The Aviva Health of the Nation Index - February 2013

7/29/2019 The Aviva Health of the Nation Index - February 2013

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The Aviva Health o theNation IndexFebruary 2013


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Contents

3 Foreword

4 Looking for the perfect practice. Life as a GP in the UK

6 Whats up? Health trends on the increase

9 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


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Foreword

Aviva Health o the Nation Index Report 3

Were always ready to take on board the views o the

people who matter most: its what helps us ocus on

providing products and services that people really need. This is the tenth year

in which weve conducted our Health o the Nation study, canvassing the

opinions o GPs right across the UK. This year weve extended our research

to include the views o 1,000 patients to understand their experiences o

healthcare in the UK.For us, the Health o the Nation study has become an

insightul means o examining key health issues over a

period o time. It helps us gauge how the environment

is evolving and identiy stakeholder views that could help

inluence 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 identiying in the patients theyre

seeing and, in particular, the continuing impact on their

workload o mental health issues and health concernsarising rom the workplace.

Weve canvassed GPs on their views about health

education and the inormation, or lack o it that aects

the patient-doctor relationship; we asked or opinions

on the quality o both established and potential uture

clinical pathways, and we questioned GPs about their

engagement with the NHS.

Bearing in mind the changes that may happen as a

result o Clinical Commissioning Groups (CCGs) coming

into eect rom April 2013, our study has highlightedsome o the situations in which GPs still appear to need

more support, and reasons why patients may suer the

consequences o 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 o care theyre expecting,

and which steps theyre taking to engage with the

medical proession or support and more inormation

about their health and wellbeing.

The result? Another insightul cross-section o opinions

on the state o our nations health services. We hope you

ind this Health o the Nation study as useul as we have

ound it to be revealing.

Mark Noble,Managing Director, Health and

Corporate Benefits, UK & Ireland Life


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Looking or the perect practiceLie as a GP in the UK

A GPs practice already shoulders the burden o a diverse range o responsibilities:

to individual patients as well as regulating bodies and Primary Care Trusts.

The Royal College o General Practitioners has agreed that

eective commissioning will depend on continuous analysis

o a communitys needs, and the design, speciication and

procurement o services to meet those needs. Inevitably, the

onus will all on GPs to collect data that can be analysed to

help achieve those aims.

But it is, perhaps, thanks to the diverse nature o their work

that the majority o GPs (73%) have told us theyre deriving

moderate or high levels o satisaction rom their jobs.

It will be interesting to see i this changes over the nexttwelve months, as the impact o commissioning takes

ull eect.

The likelihood is that GPs may eel more obliged to be

involved in administrative activities than they are at present.

Reassuringly, our study reveals their ocus is still clearly on

attending to patients clinical concerns.

Highlights

20%ofGPstimeisspentdealingwithminorconcerns

that could have been seen to by practice nurses or

may not have warranted an appointment at all. As

insuicient time with patients is still our GPs greatest

concern, we believe this clearly emphasises the need or

more initiatives (and resources) that could help direct

patients to the most appropriate support.

Withoutcountrywideguidelinestohelpprioritisethe

many actors involved, GPs are - on average giving78% o patients an open reerral through the choose

and book system. However, most patients are unable

to compare the quality or cost o treatment thats being

recommended, and may be choosing a reerral pathway

based on convenience alone.

OlderGPsareconcernedabouttheimpactoftheHealth

and Social Care Bill, but also see the appearance o

CCGs as an opportunity to procure better services or

their patients.

GPsinNorthernIrelandappeartobehappiest,with50% citing job satisaction levels as high; in the

South West however, over a quarter (26%) said their

satisaction levels were low.

Onaverage

GPs spend 67%o their timewith patients.

4 Aviva Health o the Nation Index Report


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The working day

GPs in the UK oer the complete spectrum o care

to people in their local community. From in-surgery

appointments that will be dealing with psychological,

physical and social concerns through to o-site attendance

in clinical centres and, i 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 ree up more patient

time, by delivering resources that would better inorm

individuals about medical health matters. Just seven

GPs, less than 3%, told us part o their working day was

currently spent teaching, training or educating and raising

health awareness.

Reassuringly however, a low 3% o GPs time was

committed to dealing with cases that should have been

seen by personnel in an Accident and Emergency unit.

Onaverage:

39%oftheworkingdaywasspentdealingwithmedical

issues that required a GPs attention

20%ofthedaywasspentdealingwithsocialcareissues

or the worried well

16%ofthedaywastakenupwithadministrationorpractice issues

Onaverage,afifthofGPsworkingdaysarespenttaking

care o issues that either a practice nurse could deal with

(9%),ordealingwithminormedicalconcernsthatdidnt

warrant proessional medical attention (11%).

GPsare,onaverage,contractedtowork36hoursper

week, but most appear to be working 42 hours or more.

While45%oftheGPswespoketoexpectedthose

hours to stay the same, over hal (51%) expected to be

working longer hours in the uture.

Year on year, our studies showwere making GP appointments orproblems that could be dealt withby a practice nurse or that may not

need medical attention at all. Moreawareness o health matters couldhelp address this situation, andree up GPs time to deal with moreimportant medical cases.

