Association of deprivation, ethnicity, and sex with quality indicators for diabetes: population based survey of 53 000 patients in primary care
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7477.1267 (Published 25 November 2004) Cite this as: BMJ 2004;329:1267
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Dr Sheperd (1) is right in stating the contract has been designed to
perversely disadvantage high prevalence practices. It is perhaps telling
that the 'diabetes tsar' works in a practice with a prevalence of 2.3% in
leafy Surrey(2). A fourfold increase of prevalence will half the Quality
payment per patient for the same achievement.
However this will not take effect until April 2005 when Quality
payment falls due and does not explain the current or historic differences
in data recording Quality.
The current differences could be explained by the historic under-
funding of deprived practices in the UK. Less money means fewer staff to
do fewer consultations and less data entry. There is less time to organise
and summarise notes and manage the practice.
The nGMS (new General Medical Services) contract should have
rectified this through the Allocation Formula (Carr-Hill). The
introduction of the MPIG (Minimum Practice Income Guarantee) has however
intentionally annihilated any redistribution of practice income and has
perpetuated the historic inequalities (3).
Hippisley-Cox (4) indicates that factors for deprivation and
ethnicity were not included in the Allocation Formula Weighting for
practices. The reason given for this paradoxal omission by the negotiating
parties was that prevalence is a better indicator than deprivation for
workload. However the prevalence will not be part of the Allocation
Formula until 2006 the earliest.
Dr Shepherd states it is more likely that deprived patient attend
with a larger agenda and that health promotion is lower on their agenda.
This may be the case, but in my experience it just takes more time to
explain health concepts to the patients of lesser mental agility. This
type of patient is more likely than highly intelligent persons to live in
a deprived area. They are more likely not to understand the interventions
and therefore less likely to comply with best practice. This problem
applies to all consultations, not just the chronic disease ones. He is
right that longer consultations are the end result.
(1) http://bmj.bmjjournals.com/cgi/eletters/329/7477/1267#87472
(2) Pulse magazine September 6, 2004, p62
(3) Personal communication from Department of Health, TO1045722 16 January
2004
(4) http://bmj.bmjjournals.com/cgi/content/full/329/7477/1267
Competing interests:
Diabetic prevalence 5.19% and rising.
Competing interests: No competing interests
Dear Sir,
in your important paper it is interesting to note the socio-economic
gradient in diabetes care in UK, and the less optimal standard of care
given to female patients. In Sweden, we have documented that these gender
differences reflect adverse social conditions, and that women with
diabetes in association with low educational level run an increased
prospective mortality risk, also when compared with corresponding males
(1). Are any similar follow-up data available in the UK?
Yours sincerely,
Peter M Nilsson
Reference:
(1) Nilsson PM, Johansson SE, Sundquist J. Low educational status is
a risk factor for mortality among diabetic people. Diabetic Medicine
1998;15(3):213-9.
Competing interests:
None declared
Competing interests: No competing interests
Chris Burns-Cox is right - and fast off the mark. Too many authors
use the term ethnicity, or ethnic group(s) very loosely. Hippisley-Cox et
al are probably only using the term in its 'popular' conventional
conversational manner - but as a 'scientist' I must hope that we can try
for some consistency - although I, Prof. Raj Bhopal, and many others have
written exensively about this already. Maybe we can just go on trying to
insist that all of us have 'ethnicity' - are members of AN ethnic group,
and thereby contribute to the ethnic diversity of the population. Areas
also have characteristics: some are 'high in relief' (i.e. are hilly), and
others are 'high in diversity' - or maybe demonstrate the presence of
significantly high proportions of members of particular ethnic groups. As
many people have said, it does matter what we say and how we use words:
this is not just political correctness. A 'heavy metal' is not (I believe)
the same as a metal which is heavy and so it goes on.
That said, thanks to the authors for a very useful article which
illustrates clearly the longevity of the so-called 'inverse care law' and
its application to gender (males and females, both of which I insist have
'gender'), space (places, or 'output areas') and ethnicity (here reduced
to one of its most basic binary splits: 'White' and 'Non-White - or
'Majority and 'Non-Majority' in the UK context). We can debate that usage
on another occasion.
