General practice should tackle healthcare inequalities but not health inequalities

Dipesh Gopal is a GP in North London and Honorary Research Fellow at Queen Mary University of London. His research interests are in cancer recurrence and health inequalities. Connect with him on social media: https://linktr.ee/dipeshgopal.

Football is the world’s most popular game. You might have seen it, and you might have played it. The format is simple — score more goals than the other team. Galea and Stein, professors in public health, argue winning at health is very much like winning at football.¹ The goalkeeper is often frustrated at team members when they face a shot on goal. This is because goals are scored because of failures of defence, midfield, and attack: it is their failure to tackle and prevent shots occurring that could result in a goal. Health care is like the goalkeeper in ‘Team Health’. Good health and illness are a result of defence, midfield, and attack — politics, decent wages, law, and the services and products that businesses provide. However, it is the goalkeeper’s job, health care, to deal with these consequences of society.

For us in general practice, the healthcare service, we must focus on the inequalities in health care but not health. Ensuring that our populations and especially our marginalised groups receive the care they need is a priority: challenging healthcare inequalities and challenging the inverse care law. A focus on healthcare inequalities not health inequalities is important for several reasons:

1) No time clinically

It is challenging for general practice to deliver its day-to-day service. How can we possibly challenge or improve health in 10 minutes, only to the patients that attend surgery, every 10 minutes? One specific published example included GPs needing to assess brain health and prevent dementia² when clearly a public health strategy would be more efficient.³ Surely assessing the brain health of only those who attend clinic would worsen the inverse care law?

2) No means

It is impossible for general practice to reverse whole negative trajectories in health, such as type 2 diabetes outcomes, when we don’t control an ultra-processed food system and an environment that does not facilitate healthy lifestyles. Lifestyle medicine and medication can help but the drivers of diabetes are bigger than a healthcare system. Another published article suggested we should use statins to curb worse cardiovascular morbidity in deprived communities,⁴ ignoring bigger drivers of cardiovascular disease. To quote Denzel Washington, ‘Don’t confuse movement with progress’. Is doing something really better than doing nothing? Leaving the burden of responsibility of huge social problems such as housing and air pollution⁵ to social prescribers, and dietary education to voluntary, community, and social enterprises would be unrealistic. After all, despite popular belief, social prescribing may very well worsen health inequalities⁶ and provide an over-simplified transactional solution to ‘wicked’ problems.⁷

3) No idea about good

We are unsure of what an improvement in health inequality might be. We must be precise about our metrics and clear when good health and specifically equality is achieved. Is good health defined as disease prevention? If disease prevention is key, how can general practice measure disease outcomes that do not happen? How can policymakers invest in events that never happen?

This is not fatalism but realism. Even if integrated care systems, social prescribers, and community health workers improve some health outcomes we would be lying to ourselves that the roots of good health are NOT both political and economic in origin. We must advocate for our patients locally, regionally, nationally, and internationally, as Virchow envisioned us to be ‘natural attorneys for the poor’.⁸

If we focus on using a healthcare service to improve health outcomes we cannot be surprised when our health worsens or our staff become overwhelmed. Imagine putting the hopes of a nation winning a football match on a tired and injured goalkeeper without focusing on wider issues outside of the reach of the penalty box: the other 10 players, such as law, businesses, wages, and so on. After all, the goals of business and health care are not aligned, despite recent attempts to healthwash food, energy, and climate strategies through ESG, or ‘Environmental, Social, and Governance’ frameworks. In 1970, Milton Friedman, noted American neoliberal economist, said: ‘There is only one social responsibility of business — to use its resources and engage in activities designed to increase its profits so long as it stays within the rules of the game’.⁹ We must decide the rules of the game we wish to play and how we might define our ‘win’. Improving the nation’s health cannot fall to a tiny part of the healthcare service, not least general practice.

The words of Iona Heath ring true here: ‘An excessive and unrealistic commitment to prevention of sickness could destroy our capacity to care for those who are already sick.’¹⁰ It is time to focus on healthcare inequalities and NOT health inequalities otherwise there will be no healthcare service, and no primary care to save.

*Author’s note: This is an adaptation of a 6-minute presentation at the Dangerous Ideas soapbox at the Society of Academic Primary Care on Friday 5 July 2024 at Wills Memorial Building Tower, University of Bristol.

References

1. Galea S, Stein M. Creating health is like winning at soccer. 2018. https://publichealthpost.org/health-equity/creating-health-is-like-winning-at-soccer (accessed 3 Sep 2024).
2. Jones D, Drewery R, Windle K, et al. Dementia prevention and the GP’s role: a qualitative interview study. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/BJGP.2023.0103.
3. Willows TM, Gopal DP. Re-thinking the role of primary care in dementia prevention. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/bjgp24X735945.
4. Wu R, Williams C, Zhou J, et al. Long-term cardiovascular risks and the impact of statin treatment on socioeconomic inequalities: a microsimulation model. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/BJGP.2023.0198.
5. Bailey MJ, Naik NN, Wild LE, et al. Exposure to air pollutants and the gut microbiota: a potential link between exposure, obesity, and type 2 diabetes. Gut Microbes 2020; 11(5): 1188–1202.
6. Gibson K, Pollard TM, Moffatt S. Social prescribing and classed inequality: a journey of upward health mobility? Soc Sci Med 2021; 280: 114037.
7. Calderón-Larrañaga S, Greenhalgh T, Finer S, Clinch M. What does the literature mean by social prescribing? A critical review using discourse analysis. Sociol Health Illn 2022; 44(4–5): 848–868.
8. Brown TM, Fee E. Rudolf Carl Virchow. Am J Public Health 2006; 96(12): 2104–2105.
9. Friedman M. A Friedman doctrine — the social responsibility of business is to increase its profits. The New York Times 1970; 13 Sep: https://www.nytimes.com/1970/09/13/archives/a-friedman-doctrine-the-social-responsibility-of-business-is-to.html (accessed 3 Sep 2024).
10. Heath I. In defence of a National Sickness Service. BMJ 2007; 334(7583): 19.

Featured photo by Jannik Skorna on Unsplash.