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


Wales North East East Anglia Yorkshire &the Humber

NorthernIreland

Scotland South West London South East WestMidlands

EastMidlands

82%

76% 74%

71% 70% 69% 68% 68%64%

58%56%

69%

North West


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

Whats up?Health trends on the increase

GPs deal with a wide variety o health concerns. Some are major issues, some arerelatively minor, but weve looked back at our irst Health o 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 o

GPs (84%), identiied 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 o help or mental health issues,

and this could, in turn, be having a positive eect and

encouraging patients to engage more with their GPs in

general. But with so many patient cases being presented

more oten, the question quickly arises what could be

done to address the underlying causes o that stress and

anxiety, both at home and in the workplace?

Withevidencethatpeoplewithmentalhealth

conditions are eeling less stigma, it could be the case

that those with symptoms o stress, depression and

anxiety are simply more open to asking or help.

However,our2012HealthoftheWorkplacestudyrevealed many people believe theyre having to work

harder as a result o changes in the economic climate

in recent years, and that this is having a tangible eect

on their overall mental health. Just under a third o 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% o the GPs we spoke to saidthey believed Government-backed,

patient education could helpreduce instances o the conditionstheyre dealing with most oten.


84%

55%53%

50%44%

40%36%

26% 25%21%

16%12%

10% 3% 3% 2%

Mental

health

issues

excluding

stress and

anxiety

Dementia

and

Alzheimers

Stress /

Anxiety

Obesity Alcoholism

and drug

addiction

Musculo-

skeletal

conditions

Di abetes Irr it abl e

Bowel

Syndrome

ME /

Chronic

atigue

syndrome

Cancer Arthritis Migraines Heart

Disease

Stroke Other Asthma


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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 or GPs to have an opinion on the

conditions theyre likely to see most in the uture, too:

Over the last five years, have GPs seen the working environment

have more of an impact or less on the following illnesses?

Are work initiatives working?

We work alongside employers to help them promote

improvements in health and wellbeing among their

employees. Unortunately, it looks as though the

workplace is still having a notable impact on the rise in

cases o certain conditions, and one stands out above the

rest.With93%ofGPssayingtheyattributeitdirectlytoa

rise in cases o stress, theres a compelling case or 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 o the claims we deal with under ourcorporate healthcare policies are or musculoskeletal

injuries, dealing with aches and pains in the back, neck,

musclesandjoints.OurBack-Upserviceprovidesprompt

access to a clinician who can oer advice to help manage

symptoms, and (without the need or a GPs appointment

or reerral) make recommendations or appropriate

ongoing treatment.

With such a large proportion o claims being made in this

area, its not a surprise to see that 50% o GPs believe

the working environment is responsible or the cases

ofbackpainthattheyareseeing.Obesitycanalsobe

linked to musculoskeletal pain: this is one o the reasons

we encourage employers to promote improvements in

diet and itness levels to their employees using a healthinitiative such as MyHealthCounts, or example.

Most GPs believe the workingenvironment is responsibleor increases in mental healthproblems, back pain, and obesity.


21% 20% 20%

13%12%

3% 2% 2% 2% 2%1%

Stayed the same Fallen Risen

Otherstress/depression /

anxiety

work relatedstress

Diabetes Obesity Mentalhealth issues

amongstelderly

Drug andalcohol abuse

Cancer Musculo-skeletal injurye.g. back pain

Tobaccorelated illness

Other Heartconditions

RSI Back pain Stress Depression Alcoholism Headaches Drug abuse Eatingdisorders

Eye problems ME / CFS Obesity


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We asked the GPs taking part in our survey about a

number o actors that could have been aecting the

health o their patients in general over the last 5 years:

had they noticed poor diet, or example, being a greater

inluence in the cases they were seeing.

Having seen the increases in cases o some conditions

being attributed so signiicantly to the workplace, it was

perhaps to be expected that the economic climate is being

seen as having a negative impact on the health o patientsingeneral.Andunfortunately,althoughtheOlympicsmay

have stimulated greater interest in sport across the nation,

at the moment it looks as though we have yet to take

action: 64% o GPs told us that a lack o exercise was

impacting their patients health.

However, it does look as though were seeing a positive

reduction in the eects o nicotine addiction. For 43% o

GPs, the eects o smoking have made less impact on the

health o their patients over the last year.

Have these factors had more or less impact on patients over the last 5 years?

Three quarter o GPs (75%) believethe economic climate is having asignicant impact on the health otheir patients.

Poor diet

Emotional home environment

Alcohol

Smoking

Lack of exercise

Drugs

Pollution

Economic climate

Physical working environment

Emotional working environment


58%

8%

33% 26%

43%

31%

63%

5%

32% 37%

14%

50%

64%

12%23%

75%

14% 50%

10%25%

64% 71%

10%19%

43%

15%

42%

71%

5%

25%

More impact Less impact No change

100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


100%

80%

60%

40%

20%

0%


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So how are we eeling today?Health awareness among patients

Analysis o 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 someconditions, it appears that patients are becoming more health-aware in general. Whats

interesting is that their propensity to sel-diagnose has also increased signiicantly.

