RJ, Ferguson J, et al. Minority ethnicity patient satisfaction and experience: Results of the National Cancer Patient Experience survey in England. BMJ Open 2016;6:e011938

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34. Kash B, McKahan M. The evolution of measuring patient satisfaction. J Prim Health Care Gen Pract 2017;1:002 35. Lenton TM, Boulton CA, et al. Resilience of countries to COVID-19 correlated with trust. Sci Rep 2022;12:75 36. Howie JGR, Heaney DJ, et al. Quality at general practice consultations: Cross sectional survey. BMJ 1999;319:738–743 37. Dambha-Miller H, Feldman AL, et al. Association between primary care practitioner empathy and risk of cardiovascular events and all-cause mortality among patients with type 2 diabetes: A population-based prospective cohort study. Ann Fam Med 2019;17:311–318 38. Mercer SW, Higgins M, et al. General practitioners’ empathy and health outcomes: A prospective observational study of consultations in areas of high and low deprivation. Ann Fam Med 2016;14:117–124 39. Walsh CA, Cahir C, et al. The association between medication non-adherence and adverse health outcomes in ageing populations: A systematic review and meta-analysis. Br J Clin Pharmacol 2019;85:2464–2478 40. Packard KA, Hilleman DE. Adherence to therapies for secondary prevention of cardiovascular disease: A focus on aspirin. Cardiovasc Ther 2016;34:415–422 41. Hood SR, Giazzon AJ, et al. Association between medication adherence and the outcomes of heart failure. Pharmacotherapy 2018;38:539–545 42. Rasmussen JN, Chong A, et al. Relationship between adherence to evidencebased pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA 2007;297:177–186 43. Khunti K, Seidu S, et al. Association between adherence to pharmacotherapy and outcomes in type 2 diabetes: A meta-analysis. Diabetes Care 2017;40:1588–1596 4 4. Wilhelmsen NC, Eriksson T. Medication adherence interventions and outcomes: An overview of systematic reviews Eur J Hosp Pharm 2019;26: 187–192 45. Conn VS, Ruppar TM. Medication adherence outcomes of 771 intervention trials: Systematic review and meta-analysis. Prev Med 2017;99:269–276 46. van Driel ML, Morledge MD, et al. Interventions to improve adherence to lipid-lowering medication. Cochrane Database Syst Rev 2016;12:CD004371 47. Gast A, Mathes T. Medication adherence influencing factors – An (updated) overview of systematic reviews. Syst Rev 2019;8:112 48. Seaman K, Sanfilippo F, et al. Increased risk of 2-year death in patients who discontinued their use of statins. J Health Serv Res Policy 2021;26: 95–105 49. Polinski JM, Kesselheim AS, et al. A matter of trust: Patient barriers to primary medication adherence. Health Educ Res 2014;29:755–763 50. Halepian, Saleh MB, et al. Adherence to insulin, emotional distress, and trust in physician among patients with diabetes: A cross-sectional study. Diabetes Ther 2018;9:713–726 51. Rotenberg KJ, Petrocchi S. A longitudinal investigation of trust beliefs in physicians by children with asthma and their mothers: Relations with children’s adherence to medical regimes and quality of life. Child Care Health Dev 2018;44:879–884 52. Cuffee YL, Hargraves JL, et al. Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension. Am J Public Health 2013;103:e55–e62 53. Chen C-C, Tseng CH, et al. Continuity of care, medication adherence, and health care outcomes among patients with newly diagnosed type 2 diabetes. A longitudinal analysis. Med Care 2013; 51:231–237

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54. Dossa AR, Moisan J et al. Association between interpersonal continuity of care and medication adherence in type 2 diabetes: An observational cohort study. CMAJ Open 2017;5(2):E359–E364 55. Uijen AA, Bosch M, et al. Heart failure patients’ experiences with continuity of care and its relation to medication adherence: A cross sectional study. BMC Fam Pract 2012;13:86 56. Warren JR, Falster MO, et al. Association of continuity of primary care and statin adherence. PLoS One 2015;10:e0140008 57. Sidaway-Lee K, Gray DP, et al. What mechanisms could link GP relational continuity to patient outcomes? Br J Gen Pract 2021;71:278–280

CHAPTER 10

Policy and population health management

This chapter considers the role of primary health care in managing population health. The idea that the health of a population can be managed underlies the emergence of primary care networks and integrated systems in many countries. At the end of the chapter, two mechanisms are identified – the first being the adaptation of primary health care to the economic and social context, and the second the inclusion of public health expertise in primary health care. POPULATION HEALTH MANAGEMENT AND PRIMARY HEALTH CARE A report from Deloitte’s health care arm defines population health management as gathering information about population health and wellbeing to identify the community’s health care needs and to adapt services accordingly.1 Identifying the health needs of a population is a key task for public health services and strengthening the public health skills available to health care organisations is a necessary development for managing population health. In high-income countries, the ageing population and the growing costs of health care are powerful motives for illness prevention and early intervention programmes to reduce the need for expensive hospital care. The advent of the primary health care electronic medical record has made possible the identification of individuals in the population who might benefit from timely health or social care support. At the same time, the expansion of health care teams to include nurses, assistants, mental health specialists and social or community health workers, DOI: 10.1201/9781003355380-10

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has provided a means to deliver this support. It may appear, then, that population health management is a new idea driven entirely by the needs of wealthy countries in the late stages of the epidemiological transition. However, there have been many calls to more closely link primary health care and public health in past decades. Additionally, a characteristic of primary health care is its adaptability, and different versions of primary health care, designed in response to changing population needs and the resources available, can be found around the globe. Some features of these versions are summarised in the next few paragraphs.

Origins of primary health care The simplest version of primary health care can be found emerging from public health, designed to meet the needs of populations at the beginning of the epidemiological transition and when resources are few. The provision of sanitation and clean water are key steps and often occur alongside top-down health care programmes that target single diseases, malaria or polio for example, and are run from government public health departments or by international aid agencies. The funding available is severely limited but the reduction in avoidable deaths can be substantial.

Primary health care takes root The expansion of public health services leads to primary health care taking root. Multiple top-down programmes to address various communicable diseases are set up, then begin to coalesce, sharing staff and facilities. Typically, this is followed by the first evidence of a focus on a group of people rather than on a specific disease, with the group concerned typically being mothers and their younger children. Community health workers supported by nurses form the backbone of the workforce. The focus of the service is on communicable diseases and the care of mothers and children, and large reductions in mortality can be achieved. Individuals with greater wealth, education or influence tend to experience better outcomes.

Developing primary health care As the epidemiological transition advances, the burden of mortality slowly begins to shift from communicable diseases to non-communicable disease, and from young children to older adults. In response, primary health care expands its horizon to most groups in the population. There may be few doctors, with most services being provided by nurses or health workers with relatively little training. A few low-income and many

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lower-middle-income countries have health systems with this version of primary health care, bringing further benefits to population mortality. Inequity in outcomes often persist, with private health care bestowing an advantage on those who can afford it.

Transitioning primary health care In upper-middle-income countries where the epidemiological transition has progressed further, non-communicable diseases constitute the dominant cause of disability and mortality. There are more doctors and clinics. In China and Brazil, for example, primary health care has expanded to encompass almost all groups in the population. In addition to the gains achieved by the earlier stages of primary health care’s development, this transitioning version of primary health care achieves some reductions in deaths from non-communicable diseases, but in most countries inequities in outcomes continue.

Comprehensive primary health care of individuals This version of primary health care is found in most high-income countries, where the epidemiological transition is far advanced. Care is provided by multidisciplinary teams that include doctors, nurses, assistants, pharmacists, social workers and others. Usually, there is an enrolled list of patients, and a wide range of services is available to them. Care of the individual tends to take precedence over care of the population, although attention is given to the prevention of non-communicable diseases or the amelioration of these diseases through chronic disease management programmes built on evidence-based guidelines. There are reductions in deaths from non-communicable diseases, but socio-economic disadvantage continues to influence outcomes.

