The Aviva Health of the Nation Index

February 2013

Contents

3 4 6 9

Foreword Looking for the perfect practice. Life as a GP in the UK Whats up? Health trends on the increase So how are we feeling today? Health awareness among patients

14 Spotlight on mental health 16 Spotlight on the workplace 18 So do we care, about care? Engaging with the NHS 23 What have we learned? Health of the Nation a 10-year anniversary

Foreword
Were always ready to take on board the views of the people who matter most: its what helps us focus on providing products and services that people really need. This is the tenth year in which weve conducted our Health of the Nation study, canvassing the opinions of GPs right across the UK. This year weve extended our research to include the views of 1,000 patients to understand their experiences of healthcare in the UK.
For us, the Health of the Nation study has become an insightful means of examining key health issues over a period of time. It helps us gauge how the environment is evolving and identify stakeholder views that could help influence changes to our products and services. As in previous years, this time were looking at GPs lives and their views on the working environment; the trends theyve been identifying in the patients theyre seeing and, in particular, the continuing impact on their workload of mental health issues and health concerns arising from the workplace. Weve canvassed GPs on their views about health education and the information, or lack of it that affects the patient-doctor relationship; we asked for opinions on the quality of both established and potential future clinical pathways, and we questioned GPs about their engagement with the NHS. Bearing in mind the changes that may happen as a result of Clinical Commissioning Groups (CCGs) coming into effect from April 2013, our study has highlighted some of the situations in which GPs still appear to need more support, and reasons why patients may suffer the consequences of an evolving service. Patients have also given us their views. Weve asked them about health matters; how they are, or arent able to seek the levels and quality of care theyre expecting, and which steps theyre taking to engage with the medical profession for support and more information about their health and wellbeing. The result? Another insightful cross-section of opinions on the state of our nations health services. We hope you find this Health of the Nation study as useful as we have found it to be revealing.

Mark Noble,
Managing Director, Health and Corporate Benefits, UK & Ireland Life

Aviva Health of the Nation Index Report 3

Looking for the perfect practice

Life as a GP in the UK
A GPs practice already shoulders the burden of a diverse range of responsibilities: to individual patients as well as regulating bodies and Primary Care Trusts.
The Royal College of General Practitioners has agreed that effective commissioning will depend on continuous analysis of a communitys needs, and the design, specification and procurement of services to meet those needs. Inevitably, the onus will fall on GPs to collect data that can be analysed to help achieve those aims. But it is, perhaps, thanks to the diverse nature of their work that the majority of GPs (73%) have told us theyre deriving moderate or high levels of satisfaction from their jobs. It will be interesting to see if this changes over the next twelve months, as the impact of commissioning takes full effect. The likelihood is that GPs may feel more obliged to be involved in administrative activities than they are at present. Reassuringly, our study reveals their focus is still clearly on attending to patients clinical concerns. Highlights 0% of GPs time is spent dealing with minor concerns 2 that could have been seen to by practice nurses or may not have warranted an appointment at all. As insufficient time with patients is still our GPs greatest concern, we believe this clearly emphasises the need for more initiatives (and resources) that could help direct patients to the most appropriate support. ithout countrywide guidelines to help prioritise the W many factors involved, GPs are - on average giving 78% of patients an open referral through the choose and book system. However, most patients are unable to compare the quality or cost of treatment thats being recommended, and may be choosing a referral pathway based on convenience alone. lder GPs are concerned about the impact of the Health O and Social Care Bill, but also see the appearance of CCGs as an opportunity to procure better services for their patients. Ps in Northern Ireland appear to be happiest, with G 50% citing job satisfaction levels as high; in the South West however, over a quarter (26%) said their satisfaction levels were low.

On average GPs spend 67% of their time with patients.

4 Aviva Health of the Nation Index Report

The working day GPs in the UK offer the complete spectrum of care to people in their local community. From in-surgery appointments that will be dealing with psychological, physical and social concerns through to off-site attendance in clinical centres and, if necessary, their patients homes. A broad skill-set is involved that includes an opportunity to prevent illness as well as treat it.

On average, how is a GPs working day currently divided?

We asked GPs to break down their working day. Responses showed theres an opportunity to free up more patient time, by delivering resources that would better inform individuals about medical health matters. Just seven GPs, less than 3%, told us part of their working day was currently spent teaching, training or educating and raising health awareness. Reassuringly however, a low 3% of GPs time was committed to dealing with cases that should have been seen by personnel in an Accident and Emergency unit. On average: 9% of the working day was spent dealing with medical 3 issues that required a GPs attention 0% of the day was spent dealing with social care issues 2 or the worried well 6% of the day was taken up with administration or 1 practice issues On average, a fifth of GPs working days are spent taking care of issues that either a practice nurse could deal with (9%), or dealing with minor medical concerns that didnt warrant professional medical attention (11%).

Ps are, on average, contracted to work 36 hours per G week, but most appear to be working 42 hours or more. hile 45% of the GPs we spoke to expected those W hours to stay the same, over half (51%) expected to be working longer hours in the future.

Year on year, our studies show were making GP appointments for problems that could be dealt with by a practice nurse or that may not need medical attention at all. More awareness of health matters could help address this situation, and free up GPs time to deal with more important medical cases.

On average, what percentage of time are GPs spending with patients per week?

