Deep End

The three GPs assembled before me have more than 60 years’ experience between them of working in general practice.

As members of the Deep End Project – a group of GPs assembled from the 100 most deprived general practices in Scotland – the GPs from the Govan Health Centre see themselves and their colleagues as the NHS’ frontline in the ongoing battle against Scotland’s endemic health inequalities.

Life expectancy for people living in the most deprived areas of Scotland is around 20 years lower for men and 18 years lower for women, compared with those living in the most affluent areas. Further, according to a recent report by RCGP Scotland, deprived adults are nearly four times more likely to die from coronary heart disease between the ages of 45-74, and more than 12 times more likely to die of an alcoholrelated condition.

GPs face the stark realities of these inequalities on a daily basis. However, despite their unique vantage point, the Deep End Project, established two years ago, is the first time in the NHS’ 60-plus year history that these practices have been convened and consulted in an attempt to capture their previously unheard views and experience.

The GPs from Govan clearly relish the opportunity to speak up for their patients.

“We work in an area with lots of people who have got huge problems with deprivation, which has a massive impact on their health and not enough people care enough about that and it is not fair. That sounds a bit idealistic but that is generally what it is about: a good bunch of people who have got a raw deal and something needs to be done,” says GP Euan Paterson.

His colleague, GP Anne Mullin, also got involved because she believes patients’ everyday struggles need to be shared more widely.

“That’s why I got involved in the Deep End because I thought this micro-political level of the everyday stories we hear - people say that is just an anecdote, it isn’t really evidence, but that’s nonsense. This is evidence. What these people tell us is evidence of whether the system is working or not. Whether society is functioning or not functioning.

“…But we don’t yet have a sophisticated way of doing that because it is part of the patients’ narrative and so it is not really regarded in the same way as, say, a blood pressure measurement in terms of evidence.” Woven together, however, patients’ narratives create a more complete picture of what life is like for those who bear the brunt of inequality.

Completing the trio, Dr Carolyn Gillies reflects on her experiences with one young patient who, she says, typifies the multiple challenges her patients face.

“This is a young guy, he’s now 22. He was brought up in poverty with a big family, none of whom have ever worked but despite this - and despite being assaulted when he was 16 and nearly killed, after someone came up and hit him around the head with a metal bar, fracturing his skull, which he got over and got a plumber’s apprenticeship. But he has been to see me a few times recently because he is not coping emotionally. Because he can’t get a job.

“He can’t get a job with a firm because it depends on who you know. He can’t get a job on his own because he can’t afford driving lessons, let alone get his own vehicle. He currently has a girlfriend who he would quite like to get married to and settle down and have kids with but they are living with his mum.

He is really quite an old-fashioned boy and he doesn’t want to do that until he has got enough money saved. And he is one of these people who comes through all of this still intact, but not working and living on benefits and now seeing me because he just needs to chat about it sometimes.” None of the GPs is under any illusion about the numerous social determinants of poor health; nor that many of the solutions lie beyond their remit and outwith general practice.

Sometimes, Paterson says, all he can offer is to “simply sit and witness their suffering,” and let them know that they have been heard.

“Not with any intent to do anything about it,” he says, “but just to sit there and give validity to their story so they hopefully go away thinking it is at least entirely appropriate for me to feel the way I feel. I’m not going mad. I’m not a bad person. I’m not part of the sick society that we hear about from our esteemed leaders down south. It is just rotten and at least someone has said to me, ‘Yeah, it is rotten and I’m sorry that it is.’” Collectively, this turns GPs into a valuable source of information with the knowledge to flag up emerging challenges much earlier than they are currently being identified, Mullin argues.

“Look at heroin in Glasgow. It was established probably in Possil before anywhere else in Glasgow. It was there for about ten years before, politically, it became a huge issue, but by then you’ve had a decade of it mushrooming out of control.” The same is true today of the impact the welfare reforms are having in these communities, she adds: “I might see ten people coming in saying they are destitute this week. If we are all seeing that then that is a huge problem. That is not just ten isolated cases. It is an issue that, politically, has to be dealt with.” GPs are a treasured resource in these communities, and yet general practice itself is under-resourced to deliver all that the NHS could be achieving in terms of improving health and narrowing health inequalities, they argue.

