In this post Ruth Abrams and Sophie Park reflect on the current pressures facing GPs and NHS today.
In a recent expose called ‘GPs: Why Can’t I Get an Appointment?’, a Panorama documentary, which aired on BBC1 on Wednesday 8th May, emphasised the current limits of and pressures on the NHS system. The programme featured interviews with overworked GPs and allied healthcare professionals, painting a rather bleak picture. Practices are merging and closing at an ever increasing rate. Patient loads increase as patient lists are subsumed. Patient multi-morbidities have increased the need for chronic conditions to be monitored with regular GP appointments. Yet on average patients wait a minimum of two weeks for a routine appointment. Early retirement and a limited flow of trainees into General Practice also contribute to the strain, making practice sustainability difficult to envisage. Inevitably, pressure and frustration are being felt amongst both patient groups and the primary care workforce.
Whilst those researching, working in and experiencing primary care within the UK will already be familiar with these factors, what has become a pressing concern since the 2015 publication of the BMA’s, National survey of GPs: The future of General Practice, is patient safety. At present only the most urgent of cases are seen quickly in General Practice. Yet still an unsafe number of patients are seen by any one GP in a day. This high demand placed upon GPs makes for little time to reflect on cases.
Enter- the release of the new GP contract and the NHS long term plan which intend to employ a multi-disciplinary army of healthcare professionals. Within this new way of working, workloads will be shared amongst staff, with greater efforts being made for both integration and collaboration. A typical GP’s day will begin to look very different. Micro-teams will have time to discuss patient cases, a GP’s time can once again be focused on the professional tasks only they can undertake and overall there begins to be a healthier outlook to teamwork.
Some promote this utopian vision of General Practice working unquestioningly. Pots of money, such as those made available through the Prime Minister’s Fund, have encouraged new ways of working with very limited evidence base. Yet one aspect seemingly unaddressed within the new plans is the disparity across patient access and levels of deprivation within the UK. In a recent report by the Health Foundation, GPs working in higher deprived areas see more patients compared to their counterparts. These are areas where recruitment of this new workforce will inevitably be harder. This raises questions about how best to incentivise recruitment so that patient access to care remains equal for all.
There is also a certain feel that these plans are being done to, rather than with GPs. We need only reflect back a few short years to the junior doctor protests to recall that in order for patient safety to happen, workforce perspectives must be accounted for. In order for the NHS to remain as successful as it has been and for the principles of Astana declaration to be realised, GP engagement rather than negation needs to remain central to all future planning activities.
Unequal access to care and a disruption to professional identities present major issues. But doing nothing is no longer an option. At a time when the NHS is so often synonymous with the words crisis and strain rather than success, a Utopian vision for both staff and patients may be both timely and necessary. Reifying this however, becomes a different matter all together.
Across the globe, more people are spending more time in retirement than ever before. So staying healthy in later life is critical. Yet political debates on ageing tend to ignore a growing body of research on how retirement can affect our health. Baowen Xue and colleagues from the Department of Epidemiology and Public Health at UCL looked at links between retirement and cardio-vascular disease – and found unexplained differences between Europe and the US.
Is retirement good for your heart, or bad for it? The question is an important one because cardio-vascular disease (CVD) is the biggest cause of death globally and costs health services a huge amount of money.
Some studies have shown retired people have a higher risk of being diagnosed with CVD than those who are still working. But until now the evidence has been unclear.
We set out to review evidence from across the world, so that we could help to build a more accurate picture of whether, and how, retirement might affect our cardio-vascular health. As CVD is linked to our lifestyle, diet and other behaviour, there are lots of ways in which changes that take place in retirement might have an effect – both negative or positive.
Longitudinal studies
We looked for longitudinal studies that could help answer our questions, and found 82 which measured risk factors for CVD and 14 which looked at actual incidence of CVD. The second set of 14 papers provided the answer to our first question – does retirement affect our cardio-vascular health?