82% 76% 74% 71% 70% 69% 69% 68% 68% 64% 58% 56%

Wales

North East

East Anglia Yorkshire & the Humber

Northern Ireland

Scotland

North West South West

London

South East

West Midlands

East Midlands

Aviva Health of the Nation Index Report 5

Whats up?
Health trends on the increase
GPs deal with a wide variety of health concerns. Some are major issues, some are relatively minor, but weve looked back at our first Health of the Nation study to remind ourselves about health concerns that appeared to be on the increase a decade ago and compared those with the trends were seeing today.
Topping the list ten years ago were ME and Chronic Fatigue Syndrome; obesity, stress, depression and alcoholism. And in some respects, the landscape has changed relatively little those issues are still prevalent in the top ten conditions on the increase. This year however, an alarmingly high proportion of GPs (84%), identified stress and anxiety issues being the greatest upward trend in their practices; 55% cited other mental health issues as being noteworthy. Media campaigns and Government initiatives may be helping to raise awareness of help for mental health issues, and this could, in turn, be having a positive effect and encouraging patients to engage more with their GPs in general. But with so many patient cases being presented more often, the question quickly arises what could be done to address the underlying causes of that stress and anxiety, both at home and in the workplace? ith evidence that people with mental health W conditions are feeling less stigma, it could be the case that those with symptoms of stress, depression and anxiety are simply more open to asking for help. owever, our 2012 Health of the Workplace study H revealed many people believe theyre having to work harder as a result of changes in the economic climate in recent years, and that this is having a tangible effect on their overall mental health. Just under a third of the employers we spoke to had introduced initiatives to help manage workplace stress, but the employees we spoke to believed much more could be done.

20% of the GPs we spoke to said they believed Government-backed, patient education could help reduce instances of the conditions theyre dealing with most often.

For which conditions have GPs noticed an increase in patient numbers over the past year?

84%

55%

53%

50%

44%

40%

36% 26% 25% 21% 16% 12%

Migraines

10%
Heart Disease

3%
Stroke

3%
Other

2%
Asthma

Stress / Anxiety

Mental Dementia health and issues Alzheimers excluding stress and anxiety

Obesity

Alcoholism Musculoand drug skeletal addiction conditions

Diabetes

Irritable Bowel Syndrome

ME / Chronic fatigue syndrome

Cancer

Arthritis

6 Aviva Health of the Nation Index Report

Which conditions are GPs expecting to treat more often over the next year?
As they deal with patients who have already made appointments, its natural for GPs to have an opinion on the conditions theyre likely to see most in the future, too:

Most GPs believe the working environment is responsible for increases in mental health problems, back pain, and obesity.

21%

20%

20%

13%

12%

3%
Other stress / depression / anxiety work related stress Diabetes Obesity Mental health issues amongst elderly Drug and alcohol abuse

2%
Cancer

2%
Musculoskeletal injury e.g. back pain

2%
Tobacco related illness

2%
Other

1%
Heart conditions

Over the last five years, have GPs seen the working environment have more of an impact or less on the following illnesses?

RSI

Back pain

Stress

Depression

Alcoholism

Headaches

Drug abuse

Eating disorders

Eye problems

ME / CFS

Obesity

Stayed the same

Fallen

Risen

Are work initiatives working?

We work alongside employers to help them promote improvements in health and wellbeing among their employees. Unfortunately, it looks as though the workplace is still having a notable impact on the rise in cases of certain conditions, and one stands out above the rest. With 93% of GPs saying they attribute it directly to a rise in cases of stress, theres a compelling case for more mental health services such as stress counselling, or the support provided by an employee assistance programme to be made available to employees. Around a third of the claims we deal with under our corporate healthcare policies are for musculoskeletal injuries, dealing with aches and pains in the back, neck, muscles and joints. Our Back-Up service provides prompt access to a clinician who can offer advice to help manage symptoms, and (without the need for a GPs appointment or referral) make recommendations for appropriate ongoing treatment. With such a large proportion of claims being made in this area, its not a surprise to see that 50% of GPs believe the working environment is responsible for the cases of back pain that they are seeing. Obesity can also be linked to musculoskeletal pain: this is one of the reasons we encourage employers to promote improvements in diet and fitness levels to their employees using a health initiative such as MyHealthCounts, for example.

Aviva Health of the Nation Index Report 7

We asked the GPs taking part in our survey about a number of factors that could have been affecting the health of their patients in general over the last 5 years: had they noticed poor diet, for example, being a greater influence in the cases they were seeing.

Three quarter of GPs (75%) believe the economic climate is having a significant impact on the health of their patients.
Smoking
100% 80% 60%

Have these factors had more or less impact on patients over the last 5 years? Poor diet
100% 80% 60% 40% 20% 0%

58% 33% 8% More impact Less impact No change

43% 26% 31%

40% 20% 0%

More impact

Less impact

No change

Alcohol
100% 80% 60% 40% 20% 0%

Drugs
100%

63% 32% 5% More impact Less impact No change

80% 60% 40% 20% 0%

37% 14% More impact Less impact

50%

No change

Lack of exercise
100% 80% 60% 40% 20% 0%

Economic climate
100% 80% 60%

64% 23%

75%

40% 20% 0%

12% More impact Less impact

14% More impact Less impact

50% No change

No change

Pollution
100% 80% 60% 40% 20% 0%

Emotional working environment

100%

64% 25% 10% More impact Less impact No change

80% 60% 40% 20% 0%

71%

10% More impact Less impact

19% No change

Physical working environment

100% 80% 60% 40% 20% 0%

Emotional home environment

100% 80%

71% 25% 5% More impact Less impact No change

43% 15% More impact Less impact

42%

60% 40% 20% 0%

No change

Having seen the increases in cases of some conditions being attributed so significantly to the workplace, it was perhaps to be expected that the economic climate is being seen as having a negative impact on the health of patients in general. And unfortunately, although the Olympics may have stimulated greater interest in sport across the nation, at the moment it looks as though we have yet to take
8 Aviva Health of the Nation Index Report

action: 64% of GPs told us that a lack of exercise was impacting their patients health. However, it does look as though were seeing a positive reduction in the effects of nicotine addiction. For 43% of GPs, the effects of smoking have made less impact on the health of their patients over the last year.