Local population primary health care Although aspects of population health management, involving collaboration with public health services, have long been found in primary health care, policymakers now think that the process should be increasingly systematic and extended through other sectors of the health system and even include social care services. This is expected to help providers to concentrate their efforts on early interventions for those patients most likely to benefit and could reduce the need for costly specialist care. It might even help services recognise and respond to the needs of disadvantaged or marginalised groups.

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The idea of population health management has influenced two contemporary developments, one specific to primary health care and the second to health and social care services more widely. The first is the designation of groups of providers or practices who collaborate together to meet local population needs. Referred to as groups, networks, divisions or clusters, these are appearing in many countries. Bringing local providers together enables the pooling of some resources such as the public health expertise required for analysing data to inform the planning and delivery of services, or the community health workers to deliver care to marginalised groups. It can facilitate the development of more substantial programmes to meet the needs of specific sub-groups such as the socio-economically disadvantaged, ethnic minorities or the homeless. The second development is on a larger scale. Referred to as integrated health care systems, they serve large populations and unite the management of primary health and secondary care. This is expected to provide further opportunities to target resources to patient groups with the greatest need. A typical activity is the segmentation of the population into groups differentiated by their likely need for hospital care. The aim is to reduce the demand for hospital care by the identification of frail patients and the delivery of interventions to support them in the community. Population health management, of which population mortality is one outcome, will be discussed in the context of these two policy developments. They both build on the widespread adoption of electronic records and information systems in primary health care combined with the growth of multi-professional teams who draw on the skills of public health professionals. The first step was the replacement of the doctor’s office of old, staffed by a receptionist and perhaps a nurse, by health facilities equipped to deliver preventive and anticipatory care to a registered population. Services of this type are found throughout high-income countries and in many middle-income countries. They include the primary health care teams of Europe and the patient-centred primary care medical homes of the United States, elements of both these forms being found in service models in Australia, New Zealand and more widely. By bringing primary health care teams together to establish larger management units such as primary care networks or integrated care systems, it may be possible to strengthen the impact of primary health care on population health. One argument used to justify these large new organisations is that small organisations have neither the resources to thoroughly analyse the needs of their populations nor the range of staff to meet the diverse needs of every patient group. Larger organisations can bring greater expertise in public health to the analysis of needs and a wider range of staff to meet the needs of everyone. Their information

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systems and larger workforce may be better able to identify and offer help to people likely to benefit from preventive health or social care interventions. They may be able to meet the needs of some patient groups who constitute only a small proportion of any single practice population, for example, the homeless, drug users or travellers. NETWORKS Groupings of primary health care practices have the potential to benefit from shared administrative and management capacity, and offer a wider range of services than individual practices can on their own. Examples of groupings can be found in several high-income countries. In Australia, divisions of general practice were introduced as membership organisations from 1992 and were intended to improve the coordination of services.2 There are regional primary care networks in Germany that collaborate to set goals, improve services and share continuing education.3 Early evidence about potential benefits can be found in the introduction of primary care networks in England in 2019. The priorities were to improve access to primary health care, improve population health, and limit the use of more costly hospital services by extending the range of professionals in the community. The example of the local creation of networks in the London borough of Tower Hamlets in 2009 was discussed in Chapter 6.4 These were followed by improvements in the care of people with type 2 diabetes including control of glycated haemoglobin, blood pressure and cholesterol, and an increase in the proportion of patients receiving retinal screening.5 There were also improvements in managing cardiovascular disease, including the prescribing of statins to people with coronary heart disease, reductions in cholesterol levels in people with coronary heart disease or a history of stroke, and improved blood pressure levels in people with coronary heart disease, stroke or hypertension.6 There was also a reduction in mortality from myocardial infarction. An initiative in Stoke-on-Trent also suggests sharing objectives and ideas between practices can improve outcomes. The scheme involved all 55 practices in the area and built on the national quality and outcomes framework through the addition of local quality targets including, for example, the identification and review of patients with specific long-term conditions.7 In comparison with the national trend in mortality from coronary heart disease, the locally set target-driven strategy was associated with an additional annual reduction in age-standardised mortality due to coronary heart disease of 36 deaths per 100,000 people. The findings from these non-experimental pilot studies of primary care networks are encouraging but achieving similar benefits throughout

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all networks will be challenging. An evaluation of several networks showed how benefits may be limited or very slow to materialise, impeded by the ability of practices to work together, the resources available to them, and their accountability to the wider health system.8 There are wide variations in the configuration of networks. Of the 1,250 in place in January 2020, only 58% had between 30,000 and 50,000 patients, the size stipulated in NHS guidelines, and 7% had fewer than 30,000 and 35% more than 50,000.9 Undersized networks tended to serve rural areas. The average number of general practices per network was five but there was wide variation from just one practice to over ten. There was also wide variation in levels of deprivation and chronic disease among the populations served. A study that involved interviews and surveys of the staff of four networks highlighted some friction between the national requirement for employment of certain professionals and designing local services to address local health needs.10 In addition, despite being only small organisations, networks require advanced leadership skills to bring practice teams together around a common purpose. Substantial management capacity is needed to oversee the accounts, appoint and supervise staff, collect and analyse information, maintain staff engagement and monitor performance. Staff interviewed in the study reported frustration at the amount of work involved in establishing and running a network, and the staff time lost to clinical activities. The very limited evidence summarised here suggests that networks have potential to reduce mortality and perhaps inequities as well, particularly from cardiovascular disease. However, it should not be assumed that the benefits associated with a few early examples or precursors, including their impressive leadership, collective will and information management expertise, can be replicated throughout every network in the NHS. Nevertheless, the experience of networks during the pandemic is cause for some optimism. A review of the first two years of networks was able to highlight the role they played in the administration of COVID-19 vaccinations and in developing outreach services to reach marginalised groups.11 Networks, then, may have played a part in reducing the toll of COVID-19. INTEGRATED CARE A valuable review of the concept of integrated care has been published by Hughes and colleagues and forms the starting point for the observations here.12 The review makes clear that integrated care is not a specific intervention, model of care or organisational configuration but a

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collection of different versions of all these entities, chosen, adapted and implemented in response to the prevailing circumstances and policies. Integrated care, therefore, is better thought of as an idea, a belief that aligning and coordinating segments of care into a continuous whole will produce desirable improvements in comparison with fragmented care systems in which patients are directed hither and thither, with fingers crossed they do not get lost in the system. Sometimes, in some settings, the different forms of integrated care appear to have measurable benefits but on other occasions there are no benefits. Convincing evidence of reductions in mortality are difficult to identify. For example, Kaiser Permanente Northern California, a US integrated care provider, was able to report a reduction in heart disease age- and sex-adjusted mortality from 183 per 100,000 population in 1994 to 136 per 100,000 in 2004, but the decline for the rest of California was from 274 down to 188 per 100,000 over the same period.13 The decline in mortality was therefore no faster among patients of Kaiser than among the population as a whole, and the findings are compatible with people who enrol with Kaiser having a lower risk of heart disease mortality than the general population. Another report of mortality trends from 2000 to 2015 compared age-adjusted and age- and sex-specific all-cause, heart disease, coronary heart disease and stroke mortality rates between the population enrolled with Kaiser Permanente Northern California and those of the entire United States.14 The declines in age-adjusted mortality rates among the people enrolled with Kaiser were similar to those of the United States as a whole, but there were some differences in the age-specific rates. Declines were greater in the under aged 45 and aged 45–65-year age groups in the Kaiser population, suggesting that the detection and management of people at risk of cardiovascular disease was more systematic in the integrated care system. However, it should be borne in mind that the US national mortality rates include people without health insurance. An analysis of mortality between 2001 and 2016 in Kaiser Permanente Southern California reported that reductions in ageadjusted all-cause and cancer and heart disease mortality were similar to those seen in California or the United States as a whole.15 These findings should make us cautious about concluding that integrated care systems will reduce population mortality. A review of integrated care systems in the 28 countries of European Union plus Norway and Iceland found initiatives in all 30 countries, although wide variation in the extent to which they had been developed within each country.16 Factors observed to be important to the creation of well-­functioning systems included political support and leadership, resources, effective collaboration between organisations and professionals and functional

