Today I had an article published in the British Medical Journal, along with an accompanying editorial[1] and a front page press release (which will be visible for about 3 minutes before the next health care fad overwhelms it). The article itself is an investigation of rates of referral to secondary care (that’s “hospital” to the non-initiated) by General Practitioners (“Doctors” to the non-initiated), which uses GP routine monitoring data to estimate the difference in rates of referral for key conditions by socioeconomic status, age and sex. The key finding is that poorer people tend to be referred less frequently or at longer time intervals than wealthier people, as do the very old, except where strict guidelines exist that restrict GP choice. The implication, of course, is that something happens in the GP consultation that disadvantages poorer or older people.
The research was conducted in conjunction with a Public Health Trainee and two other academic departments while I was working at the King’s Fund, in London. The statistics are, in my opinion, pretty robust, and the findings pretty stark, and the diseases we considered are interesting for their implications. We looked at referral rates for three conditions:
- Post Menopausal Bleeding, which is a symptom of serious health conditions and should always be referred to further care
- Dyspepsia, which is a symptom of illness in people over 55, and for which referral guidelines exist in this age group
- Hip Pain, which by contrast is generally considered an indicator of osteoarthritis and which has no clear guidelines or medical opinion on what level of referral should be provided
Our hypothesis was that the existence of guidelines would eliminate referral rate discrepancies (in the case of dyspepsia) and that the vague nature of hip pain science would mean that referral rates would be dependent upon the GP-patient interaction. Our hypothesis got strong statistical confirmation from a very robust dataset. The accompanying editorial attempts to present a theory of how this might occur, because it’s not immediately obvious why. Noone who wrote this paper thinks that GPs are sitting behind their desk concluding that poor people don’t deserve care, and the data don’t tell us why the discrepancy exists. Note that in the case of hip pain the available knowledge is such that we don’t even know what the right referral rate is.
My personal theory (not necessarily shared by my co-authors, who are quite capable of speaking for themselves) is that poorer patients are less capable of representing their interests to a better educated and highly respected, wealthy doctor. They don’t express the need for pain relief or advanced care, and they don’t advocate for their own needs. I think there may also be an internalized social view, held by many poor people (deferential toryism) and some doctors that poor people don’t deserve the same quality of life as wealthy people, and should be thankful for what they’ve got. This means that everyone involved in the consultation is not advocating for or not offering the service that should be available. Of course this only happens in some consultations and it happens subtly – it’s not like anyone is thinking “you’re poor, just go home and die already!” or even that the doctor is thinking anything less than that they should provide the best service they can. But there are different cultural expectations of health in different classes, and they create subtle barriers to the best quality of care amongst poor people. I think this is an important example of how culture is as important as simple structural or economic issues in setting the determinants of health inequality.
Other theories, of course, are welcome. This is hardly settled science, and my job is to do the calculations, not to explain them!
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fn1: incidentally, these articles require you register to read them fully. It’s probably not worth your time…
December 2, 2010 at 12:23 pm
Pretty heavy reading Faust.
That older generation at least in the US has a tendancy of being pretty distrustful of doctors, at least from what I’ve noticed. Do you think the referral rates have anything to do with the patients in question just going there to get people off their back? As in the old “I’m fine, I just wanted you to confirm it” sort of deal even though they are obviously having a little difficulty.
December 2, 2010 at 12:32 pm
It’s excellent bedtime reading, Grey – one paragraph and you’ll be fast asleep. Only government reports are better!
The issue of referral and older people is a complex one but it’s a pretty longstanding area of inequality. Part of it is probably because older people view health differently, and obviously health interventions carry a higher cost, so they’re more likely to accept a prescription of “grin and bear it” (and may even push for same). In general I think while they whinge and gripe about it endlessly, older people in Britain are very respectful of the NHS and doctors – the current crop of over 75 year olds invented the NHS, after all – so I don’t know if it’s that in particular. GPs are continuously the most trusted members of the community in surveys in the UK.