So how are we feeling today?

Health awareness among patients
Analysis of trends is what helps us plan ahead: our products and services evolve to meet peoples actual health needs. As GPs are seeing more patients presenting with some conditions, it appears that patients are becoming more health-aware in general. Whats interesting is that their propensity to self-diagnose has also increased significantly.
How do you rate your health?
2%

When, in 2011, the Government launched its Public Health Responsibility Deal to help improve the management of our health services, it said that everyone has a part to play in improving public health including individuals themselves. With that in mind its interesting to see what steps the public takes to inform themselves about health issues and monitor or improve their own wellbeing. In this study, we placed a particular emphasis on self-diagnosis asking views on health and the reasons why and how people try to find out the cause of symptoms theyre experiencing.

10%

15%

28%

45%

Very good

Good

Average

Not very good

Poor

Are there benefits to self-diagnosis?

Ten years ago, the GPs we spoke to estimated that around 15% of their patients looked up information about their condition before visiting the surgery. Two thirds had seen an increase in this trend; almost 70% of those GPs thought those patients behaviour had had a positive impact on their subsequent health. Today, with so much more information readily available online, its no surprise that more and more individuals are self-educating in advance of an appointment. Sources of insight vary, but not surprisingly almost half the patients we spoke to (44%) are turning to the Internet for information.

Do you self-diagnose, if youre unwell?

1% Yes, I look on the internet Yes, I buy kits from the Pharmacy 23% Yes, I judge my condition on my previous experience / illness Yes, I use informative TV programmes 44% 6% Yes, I read magazines Yes, I ask my friends and family for advice 25% No, Never

Why do you self-diagnose?

9% of patients want to be more informed 2 when they see their GP 3% self-diagnose out of curiosity, but not instead 3 of visiting a GP 31% self-diagnose to avoid seeing a GP % self-diagnose because they had no faith 7 in their GP

Aviva Health of the Nation Index Report 9

The whole truth?

75% of the patients we spoke to told us they were selfdiagnosing before seeing a doctor. But although 82% of GPs have seen an upward trend in people looking for information, GPs have a very different perception of how many people are actually researching their symptoms before having a personal consultation. nly 5% of GPs believed that as many as three-quarters of O their patients were self-diagnosing prior to an appointment. nly 13% were of the opinion that half their patients O were looking for information. 7% thought a quarter of their patients or fewer 6 would self-diagnose in advance. Our research shows that although patients are largely willing to self-diagnose, theyre also less than likely to share the fact theyve done some research with their GP. A quarter of the patients we spoke to told us they never self-diagnose. However, this is not the negative insight it may first appear to be, because 64% of people believed it was simply better to see a GP in person, and 28% believed self-diagnosis would raise concerns rather than lower them.
15% 23% I dont self-diagnose because I think this would cause me to worry more I dont self-diagnose because its best to just see your doctor in person I dont self-diagnose because its too time consuming 8% 28%

64%

2%

Do GPs think its beneficial for patients to self-diagnose before an appointment?

Without a guarantee of its validity, patients may be sceptical about medical information thats been sourced somewhere other than through their GP. However, it looks as though some of us are using the data as a benchmark, from which to value or potentially challenge a doctors views. A significant percentage 39% of GPs appreciated the efforts that patients made, but saw self-diagnosis as a challenge if patients were unwilling to accept a diagnosis.
39% 21%

Yes, it can be very helpful Yes, but only if they are then willing to

No, it causes scare mongering No, I think it serves no benefit at all It varies from patient to patient

10 Aviva Health of the Nation Index Report

Time to visit the GP Visiting a GP may not always be convenient, but neither is illness. We asked people to tell us how often on average they visited a GP, and why. The answers were intriguing, not least because they show a marked difference in attitudes between men and women. 0% of men said they rarely become ill compared to 3 21% of women. But 35% of men said theyd changed their views on visiting a GP in recent years, primarily as theyd become more aware of how important it is to look after your own health. or almost a fifth of men (17%), visits to the GP had F become more frequent. Only 14% of men hadnt visited their GP in the last three years, compared to 7% of women, and knowing that routine check-ups are a good idea 13% of men and 22% of women cited this as the main reason for visiting the doctor. Different approaches to health On the whole, it appears that men are less likely to pay a visit to their GP than women. We asked what were the reasons for the delay? 1% of women said they would suffer in silence if 5 unwell as there were jobs to be done; compared to this, only 44% of men took the same approach. 7% of men, however, were likely to take time off and 2 go to bed, instead of going to their GP, compared to just 21% of women. ver a fifth of our surveys respondents (21% men, O 20% women) said theyd take medicine to keep going rather than go to their GP. 9% of women would wait to see if the symptoms 2 went away, 16% blamed their inability to get a quick appointment and 9% said it would be a struggle to make an appointment that suited working hours. In comparison, 21%, 14% and 9% of men gave the same answers respectively However, we also asked about attitudes to making an appointment what, if any, would be the reasons to delay. Over a quarter of the women we spoke to (28%) said theyd never avoided going to see their GP if they were unwell. But although some are visiting their GPs more frequently, over a third (39%) of the male respondents to this survey had put off going to see their GP. Happily, only 2% of the men and women we spoke to said they would milk an illness for all its worth.