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information systems. The effects of integrated care were summarised in a review of 153 quantitative studies or systematic reviews.17 Most of the studies did not have experimental designs, but 21 included randomised controls. The evidence was rated as strong that integrated care led to improved patient satisfaction, better quality of care as perceived by staff or patients and improved patient access, but the evidence was inconsistent about the effect on other outcomes, including the costs of care. Integrated care systems are being introduced in the United Kingdom in the form of integrated joint boards in Scotland, regional partnership boards in Wales, integrated partnership boards in Northern Ireland, and integrated care systems in England. Those in England, serve populations of between one and three million people; they have replaced clinical commissioning groups and oversee the local health system, working in partnership with local government to bring health and social care together.18 Each system will work with a specified group of primary care networks, hospitals, public health services and community services. They are also intended to collaborate with agencies outside the health care sector, including social care, local government authorities and voluntary organisations. These wider linkages add the potential to improve population health by enabling coordinated initiatives to tackle the local causes of disadvantage and marginalisation. It is too early, though, to judge whether they will improve population health. The devolved health system in Greater Manchester was in many ways a pilot for integrated care systems elsewhere in the country19 and early evidence about its impact is starting to appear. An analysis of trends in mortality provides mixed evidence. Between 2016 and 2019, in Manchester the cardiovascular mortality rate fell faster, but mortality rates for respiratory disease and cancer fell more slowly, than the rates in England as a whole. 20 REFLECTIONS In policy documents, it can often appear that the principal motivation for population health management in high-income countries is the need to contain the use of costly hospital care by the growing number of older people with chronic conditions. But the improvement of population health is a key goal as well. To achieve this, two requirements stand out. The first is to address the social determinants of health. Support for families, effective education, satisfying employment and a healthy environment are all required. National policies can set the scene and allocate

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funding. The local integrated care system, with its public health expertise, can provide local leadership and build the partnerships that could make a difference. Public health expertise is also needed to describe the health needs of populations and to use data to monitor key outcomes for the management of health and social services. The second requirement is the support of primary health care, and in many countries, this will involve the support of primary care networks or their equivalent. Primary health care plays a central role in reducing population mortality, and the success of integrated care organisations in improving population health will depend in large part on their ability to support the work of local primary care networks. MECHANISMS

Mechanism XXII Primary health care reduces population mortality when adapted to the prevailing social and economic context with the aim of achieving access for as many people as possible, especially those in disadvantaged groups. Level of Evidence – Moderate COMMENTARY The various ways in which services are structured and delivered in countries at different stages of the epidemiological transition provide evidence to justify this mechanism. A health system that strives to improve population health must serve as many of the population as possible and deal with the most important health problems locally, whether they are communicable diseases in children or non-communicable diseases among older adults. Because little money is available to low-income countries, a high-income model of primary health care would be able to reach very few patients and have scanty impact on population mortality. And all systems, irrespective of national income, must adapt to meet the preferences and circumstances of disadvantaged or marginalised groups that usually experience the worst health outcomes.

Mechanism XXIII Primary health care reduces population mortality by drawing on public health expertise to describe the needs of patient groups and plan strategies to meet those needs. Level of Evidence – Moderate

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COMMENTARY Public health combines a population perspective with skills to investigate the health of groups of people and plan interventions tailored to their needs. The identification of patient groups with the worst outcomes and development of strategies to engage with them to improve health are public health priorities. Evidence from randomised trials of the impact on population mortality achieved through collaboration between public health and primary health care is not available, although non-experimental evidence can be found from middle- and high-income countries and in examples set out in Chapters 5, 6 and 7. The overlap between public health and primary health care during the emergence of primary health care services in low-income countries supports the argument that the two services increase their impact on health when they work in close partnership. REFERENCES 1. Deloitte. The transition to integrated care. Population health management in England. London: Deloitte Centre for Health Solutions, 2019 2. Smith J, Sibthorpe B. Divisions of general practice in Australia: How do they measure up in the international context? Australia and New Zealand Health Policy 2007;4:15 3. Poss-Doering R, Kamradt M, et al. Promoting rational antibiotic prescribing for non-complicated infections: Understanding social influence in primary care networks in Germany. BMC Fam Pract 2020;21:51 4. Pawa J, Robson J, et al. Building managed primary care practice networks to deliver better clinical care: A qualitative semi-structured interview study. Br J Gen Pract 2017;67:e764–e774 5. Hull S, Chowdhury TA, et al. Improving outcomes for patients with type 2 diabetes using general practice networks: A quality improvement project in east London. BMJ Qual Saf 2014;23:171–176 6. Robson J, Hull S, et al. Improving cardiovascular disease using managed networks in general practice: An observational study in inner London. Br J Gen Pract 2014;64:e268–e274 7. Gabel F, Chambers R, et al. An evaluation of a multifaceted, local quality improvement framework for long-term conditions in UK primary care. Fam Pract 2019;36:607–613 8. McDonald R, Riste L, et al. The impacts of GP federations in England on practices and on health and social care interfaces: Four case studies. Health Serv Deliv Res 2020;8(11) 9. Morciano M, Checkland K, et al. Variability in size and characteristics of primary care networks in England: Observational study. Br J Gen Pract 2020;70:e899–e905 10. Smith JA, Parkinson S, et al. Early evidence of the development of primary care networks in England: A rapid evaluation study. Southampton: NIHR Health Services and Delivery Research Topic Report, 2020. doi. org/10.3310/hsdr-tr-129678 11. Swift J. Primary Care Networks, Two Years On. London: NHS Confederation, 2021

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12. Hughes G, Shaw SE, et al. Rethinking integrated care: A systematic hermeneutic review of the literature on integrated care strategies and concepts. The Milbank Quarterly 2020;98:446–492 13. McCarthy D, Mueller K, et al. Kaiser Permanente: Bridging the quality divide with integrated practice, group accountability, and health information technology. Commonwealth Fund pub. 1278. 2009;17 14. Sidney S, Sorel ME, et al. Comparative trends in heart disease, stroke, and all-cause mortality in the United States and a large integrated healthcare delivery system. Am J Med 2018;131:829–836.e1 15. Chen W, Yao J, et al. Temporal trends in mortality rates among Kaiser Permanente Southern California Health Plan enrollees, 2001–2016. Perm J 2019;23:18–213 16. Dates M, Lennox-Chhugani N, et al. Health system performance assessment – Integrated Care Assessment (20157303 HSPA). European Commission, 2018. doi: 10.2875/627462 17. Baxter S, Johnson M, et al. The effects of integrated care: A systematic review of UK and international evidence. BMC Health Serv Res 2018;18:350 18. Anderson M, Pitchforth E, et al. The United Kingdom: Health system review. Health Syst Trans 2022;24(1):1–192 19. Walshe K, Lorne C, et al. Devolving health and social care: Learning from Greater Manchester. Manchester: The University of Manchester, 2018 20. Williams K. Is Manchester Greater? A New Analysis of NHS Integration. London: Centre for Policy Studies, 2021

CHAPTER 11

The mechanisms framework

A FRAMEWORK In the preceding pages, a considerable body of evidence has been assembled that shows not only that primary health care does reduce population mortality but also discloses some of the mechanisms at work. In this chapter, the mechanisms are ordered into a framework of five related groups – organisation, access, comprehensiveness, clinical care and the therapeutic relationship. These are set out in Boxes 11.1–11.5, each mechanism now being assigned an Arabic numeral to replace the Roman numerals that have been used up to this point. The framework offers a guide to the design of primary health care intended to help reduce population mortality but should not be assumed to apply to other outcomes such as health care costs or patient experience. It sets out a practical sequence in which features early in the framework prepare the ground for those that appear later. When the organisational features are in place (Box 11.1) it becomes easier to provide access to all who need care (Box 11.2). The process begins with planning the service by taking account of the needs of the entire population, with special attention to those most likely to face geographical, social, economic or other barriers to using care. The supply of primary health care must be sufficient, in terms of funding, staffing and public health expertise, to monitor and manage mortality. A well-planned, adequately resourced primary health care service should provide access for all those in need of care (Box 11.2). Enabling access for all is essential for reducing health inequities, and outreach that DOI: 10.1201/9781003355380-11

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BOX 11.1  Organisation

Mechanism 1 (XXII) Primary health care reduces population mortality when adapted to the prevailing social and economic context with the aim of achieving access for as many people as possible, especially those in disadvantaged groups. Mechanism 2 (XII) Increases in funding for primary health care that are used to provide more care to more patients lead to reduced population mortality, although • •

The incremental benefits diminish when funding is already at a high level And formulae for allocating funds to reduce inequity in outcomes are poorly developed

Mechanism 3 (I) An increase in the supply of primary health care doctors makes more medical care available to more patients, leading to reduced population mortality. This effect is not seen when the supply is very low and the increase is too small to have an impact, nor when the supply is already generous, in which case further increases bring no additional mortality advantage. Mechanism 4 (XIII) A blend of different professionals in primary health care, tailored to local needs reduces population mortality by • • •

Broadening the expertise available to patients Increasing access to care, including to those from disadvantaged groups Improving management of some conditions

There is more evidence about the effects of nurses and community health workers than other professional groups. Mechanism 5 (XXIII) Primary health care reduces population mortality by drawing on public health expertise to describe the needs of patient groups and plan strategies to meet those needs.

