Health inequalities and the future of general practice

12 June 2020

Have you smelled the honeysuckle yet? As we move towards the longest day of the year, the smells from the hedges near our house reignite many hidden memories. 

The scent of honeysuckle takes me straight back to my childhood holidays near Skibbereen, County Cork. Hedgerows bursting with ivory flowers wafted the scent down grass-centred lanes where the iodine tang of the sea clashed to form an unforgettable olfactory memory. 

Smells have an incredible impact on our memories. Osmophobia (the fear, dislike or aversion to smell or odours) is common in migraine but less prevalent with tension headache patients.

The pathological descriptor of anosmia in COVID-19 chills me more than pyrexia for some reason and must be due to neurological processes rather than rhinitis.

I loved the macabre, black novel Perfume: The Story of a Murderer by Patrick Suskind, showing a psychopathic obsession with smell.

Along with honeysuckle, many other smells bring back specific memories in my mind.

The strong menthol smell of Deep Heat rub immediately places me in Maysfield Leisure Centre at the start of the early Belfast marathons when I went to watch my Dad run in the 1980s.

Crushed heather under granite, emulsified with damp peat evokes walks in the Mourne Mountains.

My honeymoon in the South of France with the scent of lavender grown in fields on the hills, drifting down to the Mediterranean Sea; the smell of a Barbour jacket and its association with the cold flesh of a freshly caught trout; the front hall of Barry’s in Portrush with its distinctive air of diesel, candy floss, excitement and metallic coins. The smell of wetsuits in Donegal, slightly cold from a swim the day before.

Health inequalities

I clearly remember the first time I smelled poverty.

It was 1987 and I was visiting Dublin with my dad. Walking through the city I passed a lady with her son begging close to the Halfpenny bridge. I was young and embarrassed. Belfast had many problems at that time with deserted city streets at night, but I didn't remember people openly exhibiting need.

In 2010, Professor Sir Michael Marmot published his report 'Fair Society, Healthy Lives'. It is well worth reading and highlights the importance of early childhood experiences and how to address these through initiatives such as Sure Start and Healthy Child Programme.

The report has now been reviewed 10 years later and it makes sobering reading. The 2020 report has shown that life expectancy in England has fallen for the first time since 1900 and that it has disproportionately fallen on those in lower socio-economic categories, particularly women.

Professor Marmot spoke passionately at our RCGP Annual Conference in 2019 and his speech is well worth viewing

His book 'The Health Gap' is also well worth reading, and what struck me was his argument about how this is more than personal choice and how health inequalities are not just to do with access to health care, although that is important, but how housing, education and access to good, well paid jobs affects population health.

He eloquently highlights the English Chief Medical Officer’s advice to the population in 1999 about predictable measures: balanced diet, increase physical activity, don’t smoke etc.

By contrast, Professor David Gordon from Bristol University highlighted 10 more sobering tips, including:

  • don’t be poor
  • don’t live in deprived areas
  • don’t work in stressful, low paid manual jobs
  • don’t live in damp low quality housing or be homeless.

You can read his paper in full.

The College COVID-19 resource hub has a section entirely dedicated to health inequalities.

My colleague Dr Carey Lunan, Chair of RCGP Scotland and a Deep End GP partner in a deprived area of Edinburgh, has performed an interview with Professor Marmot where he outlines the impact of COVID-19 on the already difficult health inequalities.

It is a long piece but worth listening to in chunks.

We have an important role in raising the health of the communities we serve, and the social work and mental health practitioner elements of our Multidisciplinary Teams (MDTs) programme would be a fantastic enabler for this.

We will keep perusing this objective until all practices have equitable access to MDTs and can then make real strides to narrow this inequity.

The future of general practice

I'm aware that many of you have very real concerns about the future of general practice and around the proposals and comments that we have seen and heard in the media this week, not least of all the announcement made by the Department of Health.

There's no doubt that changes are going to happen, and for that reason it's more important than ever that the voice of general practice is heard loud and clear.

My job as Chair of RCGPNI is to represent our collective voice as GPs in all my interactions with key stakeholders and colleagues.