When, in 2011, the Government launched its Public Health Responsibility

Deal to help improve the management o 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 inorm

themselves about health issues and monitor or improve their own wellbeing.

In this study, we placed a particular emphasis on sel-diagnosis asking views

on health and the reasons why and how people try to ind out the cause o

symptoms theyre experiencing.

How do you rate your health?

45%

10%

28%

15%

2%

Ten years ago, the GPs we spoke to estimated that around

15% o their patients looked up inormation about their

condition beore visiting the surgery. Two thirds had seen

an increase in this trend; almost 70% o those GPs thought

those patients behaviour had had a positive impact on

their subsequent health.

Today, with so much more inormation readily available

online, its no surprise that more and more individuals are

sel-educating in advance o an appointment. Sources o

insight vary, but not surprisingly almost hal the patients we

spoke to (44%) are turning to the Internet or inormation.

Are there benefits to self-diagnosis?

1%

44%

23%

6%

25%

1% Yes, I look on the internet

Yes, I buy kits rom the Pharmacy

Yes, I judge my condition on my previous

experience / illness

Yes, I use inormative TV programmes

Yes, I read magazines

Yes, I ask my riends and amily or advice

No, Never

Do you self-diagnose, if youre unwell?

29%ofpatientswanttobemoreinformed when they see their GP

33%self-diagnoseoutofcuriosity,butnotinstead

o visiting a GP

31%self-diagnosetoavoidseeingaGP

7%self-diagnosebecausetheyhadnofaith

in their GP

Why do you self-diagnose?


Very good Good Average Not very good Poor


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75% o the patients we spoke to told us they were sel-

diagnosing beore seeing a doctor. But although 82%o GPs have seen an upward trend in people looking or

inormation, GPs have a very dierent perception o how

many people are actually researching their symptoms

beore having a personal consultation.

Only5%ofGPsbelievedthatasmanyasthree-quartersof

their patients were sel-diagnosing prior to an appointment.

Only13%wereoftheopinionthathalftheirpatients

were looking or inormation.

67%thoughtaquarteroftheirpatientsorfewer

would sel-diagnose in advance.

Ourresearchshowsthatalthoughpatientsarelargely

willing to sel-diagnose, theyre also less than likely to

share the act theyve done some research with their GP.

A quarter o the patients we spoke to told us they never

sel-diagnose. However, this is not the negative insight it

may irst appear to be, because 64% o people believed it

was simply better to see a GP in person, and 28% believed

sel-diagnosis would raise concerns rather than lower them.

The whole truth?

28%

8%

I dont sel-diagnose because I think this would

cause me to worry more

I dont sel-diagnose because its best to just see your

doctor in person

I dont sel-diagnose because its too time consuming

Do GPs think its beneficial for patients to

self-diagnose before an appointment?

Without a guarantee o its validity, patients may be

sceptical about medical inormation thats been sourced

somewhere other than through their GP. However, it

looks as though some o us are using the data as a

benchmark, rom which to value or potentially challenge

adoctorsviews.Asignificantpercentage39%of

GPs appreciated the eorts that patients made, but saw

sel-diagnosis as a challenge i patients were unwilling toaccept a diagnosis.

2%

21%

23%15%

39%

Yes, it can be very helpul

Yes, but only i they are then willing to

No, it causes scare mongering

No, I think it serves no beneit at all

It varies rom patient to patient


64%


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Time to visit the GP

Visiting a GP may not always be convenient, but neither is

illness. We asked people to tell us how oten on average

they visited a GP, and why. The answers were intriguing,

not least because they show a marked dierence in

attitudes between men and women.

30%ofmensaidtheyrarelybecomeillcomparedto

21% o women. But 35% o men said theyd changed

their views on visiting a GP in recent years, primarily as

theyd become more aware o how important it is to

look ater your own health.

Foralmostafifthofmen(17%),visitstotheGPhad

becomemorefrequent.Only14%ofmenhadntvisited

their GP in the last three years, compared to 7% o

women, and knowing that routine check-ups are a

good idea 13% o men and 22% o women cited

this as the main reason or visiting the doctor.

Different approaches to health

Onthewhole,itappearsthatmenarelesslikelytopaya

visit to their GP than women.

We asked what were the reasons or the delay?

51%ofwomensaidtheywouldsufferinsilenceif

unwell as there were jobs to be done; compared to this,

only 44% o men took the same approach.

27%ofmen,however,werelikelytotaketimeoffand

go to bed, instead o going to their GP, compared to

just 21% o women.

Overafifthofoursurveysrespondents(21%men,

20% women) said theyd take medicine to keep going

rather than go to their GP.

29%ofwomenwouldwaittoseeifthesymptoms

went away, 16% blamed their inability to get a quick

appointmentand9%saiditwouldbeastruggleto

make an appointment that suited working hours.

Incomparison,21%,14%and9%ofmengavethe

same answers respectively

However, we also asked about attitudes to making an

appointment what, i any, would be the reasons to delay.