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BOX 11.2 Access

Mechanism 6 (V) The extent to which primary health care reduces population mortality is dependent on the extent to which the whole population is covered by the service. Mechanism 7 (XIV) Access to primary health care and the access it controls to specialist care (gatekeeping) affect population mortality and inequity in mortality between disadvantaged and privileged groups. Level of Evidence – Strong Mechanism 8 (XV) By actively engaging with communities through outreach activities, primary health care can reduce mortality among underserved or marginalised groups.

achieves engagement with communities is often required. Inequity can also occur when access to specialist care is via primary health care, and services should monitor and minimise this problem. The purpose of access is to make available to patients a wide variety of effective health care interventions. This means that a wider range of clinical problems can be dealt with, a comprehensive service being more effective in reducing mortality than one focused on only a few health conditions (Box 11.3). Primary health care that prevents or overcomes life-threatening childhood diseases achieves greater gains in longevity for individuals than care concentrated on disorders towards the end of life. Care that encompasses the social causes of poor health is more effective

BOX 11.3  Comprehensiveness

Mechanism 9 (XVI) Primary health care reduces population mortality by providing a comprehensive service that meets the needs of most patients. Mechanism 10 (X) By caring for the patient as a whole person, primary health care addresses most of the common causes of population mortality, whether they are traditionally classified as physical or mental health conditions.

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Mechanism 11 (IV) By delivering interventions to treat or prevent the communicable diseases of childhood, the care of children by primary health care reduces population mortality. Mechanism 12 (XVII) Primary health care can reduce population mortality by • •

Supporting the health and welfare of mothers Acting to avoid or mitigate the effect of adverse childhood experiences

These interventions often involve partnership with other health or social care agencies. Mechanism 13 (VI) Primary health care is concerned with the current and future health of individuals and groups at all stages of the lifecycle from conception to old age. Care of the person throughout life enables primary health care to reduce population mortality more than can fragmented care of episodic illnesses.

than care that is solely clinically focused. Care that extends throughout life, from before conception to extreme old age, has greater benefits on mortality than care focused on specific phases of life. Competent clinical practice, from making an initial diagnosis through to agreeing treatment with the patient, reduces population mortality (Box 11.4). The prevention when possible and management when necessary of the communicable and non-communicable diseases responsible for most deaths leads to reductions in mortality. BOX 11.4  Clinical Care

Mechanism 14 (XVIII)  In primary health care, competent application of the clinical method in consultations with patients lowers population mortality. Mechanism 15 (IX) By making early diagnoses, primary health care reduces mortality caused by those conditions in which late diagnosis leads to worse outcomes. Mechanism 16 (VIII) Illness prevention delivered in primary health care reduces population mortality.

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Mechanism 17 (II) To reduce mortality from communicable diseases, primary health makes diagnoses and delivers effective preventive and therapeutic interventions in the setting of a broader service that provides advice and education for individuals and communities. Mechanism 18 (VII) The management by primary health care of those non-communicable diseases that are responsible for many deaths reduces population mortality. Mechanism 19 (XI) Primary health care can increase population mortality by prescribing • • •

Medication that leads to drug addiction Antibiotics or antivirals when they are not necessary, leading to the emergence of drug-resistant organisms Inappropriately selecting the wrong drug or dose, or a drug that causes a dangerous interaction with other medication

Skilled use of the clinical method is more effective in reducing mortality when it is delivered within the context of a therapeutic relationship (Box 11.5). The confidence and trust patients place in primary health care influence their willingness to seek help when worried or unwell and to employ the advice they receive.

BOX 11.5  The Therapeutic Relationship

Mechanism 20 (XX) The development of relationships characterised by confidence and trust between patients and professionals – therapeutic relationships - encourages patients to continue to use primary health care and to adopt the advice they receive, leading to reduced mortality. Mechanism 21 (III) By both covering the whole population and building relationships with individuals, vaccination programmes delivered by primary health care reduce mortality caused by communicable diseases.

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Mechanism 22 (XIX) By reducing the risk of mix-ups in the management of individuals and facilitating the development of therapeutic relationships with patients, relationship continuity in primary health care reduces population mortality. Mechanism 23 (XXI) In addition to building relationships of trust and confidence with patients, the employment by primary health care of specific interventions can also improve adherence and lead to reduced mortality.

THE MECHANISMS FRAMEWORK For each of the 23 mechanisms, the balance of evidence is in favour of an effect on mortality. Of the 23 mechanisms, the evidence was assessed as strong for 8, moderate for 14 and weak for 1. The lack of experimental studies was partly responsible for the evidence relating to some mechanisms being regarded as moderate rather than strong, but the non-experimental evidence was often consistent or highly consistent. Future research should involve experimental studies when possible, particularly in relation to those mechanisms for which the evidence was assessed as weak or moderate. The evidence that has been brought together shows that primary health care is important to the effect health care has on population mortality. Health systems need more than primary health care alone, of course. The overall effect of primary health care often depends on other sectors; the benefits of early detection of cancer rely on specialist treatment, for example. Primary health care functions as part of a multicomponent system, but there is a surprising amount of evidence about its effect. Hospitals treat people with acute life-threatening problems, and public health services plan care for populations, but the 23 mechanisms of primary health care are sufficiently powerful to make them critically important to the planning and operation of health systems worldwide. The effect on mortality is most evident where little or no health care is available, a situation in which the introduction of initial, low-cost features of primary health can transform life expectancy. But the effect is readily found between and within high-income countries, related to variations in the extent to which the mechanisms are implemented. From the organisational features on which services are established to the relationships between patients and practitioners, the 23 mechanisms influence mortality and collectively account for the overall effect of primary health care on population mortality. The mechanisms reflect the

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current state of evidence and understanding of them will improve as new evidence becomes available. There may be mechanisms that have been overlooked and others may be dropped as new evidence becomes available. For the present, however, the framework is a reasonable starting point for practitioners and policymakers who wish to understand the patterns of mortality in the populations for which they are responsible. It is important to remember that the framework is concerned only with mortality. Different mechanisms may be important for other outcomes such as hospital admission rates or patient satisfaction. MORTALITY AS AN OUTCOME Since it does influence population mortality, primary health care must be designed and managed to bring mortality rates down. The impact on mortality cannot be left to chance. The first rule of quality and safety in health care firmly applies. The rule is Understand your outcomes, and it has three stages 1. Which are the key outcomes? 2. What explains the current performance for the chosen outcomes? 3. Can the outcomes be improved? This rule applies to national health systems, to specific services within health systems and to clinical teams and individuals.

1.  Which are the key outcomes? Most clinical services will have a variety of outcomes and studying all of them at the same time is impractical. Understanding begins with realising which outcomes are the most important ones to get right first. Select these for attention first, and once they are consistently at the target level, keep an eye on them but move on to the next outcomes on the list. The number of outcomes that can be handled at any one time will be determined by the capacity of the organisation in question; for the small provider units of primary health care, two, three or four may suffice.

2.  What explains the current performance for the chosen outcomes? Data to inform population health management by providers is very different to data collected for external or regulatory monitoring undertaken to identify situations where something may have gone wrong. External monitoring is challenging and not considered here.