The answer revealed a major difference between the USA and Europe. Studies conducted in the US showed no significant effect, good or bad, on retirees’ cardio-vascular health. In Europe, meanwhile – with the exception of France – studies consistently showed a link between retirement and an increase in CVD.
Data from the British Regional Heart Study, for instance, showed that healthy men who retired before the age of 60 were more likely than others to die from circulatory disease within five and a half years. Fatal and non-fatal CVD was also more common among retirees in Denmark, Greece, Italy and the Netherlands.
Why might this be? Could there be cultural or lifestyle differences between Europe and the US which might cause this difference? We took a systematic look at the risk factors.
Weight gain
First, we looked at weight gain. If Americans were less likely to put on weight after retirement compared to Europeans, that might help to explain the difference. But when we looked at this, we found that body mass index (BMI) actually increased after retirement in the USA – and also Japan -but did not change in England, Denmark, France, Germany, Switzerland or Korea. While those who do physically demanding jobs are likely to put on weight after they retire, most people aren’t.
Could it be that retired people generally do less exercise – another risk factor – in Europe? The studies suggest that’s not the reason. While many retirees did more physical activities, they also spent more time sitting still – so the effect was a balanced one. For instance, a retiree might play more golf, but also watch more television.
Do retired people perhaps smoke more, we asked? Again, there were contradictory results but 12 out of 14 studies either showed no effect or showed retirement led to people smoking less.
Perhaps retired people in Europe drink more, then? Again, this couldn’t be identified as the reason. Studies in Australia, the UK, Japan and the USA suggested there was no association between retirement and alcohol consumption.
Diet is another possible cause of CVD, but again, there was no clear pattern of between retirement and diet emerged from reviewed studies.
No benefits
So the picture isn’t straightforward, and we don’t have answers as to why retirement might put Europeans at risk but not Americans. What we can say, though, is that none of the studies we looked at found any beneficial effects of retirement on CVD.
Apart from a decrease in smoking, there wasn’t evidence of any general ‘relief’ effect of retirement on people’s cardio-vascular health – so the supposition that working could be bad for our health and therefore retirement better for it doesn’t necessarily hold true.
However, studies that showed retirement brought negative health effects should be interpreted with caution. Many assessed the health effects of retirement by comparing retired people with employed people – and we know people who stay in the labour market are generally healthier than retirees. We do know people who have CVD, diabetes or hypertension are more likely to retire.
What our review has done is to reveal the complex nature of the underlying mechanism through which retirement might impact on the risk factors for CVD. Different people react differently to retirement, depending on their life experiences and the cultural and policy environments in which they live. So there isn’t one global solution to any of this – each country needs to plan its citizens’ retirement according to their individual needs.
This blog article is courtesy of the Work Life blog, which is a blog about the relationship between work and health and well-being of people, whether they are preparing for working life, managing their work / life balance or preparing for retirement and life beyond retirement. Led by the ESRC International Centre for Lifecourse Studies, University College London,
By guest blogger, on 24 April 2019
Where you live in your 20s affects when you retire – here’s how
Where you decide to live will impact your career. Shutterstock.
Across the globe, people are living longer. Many countries – including the UK – have responded by raising the age of retirement. By 2028, UK citizens will need to be 67 years old to receive their state pension, and further increases have been recommended by both government and independent reviews.
But there’s one major issue with this: most employees in the UK already stop working before the current state pension age of 65. For some, early retirement can be a positive life change which means they can afford to stop working. But for others, early retirement is a result of poor health or unemployment, which can eat into savings and widen inequalities among older people.
Previous studies have shown that in areas where there are more unemployed people, older people are also more likely to leave the workforce. In the past, researchers thought this was because older workers are more likely to be made redundant and have a harder time finding another job when they are unemployed.
But our new research shows that the link between local unemployment and retirement age actually depends on where people live as young adults. Specifically, people in their 20s who live in areas where there are fewer jobs are more likely to be unemployed and in poor health at mid-life – and these are two significant causes of early retirement.
