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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