In at the deep end

The new Possilpark health centre is shiny and new. Within the glass building, past the Citizens Advice adviser, the dental practice and up the stairs, is Keppoch Medical Practice, where the most deprived patients in Scotland are treated.

Holyrood is invited into the surgery of Dr Petra Sambale, who sits on the steering group of the ‘deep end GPs’ serving the most socio-economically deprived populations in Scotland. Keppoch has more patients in the poorest quintile than any other practice.

She is pleased to be in the new building, after moving from one which was outdated. “It was rotten. If I had visitors from Germany I didn’t bring them to the health centre. It was awful,” she says. The new centre, opened by Greater Glasgow and Clyde Health Board this year, shows “a commitment to the deprived area”, according to Sambale. “Our patients are very positive about the new building. I had one who said ‘it’s like being in town.’ I thought that’s so nice. She walks every night with her boyfriend by the health centre. It gives value, and a sense of community,” she says.
Sambale has just come out of a practice meeting, and between a repeated fire alarm test and messages popping up on her computer screen, it is clear her time is valuable.

Like other practices in Glasgow, Keppoch has broken with the GP contract, and receives different funding streams, because of the demands specific to their location.

“Our challenge is slightly different, in that we have very, very sick patients,” she says, bringing up a list of various illnesses and conditions. Alongside each is a number representing the centile of where the practice sits compared with all others across the UK. It shows Keppoch in the 96 centile for chronic heart disease, cancer 87, stroke 98, epilepsy 99, mental health 98, dementia 98, obesity 95, and depression 99. The list goes on. “For us the problem is we have extremely sick patients, and a lot of our patients have not only one disease, but four or five diseases, which makes it then extremely complex. So we have very sick patients, a lot with complex medical problems, and then on top of that you have these patients who are having housing problems, debt problems, they can’t feed their children, the older patients quite often save the bit of money they have for their grandchildren, so it comes all together,” says Sambale.

In recent years there’s been an influx of immigrants so people coming to the practice require an interpreter and therefore longer appointments, as well them being placed nearby by third sector organisations who offer supported accommodation because it is so cheap. “The beauty of it is quite often we say we never have a boring day in Possilpark. You get a lot of clinical experience. What makes it difficult is that nearly every patient who comes through the door has very complex social and medical needs.”

Last week Health Secretary Alex Neil launched the Links Worker Programme, which will see a link worker assigned to seven deep-end practices to point patients towards advice and support services in the community. Keppoch applied to take part in the pilot, but wasn’t drawn out of the hat, which Sambale says is unlucky.

“We are trying to signpost our patients already, and we know we are pretty OK with signposting for money advice, also employability services, but we also know our patients have to overcome huge barriers in accessing services that are new to them, because often they don’t feel confident enough to go somewhere they don’t know. Likewise we have a very high DNA – do not attend rate – of our patients at hospitals, and we had hoped the link worker could help us overcome these barriers.”

Time is a rare commodity for deep-end GPs, says Sambale, particularly because of the numbers of patients and the complexity of their illnesses. “We need more time, because when you and me go to our doctors with a chest infection or whatever, ten minutes is absolutely fine. For these diseases you need more time, especially if you have interacting medication and you need to consider it. And it’s continuity of care.

"Again, if I don’t have a major or chronic disease, it’s fine, but what [the stats] doesn’t show is we have a lot of patients who got abused as children. The scars they are bearing throughout their life. There is a loss of trust quite often, and being very sensitive picking up cues, that if you signal or cut them down too quickly you have lost a chance.”
Other duties like phone consultations and paperwork have increased in recent years too, she says, calling it “the unseen work.”

Sambale came to work at Keppoch in 1999, transferring from a leafy German suburban practice. Holyrood asks what drew her to the job. She laughs.
“At that point I didn’t know we were the most deprived practice! We only found that out a few years later, which explained why we were so stressed. I applied for several jobs, but there’s always this saying what is right comes for you. I joined a partnership where it felt right. The doctors who were working here at the time had the right concept of how they did medicine, and a lot of where our surgery is now is due to the work these partners have done beforehand, because I learned a lot from that team.

"I worked in Germany in a very well-off area, very rich. In Frankfurt, it’s a bit like the bankers’ area. It’s nice having had the contrast, but I think every GP has to find what feels right. For me, this just felt right, this kind of medicine.”

The move must have been a shock, given Germany is known as a more equal society?
“When I speak to my German friends they tell me it has got worse over the years, but we know Glasgow is extreme. We know our practice is extreme, because if nearly every patient who comes through the door is complex, you have a different way of practising medicine. The advantage is that your skills, hopefully, go up quite quickly, because you have to adapt to it.”

If Glasgow’s health problems are well known, Sambale has noticed some improvements, and welcomes increased investment in early years. “Quite often we get patients who are very young and move into the area and when we summarise their case records they are this thick,” she says, indicating about three inches with her fingers, “you read their life stories, and a lot has to do with early abuse. I think a focus on early years is absolutely crucial. Also giving people value in life, making them feel valued, although I don’t know how zero-hours contracts fit into this!”

Mental health is a real concern, she says. “Quite often, it is so difficult to find a way out of their situation, and trying to support them through it, and we know if you are depressed, if you then stop going out, if you’re unemployed or you lose your job then you become more and more socially isolated. I see a lot of patients where I’m the only contact, apart from their closest family. Some of them don’t even go out, and then you start to put weight on.”

This makes non-attendance at appointments an issue. The practice calls every patient the day before their appointment to remind them, or so as to make appointments available if they cannot attend. Holyrood puts Scottish Conservative Health Spokesman Jackson Carlaw’s idea of fines for missing GP appointments to Sambale. “I think if you really listen to patients, if you try to understand their journey, and where they’ve come from then you would not be able to say that.

"So many of our families are affected by death. They are affected by bereavement far too early. They are themselves young, might have children, and their parents are dead already, because they die of chronic diseases or cancer. So if you understand what the daily struggle is, then you understand why it can be so difficult to come sometimes.”

From financial advice to health visitors, retaining staff can be hard in such a stressful environment. When continuity of care is so important, staff need to be allowed enough time to do their jobs properly, says Sambale. “I think we need to make it possible to retain staff, to acknowledge our district nurses and health visitors are dealing not only with quick medical problems, quite often they are dealing with the same complexity as we are dealing with. That requires time,” she says.

Because the deep-end GPs have a different funding stream and are seen as a fringe group, there is always a concern about long-term viability, says Sambale, particularly looking at “frightening” changes to general practice in England, where the minimum practice guarantee has been pulled, and practices are closing. She points to the example of the practice meeting she has just come out of.

“We discuss once a week our patients who are complex, it could be families or cancer patients, and over the years, it’s getting longer and longer, because there are more and more. But we think it’s important, apart from what is written in the records, that we can have face-to-face communication with our district nurse, the practice nurse, our health visitors, we are all working together. It’s expensive. In England they are going for mega practices, where you can’t do that, and I think then you lose the heart of general practice, which is continuity of care, getting to know family circumstances, understanding our patient journey and then delivering good quality clinical care with a holistic approach and social prescribing. So if you put all that together, it costs time and teamwork, but it can be an extremely satisfying job that retains people. So that’s the solution.”