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Collecting data is necessary but this is only a stepping-stone to understanding. Data should be relevant and as accurate as is practicable. The question to be asked is: ‘Why do we have these outcomes?’ Although information about each death can be collected prospectively within the provider organisation, this is better reserved for identifying individual cases for detailed review since the data are unlikely to be complete. The notification of deaths to providers can be delayed when an investigation by the coroner is undertaken or when a death takes place outside the local district or country. Many countries have a national registration and statistics service and the data they provide are more complete, although the careful collation involved means the data are only available after a year or so has elapsed. The great advantage though is that their completeness makes comparisons between providers possible, and comparisons are key to investigating the reasons for the observed mortality rates. ‘Keep it simple’ is the advice to follow when choosing which measures of mortality to monitor. All-cause age-specific mortality rates may be used because they require no interpretation. All-cause age-standardised mortality is a readily understood alternative that can be reported for people aged under 75 years (premature mortality) as well as all ages together. The addition of disease-specific rates for mortality from cardiovascular disease and cancer would provide information about the two most common causes of deaths. Most primary health care professionals are likely to find a rate of deaths per unit of population more meaningful in planning clinical policies than measures that involve greater computation. Ideally, primary health care organisations should possess, or have support from, staff experienced in data analysis.1 The fact that networks or integrated care organisations are becoming commonplace throughout the world and have staff with public health expertise should mean that primary health care teams increasingly have the information they need to manage population mortality. Because many primary health care providers serve small populations, random fluctuations can cause the annual age-specific and agestandardised mortality rates to vary widely from year to year, making the identification of the underlying trend difficult. Switching to a monitoring period of several years, and updating the period with each new year to provide a moving average, levels out the variation and produces clearer information for observing changes in mortality rates. A five-year period is used for general practices in England, but when the population is larger, for example, 50,000 people typical of primary care networks, an annual or bi-annual monitoring period is likely to be adequate.

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3.  Can the outcomes be improved? The aim of this stage of the first rule of quality and safety is to identify potential explanations for the observed mortality rates and suggest practical ways to reduce them. Quantitative and qualitative approaches – statistics and stories – can be used. Comparison with similar patient populations lies at the heart of the quantitative approaches. A comparison of the mortality rate of an individual primary health care provider with the national or regional rate is usually uninformative; it is much better to compare like with like. Providers with populations with similar socio-economic characteristics should be selected, and account should be taken of patients in nursing homes and marginalised groups including the homeless, travellers, disabled persons and refugees. In comparing performance between hospitals, various statistical techniques are available for adjusting for differences between populations, a process referred to as case-mix adjustment. Helpful though these techniques may be, they are imperfect and can be avoided in primary health care. The large numbers of provider organisations almost always allow the identification of a few with similar patient populations and with which comparisons can be made without the need for statistical adjustments. A handful of comparator organisations or practices should be chosen to provide an informative comparison. Figures 3.4 and 3.5 illustrate the data that can be used to select comparators. The comparisons should examine not only the most recent rates but also look back over several years to identify any trends. This will help to show whether any other providers are achieving faster declines in mortality as well as whether the current mortality rates of comparator practices or providers are similar to, or better or worse, than those of the practice concerned. If any differences are discovered, the cause-specific mortality rates may be reviewed to discover whether they are explained by cardiovascular or cancer mortality. Discussions with the other providers may reveal features of the practice population that had not been appreciated or show what they are doing differently and suggest ways the practice can make improvements. The mechanisms framework should be consulted for ideas on doing better. The quantitative investigation will not provide all the answers. To supplement the mortality data, information from electronic health records can be used to disclose something of the deceased patients – their stories. Did they have chronic conditions that were being managed by the practice? How well were their conditions controlled? What were their social circumstances? Were there delays in diagnosing the fatal illness? Were they members of marginalised groups? Did they have a relationship with a

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particular doctor, or did they drift from one doctor to another? Were they newly enrolled with the practice or long-time patients? Using background information such as this, it will be possible to describe the people who died and begin to explore ways to strengthen the health care of future patients. The detailed review of individual cases – qualitative investigation – has a long tradition in medicine. The clinico-pathological conference has been used to teach medical students for generations in various forms is a routine part of obstetric, neonatal and surgical care. National confidential inquiries can provide background information for primary health care teams on the common reasons for avoidable deaths. In the United Kingdom, the National Confidential Enquiry into Patient Outcome and Death 2 receives proposals for topics for inquiries, conducts investigations and publishes reports that identify opportunities for reducing the number of avoidable deaths. Increasingly, though, health care organisations are expected to review and learn from deaths. In England, the Care Quality Commission3 requires hospitals to have systems to learn from deaths, and a structured judgment method has been developed to facilitate this process.4 Reviews are expected when a child dies, 5 and all parts of the health and social care systems are required to take part in reviews of the deaths of people with a learning disability or autism.6 In primary health care, the Daffodil Standards, jointly developed by the Royal College of General Practitioners and Marie Curie, include a mix of tools, quality statements, and learning exercises dealing with end-of-life care.7 Once ideas have been developed from the quantitative and qualitative evidence about the reasons for the observed mortality patterns, the time has come to devise, implement and monitor the effect of improvements. The mechanisms framework will offer ideas on what actions to consider. Small improvements may follow even minor adjustments to clinical practice, but sometimes no further improvements are possible and, whilst continuing to monitor the particular outcome, the time has come to turn the attention of those involved to other outcomes. The application of the first rule of quality and safety requires supportive leadership that creates an organisational culture that allows health professionals to learn from reviewing outcomes. Weaknesses in the quality and safety of health care are found in low-, middle- and high-income countries. Researchers, policymakers and professionals have expended much time and effort on this problem during the last 30 years but the resulting improvements in quality or safety have been modest at best. A consistent lesson from both serious adverse safety incidents and daily failures in quality is of the importance of leadership and management in applying the first rule of quality and safety. Quality and safety demand

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leadership that is compassionate,8,9 that nurtures and empowers, and management that supports and enables health professionals to learn from and improve their patients’ outcomes. There are examples of mortality reviews in primary health care. A significant event audit was used by a group of English general practices to review diagnoses of lung cancer, including among patients that had died, to identify points for learning.10 A small number of general practices have completed and published audits of deaths. A 12-month audit that included four practices identified 1,263 deaths.11 Data were collected about each death and were discussed at quarterly meetings. Potentially avoidable factors were identified in 53.7% of cases, 39.7% being patient factors including smoking, alcohol abuse, self-neglect and poor adherence. Primary health care factors were identified in 5.1% of cases, including delayed referral, failure to check blood pressure and failure to prescribe aspirin and hospital-related factors were identified in 5.7% of cases including delays in diagnosis or treatment, hospital acquired infections, pressure sores or inappropriate discharge to home. Similar investigations can be undertaken in low-income countries. A scheme in Mali and Uganda was able to identify failures in the quality of care including missing the signs of serious problems, not giving essential treatment, and the lack of timely referral of sick children to hospital.12 IT’S TIME TO USE POPULATION MORTALITY AS ONE OUTCOME OF PRIMARY HEALTH CARE In this exploration of the role of primary health care in population mortality, five points now stand out • • •

• •

Mortality and inequities in mortality are important outcomes. Primary health care definitely does reduce population mortality. The mechanisms by which primary health care affects mortality can be identified with sufficient confidence for planning and managing services today, although future research will add to, refine, confirm or overturn some of these in the years ahead. Methods are available for monitoring mortality patterns and learning from deaths. In consequence, measures of population mortality should be routinely used to inform the planning and delivery of primary health care, with the aim of reducing mortality and inequities in mortality.

There are several more general lessons as well, and these will be discussed in the final chapter.

