Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Recording useful socioeconomic data in primary care is not currently feasible
- Stephen Gardiner (18 April 1999)
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Tackling health inequalities in primary care
- Patrick Bower (19 April 1999)
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Tackling inequalities in Primary Care
- John Macleod (29 April 1999)
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Recording socioeconomic data
- Dougal Darvill (30 April 1999)
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Stephen Gardiner, General Practitioner Bridgwater, Somerset
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One of the great strengths of general practice is the personal knowledge that practitioners have of their patients. We are able to use socioeconomic, family and medical histories in order to help decide on appropriate healthcare for our patients. It is a very attractive idea for researchers to be able to easily access this information and the presence of computers in the consulting room would appear to make this straightforward. There are however a number of problems with this idea. As Smeeth and Heath pointed out in their editorial, in order to be useful, socioeconomic information should be both accurate and valid. For many of our patients recorded information would become out-of-date and therefore inaccurate within a short period of time - probably after two or three years. General practitioners would therefore find themselves having to ask and record socio-economic information on a frequent basis in order to provide useful information. Also, there is a significant difference between what we know of our patients and what is recorded in their records. My practice has used computers in the consultation for over 10 years and we have been effectively paperless since 1994. We are therefore very experienced at recording information electronically, but the prospect of recording additional information on socioeconomic background and keeping this information updated is unrealistic in everyday practice. There are already other sources of information available for research and other (perfectly valid) needs including that provided by the Office of Population Censuses and Surveys and for example immunisation and cervical screening uptake statistics which are recorded by Health Authorities. Whilst it may appear that any additional work for general practitioners "would not take up very much time" I do not believe that this information will ever come from routine consultations in general practice. Stephen Gardiner MA MRCGP General Practitioner East Quay Medical Centre East Quay Bridgwater TA6 5YB |
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Patrick Bower
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Sir, The bottom line of Iona Heath and Liam Smeeth's editorial is that, to tackle health inequalities, GPs "will need to record accurate and valid socioeconomic information about their patients".(1) This is clearly not true. To tackle health inequalities the government needs to address the causes of inequality, which are largely beyond the influence of both doctors and patients. What a GP must do is respond appropriately to the needs of the patient who is consulting them, which will inevitably require an understanding of the socio-economic context of that patient's life. Rather than focussing on obsessive recording of data, our priority must be to make sure that GPs make the best use of the few minutes they have with each patient. This is the core of General Practice. If anything is to be recorded, it should be the GP's consultation skills. The key activities have been documented, for example the GP "elicits appropriate details to place the complaint(s) in a social and psychological context " and explores "the patient's health understanding".(2) If we are skilled and empathic doctors we will maximise our limited ability to reduce health inequalities. Patrick Bower General Practitioner Balham Park Surgery London SW12 8EA 1 Smeeth L, Heath I. Tackling health inequalities in primary care. BMJ 1999;318:1020-1. 2 The Royal College of General Practitioners. Membership Examination. Assessment of Counsulting Skills. Workbook and Instructions. Examinations of 1998. |
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John Macleod, clinical research fellow Department of General Practice, University of Birmingham, Edgbaston, Birmingham B15 2TT
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Smeeth and Heath discuss how health inequalities might be tackled in primary care.(1) We endorse their views on the importance of accurate measurement of social position and their reminder of the general truism - that it is people who are most at risk of serious disease who have most to gain from effective medical interventions (2). They emphasise the assessment of socioeconomic factors in individual consultations. Whilst this may sometimes be important, in general it is not the main issue and the suggestion of yet another task to be completed within an already crowded agenda may put some people off. The recording of accurate, useful data on social position need not involve general practitioners directly at all and can be recorded at registration. Occupational class and place of residence are not fixed and some social mobility is now a feature of UK society (3). However it should be sufficient to simply ask a patient to inform the practice of changes in their address or employment - as most GPs do now. The main use of such information is not to guide the therapy of individuals, it is to allow rational resource allocation at practice or Primary Care Group level. In simple terms poorer people experience more serious pathology in their shorter lives than their more affluent counterparts. This has implications for doctors who work with them. These issues have been considered in detail in relation to child health (4), perhaps suggesting a model for use in other areas of primary care. Imprecision in the measurement of the material circumstances a person experiences is likely to have led to dilution of estimates of the health consequences of these circumstances. In other words we could improve our descriptions of health inequalities and when we do they are likely to appear even more striking. Description of a problem is important but so is exploration of a solution. It is in this latter area that we hope the bigger role for primary care lies - through advocacy, rational and equitable delivery of effective interventions and political lobbying. Yours sincerely John Macleod Rhian Loudon Health Inequalities Research Group Department of General Practice The University of Birmingham B15 2TT References 1 Smeeth L, Heath I Tackling health inequalities in primary care. BMJ 1999;318:1020-21. 2 Davey Smith G, Egger M. Who benefits from medical interventions? BMJ 1994;308:72-4. 3 Bartley M, Plewis I. Does health-selective mobility account for socioeconomic differences in health? Evidence from England and Wales, 1971 -1991. Journal of Health and Social Behaviour 1997;38:376-86. 4 Hall DMB (ed). Health for All Children. Report of the Third Joint Working Party on Child Health Surveillance. Third Edition. Oxford: Oxford University Press; 1996:1-40. no competing interests |
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Dougal Darvill
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Editor The identification of adverse socioeconomic factors can be instrumental in targeting resources to patients both at an individual level by GPs and more widely at a practice or Primary Care Group level. The formal collection of such data by general practices, as advocated by Smeeth and Heath, is fraught with difficulties. For most GPs, I suspect that the 'largely opportunistic and possibly rather haphazard' appraisal of socioeconomic factors is part of the routine assessment of his patients at an individual level. It probably does not need to be put on a more formal footing. Practice-recorded socioeconomic data could be used to allocate resources. In order to gain an extra slice of an already limited and apportioned cake, the data needs to show higher need in one area than another. To obtain such relative data requires the co-operation of practices in more affluent areas that have no vested interest in collecting data that will precipitate a diminution in their own resources. In less affluent areas with more socioeconomic problems, GPs may find that surviving the workload limits time available for recording data. In our own practice of 7500 patients, we found that collection of such data for the Fourth National Morbidity Study required the employment of two full-time workers. Asking patients to fill in questionnaires leads to piles of blank answer sheets from those unable to read and write or just too overwhelmed by social stresses to be bothered with another load of questions. Just the people that most need help. Perhaps time and resources could be better directed at improving the targeting of census and other nationally collected data to more local levels. Attempting to persuade GPs to take on recording this information on top of the myriad other demands on their time is going to be a Herculean labour. Dr Dougal Darvill Hartcliffe Health Centre Hareclive Road Bristol BS13 OJP |
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