Meeting Report -17th March 2016

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Thanks to all those who attended our positive and productive symposium, kindly funded by Health Education England (Yorkshire and Humber). The full report from the Symposium can be found here. For busy professionals, a summary of the day can be found below along with keynote presentations and tweets from the delegates.

Summary

Yorkshire and Humber GPs at the Deep End was established in 2015 in order to bring together frontline GPs working in the region’s most socioeconomically deprived areas and build links with the academic community and voluntary sector. Inspired by the Scottish GPs at the Deep End project[1], the aim of the group is to assist primary care in tackling stark and worsening health inequalities. This report summarises the problems faced by those working in Deep End General Practice as seen from the frontline. More importantly, it captures clinicians’ ideas for solving these problems.

The group’s objectives were set out following an initial meeting in October 2015:

  • Help with workforce and recruitment
  • Provide educational sessions relevant to deep end work.
  • Create a flourishing network to share ideas on planning services and strategy.
  • Act as an advocate for deprived communities and vulnerable patient groups
  • Develop sustainable links with the academic communities to evaluate the effects of interventions and record the experiences of deep end practitioners and their patients

To help the group work towards meeting these objectives, a Health Education Yorkshire and Humber funded Symposium was held in March 2016. This brought together 64 frontline GPs and representatives from academia and public health. Many of the GPs attending the symposium work in Yorkshire and Humber’s most deprived communities and there were representatives from across the region.

The Symposium heard that:

  • health outcomes and need vary dramatically by socioeconomic deprivation with the poor leading shorter sicker lives (for example, the most deprived decile of the population has a 15 year lower life expectancy and 20 year gap in disability free life expectancy compared with the most affluent decile);
  • current funding arrangements for general practice do not reflect need and exacerbate rather than ameliorate the “Inverse Care Law”;
  • whilst societal and macroeconomic factors underpin the social determinants of health, provision of healthcare can influence 10-20% of health inequity and has an important role in palliating its effects;
  • GPs have a key role as advocates for their communities and patients, but they may benefit from training
  • Deep End GP practices in Yorkshire and Humber are underrepresented in the GP training community;
  • undergraduate medical education and postgraduate training are critical in equipping GPs to care for vulnerable groups and helping to solve the workforce crisis in GP, which is most acute in deprived areas, where there are fewer GPs per capita and a higher proportion of GPs approaching retirement;
  • research is more challenging at the Deep End due to multimorbidity, chaotic lives and social complexity but that academics have a key role to play in illustrating the issues, sharing good practice and evaluating services for patients with high levels of need; and
  • specialist “inclusion health” practices caring for asylum seekers, refugees and homeless people could help mainstream primary care serve vulnerable patients better

The frontline GPs attending the Symposium were asked what their priorities were in tackling the group’s objectives. Their ideas were as follows:

  • Workforce
    • Increase GP training capacity at the Deep End with greater involvement in under and post graduate education
    • Build links between deep end training and non-training practices and explore ways of easing the transition into training
    • Improve understanding about how variations in the primary care team skill can solve the Deep End recruitment and retention crisis
    • Lobby for equitable funding and additional support create resilient and sustainable practices that improve retention of Deep End GPs
  • Education and training
    • Explore inclusion of deep end cases in postgraduate GP assessment and training
    • Enable GP trainees to swop into or do placements with deep end GP/voluntary sector organisations.
    • Develop and roll out a CPD programme for Deep End GPs and link with existing Faculty of Inclusion Health programme
    • Provide training for GPs on approaches to encourage health literacy, social prescribing, advocacy and media relations, resilience and knowledge of the asylum and benefits systems
  • Research
    • Investigate barriers to self-care, access and uptake of preventative services at the Deep End
    • Evaluate and describe new initiatives / services, for example interpreting services, social prescribing, proactive case management and care for patients with dual substance misuse and mental health diagnoses
    • Compile and share a regular synopsis of research relevant to Deep End GP that can be easily accessed and used by frontline GPs
    • Analyse attitudes of GP specialist trainees to working in areas of high deprivation
  • Advocacy
    • Develop a compendium of evidence, GP narratives and patient stories that can be used in advocacy work, including a short summary of the key evidence about health inequity, the inverse care law as it relates to Deep End GP and the role of healthcare in tackling the problem
    • Work with Patient Participation Groups to increase patient empowerment and community awareness
    • Provide guidance on how outcome-based commissioning can be used to tackle health inequity at the CCG level (i.e. by developing specific Deep End relevant key performance indicators)

Next steps

Health Education Yorkshire and Humber continue to support the group and we are also linking up with the Medical Schools in Sheffield and Leeds, initially working with students to identify and develop research questions relevant to Deep End GPs, perform a health equity audit of general practice provision in Yorkshire and Humber using HSCIC and public health outcome data and evaluate GP trainee attitudes to working in deprived areas. The University of Sheffield has secured funding to develop longitudinal clinical placements for medical students within Deep End settings.

We envisage the Deep End group acting as a catalyst to support innovative models for both under and postgraduate training, promoting recruitment and retention into our most socially deprived and under-doctored areas. Trainees will have the opportunity to work with marginalised groups through ‘social medicine placements’ modelled on those offered by the North Dublin City GP training scheme led by Austin O’Carrol (http://www.healthequity.ie/). 14 At the same time we are working to ensure that all GP trainees in Yorkshire and Humber experience teaching in health inequalities, the social determinants of health and gain the knowledge and skills, particularly around leadership, to be able to tackle these at multiple levels.

We plan to create 3 geographical professional development and advocacy hubs in South Yorkshire, West Yorkshire and Hull / North Lincolnshire, with the help of the 25 Deep End GPs who volunteered to steer the group. We will host local CPD meetings for Deep End GPs working in the most deprived 10% of these areas and aim to hold two region wide conferences a year. Through establishing the group and its blog we have created a real and online network, offering support to GPs under the greatest strain.

[1]The Scottish Deep End group includes GPs working in the 100 practices with the most deprived populations in Scotland and we extended the same definition to Yorkshire and Humber. The group’s activity was initially targeted at the GPs caring for the 100 most deprived practice populations in Yorkshire and Humber according to the Public Health England practice profile Indices of Multiple Deprivation (2015); it is recognised that the challenges these practices face will be shared across many more of the region’s 700+ GP practices.

Appendices to report

  1. Full text of feedback from Deep End GPs
  2. Deep End General Practice Map – Yorkshire and Humber

Other resources

Twitter feed from the day via Storify (thank you Alan Shirley)

Here are the presentations from our speakers:

Workforce at the Deep End – Dr Tom Ratcliffe – Health Education Yorkshire and Humber

Gradient in Health and Vulnerability – Prof Peter Goldblatt, Institute of Health Equity, UCL

GP research at the deep end Yorkshire and Humber – Dr Elizabeth Walton – University of Sheffield

GP training and education in the deep end – Dr Ben Jackson (University of Sheffield) and Dr David Blane (University of Glasgow)

GPs at the deep end: a public health perspective – Dr Greg Fell, Director of Public Health, Sheffield

What can Deep End GPs learn from specialist inclusion health services? – Bevan House, Bradford

Healthcare for vulnerable migrants – Bevan House, Bradford