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REFERENCES 1. Goldacre B, Bardsley M, et al. Bringing NHS data analysis into the 21st century. J Roy Soc Med 2020;113:383–388 2. National Confidential Enquiry into Patient Outcome and Death. 2022. www.ncepod.org.uk/ 3. Care Quality Commission. Learning from deaths. A review of the first year of NHS trusts implementing the national guidance. London: CQC, 2019 4. Hutchinson A, Coster JE, et al. A structured judgement method to enhance mortality case note review: Development and evaluation. BMJ Qual Saf 2013;22:1032–1040 5. Fraser J, Sleap V, et al. Child death review statutory and operational guidance: Maximising learning from child deaths. Arch Dis Child 2020;105:315–318 6. NHS England and NHS Improvement. Learning from lives and deaths – People with a learning disability and autistic people (LeDeR) policy 2021. London: NHS England, 2021 7. RCGP and Marie Curie. The Daffodil standards for Primary Care Networks in England – Achieving EOLC QOF. London: RCGP and Marie Curie, 2019 8. Bailey S, West M. What is compassionate leadership? London: The King’s Fund, 2022. 9. West, MA, Borrill C, et al. The link between the management of employees and patient mortality in acute hospitals. Int J Human Res Manag 2002;13:1299–1310 10. Mitchell ED, Rubin G, et al. Understanding diagnosis of lung cancer in primary care: Qualitative synthesis of significant event audit reports. Br J Gen Pract 2013;63:e37–e46 11. Holden J, O’Donnell S, et al. Analysis of 1263 deaths in four general practices. Br J Gen Pract 1998;48:1409–1412 12. Willcox ML, Kumbakumba E, et al. Circumstances of child deaths in Mali and Uganda: A community-based confidential enquiry. Lancet Glob Health 2018;6:e691–702

CHAPTER 12

New ambitions for primary health care

Some control has now been developed over the SARS-Cov-2 virus and the time has come to start thinking about the repair of disrupted health systems. Before the pandemic, primary health care was struggling. In low-income countries, lack of resources, the adoption of universal health care as a substitute for genuine primary health care and conflict or other upheavals ensured that services were patchy and fragile. Middle-income countries were making variable progress and many had not established effective systems capable of serving entire populations. In many high-income countries, an unplanned decline was underway because of the failure to prepare for the late stages of the epidemiological transition. Merely restoring primary health care after the pandemic to these unsatisfactory starting points is unthinkable. The inequities laid bare in the daily reports of deaths from COVID-19 constitute an unanswerable case for fundamental improvements. The importance of using mortality as an outcome for guiding the planning and provision of primary health care has been made clear by the evidence covered in the preceding chapters. It is time to • •

•

See primary health care in a new way, as a service with an important effect on mortality Be more ambitious for its role in health care, concentrating in particular on •• Reducing population mortality •• Reducing inequity in mortality •• Helping all children to have a healthy start in life Strengthen primary health care to prepare it for the future challenges of global warming and new pandemics DOI: 10.1201/9781003355380-12

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A NEW WAY OF THINKING ABOUT PRIMARY HEALTH CARE Policymakers, especially those in high-income countries, have for several decades been panicked by the growth in overall health care expenditure, propelled by the hospital costs of the rising number of elderly people. The need to contain costs and increase efficiency has been at the heart of every new policy development. When primary health care is reformed, the overriding motive will continue to be the containment of costs, the devising of new ways to stop patients reaching hospitals, and the careful consuming of limited resources. It is as if policy makers think primary health care is little more than a triage mechanism for the health system, that its purpose is to manage access to other health sectors that have the expertise and expensive technology needed to improve health and save lives. But primary health care is much more than a triage system. It is key to the effect of health care on population mortality. And by reducing risk and intervening early in life, primary health care achieves greater gains in life expectancy than intervention late in the evolution of disease. Unless policymakers and practitioners recognise this vital effect, the stalling rates of avoidable mortality found in some countries and the inequities in mortality found worldwide will not be overcome. We need to think about primary health care in a different way – as that part of the health system that has a powerful influence on population mortality. Other sectors of the health system do affect mortality, but the life-long, whole population properties of primary health care give it a special role. In this new way of thinking about the purpose of primary health care, policy should extend beyond the focus on containing costs and the use of hospitals to give much greater priority to improving health and reducing premature, avoidable mortality and inequities in mortality. Mortality should become one of a few key outcome measures. Levels of funding and staffing would then have to change, outreach to marginalised groups would become routine, and access and gatekeeping would be re-designed to focus on those with greatest health needs. The therapeutic relationship would be given renewed priority. And the end result would be gains in life expectancy and reductions in health inequity. GREATER AMBITION

Reducing population mortality No health system in the world has a primary health care service that achieves the reductions in mortality that are possible. No service has implemented the 23 mechanisms in full. The explanation for this state

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of affairs is easier to find in low- and middle-income countries where resources are severely constrained, but high-income countries do not have this excuse. The level of ambition for what could be achieved is disappointingly low. This must change. Now that we know that primary health care is that part of the health system with a central role in influencing population mortality, it is time for the leadership of health systems, for policymakers and governments, to look beyond the immediate challenges of helping services recover from the pandemic and survive the epidemiological transition, and instead set their sights on a longer-term goal – the creation of primary health care services that improve health and reduce population mortality. The framework of mechanisms provides a template for the construction and delivery of services for the future. In low-, middle- and high-income countries, the fragility of services laid bare by the pandemic can be used as an opportunity to demand better, to establish services adequate for the needs of the entire population and capable of improving health and reducing mortality. Health systems dominated by the hospital sector need re-balancing towards the community and primary health care. If the new interest in population health management turns our attention to population mortality, the centrality of primary health care will become obvious. Change will inevitably come in how primary health care is perceived, and in the ambitions of policymakers for its development.

Equity Primary health care has the potential to reduce inequities in mortality but it does not consistently do so. The effect is not automatic; it has to be systematically planned, managed and monitored. Usually, however, it is left to chance. The distribution of services, the levels of funding in relation to the need for care, and the systems for access and gatekeeping, all tend to disadvantage groups already disadvantaged by disability, ethnicity or poverty. It is, of course, true that inequity is a product of the social determinants of health and that these determinants must be addressed if life chances are to be equal between people. But it is not true that health services have little or no role to play. Health services should, first, not contribute to the problem. They should not make matters worse. But the allocation of resources, the access and gatekeeping systems that some patients find easier to negotiate than others, too often do make matters worse. Second, primary health care can make a difference; it can reduce inequities in mortality. Evidence for this can be found in the work of community health workers in remote regions of low-income countries,

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in programmes to extend services to underserved regions in the middleincome countries of Brazil and China, and in initiatives for marginalised groups or deprived areas in high-income countries. The problem is that these are examples, they are not the norm everywhere. Ideas for reducing inequities in mortality can be found in the mechanisms framework. The relevant organisational mechanisms include adaptation to the social and cultural characteristics of the population (Mechanism 1), adequate levels of funding allocated according to need (Mechanism 2) and the involvement of public health expertise in planning and targeting services (Mechanism 5). Population coverage (Mechanism 6), access and gatekeeping that do not act as barriers to disadvantaged groups (Mechanism 7) and outreach to marginalised groups (Mechanism 8) should be key features relating to access. Reducing inequities requires a comprehensive service that covers a wide range of health care needs (Mechanism 9), that delivers preventive care (Mechanisms 11 and 16) and that supports families and helps to give children a healthy start in life (Mechanisms 12 and 13). It also requires the development of trusting relationships with individuals and communities, giving them the confidence to use health care (Mechanisms 20 and 21). Now that there is unequivocal evidence that primary health care can reduce inequities in mortality when organised to do so, responsibility falls on policymakers and practitioners to act accordingly. Health systems are not powerless; they do have ways to reduce avoidable deaths among disadvantaged groups. Health care must play its part along with education, employment and welfare services. We can afford to be – and should be – more ambitious in improving the life chances of the poor and marginalised.