There were 2,526 cohort members, who told us whether they had retired from their main occupation or were still in work. First, we explored where they had lived in childhood (at age four), young adulthood (age 26) and mid-life (age 53). Then, for all three ages, we looked at census data to find out how many working-age people in their local authority were unemployed at the time.
By the age of 68, more than 80% of the people in the cohort had retired, with the average age of retirement being around 59 years. As seen in previous studies, those who lived in areas with higher levels of unemployment at mid-life, also tended to retire earlier. For each 5% increase in local unemployment, people retired on average roughly 1.5 years earlier.
Long-term effects
But when we started to delve into where cohort members had lived earlier in their lives – as well as considering their health, employment and education history – we realised just how strongly unemployment levels in the local area during early adulthood continued to affect people throughout their lives.
If a cohort member lived in a local authority where there was more unemployment than average as a child, it was also likely that they would live somewhere similar as an adult. And those who lived in areas with higher than average unemployment rates as young adults then went on to have poorer health and were more likely to be unemployed at mid-life – compared with those who lived in areas with lower unemployment rates.
Researchers have found that health and employment status strongly predict what age people retire. We found this as well, with cohort members who were unemployed at mid-life retiring on average about five years earlier than those who were working full time at the same age.
What’s more, we found that the link between where people live in their mid-life and their retirement age can actually be traced right back to where they lived in their 20s. So the experiences people had when they were younger had a long term impact on their health and employment status at mid-life.
For example, someone who had moved in their early 20s to Guildford, where there was high employment, was more likely to still be in work when they reached mid-life, than someone who had lived in their 20s in Glasgow – where unemployment was high – regardless of where either lived later in life (although it is likely both will have lived in the same or equivalent employment area in their 50s).
Our findings imply that people should think carefully about how where they live might affect their career. People seem to know that it’s easier to get a job in areas where there are more jobs available – indeed, graduates tend to migrate into urban centres with more employment opportunities. Our research shows that these early career decisions can have consequences into people’s retirement years.
If the government wants to encourage people to stay in work longer, it should give older workers the support they need to stay in work and in good health. It could also help them maintain their employment, even when they’re not in the best of health – for example by adapting workplaces for older workers, or encouraging flexible working. By improving job opportunities for young people living in places with high unemployment, it could help people to keep working for
Where you live in your 20s affects when you retire – here’s how
Where you decide to live will impact your career. Shutterstock.
Across the globe, people are living longer. Many countries – including the UK – have responded by raising the age of retirement. By 2028, UK citizens will need to be 67 years old to receive their state pension, and further increases have been recommended by both government and independent reviews.
But there’s one major issue with this: most employees in the UK already stop working before the current state pension age of 65. For some, early retirement can be a positive life change which means they can afford to stop working. But for others, early retirement is a result of poor health or unemployment, which can eat into savings and widen inequalities among older people.
Previous studies have shown that in areas where there are more unemployed people, older people are also more likely to leave the workforce. In the past, researchers thought this was because older workers are more likely to be made redundant and have a harder time finding another job when they are unemployed.
But our new research shows that the link between local unemployment and retirement age actually depends on where people live as young adults. Specifically, people in their 20s who live in areas where there are fewer jobs are more likely to be unemployed and in poor health at mid-life – and these are two significant causes of early retirement.
There were 2,526 cohort members, who told us whether they had retired from their main occupation or were still in work. First, we explored where they had lived in childhood (at age four), young adulthood (age 26) and mid-life (age 53). Then, for all three ages, we looked at census data to find out how many working-age people in their local authority were unemployed at the time.
By the age of 68, more than 80% of the people in the cohort had retired, with the average age of retirement being around 59 years. As seen in previous studies, those who lived in areas with higher levels of unemployment at mid-life, also tended to retire earlier. For each 5% increase in local unemployment, people retired on average roughly 1.5 years earlier.