We tried to adjust for the possibility that older people would be less well and have a lot of complex health decisions to make, but I think there remains a suspicion that GPs don’t think health resources should be spent on the very old. Certainly when I see how my Dad whinges and moans about his doctor, I agree with the Doctor! But it’s a serious issue if it enters the clinical relationship, and (as the editorial says) we need a lot of research before we can find out what is really going on in the 7 minutes (on average!) of clinical contact that patients get with their GP.
There, aren’t you glad you asked?
December 2, 2010 at 12:59 pm
Oh, heh… it gets even longer? I read the full version there but I guess I missed most of the stats and tables. I’ll get to the even longer-er one later 😉
I’m sure it probably is being rationed to an extent for GP’s, paricularly if they think it might be dangerous or not successful (even though it at least one of those it definetetly needs to be looked at.) I just mention the grin and bear it sort of treatment because I know of a number of older folks here who have a “never again” sort of policy at major procedures at their age.
December 2, 2010 at 1:05 pm
I certainly imagine that those kinds of calculations happen in older people, which is partly why huge discrepancies in access to care can tend to be overlooked. But with something like endiometrical cancer, initial investigation is very important – this is a potentially fatal problem. So one would think they wouldn’t be making such judgments in that case!
December 2, 2010 at 2:53 pm
Cool! Wild theory time! Of course I haven’t read the article as:
1. That would take time I don’t have
2. I’m used to reading your material by now from browsing this blog and I can safely say that reading it wouldn’t add anything to my life
3. Reading it would put me in the uncomfortable position of having real information for use in my wild theories. And that dog won’t hunt monseigneur.
Alternate theories that occur to me are:
1. Doctors associated with poorer patients tend to be less capable
2. Unequal doctor availability, such that poor people spend less time with doctors, possibly because there are too few doctors in their area which pushes the available ones to spend less time with patients.
3. Poorer people could have a more macho culture encouraging them to remain silent about aches and pains.
4. Poor people could be less able to get to doctors due to time commitments.
5. Poor people are healthier.
6. A witch did it.
Theory 1 would make sense in a market where doctors can charge some sort of top up fee, such as Australia, or just charge what they like (the USA?). But your data is from the UK, so there is no reason to believe that richer people and better doctors would congregate together.
Theory 2 would be easiest to spot by checking average consultation time in high v low socioieconomic areas. But when I think of London my first thought on this is remembering how some parts don’t have much of a physical divide between the “nice” bits and the “drug infused blastd wasteland” bits, which could be round the corner from each other and simultaneously occupying totally different conceptual countries. So more data needed to prove/disprove this.
Theory 3 would suggest that if we break the numbers down by gender we’d see poor men as being the greatest sufferers of problems. But I’m not sure “macho” we need to find the women to support it.
Theory 4 would find that if you break poor people up into “poor working” and “unemployed” that the health outcomes amongst the unemployed match the better off people’s outcomes
Theory 5 would suggest that poor people’s life of high spiritual and social worth compared to the materialistic behaviour of richer people has given them better health outcomes. Doctors referral rates could then be correct. This should be observable in equal or better life expectancies in poor people (don’t think this reflects the data you’ve mentioned or what I’d expect). Alternatively it could also be borne out by showing that poor people live a relatively healthy life then drop dead suddenly – that would suggest rich people are in fact kept alive longer at the cost of being sick earlier and longer than poor people.
Theory 6, you heard me.
December 2, 2010 at 2:57 pm
Opps, forgot:
Theory 7 – Poor people are whingers. If they go to doctors more frequently per capita then you’d expect lower referal rates per visit.
December 2, 2010 at 7:16 pm
I think you’ve shown once again your heightened common sense Paul, when you choose not to read the article. Reason 3 is particularly sensible, I think.