How often do you visit your GP?

40% Men 35% 31% 30% 31% Women 37%

25% 22% 20% 17% 15% 11% 10% 9% 7% 5% 4% 0%

th s s ar ly k th ee ai th ye on on on D w N ev er

18%

14%

9%

nc

re

six

nc

th

The ease with which patients can or cannot make a GPs appointment is still a concern. In all, 24% of the patients we spoke to said that, in some way, their GPs unavailability influenced a delay in seeking medical help. 48% are suffering in silence.
Aviva Health of the Nation Index Report 11

Ev

er

Ev

er

nc

Caring for each other

It was good to see that most people were aware of their partners general health. But there was also a slight difference in the way men and women then approached their concerns: 3% of men could persuade their partner to see a GP; 4 a slightly higher percentage of women, 46%, had the same influence. 9% of men had not raised a concern about their 2 partners health; only 17% of women reserved opinions in the same way. 3% of men had discussed something that was 1 worrying them about their partners health, but seen no result from the conversation; 17% of women had made unsuccessful attempts to raise concerns. The good news is that 10% of the men and women we spoke to had successfully persuaded partners to make lifestyle changes for the better. Interestingly, 10% of women had exercised those changes (such as diet), while only 5% of men had taken the same action.

If you dont check, why not?

6% 25% 11%

23%

35%

I think I am too young to need to There are no historical issues in my family and I think these things are hereditary I dont think I need to I dont know how to I am too busy and never remember

These are alarming statistics or the quarter of women F who dont self-check, 32% say theyre too busy and dont remember and an equal proportion (32%) say they dont know how. f those men who dont selfO check, 37% say they dont know how to; while 30% dont think they need to check for signs of breast cancer or testicular cancer

Feeling better
Self-examinations involve checking testicles and breasts for physical changes: when you know how your body normally looks and feels, any changes in appearance should be easier to notice. The media has raised awareness about the importance of self-examination, but it appears theres still some way to go in educating everyone as to its value.

Do you self-check for signs of testicular cancer or breast cancer?

nly 75% of the women we spoke to do any O self-examination. lower percentage only 60% of men checks A their bodies in the same way.

How often do you check?

40.9%

19.6%

8.6% 3.2% 4.5% 2%

sh Ev ow ery er tim /b e at I h Ev er y 23 w ee O ks nc e or tw ice a m on th W ee kl y

3.9%

4.5%

4.6% 1.4%

5.8% 0.7%
sh ou ld O th er Re gu la rly

0.4%
Do n tk no w

m on th s

m on th s

Tw ice

Ye ar ly

Da ily

ye ar

Ev er y

Ev er y

12 Aviva Health of the Nation Index Report

No ta so fte n

as I

Differences of opinion
As weve seen from their approaches to visiting a GP, our study highlights that men and women have differences in opinions about health matters in general.
It transpires that most people take responsibility for their own care, but we asked some pertinent questions about engagement with health services in general. 7% of the women we spoke to said they would 8 be the person to make a decision about which GP to see; only 63% of men we spoke to made the same judgement. hen it comes to being responsible for researching W insurance that could pay for medical care, 53% of those carrying out research themselves were men. 8% of those carrying out the purchase of private 4 medical insurance were men women accounted for 59% of the respondents who said they were most likely to be keeping up to date with health news. The gender division was also noticeable in perceptions of care, as were views across the country. We asked peoples opinions regarding the quality of health treatments being received in their area.
I have no point of reference 4% 4% 15%

omen were also more willing to say they would be W more likely to follow health fads, but equally, 64% of women considered they took health matters more seriously than men. 0% of the women we spoke to said they were most 7 likely to carry the responsibility of care if someone in the family was unwell. Only 34% of men voiced the same opinion that a man would be most likely to play the role of carer.

It depends on what treatment is required

6% 9% 8%

I think it is poor

I think it is sufficient

38% 40% 35%

I think it is good

42%

Women

14% of respondents in the North West believed health services in their area were comparatively poor; by contrast, just 1% of the respondents in Scotland shared the same opinion.
70% 60% 50% 40% 30% 20% 10% 0% I think it is good I think it is sufficient I think it is poor It depends on what treatment is required I have no point of reference

Yorkshire and the Humber

East Midlands

West Midlands

East

London

South East

South West

Wales

Scotland

Nothern Ireland

North East

North West

Aviva Health of the Nation Index Report 13

Spotlight on mental health

Worrying signs
A great deal of our GPs time is spent dealing with mental health issues. Its still the most prevalent type of illness, with 84% of GPs seeing more patients than ever before suffering from stress and anxiety.
Across the country, opinions vary as to the reasons for this increase. In the North West and South West, GPs believe changes in diagnostic criteria are the cause. Financial pressures could be the reason for more mental health problems, according to GPs practicing in London, the South East, East Anglia and the Midlands, and Yorkshire and the Humber region. An interesting opinion came from the East Midlands, where GPs blame the increase in mental health issues on the use of social media for friendship and resulting isolation. Just under half the GPs we spoke to (47%) believe theres still a stigma associated with mental health issues, which may be preventing people from seeking help. But its worth noting that 39% of GPs thought media campaigns were having a positive impact on that situation, most notably in the North West, where 59% of GPs shared this view.