Overaquarterofthewomenwespoketo(28%)said

theyd never avoided going to see their GP i they were

unwell. But although some are visiting their GPs more

frequently,overathird(39%)ofthemalerespondentsto

this survey had put o going to see their GP.

Happily, only 2% o the men and women we spoke to said

they would milk an illness or all its worth.

How often do you visit your GP?

Daily

Onceaweek

Onceamon

th

Everythreemon

ths

Everysix

mon

ths

Onceayear

Never

35%

40%

30%

25%

20%

15%

10%

5%

0%

The ease with which patientscan or cannot make a GPsappointment is still a concern.

In all, 24% o the patients wespoke to said that, in someway, their GPs unavailabilityinfuenced a delay in seekingmedical help.

48% are suering in silence.

Men Women

4%9%

9%

11%

17%

18%

22%

31%

37%

31%

14%

7%



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Caring for each other

It was good to see that most people were aware o

their partners general health. But there was also a slight

dierence in the way men and women then approached

their concerns:

43%ofmencouldpersuadetheirpartner to see a GP;

a slightly higher percentage o women, 46%, had the

same inluence.

29%ofmenhadnotraisedaconcernabouttheir

partners health; only 17% o women reserved

opinions in the same way.

13%ofmenhaddiscussedsomethingthatwas

worrying them about their partners health, but seen

no result rom the conversation; 17% o women had

made unsuccessul attempts to raise concerns.

The good news is that 10% o the men and women we

spoke to had successully persuaded partners to makeliestyle changes or the better. Interestingly, 10% o

women had exercised those changes (such as diet), while

only 5% o men had taken the same action.

Feeling better

Sel-examinations involve checking testicles and breasts

or physical changes: when you know how your body

normally looks and eels, any changes in appearance

should be easier to notice. The media has raised

awareness about the importance o sel-examination,

but it appears theres still some way to go in educatingeveryone as to its value.

Do you self-check for signs of testicular cancer or

breast cancer?

Only75%ofthewomenwespoketodoany

sel-examination.

Alowerpercentageonly60%ofmenchecks

their bodies in the same way.

How often do you check?

These are alarming statistics

Forthequarterofwomenwho dont sel-check, 32%say theyre too busy anddont remember and an equalproportion (32%) say theydont know how.

Ofthosemenwhodontself-

check, 37% say they dontknow how to; while 30%dont think they need to checkor signs o breast cancer ortesticular cancer


I think I am too young to need to

There are no historical issues in my amily and I thinkthese things are hereditary

I dont think I need to

I dont know how to

I am too busy and never remember

Daily

Weekly

Everytim

eI

show

er/ba

th

Every

2-3weeks

Every3m

onths

Regular

ly

Twiceaye

ar

Onc

eor

twicea

month

Nota

softe

nasIshould

Every2m

onths

Yearl

yOth

er

Dontk

now

3.2%

19.6%

4.5%2%

40.9%

3.9% 4.5% 4.6%

1.4%

5.8%

8.6%

0.7% 0.4%

6%

11%

23%

35%

25%

If you dont check, why not?


13/28

It transpires that most people take responsibility or their

own care, but we asked some pertinent questions about

engagement with health services in general.

87%ofthewomenwespoketosaidtheywould

be the person to make a decision about which GP

to see; only 63% o men we spoke to made the

same judgement.

Whenitcomestobeingresponsibleforresearching

insurance that could pay or medical care, 53% o

those carrying out research themselves were men.

48%ofthosecarryingoutthepurchaseofprivate

medical insurance were men women accounted or

59%oftherespondentswhosaidtheyweremost

likely to be keeping up to date with health news.

Womenwerealsomorewillingtosaytheywouldbe

more likely to ollow health ads, but equally, 64%

o women considered they took health matters more

seriously than men.

70%ofthewomenwespoketosaidtheyweremost

likely to carry the responsibility o care i someone in

thefamilywasunwell.Only34%ofmenvoicedthe

same opinion that a man would be most likely to

play the role o carer.

Dierences o opinion

As weve seen rom their approaches to visiting a GP, our study highlights that

men and women have dierences in opinions about health matters in general.

The gender division was also noticeable in perceptions o care, as were views across the country. We asked peoples

opinions regarding the quality o health treatments being received in their area.

14% o respondents in the North West believed health services in their area were comparatively poor; by contrast, just1% o the respondents in Scotland shared the same opinion.

38%40%

42%

I think it is good

70%

60%

50%

40%

30%

20%

10%

0%Yorkshireand theHumber

EastMidlands

WestMidlands

SouthEast

SouthWest

Wales Scotland NothernIreland

NorthEast

NorthWest

I think it is sufficient

I think it is poor

It depends on whattreatment is required

I have no point of reference


I have no point of reference 4%4%

9%

35%

Women

15%6%

It depends on what treatment is required

I think it is poor

I think it is sufficient

I think it is good

8%

East London


14/28

Spotlight on mental healthWorrying signs

A great deal o our GPs time is spent dealing with mental health issues. Its still the

most prevalent type o illness, with 84% o GPs seeing more patients than ever

beore suering rom stress and anxiety.

