If your impression of NHS general practice is one of terminal decline and despair, you’re looking in the wrong places. The wonderful paradox that is General Practice at the Deep End has proven yet again that if you want to be inspired by examples of clinical excellence, educational innovation, and passion for practice then you need to be talking to people delivering primary healthcare to the most vulnerable people in the most challenging places.
- Relationship-based care – connecting people and places
- Generalist, multidisciplinary primary care
- Proactive, anticipatory and planned care
- Education, research and advocacy for patients and providers
- Hope: focus on what is possible
- Solidarity: we’re part of a movement
The six points above are my summary of two days of presentations and conversations in Glasgow at a celebration of the life and work of Julian Tudor Hart and the launch of Professor Graham Watt’s book, The Exceptional Potential of General Practice.
- Relationship based care
Biology is bound up with biography. The doctors, nurses, social workers, health-visitors, district nurses and Focused Care Practitioners who work with vulnerable people bear witness to their lives and their stories. Adverse childhood experiences aren’t an abstract notion for professionals who visit their homes, stitch up their wounds and drink tea with people whose lives are beset with trauma we can barely imagine. We make human bonds over time, and develop trust, respect and affection that flows both ways. Our surgeries are safe havens, ‘palaces for the people’ where people who have power and privilege listen and are kind to those who do not, and are capable and use their power to heal and enable. Trusted people and places build connections and create formal and informal networks. People discover that they are worthy of care and attention. There are places where one need not feel ashamed.
- Generalist, multidisciplinary primary care
The most vulnerable people – those with learning difficulties, serious mental illnesses, the homeless, abused and addicted – die two or three decades younger than the most fortunate. They die from the complications of under-treated long-term conditions like hypertension, heart-disease, diabetes, asthma and COPD. Treating these conditions can narrow the gap in life-expectancy. But these conditions are ‘silent killers’ because they are usually symptomless. Suffering comes from anxiety and depression and the stress and distress of poverty, hunger, violence and neglect. Where we cannot offer a cure, we provide relief. Holistic, generalist primary care is concerned with the relief of any suffering, no matter what its cause.
- Proactive, anticipatory and planned care
Far from the ‘worried well’ that most GPs complain about, and the worried unwell that worry us, the unworried unwell are the ones we are most concerned about. These are the patients who attend when they are in crisis but whose arteries are about to catastrophically thrombose under the stress of uncontrolled hypertension and diabetes. Planned care with routine appointments in pre-arranged clinics doesn’t work well for people whose lives are filled with crises or whose mental health is precarious or who don’t know or don’t care or have other, more pressing concerns. They need anticipatory care – attention to what might kill them, whenever they on attend with what ails them. They need proactive care- delivered at home, in the night shelter, on the streets even, wherever we can track them down. We need to know who our patients are whose health-care needs have been neglected and make sure nobody is omitted.
- Education, research and advocacy for patients and providers
We need professionals with the skills suited to the problems that they are expected to deal with; complex multimorbidity with social insecurity, chronic pain, addiction and adverse childhood experiences are highly prevalent and can be distressing for professionals who are not prepared or well supported. We should use research to advocate for political action on the political and economic drivers of inequity, the poor housing, poverty and insecurity that results and the high prevalence of diseases that we have to treat. Failure to act upstream means we need more resources to treat the consequences downstream.
- Hope: focus on what is possible
Those of us who work in the Deep End know how bleak the situation is. We don’t go to conferences to be reminded of our daily grind. We go to discover what is possible, to hear from people who are succeeding and thriving despite austerity. Professionals who work in areas of deprivation frequently talk about how much they learn about resilience, survival and recovery from their patients. Just because it’s possible to overcome adverse childhood experiences doesn’t mean that we won’t fight for children’s rights. Just because some poor people can eat well from food banks doesn’t mean that we think that food banks aren’t the result of a profoundly unjust set of policy decisions in the wake of the global financial crisis. Focusing on the possible protects us from nihilism and despair, keeps us open to learning, helps us to seize opportunities, keeps lines of dialogue open. The hopelessness that so often accompanies poverty can be contagious, but so is the hope and optimism that goes with Deep End general practice.
- Solidarity: we’re part of a movement
Shared values, a shared mission and an infections optimism bind us together. Contributors at the conference from England, Ireland, Scotland, Wales, the US, Lebanon and Belgium showed us that at the same time as it is possible to be an expert in the health needs and behaviours of people in a specific place it is also possible to be kindred spirits with doctors from all over the world. Doctors in deprived practices are often professionally isolated and heavily burdened by the complexity and emotional labour of care. To bond with peers with whom you are morally and intellectually aligned is empowering and energising.
Thanks to GPs at the Deep End all over the world.
The Exceptional Potential of General Practice – Conference Programme
The filming of the speakers can be found here:
https://www.youtube.com/playlist?list=PL53OebaxnaDUmBu7mgP5eY1-V5YvQaYvv
The speakers’ presentations (PowerPoints) can be found here:
University of Strathclyde Technology and Innovation Centre, 99 George Street, Glasgow G1 1RD.