Indeed, it is incongruous that the availability of good medical care tends to vary inversely with the need for it in the population served, argues Graham Watt, a Professor of General Practice at the University of Glasgow who also sits on the project’s steering group. If this inverse care law is not addressed, then the health inequalities resulting from it will persist, he explains.

“Since 1948, the NHS has supplied GPs in the same way that bread, butter and eggs were rationed in World War 2 – everybody gets the same,” Watt wrote in an article published in the British Journal of General Practice earlier this year.

“In severely deprived areas, this results in a major mismatch of need and resources, with insufficient time to get to the bottom of patients’ problems – hence the swimming-pool analogy in which GPs at the Deep End are treading water.” The NHS should be seen at its best where it is needed most, he argues, adding that the goal for healthcare must be to find ways of increasing the volume, quality and consistency of care in deprived areas.

When asked in what way circumstances could be changed to allow them to achieve more, the GPs from Govan have an answer ready.

“I need more time with each individual patient. That’s it. That is the only thing I’m after,” states Paterson concisely.

Patients in deprived areas often have multiple overlapping health and social problems that a ten-minute consultation can prove insufficient to unpick, they explain.

“All that we do in general practice is narrative based,” explains Mullin. “We sift out the hard facts of their medical issues from the narratives that patients give you. We’re not vets. We don’t sit and stare at patients and try and work out what is wrong with them. They come in and tell us things and they muddle it up, though, with the story of their lives. ‘My housing is awful and by the way, I’ve had this chest pain for two days,’ and we’ve got to decide whether that is cardiac or not. That is what we do. That is what your skill as a GP is but it takes time.” They do not mean to imply that GPs working in other areas are not also busy - they know that they are - or that they do not have demanding patients; the difference is that these complex cases make up the bulk of Deep End GPs’ workload and so are the norm, not the exception. All of the Deep End practices - which were identified by ranking the practices according to the proportion of registered patients living in the most deprived 15 per cent of Scottish postcode datazones - have at least 50 per cent of their patients in this category, rising to over 90 per cent in the most deprived practice population.

Eighty-five of the Deep End practices can be found in Glasgow City; and across the river from Govan, the Keppoch Medical Practice in Possilpark has the unenviable honour of topping the list of Scotland’s most deprived practices.

Petra Sambale, GP, Keppoch Medical Centre says the main difference between the practice here and more affluent parts of the city is that “very few easy cases” come through the door.

In 2003, the practice took part in a pilot study, led by Watt and Stewart Mercer, a Professor of Primary Care Research at Glasgow University, which provided increased time for consulting with complex cases. The pilot found that extra time was associated not only with increased reported enablement by patients with complex problems, but also reduced practitioner stress and increased reported enablement by other patients receiving usual consultations. Work is currently under way to evaluate this approach in a larger number of practices, with findings due in August 2012. However, Sambale is already persuaded and argues that the “promising” initiative deserves wider and longer-term application. She also found participating in the research was a useful learning exercise all round.

“That was certainly how it started for all of us to become much more aware of the deprivation issues and the pressures we were under,” she says.

“Getting feedback from the university that we were at that time the most deprived practice in Scotland, finally, a lot fell into place for us and made it clear to us why we were so stressed.” The additional pressures working in an area of concentrated deprivation brings should not be underestimated.

“The intensity of working in a practice in a deprived community is significant,” explains Dr Alan McDevitt, deputy chairman of the BMA’s Scottish General Practitioners’ Committee.

“Patients often have multiple chronic diseases and significant health and other needs.

“Practices in these communities don’t just need more money to provide services; they need support to be able to offer patients the care they need when they come to the practice.” However, funding cuts are threatening the continuity of care and impeding the quality of service practices are able to provide, Sambale says.

“In the last five years we had periods without any health visitor in the practice. We then had a succession of three different health visitors. One, who left, was excellent. She was the best health visitor I’ve ever worked with but she left because she said she had never come across that level of deprivation and need and that lack of support like here. She became ill and had to protect herself and had to leave and there was nothing we could do.” Gaining the patients’ confidence for yet another new face can take time, however, and GPs increasingly find themselves having to fill the gap, Sambale explains.

“Our patients said to me, ‘Who is here now?

I’m not going to see that person. I’m fed up meeting new faces.’ So what is happening, again if you look at our time and resources as a GP, you suddenly have to provide health-visitor cover. You have to provide services you shouldn’t be providing because you are the only person who is there to deliver continuity of care.” In such cases, burnout is a real concern, she states, adding that if you have “the two big ‘Cs’ in your work ethic – care and compassion,” this cannot be sustained indefinitely.