Across the country, opinions vary as to the reasons or this

increase. In the North West and South West, GPs believe

changes in diagnostic criteria are the cause. Financial

pressures could be the reason or 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 rom the East Midlands, where

GPs blame the increase in mental health issues on the use

o social media or riendship and resulting isolation.

Do GPs agree that mental health is one of the

most pressing priorities for the NHS?

Are GPs seeing long waiting lists for Talking

Therapies in some areas?

Just under hal the GPs we spoke to (47%) believe theres

still a stigma associated with mental health issues, which

may be preventing people rom seeking help.

Butitsworthnotingthat39%ofGPsthoughtmedia

campaigns were having a positive impact on that situation,

mostnotablyintheNorthWest,where59%ofGPsshared this view.

Do GPs agree theres a lack of support for them,

regarding these health concerns?

Are GPs prescribing medication (anti-

depressants), when they believe TalkingTherapies would be more beneficial?

Less than a quarter o the GPs we spoke to (23%) believed that access to Talking Therapies such as cognitive behavioural

therapy would improve over the next ew years. A telling statistic is the act that 77% o GPs believed the workplace is

one o the biggest causes o stress and anxiety or patients in the UK.

Problems such as anxiety, depression, stress and phobias are very common. Talking Therapies is a Government-

sponsored, nation-wide service that oers help to people with those problems.

Yes

59%

36%

4%

Neutral Yes

68%

21%

11%

Neutral

Yes

84%

12%

3%

Neutral Yes

74%

20%

Neutral


6%

No No

No No


15/28

Overhalfofourrespondents(52%)toldusthattheyve

suered rom one mental condition or another during

their lietime; many had experienced symptoms aligned

with more than one type o illness and the majority o

people (74%) knew someone else who had suered or

was suering rom mental health problems.

Ofthepeoplewespoketo,22%saidtheywerenow

feelingbetter;9%saidtheywerestillunwelland21%of

our survey said they still experienced symptoms rom time

to time. It was encouraging to see that 57% o 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:

The majority o patients (51%) elt that a period o 2 to

3 weeks was the maximum time they should wait or

a reerral to counselling or a psychological service, to

ind out more about and get support or 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 i they had to wait a long time beore

getting a reerral.

What support did you receive for these conditions?

Its alarming to note that 8% o patients believed they

were sent away rom their GP having been given no

support or one type o mental health issue or another.

Nearly three-quarters o 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%ofGPsbelievetheirlocaltrustprovidesapoor

service or patients with mental health issues.

37%ofGPsbelievetheserviceispoorforpatients

with depression, one o the highest prevalences o mental

health issue in our survey.

Work-relatedstress

Depression

SAD(Seasonal

AffectiveDisorder)

Mildanxietyand/or

depressionrelatedto

stressortrauma

Panicattacks

Phobias

Paranoia

Digestivedisorder

relatedtostress/

Frequentheadaches

relatedtostress/anxiety

Bi-polardisorder

OCD

Chronicfatigue/ME

40%

35%

30%

25%

20%

15%

10%

5%

0%

I was prescribed drugs suchas anti-depressants

58%

32%

29%

24%

14%

14%

8%

6%

I was referred for counselling /cognitive behavioural therapy

I was referred for aspecialist consultation

I was told to reduce my hours /signed off work

The GP sent me away withno support

I was told to take more exercise

Other

I was referred for further tests


35%

31%

23% 21%

14% 14%

10%7%

5% 5% 5% 1%

anxiety

e.g.

IBS


16/28

Spotlight on the workplaceWorking harder

A Fit Note is the inormal name or the Statement o Fitness or Work; a computer-

completed version was introduced in July 2012 with the aim o urther smoothing

the process or GPs who are helping employees get back to work as soon as possible.

There was reason to believe the ormalised Fit Note would

provide a useul platorm or GPs to open discussions with

patients about their health, with a view to helping them

reduce long-term sickness absence a clear beneit to

employers, as well as employees. Theres an even opinion

on whether or not its working:

Is the fit note an effective tool?

Overallhowever,itappearsGPsstillfeeltheonusshould

be on companies and their sta to take more responsibility

or their health in the irst place, which would hopeully

lead to a reduction in the need or GP appointments.

85%ofGPsthoughtemployerscoulddomoretohelp

their sta get back to work

75%ofGPsthoughtemployerscoulddomoretohelp

their employees stay healthy

71%ofGPsthoughttheNHSwasnotappropriately

resourced to help employees return to work

Those look like substantial igures. However, its vitally

important to keep statistics in context.

WeaskedGPswhetherornottheyhadacloseenough

relationship with patients to understand their individual

needs in terms o making a successul return to theworkplace ater illness or injury.

Only 50% felt they did.

Yes

32% 32%

36%


NoNeutral


17/28

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.

Ofthepeoplewespoketoforthisstudy,9%hadsuffered

rom conditions resulting in the replacement o one or

more o the ollowing joints: hips, ankles, knees, elbows or

shoulders (over 130 dierent operations in all). However, astaggering 76% o respondents said they knew someone

who had undergone at least one o those operations.

