Health of the Socially Excluded

Definition of social exclusion:

…"the inability of our society to keep all groups and individuals within reach of what we expect as a society and the tendency to push vulnerable and difficult individuals into the least popular places".

So who are the socially excluded? Traditionally they are those who live with poverty: the homeless, the unemployed, but also ethnic minorities, asylum seekers, refugees, those with learning disabilities, travellers, people with mental health or behavioural problems, sometimes the disabled or the elderly. It is not only adults that are affected …children suffer as a result of exclusion from the benefits of society.

The problem:

The Acheson report (The Independent Inquiry Into Inequalities In Health), 1998 revealed that over the 20 years preceding 1998 health inequality has increased markedly.

The proportion of children brought up in households earning less than half the national average income tripled in the 1980s; nearly ¼ of children are currently in families without a working parent.

Between 1930 and 1990 the gap between mortality in professional men and those in unskilled manual jobs increased almost 2.5 times, resulting in 9.5 yrs greater life expectancy between classes 1 and 5.

Infant mortality rates in deprived areas are double those of affluent regions.

Consequences

The effects of social exclusion are far reaching and begin at an early age. Known consequences include:

• Delayed development/reading skills
• Antisocial behaviour
• Drug and alcohol misuse
• Unemployment
• Teenage pregnancy
• Crime
• Homelessness
• Suicide
• Increased demand/cost to social, educational and health services

Examples:

• One cross sectional survey showed that 49% of children of women in refuges had probable mental health problems.
• A paper compared costs of children with and without conduct disorder (health, crime, foster care, benefits, extra education); total costs by age 28 were £70,019 for a child with conduct disorder compared with £7,423 for a child without.
• Researchers found that people in social class 5 were less likely to survive 2/3 of the commonest cancers than their richer counterparts.

Very scary, all this, and obviously there is an enormous need to rectify the balance between those within the acceptance of society and those who are excluded.

Who is responsible?

This is a problem created by society, and it is within the whole of society that the consequences of social exclusion will be felt. The Government has initiated several projects not only to reduce poverty itself but to enhance educational and social progression, such as the Sure Start programme, which provides resources during preschool years to underprivileged families.

As General Practitioners we have to be aware of the problem of health inequality and be involved in approaches to counter it. We are the ones who are in the same places as the socially excluded.

Issues surrounding health provision

There are a number of difficulties with provision of services for the homeless, asylum seekers etc. and a number of reasons why there is low uptake of services by the socially excluded:

Availability of specialist services: not all GP practices are equipped or have the time to adequately treat large populations which may require more input than other patients.

Lack of provision for deaf/blind/wheelchair users.

Mobile population, so unable to register with practices.

Language/cultural barriers.

Children at risk not known to services.

Lack of awareness of existing services.

Lack of health awareness-those who are not used to the concept of accessing medical services during illness will not naturally do so.

Past experience and expectation.

Mental health patients with physical problems frequently are overlooked.

Attendance at A&E rather than GP practices-acute problem sorted out rather than overall health.

Primary care provisions

Drop in clinics, walk in centres and specific GPSI clinics have been set up in regions with high levels of deprivation. They frequently work in collaboration with other professionals: health and housing access workers, CPNs, counsellors, drug and alcohol rehab workers, dentists, podiatrists.

Leaflets advertising access times and services available ensure knowledge about services.

Some homeless shelters have dedicated GP clinics within the buildings.

References

1 Power, A. Social exclusion. Royal Society of Arts Journal 2000; 2/4:47-51

2 McKee, M. Poor children in rich countries BMJ 1993; 307:1575-76

3 Webb et al. The health of children in refuges for women victims of domestic violence BMJ 2001; 323:210-213

4 Scott, S et al. Financial cost of social exclusion BMJ 2001; 323:191

5 Burke, K. Poverty gap for cancer survival widens BMJ 2004;328:599

MRCGP example question:

Your health visitor has identified several families with children whom she has concerns about. They live in the most deprived part of your practice area and are registered with the practice but attend infrequently. How could you ensure that there is adequate provision of health services for them, and that they are aware of these?