Competing interests:
Prof. Johnson directs a research centre dealing with 'ethnicity' and health issues
Competing interests: No competing interests
Hippisley-Cox et al confirm what those of us working in deprived
areas know. They do not speculate on the reasons why we find it harder to
meet GMS2 targets. In many consultations the sheer weight of psycho-social
comorbidity render the doctor's agenda of BMI etc irrelevant within the
context of the patient's ideas, concerns and expectations. To tackle my
agenda before a consultation has run for at least 15 minutes merely feels
like adding to the person's considerable burdens rather than meeting a
health need. And anyway that consultation has to finish before 10 minutes
to make room for the next one. Add to this the uncanny knack of crises to
cause nurse appointment cancellations, recruitment problems, language
barriers, cultural barriers and low expectations and one is suprised the
results in deprived areas are as good as they are.
Hippisley-Cox et al do not report the variation of diabetes
prevalence by ethnicity or deprivation. In my view it is this variation
that will cause much bigger problems for ethnically diverse practices than
the data recording issue. In Leicester City we have practices serving
South Asian populations reporting diabetes prevalences of up to 8%.
Because of the method of calculation of Quality and Outcome Framework
payments, (which is proportional to the prevalence adjustment factor
consisting of the square root of the ratio of practice prevalence to
national and which was introduced after the GPs voted on the New Contract)
for the same standard of care, each diabetic patient in an 'Asian'
practice generates only 61% of the income generated by a white diabetic
patient in a leafy practice with a prevalence of 3%. Thus practices with
high ethnic populations are doubly disadvantaged by GMS2. Firstly, as this
paper shows, it is harder work recording the data. Secondly, even if high
ethnicity practices hit the outcome targets they will be paid less per
capita for the work, even though their
costs per capita are the same or possibly higher, given the recruitment
situation.
It is hard to avoid a charge of 'institutional racism in the NHS'
here and although I am certain that it was not intended by the authors of
the New Contract, it needs addressing urgently if health inequalities are
not to be further widened by GMS2.
Competing interests:
Our practice contributes to the QRESEARCH database and serves a predominantly white population.
Competing interests: No competing interests
Hippisley-Cox and others write on the Association of deprivation,
ethnicity and sex.... They state they use the word to mean the proportion
of non-white people in the population.
That is what should be written and not the word ethnicity which has a
different meaning and is popularly perverted for all sorts of reasons.
There are so many non-white groups in our country that the above
definition is simplistic and quite inadequate.
Incidentally did the 'ethnicity' of the relevant GPs affect the
results?
Competing interests:
None declared
Competing interests: No competing interests
New Contract Prelevance Factor...Future Cause Of Inequalities In Health?
While Hippisley-Cox et al(1) are helpful in highlighting the fact
that it is likely that doctors working in deprived areas will achieve less
quality points and therefore lower income from diabetes care under the new
contract; I agree with Dr Sheperd(2), the biggest failling with the
contract is the peverse treatment of prevalence.
Prevalence of diabetes varies widely between practices, being
particularly more prevelant among the less affluent- the NSF for
diabetes(3) indicates that it is one and a half times more likely to
develop in a patient in social class V than I, (and morbidity from
complications to be three and a half times higher).
Under the new contract an "average practice" with 5000 patients if it
achieves 90 of the 99 quality points for diabetes wold recieve £6,750 for
looking after approx. 150 patients, or £45/ patient for the year 2004-5.
A practice with only half the average prevalence (75patients),would
recieve 70% of £6,750 (square root of 0.5=0.7), or £63 per patient.A
practice with twice the average prevalence,300 patients, would recieve
40% more than the average (square root of 2 = 1.41) but this is less than
£32/patient.
This payment is not income for the doctor, but has to cover the
practice expenses as well- for nursing time etc. If this is, say
£20/patient/ annum, then the finacial recompence to the doctor for his
time will be nearly four times greater in the low prevalence than the high
prevalence,and likely deprive, area.
Because of the workings of the formula,the variation in reward, for
identifying a new patient is even worse...
the doctor in a high prevalence area will likely be "paying for the
privilege " for every new patient he identifies 2004-5.
Even with the increased payments due in 2005, the difference in
remuneration for identifying new patients is stark - in the case as set
out above the doctor in the low prevalence practice would expect to
recieve £55/ annum of additional income for the trouble of diagnosing each
new patient; the doctor in the high prevalence area...£6.65p.
All this before we even ask Dr Hippisley-cox's question on the
difficulty of achieving the quality points in areas of deprivation.
With an estimated 1 million people with diabetes yet to be diagnosed,
the faillures of the New Contract may be long felt.
1.Julie Hippisley-cox et al BMJ 2004;329 1267-1269
2.David Shepherd Rapid Responses
3.NSF for diabetes,DoH, 2004
Competing interests:
None declared
Competing interests: No competing interests