However, joint replacement is not necessarily always linked

to the deterioration o health in old age: a quarter o 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 o age. We asked everyone in

our survey:

How would you cope if you needed a joint

replacement, but werent able to have one? 24%ofrespondentsthoughttheywouldfindawayto

cope inancially and emotionally

22%ofrespondentssaidtheywouldcomplain,14%

thought it likely they would get depressed about the

situation

13%ofrespondentssaidtheywouldchangetheir

liestyle in an attempt to cope

Overaquarterofthepeoplewespoketo(28%)said

everyday things, like driving or getting shopping done,

would be their primary concern i 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 amily would worry

them most.

How long would you be prepared to wait for

this type of operation?

Waiting times or joint replacements vary across the

country. We also asked respondents to indicate how long

theyd be prepared to wait or treatment what did they

consider to be a reasonable amount o time i they were

struggling to walk, and needed a hip or knee joint to be

replaced.

Onaverage,mostpeoplethoughtthatawaitingtimeofbetween one and three months would be acceptable

which is roughly in line with the NHSs 18-week maximum

waiting period guidelines.

Spotlight on joint replacementsHips and knees

This year we looked at replacements, putting a ocus on the experiences orespondents whod had operations to replace hip or knee joints in particular.

43% o people know someone

who has had a hip replacement.28% know someone who has hada knee replacement.

2 weeks

15%

34%

4%

33%

12%

2%

3 months Six monthsto a year

More thana year


1 Month 6 Months


18/28

So do we care about care?Patients views on unding care

Whether or not its to do with absence rom work, its important to be conident inthe person rom whom were seeking help.

The NHS provides varying levels o support across the

country, and our survey showed that patients have irm

opinions about their relationships with GPs and the

system in general. We asked, I there were long waiting

times would you consider going private or treatment?

55%saidtheywouldntbeabletoself-fundtreatment

13%felttheycouldclaimonaprivatemedical

insurance policy

23%wouldfindfundsthemselvestopayfortreatment

9%saidtheywouldsuffer,andwaituntil

treatment was available rom the NHS

The views on what was an acceptable price or improved

health varied. We asked how much people elt they could

aord, i they chose to sel-und treatment almost hal

(47%) said they would ind money rom their personal

savings. However:

58%couldafford1,000orless

27%couldaffordbetween1,000and5,000

Only5%couldaffordbetween5,000and10,000

So how would you pay for treatment?

Overaquarter(27%)oftherespondentstooursurvey

said theyd be prepared to borrow rom riends or amily,

takeoutaloanorincurcreditcarddebttoself-fund;19%

were prepared to re-mortgage their property. We believe

these igures highlight the act that many people are

aware o costs, but without private medical insurance

they would be ill prepared to pay or treatment i they

opted or private care.

For many people, private medical insurance negates

the need to worry about access to care irrespective o

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?

7%

3%

9%

3%

13%

65%

It depends on the condition -I wouldnt want my taxes spent on

conditions that arent essential

I think people should ensure theyhave health insurance to protect

themselves from this

I think it is very unfair

I was not aware of this

5%

7%

7%

36%

27%

8%

Very concerned, I have noconfidence in the leadership

of the DOH & NHS

Very concerned - I cantsee 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 haveconfidence in the leadership

of the DOH & NHS

Optimistic - I feel that thedirection the NHS is going in will

deliver better care for patients

I dont have an opinion on this

Probing urther into their opinions as patients, we

then asked:

As a patient, whats your outlook for the NHS?


Its an unavoidable act,treatment quality cannot be

consistent across the country

I think people should be able toselect where they get treated

10%


19/28

Engaging with the NHSGPs views, patients opinions

We asked patients what they thought about the quality o care provided by theNational Health Service (NHS) today.

Opinionsvaried,buttheresanindicationthatthegeneral

public is concerned that some areas o the NHS are

coming under undue pressure.

13%ofpeoplethoughttheNHShaddeclinedinits

quality o services over the last decade

Just15%felttheUKsNationalHealthServicewasone

o the best state-provided health services in the world

Very ew people 3% declined to share an opinion

on this.

For which services do GPs feel the NHS provides a good service? Where does the

NHS not deliver an adequate service to its customers?

Opinion highlights

In general, GPs eel 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 or which individuals are catered relatively well.

This is interesting, because 20% o GPs cited diabetes as being one o the conditions most likely to increase over

the coming year and diabetes can be linked with obesity. Sadly, irrespective o being due to general budget cuts,

redistribution o unds, or allocation o unds or more lie-threatening conditions, 16% o GPs expect their local NHS to

stop oering treatment or eating disorders in the next 5 years.

Alcoholism

and drug

addiction

Alzheimers

and

dementia

Arthritis Asthma Cancer Cataracts Diabetes Eating

disorders

Heart disease Hip / knee

replacements

D epression Mental

health issues

(excluding

stress /

anxiety)

Stress /

anxiety

Musculo-

skeletal

conditions

needing

physiotherapy

People

wanting

health advice

Strokes Obesity

80%

70%

60%

50%

40%

30%

20%

10%

0%

Poor Adequate Good


I dont have an opinion on this

I believe the NHS variesacross the country

I think the NHS has declined inquality over the past decade

I think some areas o the NHS are

under a lot o pressure: care othe elderly or example

I think generally speaking theNHS is very good, but some areas

are stronger than others

I think our health service isone o the best in the world

3%

5%

13%

26%

37%

15%


20/28

According to GPs, who owns the referral

process?