Do GPs agree that mental health is one of the most pressing priorities for the NHS?
59%

Do GPs agree theres a lack of support for them, regarding these health concerns?
68%

36%

21% 11% 4% Yes Neutral No Yes Neutral No

Problems such as anxiety, depression, stress and phobias are very common. Talking Therapies is a Governmentsponsored, nation-wide service that offers help to people with those problems.

Are GPs seeing long waiting lists for Talking Therapies in some areas?
84%

Are GPs prescribing medication (antidepressants), when they believe Talking Therapies would be more beneficial?
74%

20% 12% 3% Yes Neutral No Yes Neutral 6% No

Less than a quarter of the GPs we spoke to (23%) believed that access to Talking Therapies such as cognitive behavioural therapy would improve over the next few years. A telling statistic is the fact that 77% of GPs believed the workplace is one of the biggest causes of stress and anxiety for patients in the UK.
14 Aviva Health of the Nation Index Report

Over half of our respondents (52%) told us that theyve suffered from one mental condition or another during their lifetime; many had experienced symptoms aligned with more than one type of illness and the majority of people (74%) knew someone else who had suffered or was suffering from mental health problems.

Of the people we spoke to, 22% said they were now feeling better; 9% said they were still unwell and 21% of our survey said they still experienced symptoms from time to time. It was encouraging to see that 57% of people would not be embarrassed to admit having a mental health problem.

We asked patients to detail which types of mental health issue theyd experienced:
40%

35%
35% 30% 25% 20% 15% 10% 5% 0% Mild anxiety and / or depression related to stress or trauma Digestive disorder related to stress / anxiety e.g. IBS Frequent headaches related to stress / anxiety Work-related stress SAD (Seasonal Affective Disorder) Phobias Depression Panic attacks Paranoia OCD Chronic fatigue / ME Bi-polar disorder

31%

23%

21% 14% 14% 10% 7% 5% 5% 5% 1%

What support did you receive for these conditions?

I was prescribed drugs such as anti-depressants I was referred for counselling / cognitive behavioural therapy I was referred for a specialist consultation I was told to reduce my hours / signed off work 58%

32%

29%

24%

I was referred for further tests

14%

The majority of patients (51%) felt that a period of 2 to 3 weeks was the maximum time they should wait for a referral to counselling or a psychological service, to find out more about and get support for that condition. Its worth noting that the 18-week maximum waiting period set by the NHS does not apply to non-medical, consultant-led mental health services. Most people (85%) were understandably concerned that a condition could worsen if they had to wait a long time before getting a referral.

I was told to take more exercise

14%

The GP sent me away with no support

8%

Other

6%

Its alarming to note that 8% of patients believed they were sent away from their GP having been given no support for one type of mental health issue or another. Nearly three-quarters of the patients we spoke to (73%) dont think the Government and / or the NHS do enough to tackle mental health problems.

GPs share those patients concerns: 50% of GPs believe their local trust provides a poor service for patients with mental health issues. 37% of GPs believe the service is poor for patients with depression, one of the highest prevalences of mental health issue in our survey.
Aviva Health of the Nation Index Report 15

Spotlight on the workplace

Working harder
A Fit Note is the informal name for the Statement of Fitness for Work; a computercompleted version was introduced in July 2012 with the aim of further smoothing the process for GPs who are helping employees get back to work as soon as possible.
There was reason to believe the formalised Fit Note would provide a useful platform for GPs to open discussions with patients about their health, with a view to helping them reduce long-term sickness absence a clear benefit to employers, as well as employees. Theres an even opinion on whether or not its working: Overall however, it appears GPs still feel the onus should be on companies and their staff to take more responsibility for their health in the first place, which would hopefully lead to a reduction in the need for GP appointments. 5% of GPs thought employers could do more to help 8 their staff get back to work 5% of GPs thought employers could do more to help 7 their employees stay healthy
36%

Is the fit note an effective tool?

1% of GPs thought the NHS was not appropriately 7 resourced to help employees return to work Those look like substantial figures. However, its vitally important to keep statistics in context.

32%

32%

Yes

Neutral

No

e asked GPs whether or not they had a close enough W relationship with patients to understand their individual needs in terms of making a successful return to the workplace after illness or injury.

Only 50% felt they did.