Long-term effects
But when we started to delve into where cohort members had lived earlier in their lives – as well as considering their health, employment and education history – we realised just how strongly unemployment levels in the local area during early adulthood continued to affect people throughout their lives.
If a cohort member lived in a local authority where there was more unemployment than average as a child, it was also likely that they would live somewhere similar as an adult. And those who lived in areas with higher than average unemployment rates as young adults then went on to have poorer health and were more likely to be unemployed at mid-life – compared with those who lived in areas with lower unemployment rates.
Researchers have found that health and employment status strongly predict what age people retire. We found this as well, with cohort members who were unemployed at mid-life retiring on average about five years earlier than those who were working full time at the same age.
What’s more, we found that the link between where people live in their mid-life and their retirement age can actually be traced right back to where they lived in their 20s. So the experiences people had when they were younger had a long term impact on their health and employment status at mid-life.
For example, someone who had moved in their early 20s to Guildford, where there was high employment, was more likely to still be in work when they reached mid-life, than someone who had lived in their 20s in Glasgow – where unemployment was high – regardless of where either lived later in life (although it is likely both will have lived in the same or equivalent employment area in their 50s).
Our findings imply that people should think carefully about how where they live might affect their career. People seem to know that it’s easier to get a job in areas where there are more jobs available – indeed, graduates tend to migrate into urban centres with more employment opportunities. Our research shows that these early career decisions can have consequences into people’s retirement years.
If the government wants to encourage people to stay in work longer, it should give older workers the support they need to stay in work and in good health. It could also help them maintain their employment, even when they’re not in the best of health – for example by adapting workplaces for older workers, or encouraging flexible working. By improving job opportunities for young people living in places with high unemployment, it could help people to keep working for longer.
Emily Murray, Senior Research Fellow, Department of Epidemiology & Public Health, UCL
Would you let a stranger into your home? Would you then answer questions about yourself, your family and your health for an hour or so? Luckily, 10,000 people in England do so every year. Most also allow the interviewer to measure their height and weight. Many agree to a nurse visiting them later. The nurse measures their waist and blood pressure and takes blood, urine or saliva samples.
The Health Survey for England (HSE) is one of the biggest and longest-running health examination surveys in the world. It is organised by NatCen Social Research and UCL. What makes the HSE unique in the UK is that we take these measurements and we ask the general population – anyone living in a private home. We don’t rely only on questions (a ‘health interview survey’). We don’t rely only on information collected by the NHS. We work on three surveys at a time. We are currently: writing the report for the 2017 survey, running the 2018 survey, and preparing for the 2019 survey. We always obtain approval from an NHS Research Ethics Committee for the questions and measurements we plan to include before we start the survey.
Why is this important? Most people report that they are taller than they actually are, and weigh less than they actually do. Relying on self-reported information underestimates how big the obesity problem is in England. People who have undiagnosed diseases cannot tell us about them. By measuring blood pressure, we can find out how many people have high blood pressure (‘hypertension’) but don’t know it. We do the same for diabetes by measuring blood sugar levels. We also collect saliva to measure cotinine. This is made by the body when exposed to nicotine. Smokers have high levels. Non-smokers have measurable cotinine if they spend time in places where other people smoke. Although levels are much lower, it shows they are exposed to the thousands of harmful chemicals in tobacco smoke.
The HSE has been running since 1991. Some information on how health and health risk factors have changed over time has been put onto the HSE website. Obesity in children increased from the early 1990s to the early 2000s. It fell a little but is still too high. We also showed that waist circumference has increased in teenagers even more than general obesity. In adults, too, obesity increased in the 1990s to the mid-2000s. It hasn’t changed much in recent years. However, waist circumference continues to rise. This is more worrying as it is a marker of ‘abdominal obesity’, with fat collecting in the abdomen. This gives people a high risk of developing diseases such as diabetes, heart disease, or some types of cancer.