ReerralsFrom patient, to GP, and others

Overthelast10years,medicaladvancesmeanthatrecommendationsfortreatmentmay have changed. However, the reerral process rom a patients initial concerns

through to the irst appointment with a specialist who can make a detailed diagnosis

has altered very little.

In the patients journey, the role o a GP extends

rom counsellor, conidante and assessor, to both

communicator and acilitator. Its the GPs role to make

appropriate reerrals or more investigation o a condition

or symptoms, but data to inorm their decision is notreadily available.

Theres a great deal o variation in the way GPs make

reerrals, and relatively ew patients would query

their recommendation.

However, as part o the Competition Commissions

investigation into the supply and acquisition o private

healthcare services in this country, the reerral process is

undergoing close scrutiny.

Aviva is contributing to this investigation, assisting the

Competition Commission as they look at actors that could

be aecting GPs reerral choices:

Arepotentialclinicaloutcomestakenintoconsideration

enough by GPs?

Isthereenoughtransparencyregardingthecost,

quality and availability o one speciic treatment in

comparison to others?

Perhapsmostimportantly,arepatientsviewsbeing

considered enough during the reerral process thats

supposed to aord them the best possible treatment

and recovery?

Only15%ofGPsbelievetheirpatients own the reerral process.We believe theres an urgentneed or patients to see moreinormation, and be more involved

in the decision-making processesthat aect their treatment and care.

61%15%

9%

14%

The majority o GPs - 62% - believed they were completely in control o the reerral 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 o reerral.


GP

Patient

Specialist

Insurer

Other(combination)


21/28

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 o 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 o care or cost o treatment.

The reerral options provided by GPs may be based on

previous experience or reputation rather than a quantiied

measurement o clinical outcomes.

For private treatment, which factors do GPs

consider in their referrals?

When reerring patients or private treatment that will be

either sel-unded or covered by an insurance policy, there

are many actors that have to be considered in addition to

the individuals immediate clinical needs.

However, one o the challenges aced by the Competition

Commission (and patients) is the lack o consistency

or guidelines inorming the way in which GPs should

prioritise those actors, 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 o a treatment rom acility

to acility, or even among specialists and/or anaesthetists

or example could help.

Onaverage,GPsaregiving78%o patients an open reerral.However, most patients are unableto compare the quality or cost o a

treatment and may be selectinga reerral pathway based onconvenience alone.

48%

22%

6%

24%

30%

29%

35%

1%

3%

2%


I gave them a choice o specialists and hospitals tochoose rom

I select the specialist I eel is best or them

I ask the patient which specialist theyd like to seeand reer them to the one they choose

I give the patient an open reerral

Quality o care / outcomes

Quality o acilities

Waiting times or NHS treatments

Financial penalty o premium increase when an insurerdoes not cover the ull cost o treatment

Choice o specialist / consultant

Availability o advanced treatments / technologies


22/28

Which conditions do GPs find most challenging to refer for specialist attention?

Consistent with our previous Health o the Nation reports. We asked which reerrals GPs were inding most challenging.

Its worth noting that, in comparison with the results o our irst Health o the Nation study ten years ago, the reerral

landscape has changed very little although ewer GPs are inding the process quite such a challenge, overall.

Tired of dealing with ME and CFS?

As with last years survey, GPs told us that they were still struggling to reer patients on or more

specialistinsightstoMyalgicEncephalomyelitis(ME)andChronicFatigueSyndrome(CFS).Overa

period o ten years, these are still the number one conditions that GPs nd most challenging toreer on or specialist attention. Whats most alarming however, is that 42% o GPs thought the

NHS would no longer provide services or ME and CFS by 2015.

2012: top 10 conditions and % of GPs who find these referrals challenging

ME / Chronicatigue syndrome

Obesity Drug / alcoholabuse

Mental health(exc. stress)

40%

35%

30%

25%

20%

15%

10%

5%

0%

Stress(work related)

Depression Stress (nonwork related)

Back pain Headaches Irritable BowelSyndrome

45%

39%

24%

20%17% 17%

16% 16% 15% 14%12%


Foodallergies

Fibromyalgia Eatingdisorders

70%

60%

50%

40%

30%

20%

10%

0%

Learningdiicultiesin children

Alcoholism Drug abuse Headaches Musculo-skeletal

ObsessiveCompulsiveDisorder

80% 76%72%

59%

44% 43%

34%

55%

37%

31%

44%

2003: top 10 conditions and % of GPs who found those referrals challenging


Foodallergies

Eatingdisorders

Stress(work related)

70%

60%

50%

40%

30%

20%

10%

0%

Learningdiicultiesin children

Stress (notwork related)

Drug abuse Obesity Musculo-skeletal

Mentalhealth issues

60%56%

53%

45% 44%40%

36%

53%

40%

35%

2011: top 10 conditions and % of GPs who found those referrals challenging



23/28

What have we learned?Health o the Nation a 10-year anniversary

OurHealthoftheNationstudywasfirstpublishedin2003.Webelievethismakesit the longest-running private medical insurers study o GPs views in the UK. Now,

10 years on, were about to see some o the most radical reorms in the 63-year

history o the National Health Service (NHS) take place so this study holds even

greater signiicance or anyone seeking insights to the views o 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 reorm the service

(in England at least), that have proved hugely controversial

over the last twelve months.