16 Aviva Health of the Nation Index Report

Spotlight on joint replacements

Hips and knees
This year we looked at replacements, putting a focus on the experiences of respondents whod had operations to replace hip or knee joints in particular.
According to the National Joint Register, there were over 84,000 hip and more than 87,000 knee replacements in England alone in 2011/12. Of the people we spoke to for this study, 9% had suffered from conditions resulting in the replacement of one or more of the following joints: hips, ankles, knees, elbows or shoulders (over 130 different operations in all). However, a staggering 76% of respondents said they knew someone who had undergone at least one of those operations. However, joint replacement is not necessarily always linked to the deterioration of health in old age: a quarter of the respondents whod had an operation themselves were 25 years old or younger at the time; only a third (36 people in all) were older than 60 years of age. We asked everyone in our survey: Over a quarter of the people we spoke to (28%) said everyday things, like driving or getting shopping done, would be their primary concern if a knee joint or hip needed to be replaced. 34% said that not being able to work, becoming a burden, or not being able to support a family would worry them most.
33% 34%

15% 12% 4%

2% More than a year

How would you cope if you needed a joint replacement, but werent able to have one?
4% of respondents thought they would find a way to 2 cope financially and emotionally 2% of respondents said they would complain, 14% 2 thought it likely they would get depressed about the situation 3% of respondents said they would change their 1 lifestyle in an attempt to cope

2 weeks

1 Month

3 months

6 Months

Six months to a year

How long would you be prepared to wait for this type of operation?
Waiting times for joint replacements vary across the country. We also asked respondents to indicate how long theyd be prepared to wait for treatment what did they consider to be a reasonable amount of time if they were struggling to walk, and needed a hip or knee joint to be replaced. On average, most people thought that a waiting time of between one and three months would be acceptable which is roughly in line with the NHSs 18-week maximum waiting period guidelines.

43% of people know someone who has had a hip replacement. 28% know someone who has had a knee replacement.
Aviva Health of the Nation Index Report 17

So do we care about care?

Patients views on funding care
Whether or not its to do with absence from work, its important to be confident in the person from whom were seeking help.
The NHS provides varying levels of support across the country, and our survey showed that patients have firm opinions about their relationships with GPs and the system in general. We asked, If there were long waiting times would you consider going private for treatment? 55% said they wouldnt be able to self-fund treatment 3% felt they could claim on a private medical 1 insurance policy 23% would find funds themselves to pay for treatment % said they would suffer, and wait until 9 treatment was available from the NHS The views on what was an acceptable price for improved health varied. We asked how much people felt they could afford, if they chose to self-fund treatment almost half (47%) said they would find money from their personal savings. However: 58% could afford 1,000 or less 27% could afford between 1,000 and 5,000 Only 5% could afford between 5,000 and 10,000

So how would you pay for treatment?

Over a quarter (27%) of the respondents to our survey said theyd be prepared to borrow from friends or family, take out a loan or incur credit card debt to self-fund; 19% were prepared to re-mortgage their property. We believe these figures highlight the fact that many people are aware of costs, but without private medical insurance they would be ill prepared to pay for treatment if they opted for private care.

For many people, private medical insurance negates the need to worry about access to care irrespective of where they live. We asked respondents: What do you think of the postcode lottery system, in which some areas of the country offer better access to care for some conditions than others?

Probing further into their opinions as patients, we then asked: As a patient, whats your outlook for the NHS?

I dont have an opinion on this

I was not aware of this It depends on the condition I wouldnt want my taxes spent on conditions that arent essential 7%

5%

3%

Very concerned, I have no confidence in the leadership of the DOH & NHS Very concerned - I cant see a future for the NHS Concerned - I expect patient care and the breadth of services to decline in the future Neutral - I feel that changes in the NHS will have little impact on patients Optimistic - I have confidence in the leadership of the DOH & NHS Optimistic - I feel that the direction the NHS is going in will deliver better care for patients

7%

Its an unavoidable fact, treatment quality cannot be consistent across the country
I think people should ensure they have health insurance to protect themselves from this 3%

7%

9%

36%

I think people should be able to select where they get treated

I think it is very unfair

13%

27%

65%

10%

8%

18 Aviva Health of the Nation Index Report

Engaging with the NHS

GPs views, patients opinions
We asked patients what they thought about the quality of care provided by the National Health Service (NHS) today.
Opinions varied, but theres an indication that the general public is concerned that some areas of the NHS are coming under undue pressure. 3% of people thought the NHS had declined in its 1 quality of services over the last decade ust 15% felt the UKs National Health Service was one J of the best state-provided health services in the world Very few people 3% declined to share an opinion on this.

I dont have an opinion on this

3%

I believe the NHS varies across the country I think the NHS has declined in quality over the past decade I think some areas of the NHS are under a lot of pressure: care of the elderly for example I think generally speaking the NHS is very good, but some areas are stronger than others I think our health service is one of the best in the world

5%

13%

26%

37%

15%

For which services do GPs feel the NHS provides a good service? Where does the NHS not deliver an adequate service to its customers?
80% 70% 60% 50% 40% 30% 20% 10% 0%
Alcoholism and drug addiction Alzheimers and dementia Arthritis Asthma Cancer Cataracts Diabetes Eating disorders Heart disease Hip / knee replacements Depression Mental health issues (excluding stress / anxiety) Stress / anxiety Musculoskeletal conditions needing physiotherapy People wanting health advice Strokes Obesity

Poor

Adequate

Good

Opinion highlights In general, GPs feel the NHS doesnt provide adequate services to help patients with eating disorders; obesity is also poorly addressed. In contrast, cancer, cataracts and diabetes are conditions for which individuals are catered relatively well. This is interesting, because 20% of GPs cited diabetes as being one of the conditions most likely to increase over the coming year and diabetes can be linked with obesity. Sadly, irrespective of being due to general budget cuts, redistribution of funds, or allocation of funds or more life-threatening conditions, 16% of GPs expect their local NHS to stop offering treatment for eating disorders in the next 5 years.