To help me do this we arranged a series of virtual roadshows this week to hear what's happening on the ground at the minute and what resources you need to make your jobs easier.

The response has been clear:

  • practices are getting much busier
  • it's taking more time to 'process' a patient through the building using PPE
  • you need proper access to appropriate technology
  • your workload processing bloods is becoming problematic.

I really want to thank all of you who gave up your time to take part. It was so helpful for me to hear your voice. It is brilliant to have this feedback and it allows us to shape future policy direction and lobby for resource to help us provide high quality community healthcare.


Throughout the pandemic many of us have witnessed better collaboration with our secondary care colleagues and sense a real desire between us both to work better together.

We have an excellent relationship with the other Medical Royal Colleges, and it was great to meet with our Health Minister Mr Robin Swann on Wednesday with Mr Mark Taylor (Royal College of Surgeons), Dr Hamish Courtney (Royal College of Physicians) and Dr Paul Kerr (Royal College of Emergency Medicine).

We were able to highlight to the Minister the need for a regional approach to finding solutions. We advised him of the importance of clinicians being able to influence strategic policy making and our appetite for working together.

It was terrific to hear Dr Hamish Courtney describe how better care for diabetic patients could be facilitated by consultants coming out of their hospitals and into our surgeries.

COVID-19 assessment centres

I fully understand that there is considerable unease about the future plans of the COVID-19 assessment centres, but I was able to inform the Minister that the centres are designed for assessment and not equipped for treatment or diagnostics.

What we do want to take forward is our learning from the COVID-19 centres which has highlighted that with good triage, with the right patient going to the right person, we can ensure that the patient experience is improved, and it reduces workload for the GP as "today’s work is dealt with today" and not just put on a waiting list. 

If you were unable to attend one of the sessions, please get in touch with me. I need to hear all your views, so I can represent you properly.

It was great to see some old friends through the roadshows and meet some new ones. Dr Louise Rusk joined the debate on Wednesday, and it was great to hear her experiences in East Belfast.

As well as a GP, Louise has exceptional skills as a GP with special interest (GPwSI) in headache and neurology. She is also an exceptional teacher so if you get the opportunity, go and hear her speak.

Headache is a very common condition in our surgeries, and we are always nervous when assessing patients - particularly now when we are working remotely.

Headache and migraine

Louise has suggested some excellent resources to help us manage headache and migraine and I am very grateful for her suggestions:

  • The Migraine Trust: a research-driven charity that helps support people affected by migraine throughout COVID-19 with blogs by GPwSI. They have also just started virtual Q&A sessions.
  • Heads Up Podcast: an excellent series of podcasts with GPwSIs doctors Katy Munro and Jessica Briscoe. A huge range of topics from acute treatment, medication overuse and prevention to hormonal effects, vestibular migraine and recently a podcast specifically on migraine in COVID-19
  • COVID-19 Podcast: useful not only for patients, but also for GPs (packed full of information but also helpful to hear how headache specialists explain concepts to patients).

The College website also has some useful resources and the below section contains a helpful joint document with the Royal College of Nursing on how we can help manage headaches in schools.

We are in the process of a significant change in our health service, but we will continue to highlight the importance of general practice and how we can serve our communities best.

Thank you for all your care for your patients.

Twitter: @laurence903

Post written by

Dr Laurence Dorman, Chair of RCGP Northern Ireland

Dr Laurence Dorman took office in November 2019 after three years as Deputy Chair of Policy for RCGPNI. A GP principal in Mourne Family Surgery, Kilkeel, Co Down, since 2007, he is the fourth generation of GPs in his family. He was also, until recently, the Chair of Newry and District GP Federation. 

Laurence has particular interests in new ways of working in primary care, cancer care, and inspiring the next generation of GPs. He set up the successful 'Dear Colleague' initiative to improve the interface between primary and secondary care and has been a strategic advocate for interface and communication since September 2017.

During his time as Chair, he wants to support College members to ensure that the future of GP services is protected, supported and sustainable.

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