Political dierences and the challenges inherent in

such a substantial programme o change resulted in us

seeing a new Health Minister take the helm; there are

major implications or the NHSs workorce that are still

stimulating vigorous debate; as the Clinical Commissioning

Groups (CCGs) come into eect rom April 2013, GPs willhave their hands ull adapting to change and need

our support, and patience, as they get to grips with the

evolving landscape.

Whats clear is that, i these revolutionary changes are to

work in the way in which they are intended reducing

costs while improving patient choice, transparency and

quality o 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 act that 13% othe patients we spoke to elt the quality o services

being provided has declined over the last ten years. 36%

believed that trend will continue over the next ive years,

and 14% elt there was either no uture or the NHS or

they had very little conidence in its current leadership

in the orm o the Department o 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

forupto65bnofthe95bnNHSCBbudget.Thismeans

that 8,000-plus GP practices in England will be members

o a CCG, so the bulk o the NHS budget will be in the

control o GPs or the irst time.

Those CCGs will need to be robust: this Health o the

Nation study made certain aspects o our nations health

ocus very clear. 13% o men and 22% o women are

now visiting a GP or routine check-ups, and almostone ith (17%) o us have started seeing our GP more

requently. To be successul, the CCGs will have to

decrease levels o 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 o poor health in the uture.

More pressure, less time

This year, responses have also shown that many o those

GPs whove experienced diiculties reerring patients onto high quality care previously are now looking orward 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 uture) but will

eel less in control ater CCGs come into eect.



24/28

Uncertain focus

Whether or not increasing trends are due to more

instances o a particular condition or presentation o

that problem as a result o greater awareness among its

suerers is a subject thats worthy o much debate: it

certainly links the importance o education to the cost o

treatment and better health in general.

Withthatinmind,itwasinterestingtonotethat29%of

respondents to this survey believed high-proile celebrity

illnesses (such as Ruby Waxs mental health challenges)

helped highlight symptoms o concern. 10% o the people

we spoke to believed that media attention could actually

save lives.

GPs agree: 76% o the practitioners we spoke to had

experienced more patients seeking treatment or guidance

or a speciic condition as a result o a celebrity or high-

proile personality publicising their own health concerns

so education and awareness should still be a highlysigniicant, contributing actor to the way our health

service reorm takes place.

Looking to the future

Not everything looks gloomy. We are learning the value o

being more inormed; GPs as a whole, still eel in control

o the reerral process and 83% o GPs told us they were

experiencing either moderate or high levels o job satisaction.

In summary, however, this study points once again

towards an ever-increasing need or patient education;

more commitment to higher quality clinical pathways, and

a requirement or greater transparency that will help us all

benchmark the quality o service were able to access and

entitled to expect.

We believe this, Health o the Nation study is another

incisive commentary on the nations healthcare landscape

and we hope youll ind it useul.



25/28


26/28

Notes


27/28

Methodology

Aviva canvassed the opinions o 202 GPs across the UK, asking the same questions o an equal number o men and

women. To make sure this was a broadly even data sample, we also took population density into account: using the

opinions o 46 individuals in the Greater London area or example, while taking on board the views o 12 in Northern

Ireland.

AlloftheseGPswereinterviewedduringOctober2012,inanonlinesurveyconductedonourbehalfbythe

independent research company Watermelon.

We also spoke to 1,001 individuals, to canvas their views on a wide range o subjects concerning health matters and

their engagement with care across the country. Again, population density was taken into account; 55% o respondents

were emale, 45% male.

About Aviva

Aviva UK Health is one o the largest providers o private medical insurance, and Group Risk products and services in the

UK. We oer everything rom individual, personal policies through to corporate cover beneiting 1000s o employees.

We were recently voted Health Insurance Company o the Year at the 2012 Health Insurance awards or the third

year running and Aviva also came irst in our other categories including Best Group PMI Health Provider (again, or the

third year running) and Best Customer Service.

We believe high quality healthcare should be available to all, and that healthcare itsel 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 o everything we do.

For us, the Health o the Nation study has always been a means o visiting key issues over a period o time. It helps us

gauge how the environment is changing and identiy GPs and patients thoughts to help inluence improvements in

our products and services.


28/28

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RegisteredOffice8SurreyStreetNorwichNR13NG.ThisinsuranceisunderwrittenbyAvivaInsuranceUKLimited.RegisteredinEnglandNumber99122,

RegisteredOffice8SurreyStreetNorwichNR13NG.

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Documents

The Aviva Health of the Nation Index - February 2013