For educational materials to support learning around GP at the deep end, visit this page.
The inverse care law states that ‘The availability of good medical care tends to vary inversely with the need for it in the population served’. This is not the difference between ‘good’ and ‘bad’ care but the difference between what ‘can’ be done and what ‘could’ be done if care was adequately resourced, according to need.
Whilst GPs working at the deep end experience the highest levels of stress and rates of burnout, it has been suggested that involvement in training and education can be a protective factor. Unfortunately, the distribution of opportunities for education and training are inversely proportioned to the need for care. In Scotland in 2010, 22.8% of training practices were in the most deprived quarter of practices compared with 39.4% in the least deprived. The situation in Yorkshire and the Humber is similar.
It is probable that if a GP trainee is not exposed to deprivation in their training, they are less likely to work in a deprived area later on. It is only through exposure to the provision of care to vulnerable groups in these communities (e.g. homeless or asylum seekers), to the effect of social determinants on health (e.g. unemployment, drugs, alcohol) and to the additional challenges of providing care in Deep End practices (e.g. multiple morbidity and complexity, reduced expectations, lower enablement and health literacy) that students will get a chance to understand and explore the effects of the inverse care law, to appreciate its injustice, and resolve to attempt to make a difference during their professional lives.
What is currently being done?
The Health Inequalities Standing Group of the Royal College of GPs, in collaboration with the Institute of Health Equity at University College London, recently published a Delphi Study that described what the core learning outcomes for tackling health inequalities in undergraduate medicine might be, reporting that provision of these was patchy across the United Kingdom.
In Scotland, a Student Selected Component (SSC) in the social determinants of health is available to medical students at the University of Glasgow, which includes visits to addictions services, the homeless health service, Deep End GP practices and asylum seeker health services. They have also been running an Intercalated BSc course in Global Health, which includes a module on the social determinants of health. In postgraduate training, there are teaching days on health inequalities for GPST1 and 2s in the West of Scotland, placements in a homeless health centre for GPST3s, and a number of one-year post-CCT Health Inequality Fellowships.
The North Dublin City GP Training Programme, a tailored programme that specifically provide trainee GPs with the skills to work in areas of deprivation and with marginalised groups, was also discussed (See http://www.healthequity.ie/#!education-ndcgp/w4hs9).
Continuing professional development was the focus of a Deep End report from Scotland where GPs suggested eleven prime learning needs including addressing low engagement and increasing health literacy, maintaining therapeutic optimism, how to use EBM effectively with high levels of multi-morbidity and how to meet the health needs of migrants including people seeking asylum and refugees (see Deep End Report 24).
Views of Yorkshire and Humber GPs
Yorkshire and Humber Deep End GPs came up with the following ideas regarding their own practice for education and training others as well as their own CPD needs:
Undergraduate medical education: broaden access to medical training; ensure health inequity is included at an early stage, using narratives alongside statistics; and provide opportunities for students to work in communities and deep end settings
Postgraduate GP training: ensure work around deprivation and health inequity is delivered as part of the curriculum; identify deep end GP role models; make the values of deep end GPs explicit; promote positive aspects of deep end work; encourage a proportion of out of hours GP training to be undertaken in Deep End settings; include Deep End subject matter in assessments (i.e. CSA and mock-CSA); support learning through HDR sessions and virtual learning round health inequity; and involve patients and specialist inclusion health services in the delivery of training.
CPD: health literacy; social prescribing (to include awareness of voluntary sector organisations); acting as an advocate / media training; self-care for GPs / resilience; updates on asylum and benefits systems; and develop links with Faculty of Inclusion Health CPD programme to avoid duplication.
EDUCATION AND TRAINING: immediate actions identified by GPs
- Deliver training on health inequity as part of Yorkshire and Humber postgraduate GP training
- Lobby RCGP and Health Education Yorkshire and Humber to include Deep End relevant cases in the national CSA and local mock-CSA respectively
- Develop and roll out a CPD programme for Deep End GPs and link with existing Faculty of Inclusion Health programme, could include: social prescribing and resilience at the Deep End, as well as advocacy (see below)
- Develop schemes for GP trainees to gain experience of Deep End work through swops or placement in GP/voluntary sector organisations