by Breannon Babbel.
What happens when the overall health of a population improves, but groups at the bottom fail to keep up? Dramatic health inequalities, where your socioeconomic status is fundamentally related to how long you can expect to live. Health inequalities affect Scotland overall, but are especially pernicious in Glasgow due to its high concentration of socioeconomic deprivation, mixed in with more affluent neighbourhoods. For example, within just a 6-mile stretch you can see life expectancy drop almost 14 years for men and 9 years for women. Since there is no law of nature that dictates low-income groups should have worse health than those above them, health inequalities represent an issue of social injustice that demands action.
Data mapping showing Glasgow’s high concentration of Scotland’s most deprived 20% around the urban centre, 2012 (Captured using Alasdair Rae’s site, https://sites.google.com/site/scotdep2012/)
The role of general practice
It’s certainly crucial to address wider social and economic factors (such as income inequalities) to successfully tackle health inequalities, but the role of general practice and health care services—especially in deprived areas—should not be ignored. This is because unhindered access to culturally appropriate health care can slow the progression of disease and reduce the effects of illness, thus helping to alleviate existing health inequalities.
The effects of deprivation, however, can be particularly challenging for GPs working in these areas. Not only do individuals in deprived areas face poorer health outcomes than those in affluent areas, they’re also more likely to suffer from multiple illnesses at a much earlier age, with the rate of mental illness almost twice as likely in the most deprived areas. These challenges are further aggravated by problems related to social deprivation such as higher levels of unemployment, fewer financial and other material resources, and higher rates of addiction. The result is an element of complexity so that in the context of a 10-minute GP consultation, GPs working in deprived areas face a major challenge in adequately addressing all the problems their patients show up with.
Possilpark Health Centre – Location of Scotland’s 1st, 4th and 25th most deprived practices
‘Going the extra mile’
Within medicine there’s an inherent social responsibility suggesting GPs have obligations not only to individual patients, but also to the communities in which they practice. But do GPs actually view themselves as advocates in tackling health inequalities and, if so, how do GPs view themselves ‘going the extra mile’ to help their patients? These overarching questions set the framework for my PhD research conducting interviews with 24 GPs working in Scotland’s most deprived practices. Harking back to 19th century German physician, Rudolf Virchow’s description of physicians as ‘natural attorney(s) of the poor’, findings very much revealed an advocacy role.
Specifically, GPs saw themselves as part of the solution to addressing health inequalities in deprived areas through various ways, including strengthening community linkages and advocacy on behalf of their patient populations. Almost all felt a responsibility in some way to help strengthen connections with other services and resources within the communities they practice. This is because treating medical illness is only part of the solution for patients in deprived areas. Another major part of the solution involves addressing social factors, which are often out of GPs’ control.
As one GP put it, “we don’t have the resources to give people jobs or give people better housing, or more money, or deal with child poverty… we can only advise what we see and what the effects of that is on patients health.”
Linking practices to social services within the community is integral to strengthening health systems and tackling health inequalities.
Advocacy in the ‘Deep End’ of Scotland
Beyond building linkages within the community, a subset of the GPs also felt responsible for lobbying directly to the government for policy change as a “frontline voice to what’s actually happening” in deprived communities. This is because they witness first hand the damaging effects things like welfare reform and austerity has on their patients. One of the key elements to the organisation of this advocacy has been the group ‘General Practitioners at the Deep End’. The Deep End group first convened almost 7 years ago and represents GPs working across the 100 most deprived practices in Scotland.
The Deep End group has been influential in not only providing a platform for GP advocacy, but also for enabling collaboration between health and social services. This is evident in various projects including:
- The Care Plus Study– a randomized control trial which examined the effect additional patient consultation time has on patients in primary care.
- The Links Worker Programme– a project exploring the use of a practice attached links worker, to help connect a practice’s patient knowledge to available community resources.
- Govan Social & Health Integrated Partnership (SHIP) Project– a project focusing on integrated care between general practice and social work via extended consultations, extra GP time and leadership, attached social workers and support for multidisciplinary team meetings.
One of the GPs noted the Deep End group had been particularly successful in “[getting] the ear of the government” through lobbying directly to Scottish Parliament, and government funding for these projects is evidence of this. While the success of the group is partly due to academic support from the University of Glasgow, it mostly boils down to its GP-led format. The group is driven by frontline experience and GPs are the ones setting the agenda regarding the needs of their practice population.
One of the more topical measures of success, however, remains to be seen. This relates to recent findings from a 2015 study showing that practices in areas of high deprivation have an increase in consultation rates per patient, but no increase in funding as a result. With the Scottish GP contract currently in negotiations for 2017, there is potential to ensure practice funding levels match need. Ensuring funding levels are distributed according to need is perhaps one of the most important factors for Scotland’s general practice to effectively tackle health inequalities. It also potentially demonstrates just how successful the Deep End group has been in ‘getting the ear of the government’.
Regardless of changes in the 2017 GP contract, this research found that GPs working in deprived areas see themselves going ‘beyond the call of duty’ to make a difference in the lives of their patients and patient populations. GPs working in deprived areas should be encouraged to use their professional clout to not only strengthen local communities, but also to advocate against policy change—including both health and social—that might potentially affect their patients.
Reflections on conducting research in another country
I’m not originally from Scotland and four years ago began my PhD journey conducting research in an entirely unfamiliar health care context. My home country, the United States, is currently undergoing a major health reform, which has the potential to make huge strides towards achieving universal health coverage. Many countries, including the UK, have taken the necessary steps to 1) assert health care as a basic human right and 2) establish a health system in which everyone has access to services without incurring financial hardship. Thus, conducting research under a universal health context was the primary draw to study in Scotland. It’s also been enlightening in demonstrating that universalism is not enough, as Scotland’s rise in health inequalities over the past 50 years signifies an insufficient focus on the most deprived areas.
In terms of the U.S., it’s not a matter of copying another country’s health system, but finding a way to achieve universal health coverage that’s politically, socially, and culturally acceptable (no small feat by any means!). The same can be said for general practice in Scotland’s deprived communities. The solution isn’t applying a blanket approach to practices in deprived communities across Scotland, but providing flexibility and sufficient resources to allow practices to develop innovative solutions that meet the needs of their practice population.
Waiting area for Wester Hailes Medical Practice, Scotland’s 19th most deprived practice