Aviva Health of the Nation Index Report 19

Referrals
From patient, to GP, and others
Over the last 10 years, medical advances mean that recommendations for treatment may have changed. However, the referral process from a patients initial concerns through to the first appointment with a specialist who can make a detailed diagnosis has altered very little.
In the patients journey, the role of a GP extends from counsellor, confidante and assessor, to both communicator and facilitator. Its the GPs role to make appropriate referrals for more investigation of a condition or symptoms, but data to inform their decision is not readily available. Theres a great deal of variation in the way GPs make referrals, and relatively few patients would query their recommendation. However, as part of the Competition Commissions investigation into the supply and acquisition of private healthcare services in this country, the referral process is undergoing close scrutiny. Aviva is contributing to this investigation, assisting the Competition Commission as they look at factors that could be affecting GPs referral choices: re potential clinical outcomes taken into consideration A enough by GPs? s there enough transparency regarding the cost, I quality and availability of one specific treatment in comparison to others? erhaps most importantly, are patients views being P considered enough during the referral process thats supposed to afford them the best possible treatment and recovery?

According to GPs, who owns the referral process?

14% 9%

15%

61%

GP Patient Specialist Insurer Other (combination)

Only 15% of GPs believe their patients own the referral process. We believe theres an urgent need for patients to see more information, and be more involved in the decision-making processes that affect their treatment and care.

The majority of GPs - 62% - believed they were completely in control of the referral process. Given the emphasis on transparency in recent years, and the desire that patients should have an opportunity to become more involved in the decisions surrounding their treatment, a surprisingly low number - 15% - believed that, ultimately, their patients were the decision-makers at the point of referral.

20 Aviva Health of the Nation Index Report

How do GPs decide which specialist a patient sees, or where theyre treated?
Whenever its practical, GPs are likely to give patients an option to choose their specialist and place of treatment. We believe the decision a patient takes, at that point, is more likely to be based on geographical convenience than data available about quality of care or cost of treatment. The referral options provided by GPs may be based on previous experience or reputation rather than a quantified measurement of clinical outcomes.
6%

24%

48%

22%

I gave them a choice of specialists and hospitals to choose from I select the specialist I feel is best for them I ask the patient which specialist theyd like to see and refer them to the one they choose I give the patient an open referral

For private treatment, which factors do GPs consider in their referrals?

When referring patients for private treatment that will be either self-funded or covered by an insurance policy, there are many factors that have to be considered in addition to the individuals immediate clinical needs. However, one of the challenges faced by the Competition Commission (and patients) is the lack of consistency or guidelines informing the way in which GPs should prioritise those factors, one over the other. Clinicians take a very individual approach to making a recommendation. We believe that greater transparency regarding the comparative quality and costs of a treatment from facility to facility, or even among specialists and/or anaesthetists for example could help.

1%

30% 35%

3% 2% 29%

Quality of care / outcomes Quality of facilities Waiting times for NHS treatments Financial penalty of premium increase when an insurer does not cover the full cost of treatment Choice of specialist / consultant Availability of advanced treatments / technologies

On average, GPs are giving 78% of patients an open referral. However, most patients are unable to compare the quality or cost of a treatment and may be selecting a referral pathway based on convenience alone.
Aviva Health of the Nation Index Report 21

Which conditions do GPs find most challenging to refer for specialist attention?
Consistent with our previous Health of the Nation reports. We asked which referrals GPs were finding most challenging. Its worth noting that, in comparison with the results of our first Health of the Nation study ten years ago, the referral landscape has changed very little although fewer GPs are finding the process quite such a challenge, overall.

2012: top 10 conditions and % of GPs who find these referrals challenging
45% 40% 35% 30% 25% 20% 15% 10% 5% 0% ME / Chronic fatigue syndrome Obesity Drug / alcohol abuse Mental health (exc. stress) Stress (work related) Depression Stress (non work related) Back pain Headaches Irritable Bowel Syndrome 24% 20% 17% 17% 39%

16%

16%

15%

14%

12%

2011: top 10 conditions and % of GPs who found those referrals challenging
70% 60% 50% 40% 30% 20% 10% 0% ME / Chronic fatigue syndrome Food allergies Eating disorders Stress (work related) Learning difficulties in children Stress (not work related) Drug abuse Obesity Musculoskeletal Mental health issues 60% 56%

53%

53% 45% 44% 40% 40% 36% 35%

2003: top 10 conditions and % of GPs who found those referrals challenging
80% 70% 60% 50% 40% 30% 20% 10% 0% ME / Chronic fatigue syndrome Food allergies Fibromyalgia Eating disorders Learning difficulties in children Alcoholism Drug abuse Headaches Musculoskeletal Obsessive Compulsive Disorder 59% 55% 44% 44% 43% 37% 34% 31% 76% 72%

Tired of dealing with ME and CFS?

As with last years survey, GPs told us that they were still struggling to refer patients on for more specialist insights to Myalgic Encephalomyelitis (ME) and Chronic Fatigue Syndrome (CFS). Over a period of ten years, these are still the number one conditions that GPs find most challenging to refer on for specialist attention. Whats most alarming however, is that 42% of GPs thought the NHS would no longer provide services for ME and CFS by 2015.
22 Aviva Health of the Nation Index Report

What have we learned?

