L’approche britannique pour accroître l’impact de la première ligne sur la santé de la population

Sir Liam DonaldsonMSc, MD, FRCS(Ed), FFPHM, FRCP, FRCP(Ed),

FMedSci, Chief Medical Officer, The Department ofHealth, Angleterre

Journées annuelles de santé publique 2002La consolidation des liens entre la santé publique et la première ligne

: un agenda à partager

Québec, 21 novembre 2002www.inspq.qc.ca/jasp

PRIMARY CARE IN ENGLAND: KEY FACTS

99% of population registered with a general practitioner

8 out of 10 contacts with the NHS are in primary care

75% of NHS spending goes through primary care

A Director of Public Health in every primary care organisation

Source: Audit Commission, 2002

Inequality: social classShortened life for men in non-professional classes

England & Wales 1997-99

71.1

72.7

74.7

76.2

77.5

78.5I - Professional

II - Managerial

IIIN - Skilled (non-manual)

IIIM - Skilled (manual)

IV - Partly Skilled

V - Unskilled

Male life expectancy at birth

Source: ONS, Health Statistics Quarterly No.15

1949-53 1959-63 1970-72 1979-83 1991-93

SOCIAL INEQUALITIES IN THE PATTERN OF DEATH FROM CORONARY HEART DISEASE

Social class I

Social class V

Standardised mortality ratios (Indexed to 1949-53)Log scale

England and Wales average of all social classes in 1949-53 = 100

200

160

125

100

80

63

50

0

40

Years

2.9times greater

2.0times greater

1.3times greater1.1

timesgreater1.7

timesgreater

Source: Audit Commission

The position of general practice in relation to all health services

NHS STRUCTURES

Department of Health**

28 Strategic Health Authorities

300 Primary Care Trusts*

318 Hospital Trusts

Fund andcommission services

TAXPAYERS

PATIENTS AND PUBLIC

Financial FlowManagement Accountabilities

Note: ** Public Health Regions and * Care Trusts not shown

Manage performance

Sets policy, strategy and standards

Government Offices co-ordinate local organizations and national funding streams:

regeneration of neighbourhoodsand communities sustainable environmentbusiness and employmenteducation and trainingsocial inclusionreduce crimepromote innovationcreate integrated transportpublic health

English regions: regeneration and health

Source: Audit Commission

General practice as part of wider primary care

Source: MORI poll commissioned for Audit Commission, 2000

Satisfaction with GP services

Source: Audit Commission

Tensions in general practice

PUBLIC HEALTH IN PRIMARY CARE

Preventive programmes

Implementing National Service Frameworks

Community development and regeneration

PREVENTIVE PROGRAMMES

Smoking cessation

Cancer screeningRisk factor modification

Immunisation andvaccination

Source: Audit Commission

Changes in cervical cytology

0

100

200

300

400

500

600

700

1997 1998 1999 2000 2001 2002

Year (by quarter)

No o

f lab

orat

ory

conf

irmed

cas

es

Serogroup CSerogroup B

Impact of meningococcal C conjugate vaccine in the under 25 population

Source: PHLS

0

5

10

15

20

25

30

35

40

45

50

0-10% 11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%Percentage of CHD patients prescribed aspirin

Per

cent

age

of p

ract

ices

Jul-00 Jun-02

Percentage of CHD patients prescribed AspirinFirst Wave Collaborative practices

July 2000 - June 2002

0

5

10

15

20

25

30

35

40

0-10% 11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%Percentage of post-MI patients on beta-blockers

perc

enta

ge o

f pra

ctic

es

Jul-00 Jun-02

Percentage of post-MI patients on Beta-BlockersFirst Wave Collaborative practices

July 2000 - June 2002

POORDIET

Low income

Lack of car/transports

No cheaphealthy

convenience food in shops

Lack of local shops

lack access to cheaper

shops

Long hours, no time or

energy

healthy food unaffordable

unhealthy convenience food/eat at

strange times

Lack education

Stressanxiety

depression

Inherited cultural norms

lack awareness/information

comfort eating

Source: MORI

FACTORS THAT CONTRIBUTE TO HEALTH INEQUALITIES

Macroeconomic: including poverty and low incomes; worklessness

Environmental: poor housing, lack of green space, pollution

Poor access to services: healthcare; food shops, local transport

Poor quality services: including lack of leisure facilities, limited healthcare

Limited early years development

Poor educational attainment

Damaging lifestyle choices

INFECTIOUS DISEASE ISSUES MAKING THE HEADLINES

Public Health Observatories on the Internet

www.pho.org.uk

Regional Public Health Observatories: focusing on health issues

TACKLING WIDER DETERMINANTS OF HEALTH

PREVENTIVE SERVICES

HEALTH PROTECTION

HIGH QUALITY CARE

HEALTHIEROPPORTUNITIES

HEALTHYLIFESTYLES ANDREDUCED RISKS

REDUCED THREATS TO POPULATION

HEALTH

IMPROVEDOUTCOMES OF HEALTHCARE

PUBLIC HEALTH IN PRIMARY CARE: CULTURE

Leadership

High quality partnerships

Multidisciplinary practice

Performance emphasis

Public engagement

Use of evidence and information