Do I have to choose any particular one of your wild theories? Because I think most people with an opinion would take most of them…
I’m no expert on the causes of health inequality and I should stress that my theories don’t match up against those of my colleagues on the paper, who are experts in the field and whose statements on the matter need to be given much more weight than mine. The interesting thing about our paper is that one condition came with guidelines above a certain age, and for that condition, above that age, there was no socioeconomic gradient in referral. This suggests that the cause of the referral gradient occurs inside the consultation itself, and isn’t a strucutral phenomenon per se. But we don’t know, because research into the patient-GP dynamic is not yet up to this topic. Give it time!
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fn1: what an archaic notion!
December 3, 2010 at 10:20 pm
The poor-people-have-time-commitments thing strikes me as the reverse of the truth. Many poor people are in long-term unemployemnt – they have time coming out of their arses. Rich people, on the other hand, if we’re talking about professionals like lawyers, accountants, etc., tend to put in very long hours. The era of the working classes slaving down a mine for 14 hours a day is long, long gone.
December 3, 2010 at 11:30 pm
I think that’s partly not true, noisms, because the working poor are a new and growing phenomenon in western countries. But more relevantly, for the working poor on 9-5 jobs, the problem is inflexibility. GP surgeries tend to be only open 9-5, and flexible working hours are very much a middle class and professional phenomenon. This is why polyclinics and large, multi-handed surgeries are important.
Incidentally, this is why British elections are a travesty. Elections on a Tuesday are anti-democratic.
Though largely although inflexible working is a problem for access to medical care, I don’t think it’s the main issue. I’m much more inclined towards cultural explanations, either complexities in the consultation itself, or different attitudes towards health and health care. Plus infrastructure issues.
December 3, 2010 at 11:37 pm
From my own experience the machismo explanation is a pretty good one at least as far as working class men go. Both my grandfathers and my dad never really went to the doctor in their entire lives – except when one of them eventually developed Alzheimer’s and had no choice.
They were/are also all Glaswegians, so they had a double-machismo thing going on (Scottish and working class).
December 3, 2010 at 11:43 pm
It’s worth noting that this study was of people who go to the doctor – it explicitly concerns the time between attendance at the doctor and referral, so unwillingness to attend a GP is not the cause. Also in some cases (e.g. postmenopausal bleeding) we analyzed explicitly whether patients received a referral at first attendance for the problem, since the indication is for immediate referral. It’s hard to see that machismo or culture can play a big role in whether you get offered a referral on the first attendance for a problem – you’re in the doctor’s surgery for, on average, 7 minutes, so how does your personal view of health affect whether or not you get a referral in that kind of circumstance? Our analysis of hip pain is more amenable to this explanation, since we studied time to referral (hip pain is not a cause of immediate referral and there is no clear idea of when exactly one should be referred). In this case it’s easy to see that patients wouldn’t push for things they really actually need, if they have certain views of health. It’s worth noting though that in the case of a condition like hip pain, where there is no clear rule about what should or shouldn’t be done, that it’s just as possible that wealthy people are being over referred as that poor people aren’t being referred fast enough.
December 15, 2010 at 4:54 pm
A brief update: the original article now has 3 “rapid responses” (like letters to the editor) which make some interesting points:
1. the first letter suggests that gender and risk aversion affect GP willingness to refer, and that this may be playing a role. Female GPs are more likely to refer, so if there were a gender pattern in General Practice in poor areas this would be shown. We didn’t do a proper multi-level model in this study, maybe if we did we would get an insight into the relationship between GP characteristics and referral patterns
2. Someone from Taiwan pointed out that patient choice plays a role, and the managed system of the NHS may be restricting patient choice. Taiwan has a single-payer insurer with free market providers (hospitals) and they argue that this works better for speeding referrals. I don’t know much about the Taiwanese system, but it could be it works more like the Australian system. This is a hint at infrastructure issues underlying GPs’ decision to refer – you don’t refer people if they’re never going to get to hospital, or will end up in a hospital that is so bad it should be closed…
3. A letter from NICE selling the benefits of guidelines. Fair enough…