A healthy start in life The pandemic has negatively affected the health care of children. Services have been disrupted, with impacts in low- and middle-income countries on the supply of medicines and diagnostics, the disorganisation of vaccination programmes, and some families deterred from seeking care. In high-income countries, the suspension of education, long weeks spent at home, lack of exercise and the loss of social interaction have all taken their toll on mental and physical health. Tired and weakened primary health care will struggle to respond. Before the pandemic, services in some countries were already failing children. Sustainable Development targets for mortality were not being met and even in some high-income countries progress has slowed, and in some countries social and health inequalities have increased.1

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Yet there is more to do than simply correct the longstanding neglect of primary health care to help children overcome the harm the pandemic has caused them. The life-course theory of health inequalities shows how important the early years are to lifelong health. Investment in the health and wellbeing of children has benefits that last throughout life. Primary health care provides lifelong care. When it is population focused and supported by public health, it is in contact with almost everyone in the population and therefore is the key branch of the health system for reducing health inequities. Its work begins before conception and continues into childhood. Primary health care must be adequately provided with community health workers, children’s nurses or health visitors to create a comprehensive service for parents and children. The service should be proactive; waiting for problems to be brought to the clinic will create inequities. Outreach, screening and preventive activities are all part of the process to involve every child in the area. In addition to dealing with the physical and mental health of children, the service should be reliably connected to the network of community and voluntary agencies that support families. When the need for support is detected, referral to the agencies that can help should be as simple and quick as referral for suspected cancer. Care of children is both important and urgent. Health systems worldwide could be much more ambitious in their plans to give all children a healthy start in life. FUTURE THREATS Primary health care is not ready for some of the future threats to population health. Although the COVID-19 pandemic is currently receding, new virus variants could emerge at any time. Pandemics caused by other viruses will happen eventually. Lessons will emerge from research and inquiries that look back at how the pandemic was handled around the globe and they will show how health services should be prepared for the next outbreak. A priority will be ways to help low-income countries develop health system resilience. They will need primary health care to be available to all people to build trust with communities, to deliver care to affected individuals in the community, and to administer vaccination programmes. A short while ago, climate change was seen as a threat to health in the future. That is no longer the case. The latest report of the Intergovernmental Panel on Climate Change (IPPC)2 has revealed that health effects are already occurring, and the most vulnerable people are being disproportionately affected. The IPCC report, after its latest review, expressed very high confidence in the evidence that climate change has affected the

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physical health of people in all regions of the world. The health effects include human heat-related morbidity and mortality, harm from wildfire, nutritional deficiencies and mental health impacts from extreme weather events. The risks of vector-borne and water-borne diseases have increased in some regions. The report recommended improving the climate resilience of health systems and improving access to mental health care. The actions recommended included strengthening primary health care services around the world to help minimise the impact on population mortality. Ambitions for the role of primary health care in human health can therefore be extended to the response to future threats that could be mitigated by preparation today. CODA In the last few days, I have been exploring the preparation of an advance decision, also known as a living will. Should the time come when I am no longer myself, when irreversible neurological decline or physical distress rob me of dignity and the ability to take part in human relationships, please do not give me active treatment, let nature take its course and allow me to depart. Let me rage against the dying of the light so long as some light remains, but when the light has gone, let me go too. Today, too many people die prematurely. The mission of primary health care is to help everyone – the entire population – complete their natural lives, to remain healthy and if possible, avoid premature death. It follows that fighting disadvantage and eliminating inequities in mortality are core duties of primary health care. It shares these duties with all branches of health and social care systems, but its daily contact with people, its comprehensive services for all from before conception to the end of life, its reaching out to marginalised and underserved groups, and its guidance of patients to specialist care when needed, together ensure that strong primary health care is vital to the health of populations. REFERENCES 1. Batcheler R, Hargreaves D et al. Are young children healthier than they were two decades ago? The changing face of early childhood in the UK. London: Nuffield Foundation, 2021 2. IPCC. Climate Change 2022. Impacts, Adaptation and Vulnerability. IPCC WGII Sixth Assessment Report. International Panel on Climate Change, 2022. www.ipcc.ch/report/ar6/wg2/

Index

Note: Locators in italics represent figures and bold indicate tables in the text. A Access, 150–152, 195, 197 Adherence, 175–178 Adoo-Kissi-Debrah, E., 43 Affordable Care Act, 143 Age, 32, 33 Air pollution, 43 Alma-Ata Declaration, 6 American health care system, 62 ‘Apples and oranges’ comparison, 146 Asthma, 120–123 Australia, 41, 188 Avoidable mortality, 21–23 B Bangladesh, 107 Beale, N., 35 Blood pressure, 102–103, 105, 107–109, 134, 147–148, 188, 205 Brazil, 53–54, 70, 111, 186, 210 asthma in, 121 COVID-19, 85–86 Breast cancer, 112–114 British Lung Foundation, 79 British Social Attitudes Survey, 7 Burundi, 51 C Cancer breast, 112–114

CCGs variation in mortality, 30 cervical, 111 colorectal, 112–113 lung, 11, 111, 114, 143, 205 in primary health care, 112–115 prostate, 165–166 screening, 111–112 throat, 165 Candidacy, 151 Cardiovascular disease hypertension, 106–109, 107 package, 103 statins, 109–111, 110 Care Quality Commission, 144 CCGs, see Clinical commissioning groups CHD, see Coronary heart disease China, 54–56, 70 COPD in, 123 hypertension in, 107–108 primary health care, 186 Chinese Communist Party, 54 Chronic obstructive pulmonary disease (COPD), 64, 120–121, 123–126 Chronic respiratory disorders asthma, 120–123 COPD, 123–125 Climate, 43–44 Clinical care, 198–199

214   Index

Clinical commissioning groups (CCGs), 29–30, 110 Clinical method, 164–165 Cochrane Systematic Review, 78, 104, 112, 171–172 CODA, 212 Coding, 17 Cohort life expectancy, 24 Communicable diseases, 56, 76, 77, 92–96, 185, 192, 199 Community engagement, 154–156 Community health workers, 50, 53, 55, 146–147 Comprehensiveness, 152–154, 197–198 Consultations via email, 171 Continuity, 167–168 Coordination, 168–169 COPD, see Chronic obstructive pulmonary disease Coronary heart disease (CHD), 63, 103, 108, 111, 188, 190 Costa Rica, 107 COVID-19 pandemic, 6, 10, 17, 21–22, 24, 39, 43, 56, 76, 85–87, 91, 91, 105, 114, 127, 132, 154, 170, 179, 189, 207, 210–211 Crude death rates, 18 Cultural competence, 169–170 D Death certification, 14–17 Death rates, 17–18 crude, 18 standardised mortality rate, 18–20, 19 Death registration, 15–17 Denmark, 113 statins in, 109 Diagnostic errors, 165 Diarrhoeal diseases, 79–80 Direct standardisation, 18–19 Disability-adjusted life years (DALYs), 25 Disability-free life expectancy (DFLE), 24 Disease-free survival, 23 Disease-specific mortality, 20–21 Doctors, substitution of, 145–146 Drug-poisoning rates, 131 E Empathy, 174–175 Employment, 35

Enablement, 174–175 England, 5, 28–30, 44, 83, 85, 91 cancer in, 112, 114 Care Quality Commission, 204 COPD in, 124–125 death rates in, 64 ethnic groups, 40 funding formula, 144 homeless in, 152 hypertension in, 107, 107, 108 life expectancy, 10, 29 patient awareness, 114 social and health care, 144 statins in, 110 suicide rates in, 128 TB in, 81 Environment, 43 Epidemiological transition, 32, 33 Equity, 209–210 Ethiopia, 50, 67 Ethnicity, 39–43, 176 Europe, 8, 44, 84, 111, 131–132, 187 primary health care for children, 153 European Standard Population, 18 Eurostat, 22 Experiences of Discrimination Scale, 177 F Face-to-face consultations, 170–172 Family Health Programme, 53–54 Finland, asthma in, 122, 124 First-contact care, 148–150 First rule of quality and safety in health care, 201–205 G Gatekeeping, 148–150 Gender, 32, 34 Ghebreyesus, T., 6 Glasgow Deep End Link Worker Programme, 155 Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD), 80 Global Alliance against Respiratory Diseases (GARD), 121 Global Burden of Disease, 16, 53 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 123 Global Vaccine Action Plan, 87 Gray, D. J. P., 167

Index   

215

Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER), 17 Gulliford, M., 62–63

International Form of Medical Certificate of Cause of Death, 14–15 Ischaemic heart disease, 22, 34

H Hart, J. T., 7, 102 Health care, see Primary health care Health Extension Programme, 50 Health inequalities, vii, 4–5, 10, 94, 133, 210–211 Health inequities, 4–5, 48, 57, 68–69, 78, 110, 147, 153, 195, 211 Heart failure, 64, 165, 171, 175, 177 High-income countries, 7–8, 87 Hispanic, 41 HIV/AIDS, 81–84 HPV vaccination, 111 Hughes, G., 189 Hungary, 109 Hypertension, 35, 63, 102–103, 106–111, 107, 110, 177

