I can’t live without my burgers, my chips or the doner meat. I know they are bad, I can see the fat dripping out of it…
Not my opinion, although the kebab vans on the High Street used to exercise a compelling attraction at 2am, but that, to borrow Christopher Marlowe’s phrase, “was in another country; And besides, the wench is dead”.
I didn’t have enough money, so I bought my 20 fags and two energy drinks; I was losing weight. I didn’t have the money. I went to the doctor’s to give up.
Again, not me; that was Yasser, who realised at the age of 16 that smoking over 20 a day was not good for him and, more importantly, was unaffordable.
Danielle makes sure she has a monthly sunbed session to disguise scars from scabies, even when she has to order her Asda internet delivery on her mother in law’s credit card.
Four years ago, we had identified that to make any impact on our premature mortality in men we would have to make a difference to the prevalence and management of cardiovascular disease. Across Birmingham, suggestions emerged for payments to GPs to identify and assertively manage at-risk patients. Given this was their job anyway we were wary of this route.
We decided to ask some men in our target groups about their health, their use of services and what kind of service they would like to see.
Through Dr Foster, we interviewed men aged 55-75 in six key groups. The results were instructive. The Bangladeshi men were high users - they liked to visit the GP regularly. One described his weekly visit as like having his car MoT “just to check there is nothing wrong”. The poor outcomes for this group may arise because their GPs are so fed up with seeing them they have stopped looking for disease.
The other five groups, diverse in ethnicity, were remarkably consistent on one point - it was a badge of pride that they never darkened the door of their GP. This suggested a screening programme based on visiting the GP may not be the best route.
The men were very open about what they would like: to be contacted rather than relied on to present themselves; to be able to fit any screening into their regular routine. Many suggested a mobile service which could park at football clubs and supermarkets.
We took the proposals seriously and successfully screened more than 9,300 men in 10 months who had previously been out of contact with services. We found frank, unmanaged disease in over 10 per cent, with 36 per cent identified as high risk for cardiovascular disease. Perhaps most importantly, 99 per cent were satisfied with the way they had been contacted and how the results had been explained, 98 per cent would recommend the clinics to another man and 97 per cent said they would attend again. They were more comfortable about visiting their GP as they were now legitimately “ill”.
We also sent all results to GPs for updating disease registers and active follow-up with high risk patients.
This experience raised some serious questions for us as commissioners. It laid bare how much we design services that make sense to us as health professionals, rather than consider the preferences and lifestyles of our target audience. We assume a single set of preferences, which looks remarkably like our own.
This default design for the majority is then reinforced by policies that reward achieving 80 per cent coverage.
So what is happening to the other 20 per cent? Is it not a reasonable hypothesis that the disengaged 20 per cent are those at greatest risk of ill health?
We have not as a service historically invested much time or energy in understanding the preferences of this group. Rather we demonise them as the irritating “hard to reach” and ensure we get paid and hit performance targets without having to deal with them.
Now the public service agreement targets may force us to develop better insight into the priorities and preferences of our local 20 per cent. To tackle our long standing health inequalities we have to begin to understand specific groups of people.
We have identified 10 different health “types” within our 440,000 people, which broadly fall into three groups with some common features.
Yasser shares many characteristics with the “unemployed tween” group: he is in further education, he engages in a variety of high risk behaviours (from gang violence to excess kebab eating). He is also very thoughtful when challenged about health, pointing out that all the cheap fast food outlets encourage poor diet. He sought help early for his smoking, and recognised that perhaps it was too early to be taken seriously by a service which focuses smoking cessation activity on those old enough to vote. We need to partner more effectively with youth services.
Danielle has more in common with our “troubled dependence” group: most of the family income is benefit, she has a young child and suffers post-natal depression. Her medication ran out a month ago, but all GP appointments are gone by the time she gets up in the morning. She gets most of her information from the internet. She is helping us gain more insight into local life. If we are now to design and deliver more productive services which reach those most at risk, we have a lot to learn.