Not everyone is suited to work under such conditions, explains practice manager, Fiona McKinlay.

“They are not going to have the same career … the same income if they went anywhere else… the same work/life balance. I think it is almost the old-style doctor who chooses to come here.

Watching the trainees who are coming through now there are fewer and fewer of those young GPs with that kind of mindset that the old-style family doctor had so I think it will be harder and harder to recruit doctors to come and work in areas like this.” The practice’s recent experience of recruiting a new partner only served to confirm McKinlay’s fears.

“We advertised for a new partner and we had about 25 applications, many of them were clearly unsuitable. Once we had it narrowed down, we interviewed three people, actually, one didn’t turn up because she got mugged on the way here. She got lost and stopped to get her phone out of the boot and got her handbag stolen. So she obviously decided she didn’t want to work here after all. So in the end, we ended up interviewing two people.

“Now, I know from colleagues that if they advertise for a partner in other areas you are overwhelmed and it is very, very easy to find another partner. But for us, there are so many aspects to the person that you are looking for that it is very complex.” I ask Sambale what the attraction of working in such a deprived area is.

“What keeps me here is that I think it is one of the most challenging jobs you can have as a GP,” she answers.

While this complexity is often overwhelming, she says it is also very stimulating to have had a unique opportunity to specialise in deprivation.

“I can say that because I have worked in one of the most expensive areas in Europe before this so I have the direct contrast. But for me, the difference is this complexity. It is fun.” Similarly, back in Govan, Gillies says she has learned a lot from working in an area of deprivation.

“I love working in Govan. I’ve been here about 25 years. I come from a nice middle-class background – my parents were teachers, nice upbringing and all the rest of it. But the amount that you learn about humanity and human nature is enormous.” Middle-class areas may see it as well, she continues. “It has been so long since I’ve worked in one. But we see lots and lots of unhappiness due to circumstances and I think that is what we learn to deal with.” For Mullin, working in Govan is simply a more natural fit.

“I identify with people living here. I come from a quite working-class background myself and the stories I hear are quite familiar stories, they are not alien to my ears. I think if I was brought up in social class one area and a quite aspirational family, perhaps I couldn’t get on an equal field with them. But I actually don’t see any difference between myself and my patients other than that I am now an educated person who has gone to university and got a profession.” Putting aside these differences and meeting as equals is key to the success of the patient: doctor relationship, explains Paterson.

“I think that is something we can do in general practice that is massively important, which is to treat our patients as absolutely equal human beings at a human being level.” He continues: “They seem to accept that there is a professional gulf, that we know more, we’ve got more money, otherwise they wouldn’t be coming to you. But it is a partnership that is based on the fact that I am a human and have been very lucky and you’re a human and you’re really unlucky. I think there is a huge role for general practice there because that then is about empowerment and that then is about worth.

That is about self-help and betterment and sustenance and reliance. And we can start that process.” Beginning the much needed process of engagement and making these connections across the practices that work in such deprived areas has been an important achievement of the Deep End, argues Watt. The group has met 15 times to date and has reported thoroughly on the discussions that ensued even producing a manifesto before the recent Scottish elections outlining key areas where improvements could and should be made. However, while the first meeting was jointly funded by RCGP Scotland and the Scottish Government, and subsequent meetings were supported by Glasgow Centre for Population Health, this funding is coming to an end. Watt hopes the project can secure additional funding, however, he is concerned that their efforts will be dismissed as “a talking shop” for GPs.

“Whenever I present the Deep End work to NHS colleagues, I make the point that none of them had to negotiate their attendance at the meeting with a colleague, who would fill in for them while they were absent,” he says.

“But with that funding at an end, the initiative is in danger of being stalled.” The process of meeting with other GPs working in similarly challenging circumstances and discovering how much convergence there is in terms of the problems they face has clearly been cathartic, professionally. They have valued the opportunity to come together and pool their experience in an attempt to improve services for their patients, and feel they have more to contribute to the debate.

“We inhabit a phenomenal position of trust in the community, which is a huge privilege, a bit worrying and very scary at times, but that is how it is,” says Paterson.

“I think we have a massive political advocacy role in this with a capital ‘P’. We are seeing this.

We are living in it. We are working in it and you need to pay attention to this if you want a decent society for all.”