Deep End group
Dr Gabi Woolf
Tackling Health Inequalities in General Practice
A man from the most deprived decile in England can expect to die 9 years earlier, and have 18.3 more years of ill health than a man in the least deprived decile. Similarly, women in the most deprived decile on average die 6.9 years earlier with 18.9 more years of ill health than a woman in the least deprived decile (1). A wide range of social and economic inequalities have been found to influence health including financial situation, social environment, biological and psychosocial factors, behaviours, education, occupation and ethnicity (2), (3). Health inequalities continue to be an important contributor to disability and poor physical and mental health, and therefore are directly relevant to our work as General Practitioners.
In General Practice we are privileged to work closely with people from all parts of society – those from different ethnic, social and economic groups. We may be the first port of call or the last hope for patients suffering as a result of the social or economic circumstances.
In reality, however, we often do not have the time or resources to deal with these underlying contributors to ill health. Trying to deal with these issues within the current framework of General Practice and the NHS as a whole can be difficult, leaving both doctor and patient frustrated. We can become hopeless with the increasing pressures upon us. Or we can use these challenges as an opportunity to change the way we practice.
I have been privileged to interview a number of individuals involved in services which have been implemented around the UK, which seek to tackle some of the wider determinants of health and target those vulnerable individuals who are sometimes forgotten.
The Deep End Group, Scotland
The Deep End group is a network of GP surgeries in Scotland which cover the 100 most deprived patient populations. It was developed by the RCGP Scotland working group on Health Inequalities in 2009 (4), in order to enable GPs to share experience of the challenges they face in dealing with some of the most deprived sectors of society. The ranking is based on the Scottish Index of Multiple Deprivation (5). Almost 80% of the participating practices are in Glasgow (6).
This group acts as a network for GPs who are dealing with similar problems of health inequalities on a day to day basis. This may include complex multimorbidity, drugs and alcohol problems, and social isolation. 20% of the surgeries in the group are single handed, so GPs previously may have lacked support and advice from peers. They use these groups to improve practice, frequently working in conjunction with the RCGP (Scotland) and the Scottish Parliament.
The steering group meets every six to eight weeks to discuss common issues these GPs face. There is funding provided by the Glasgow Centre for Population Health for locum cover to enable GPs to attend.
One of the most significant developments was the introduction of a ‘Links Practitioner’, a member of staff funded by the Scottish Government, and assigned to a single practice. Patients from more deprived sectors of society frequently present with psychosocial complaints, for example depression or chronic back pain. One problem faced by GPs is a lack of knowledge about local services which may benefit these patients, and often there is poor communication between primary care, social care and voluntary and community services.
The Links Practitioner sees those patients whom the GP or another member of staff within the surgery recognise needs a more holistic approach and may benefit from non-clinical support. Some individuals may have been previously signposted to services, but have not attended possibly due to a lack of confidence or trust in professionals. The Links Practitioner aims to break down these barriers, and if necessary may attend the services with the patient. There is no fixed follow up period, and they will continue to follow up the patient as long as is deemed necessary. It is common for patients not to attend an initial appointment with Links Practitioner, so they take a pro-active approach contacting such patients either by phone or text, recognising that this may be down to fear or lack of trust.
Four of the surgeries have also had an attached Adult and Child Social Worker as part of the Govan Integrated Care Project. This has been an attempt to improve integration between health and social care, in response to the Low Commission on ‘Getting it Right in Social Welfare Law (7)’.
Some of the practices have alcohol workers attached to them who also do outreach work. They are looking into further services such as attached mental health workers.
Emphasis is also placed on Practice wellbeing; it is recognised that these Practices in the Deep End are under considerable pressure and staff need to be taken care of to help prevent burn-out.
The Deep End project has used the combined experience of the GPs involved to develop a collective vision on how to improve care in these very deprived areas. In 2013 they published a report to highlight six ways to improve health and reduce inequalities (see box 1).
Deep End Scotland have established links with Irish Deep End GPs and the Welsh Government Inverse Care Law Programme. In 2015 a Deep End group in Yorkshire and Humber was formed.
The Deep End Project appears to be a simple yet effective method to link GPs working with the most deprived members of society, pooling their understanding and experience, in order to make longstanding, sensible changes to practice at a grassroots level. This model may have the potential to be used in other parts of the UK.
Thank you to Dr Susan Langridge, Deep End GP at Possilpark Health Centre in Glasgow, and Dr Euan Paterson, Deep End GP at the Govan Health Centre in Glasgow, for taking time to talk to me.
(1) Office for National Statistics. Dataset: Inequality in healthy life expectancy at birth by national deciles of area deprivation: England. 2011-2013 data 5/3/2015 http://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/datasets/inequalityinhealthylifeexpectancyatbirthbynationaldecilesofareadeprivationengland. (accessed 1/3/16)
(2) Commission on Social Determinants of Health (2008) CSDH Final Report: Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization.
(3) Marmot M. Fair society, healthy lives. 2010. http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review (accessed 1 Feb 2016).
(4) Watt G. CONNECTING WITH GENERAL PRACTICE TO IMPROVE PUBLIC HEALTH: Findings of the Primary Care Observatory and Deep End projects. 2011.http://www.gcph.co.uk/assets/0000/2586/final_version_for_publication_without_financial_statement.pdf (accessed Oct2015).
(5) University of Glasgow. - Research Institutes. http://www.gla.ac.uk/researchinstitutes/healthwellbeing/research/generalpractice/deepend/about/ (accessed 2015).
(6) Watt G. GPs at the Deep End 12/02/2016. Cited from http://www.gla.ac.uk/media/media_443692_en.pdf
(7) Lord Low. Second Report of the Low Commission on the future of advice and legal support: GETTING IT RIGHT IN SOCIAL WELFARE LAW. 2015.http://www.lowcommission.org.uk/dyn/1435772523695/getting_it_right_report_web.pdf (accessed Dec2015).