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Inside Track Insight

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.” Te 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. Tat’s it. Tat 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. Tey 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. Tat is what we do. Tat is what your skill as a GP is but it takes time.” Tey 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.

34 19 September 2011

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. Te 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. “Tat 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

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?

“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”

Scotland, finally, a lot fell into place for us and made it clear to us why we were so stressed.” Te additional pressures working in an area of concentrated deprivation brings should not be underestimated.

“Te 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

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. “Tey 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.” Te 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

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