There is also good news in the health trends. The proportion of adults who smoke cigarettes has fallen from 27% in 1993 to 18% in 2016. Even where parents smoke, the proportion who try to keep their home smoke free has increased.[i] In 2006, two-thirds of non-smoking children had cotinine in their saliva, because of exposure to other people’s smoke. By 2014/15, this had fallen to just over one-third of non-smoking children. The management of high blood pressure is much better than it used to be.[ii] However, it still needs to improve further.
The Health Survey for England 2016 report provided information on many topics. 16% of children, 26% of men and 27% of women were obese. Chronic liver disease was most common in adults aged 55 to 64 years. Almost one in five adults (19%) had probable mental illness. Almost one in four adults (24%) had taken three or more prescribed medicines in the previous seven days. 66% of men and 58% of women met the aerobic physical activity guidelines.
Cases of diabetes are on the rise. Is that because more people are becoming diabetic or because doctors are better at finding those people? HSE data show that both are happening. At one time, for every diagnosed case of diabetes, there were two more people with undiagnosed diabetes. By 2013, 7% of people had diabetes. Four-fifths were diagnosed.[iii] In other words, there were eight people with diagnosed diabetes for every two who didn’t know they had diabetes. A great improvement.
UCL staff are analysing data on adult health; combinations of health risk factors; and circulatory diseases, such as heart attacks and strokes. NatCen staff are analysing data on social care; adult and child obesity; and health of children. Watch out on the UCL, NatCen and NHS Digital websites (listed below) and in the news to see what we find. And if you ever receive a letter inviting you to take part in the HSE, please do!
Professor Jennifer Mindell is a public health doctor who has also worked in general practice and health promotion. She is interested in policies outside the health services that affect health and inequalities. She leads the UCL team dealing with the Health Survey for England and other health examination surveys in the UK; comparative work across Europe (EHES); and a comparison project (ESARU) across the Americas and the UK. Prior to this, she was the Deputy Director of the London Health Observatory. She led health impact assessments (HIAs) of the London Mayor’s Transport and other strategies. She was the chief investigator for a large research project at UCL, Street Mobility. This developed tools to measure the barrier effect of busy roads and the effects on local people. She chairs the UK Faculty of Public Health’s Health Improvement Committee and sits on the FPH Health Policy Committee. She is the health lead for the UCL Transport Institute. She is also Editor-in-chief of the new, award-winning Journal of Transport and Health. She was also very involved nationally in tobacco control for many years. See Jenny Mindell’s IRIS profile web page
For more information about the Health Survey for England, visit the following websites:
[i] Jarvis M, Sims M, Gilmore A, Mindell JS. Impact of smoke-free legislation on children’s exposure to passive smoking: cotinine data from the Health Survey for England. Tobacco Control. 2012;21:18-23. https://tobaccocontrol.bmj.com/content/21/1/18
[iii] Moody A, Cowley G, NgFat L, Mindell JS. Social inequalities in prevalence of diagnosed and undiagnosed diabetes and impaired glucose regulation in participants in the Health Surveys for England series. BMJ Open. 2016;6:e010155. https://bmjopen.bmj.com/content/6/2/e010155
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In a recent expose called ‘GPs: Why Can’t I Get an Appointment?’, a Panorama documentary, which aired on BBC1 on Wednesday 8th May, emphasised the current limits of and pressures on the NHS system. The programme featured interviews with overworked GPs and allied healthcare professionals, painting a rather bleak picture. Practices are merging and closing at an ever increasing rate. Patient loads increase as patient lists are subsumed. Patient multi-morbidities have increased the need for chronic conditions to be monitored with regular GP appointments. Yet on average patients wait a minimum of two weeks for a routine appointment. Early retirement and a limited flow of trainees into General Practice also contribute to the strain, making practice sustainability difficult to envisage. Inevitably, pressure and frustration are being felt amongst both patient groups and the primary care workforce.
The