J Japan, 65, 70, 165 Joint United Nations Programme on HIV/AIDS (UNAIDS), 83

I IMD, see Index of Multiple Deprivation Index of Multiple Deprivation (IMD), 36–38, 37, 110 Indirect method of standardisation, 19–20 Infant mortality, 20 Infection management COVID-19 pandemic, 85–87 diarrhoeal diseases, 79–80 HIV/AIDS, 82–84 lower respiratory, 76–79 TB, 81–82 Influenza, 90–91 Informational continuity, 167 Institute for Health Metrics and Evaluation, 48, 49 Integrated care, 187, 189–191 Integrated Management of Childhood and Neonatal Illness (IMNCI), 78, 80 Integrated Management of Childhood Illness programme, 121 Intergovernmental Panel on Climate Change (IPPC), 211 International Association of Cancer Registries, 16 International Classification of Diseases (ICD), 17, 27, 28

K Kaiser Permanente Northern California, 190 Kaiser Permanente Southern California, 190 Keefe, P., 131 Korea, 65 Kyrgyzstan, 107 L Language, 11, 17, 82, 170 Leicester City, 37–38, 38 LGBT+ people, 152 Life expectancy, 8–10, 9, 23–25, 49 Lifelong care, 211 Longitudinality, 167–168 Long-term exposure, 43 Lower-middle-income countries, 5–7, 56–57 Mongolia, 51–52 Pakistan, 52–53 Lower respiratory infections, 76–79 Low-income countries Ethiopia, 50 Rwanda, 50–51 Lung cancer, 11, 111, 114, 143, 205 M Malmö General Hospital, 103–104 Management continuity, 167 Mandela, N., 89–90 Mao Zedong, 54 Marmot, M., 4 Maternal mortality, 20, 32, 41, 50–52, 55, 155 Measles, 88, 88–89 Mechanism I, 69–70 II, 93–94 III, 94 IV, 95 V, 133 VI, 133–134 VII, 134 VIII, 134

216   Index

IX, 134–135 X, 135 XI, 135–136 XII, 156 XIII, 157 XIV, 157–158 XV, 158 XVI, 158–159 XVII, 159 XVIII, 178 XIX, 178–179 XX, 179 XXI, 179–180 XXII, 192 XXIII, 192–193 Mechanisms framework, 200–201 access, 195, 197 clinical care, 198–199 comprehensiveness, 197–198 organisation, 195–196 therapeutic relationship, 199–200 Medicaid, 62 Medicare, 62 Mental health physical conditions and multimorbidity, 125–127 suicide, 128–130 treatment, 130–132 Mixed ethnicity, 39 Mobile health (mHealth), 170 Mongolia, 51–52, 70 Mortality, 2, 49, 201–205, see also Population mortality avoidable, 21–23 disease-specific, 20–21 infant, 20 maternal, 20, 32, 41, 50–52, 55, 155 measures of avoidable, 21–23 disease-specific, 20–21 mothers and children, 20 premature, 21 neonatal, 20, 52, 66, 147, 155 perinatal, 20 practice-level, 27–29, 28, 29 premature, 21 rate, 17–18, 24, 30–31, 31, 85, 203 variations in age, sex and gender, 32, 33, 34 climate, 43–44 environment, 43

ethnicity, 39–43 social determinants, 34–39, 36–37, 38 Myocardial ischaemia, 35 N National Confidential Inquiry into Suicide and Safety in Mental Health, 128 National Health Service (NHS), 3, 42, 86, 143–144, 153, 189 National registration systems, 15–16 Neonatal mortality, 20, 52, 66, 147, 155 Networks, 188–189 New Zealand, 41 statins in, 109–110 NICE, 84, 126, 128 Non-adherence, 175 Non-communicable diseases, 5, 10, 32, 34, 54, 68, 96, 101, 115, 133–136, 146, 159, 185–186, 192, 198–199 Norway, 70 Nurses, 53, 122, 127, 145–147, 187 O Obesity, 10, 105–106 ONS analysis, 40–41 Oral rehydration solution, 79–80 Organisation, 195–196 Organisation for Economic Co-operation and Development (OECD), 7–8, 22, 35, 48, 66, 69, 143, 154 Outreach, 154–156 P Pakistan, 52–53 Patient-centred clinical method, 165–166 Perinatal mortality, 20 Period life expectancy, 24 Pharmaceutical Benefits Scheme, 176 Physical activity, 103, 106 Pickles, W., 167 Policymakers, 208 Polio, 89–90 Population health management, 184–188, 191, 201, 209 Population mortality, 67–68, 205, 208–209 administrative units, 29–30, 30 epidemiological transition, 32, 33

Index   

life expectancy, 30–31, 31 practice-level mortality, 27–29, 28, 29 Potential years of life lost, 23 Practical Approach to Care Kit (PACK), 121 Practice-level mortality, 27–29, 28, 29 Premature mortality, 21 Primary health care, 1–4, 208 administrative units, 29–30, 30 ambition, 208–211 cancer in, see Cancer for children, 153–154, 210–211 comprehensive, 186 definition of, 3 disadvantage for, 20 expenditure on, 141–144 health inequities and, 68–69 mechanisms, 2 models of, 153–154 origins of, 185 population health management, 186–188 population mortality and, 67–68, 205 strength, 65–67 Public Health England, 43 Purdue Frederick, 131 Q Qualitative approach, 203–204 Quality-adjusted life years (QALYs), 25 Quantitative approach, 203–204 R Racism, 39, 42, 177 Relationship continuity, 167 Rutstein, D. D., 21 Rwanda, 50–51, 67 S Satisfaction/experience, 172–173 Scotland, 19 Sex, 32, 34 Shared decision-making, 166 Shi, L., 57, 62 Shipman, H., 3 Short-term exposure, 43 Slovak Republic, 65, 70 Smoking, 106 Social determinants, 34–39, 36–37, 38 Social prescribing, 155 Socio-economic classification, 35–36, 36

217

South Africa, 64, 84, 121 asthma in, 121 Staffing, 145–148 Standardised mortality or death rate (SDR), 18–20, 19 Standardised mortality ratio (SMR), 19–20 Starfield, B., 2, 48, 57, 62, 65–66, 148, 167 Statins, 109–111, 110 Stoke-on-Trent, 188 Streptococcus pneumoniae, 77 Suicide, 128–130 Survival rates, 23 T Teamwork, 148 Telemedicine, 170–172 Telephone consultations, 171 Therapeutic relationship, 172, 199–200 adherence, 175–178 enablement and empathy, 174–175 satisfaction/experience, 172–173 trust, 173–174 Tobacco, 106 Tower Hamlets, 103, 188 Tuberculosis (TB), 81–82 Type 2 diabetes, 105–106, 109, 174, 176–177, 188 U United Kingdom, 8, 9, 10, 41–43, 62–64, 80 cancer in, 111–112 gatekeeping, 149–150 National Confidential Enquiry, 204 statins in, 109 suicide in, 129 United States, 2, 8, 21, 41–42, 57, 58–61, 62, 90 access to primary health care, 150 community health workers, 147 hypertension in, 108 suicide in, 129 United States Agency for International Development (USAID), 6 Upper-middle-income countries Brazil, 53–54 China, 54–56 US Institute of Medicine, 169 V Vaccination, 87–88 COVID-19, 91, 91

218   Index

influenza, 90–91 measles, 88, 88–89 polio, 89–90 uptake, 92–93 whooping cough, 90 W Wakefield, A., 88 Wales asthma in, 121 COPD, 124 mortality in, 39 suicide rate in, 128

White ethnicity, 39 Whitehall programme, 126 Whooping cough, 90 World Bank, 6, 30, 32, 33, 83 World Health Assembly, 89 World Health Organization (WHO), 2–3, 6–7, 10, 14, 16–17, 25, 78, 83–85, 87, 89, 92, 121, 165 Z Zero Suicide programme, 129–130