Health of the Nation a 10-year anniversary
Our Health of the Nation study was first published in 2003. We believe this makes it the longest-running private medical insurers study of GPs views in the UK. Now, 10 years on, were about to see some of the most radical reforms in the 63-year history of the National Health Service (NHS) take place so this study holds even greater significance for anyone seeking insights to the views of the GPs and patients it serves.
Doubts about the future
It seems a long while since the Government introduced its health white paper in July 2010, entitled Liberating the NHS. Since then, plans have emerged to reform the service (in England at least), that have proved hugely controversial over the last twelve months. Political differences and the challenges inherent in such a substantial programme of change resulted in us seeing a new Health Minister take the helm; there are major implications for the NHSs workforce that are still stimulating vigorous debate; as the Clinical Commissioning Groups (CCGs) come into effect from April 2013, GPs will have their hands full adapting to change and need our support, and patience, as they get to grips with the evolving landscape. Whats clear is that, if these revolutionary changes are to work in the way in which they are intended reducing costs while improving patient choice, transparency and quality of care then the Government will need to listen closely not only to GPs but also to the patients whose health they are trying to improve. This year, our study highlighted the fact that 13% of the patients we spoke to felt the quality of services being provided has declined over the last ten years. 36% believed that trend will continue over the next five years, and 14% felt there was either no future for the NHS or they had very little confidence in its current leadership in the form of the Department of Health. This is not a healthy opinion.

GPs taking the helm

By 1st April 2013, the NHS Commissioning Board (NHSCB) is likely to have tasked over 200 new organisations clinical commissioning groups (CCGs) with responsibility for up to 65bn of the 95bn NHSCB budget. This means that 8,000-plus GP practices in England will be members of a CCG, so the bulk of the NHS budget will be in the control of GPs for the first time. Those CCGs will need to be robust: this Health of the Nation study made certain aspects of our nations health focus very clear. 13% of men and 22% of women are now visiting a GP for routine check-ups, and almost one fifth (17%) of us have started seeing our GP more frequently. To be successful, the CCGs will have to decrease levels of disengagement among member practices and work hard at not only improving the services currently being delivered but also at increasing general health awareness among the population, to help reduce instances of poor health in the future. More pressure, less time This year, responses have also shown that many of those GPs whove experienced difficulties referring patients on to high quality care previously are now looking forward to the possibilities those CCGs may bring. In general though, GPs are still voicing concerns theyll have more to do (51% envisage their hours increasing in the future) but will feel less in control after CCGs come into effect.

Aviva Health of the Nation Index Report 23

Uncertain focus
Whether or not increasing trends are due to more instances of a particular condition or presentation of that problem as a result of greater awareness among its sufferers is a subject thats worthy of much debate: it certainly links the importance of education to the cost of treatment and better health in general. With that in mind, it was interesting to note that 29% of respondents to this survey believed high-profile celebrity illnesses (such as Ruby Waxs mental health challenges) helped highlight symptoms of concern. 10% of the people we spoke to believed that media attention could actually save lives. GPs agree: 76% of the practitioners we spoke to had experienced more patients seeking treatment or guidance for a specific condition as a result of a celebrity or highprofile personality publicising their own health concerns so education and awareness should still be a highly significant, contributing factor to the way our health service reform takes place.

Looking to the future

Not everything looks gloomy. We are learning the value of being more informed; GPs as a whole, still feel in control of the referral process and 83% of GPs told us they were experiencing either moderate or high levels of job satisfaction. In summary, however, this study points once again towards an ever-increasing need for patient education; more commitment to higher quality clinical pathways, and a requirement for greater transparency that will help us all benchmark the quality of service were able to access and entitled to expect. We believe this, Health of the Nation study is another incisive commentary on the nations healthcare landscape and we hope youll find it useful.

24 Aviva Health of the Nation Index Report

Notes

Methodology
Aviva canvassed the opinions of 202 GPs across the UK, asking the same questions of an equal number of men and women. To make sure this was a broadly even data sample, we also took population density into account: using the opinions of 46 individuals in the Greater London area for example, while taking on board the views of 12 in Northern Ireland. All of these GPs were interviewed during October 2012, in an online survey conducted on our behalf by the independent research company Watermelon. We also spoke to 1,001 individuals, to canvas their views on a wide range of subjects concerning health matters and their engagement with care across the country. Again, population density was taken into account; 55% of respondents were female, 45% male.

About Aviva
Aviva UK Health is one of the largest providers of private medical insurance, and Group Risk products and services in the UK. We offer everything from individual, personal policies through to corporate cover benefiting 1000s of employees. We were recently voted Health Insurance Company of the Year at the 2012 Health Insurance awards for the third year running and Aviva also came first in four other categories including Best Group PMI Health Provider (again, for the third year running) and Best Customer Service. We believe high quality healthcare should be available to all, and that healthcare itself is a very personal matter. In delivering our products and services, we try to make sure our customers always get the right treatment at the right time and to do that, we have to keep our customers at the heart of everything we do. For us, the Health of the Nation study has always been a means of visiting key issues over a period of time. It helps us gauge how the environment is changing and identify GPs and patients thoughts to help influence improvements in our products and services.

Aviva Health UK Limited. Registered in England Number 2464270. Registered Office 8 Surrey Street Norwich NR1 3NG. This insurance is underwritten by Aviva Insurance UK Limited. Registered in England Number 99122, Registered Office 8 Surrey Street Norwich NR1 3NG. Authorised and regulated by the Financial Services Authority. Aviva Health UK Limited, Head Office: Chilworth House Hampshire Corporate Park Templars Way Eastleigh Hampshire SO53 3RY. aviva.co.uk/health GEN4805 01.2013 Aviva plc