Day One: Thursday, 14 February 2019
13.00 Arrival and registration
SESSION ONE: Dr Julian Tudor Hart and The Inverse Care Law
Chair: Dr Carey Lunan, Chair of RCGP Scotland
14.00 Welcome and introduction: Dr Carey Lunan
14.10 The example of Dr Julian Tudor Hart: Professor Graham Watt
14.30 The Inverse Care Law – market forces: Professor Allyson Pollock
14.50 The Inverse Care Law – research evidence: Professor Stewart Mercer
15.10 Discussion
15.25 Break
SESSION TWO: The Exceptional Potential of General Practice
Chair: Dr Carey Lunan, Chair of RCGP Scotland
15.55 Serial encounters: Dr Iona Heath
16.15 Community practice: Dr Peter Cawston
16.35 Big data: Dr John Robson
16.55 Discussion
17.10 Close
Day Two: Friday 15 February 2019, Morning Session
From 08:45 Registration
SESSION THREE: General Practitioners at the Deep End
Chair: Professor Graham Watt, University of Glasgow
09.15 Welcome and introduction
SCOTLAND
09.20 General Practitioners at the Deep End: Dr Anne Mullin
09.30 Govan SHIP: Dr John Montgomery
09.45 The Pioneer Scheme: Dr Petra Sambale
10.00 Discussion
IRELAND
10.15 The Irish Deep End Project: Dr Patrick O’Donnell
10.30 GP training and recruitment: Dr Austin O’Carroll
10.45 Discussion
11.00 Break
ENGLAND
Chair: Dr Helen Stokes-Lampard, Chair of RCGP Council
11.30 Yorkshire/Humber: Dr Elizabeth Walton
11.45 Greater Manchester: Dr John Patterson
12.00 Discussion
PANEL AND PLENARY DISCUSSION
12.15 Where next for the Deep End Projects?
13.00 Lunch
Day Two: Friday 15 February 2019, Afternoon Session
SESSION FOUR: Future Challenges
Chair: Dr Khairat Al-Habbal, Lebanese American University, Beirut
14.00 Welcome and introduction
14.05 Social Medicine: Professor Jan De Maeseneer
14.25 The Wider World: Professor Sir Andy Haines
14.45 The Educational Challenge: Dr David Blane
15.05 Break
SESSION FIVE: What Does the Future Look Like for General Practice?
Moderator: Dr Richard Horton, Editor, The Lancet
15.30 Plenary discussion with panel
16.30 Close
The Exceptional Potential of General Practice
Speaker Biographies
David Blane is an academic General Practitioner at the University of Glasgow and has been involved in the Deep End group since 2010, combining clinical work as a part-time GP with teaching and research commitments. He was awarded a Master of Public Health degree with distinction in 2012 and his PhD in 2018. He has authored several Deep End reports and manage the group’s social media presence. He is Academic Co-ordinator of the Deep End GP Pioneer Scheme.
Peter Cawston is a full-time GP Principal in a Deep End practice and was GP Cluster Quality Lead for seven Deep End GP practices in Drumchapel, Glasgow, Scotland. He qualified in Glasgow in 1993 and after working in France for two years completed GP training and a GP higher professional fellowship in Glasgow, where he has now served as a Deep End GP since 1999. Other roles have included: clinical lecturer, working with several patient groups and leading the Scottish Government’s pilot Link Worker Programme. “The mainstay of my working life, however, have been the long term relationships with colleagues in my practice team and with our patients on whose trust, forgiveness, good humour and resilience we rely every day.”
Jan De Maeseneer chaired the Department of Family Medicine and Primary Health Care at Ghent University from 1991-2017. He contributed to the development of inter-professional Community Health Centres in Belgium, with integrated needs-based capitation financing. His research focused on equity in health, strengthening PHC and improving social accountability. He chaired the European Forum for Primary Care from 2005-2017 and was Secretary General of The Network: Towards Unity For Health from 2007-2015. He chairs the Expert Panel on Effective Ways of Investing in Health, advising the European Commission.
John Frey qualified in medicine in 1970 from North Western University, Chicago. When he worked with Julian Tudor Hart in South Wales in the early 1970s he was the first family medicine-trained US doctor to work in the British NHS. He was head of the Department of Family Medicine at the University of Wisconsin, Madison for 13 years. Now retired, he remains active and is a regular contributor to the BJGP on US health care issues.
Andy Haines was Dean (subsequently Director) of the London School of Hygiene & Tropical Medicine for nearly 10 years until October 2010 and is currently Professor of Environmental Change and Public Health. He was a family doctor in inner London for many years and formerly Professor of Primary Health Care at UCL. He has been a member of many national and international committees, including the UN IPCC, and was chair of the Rockefeller Foundation /Lancet Commission on Planetary Health. His research interests focus on the linkages between health and environmental change including sustainable healthy cities and food systems.
Iona Heath, General Practitioner at Kentish Town, London for 35 years, and Past-President of the RCGP, has written regularly for the British Medical Journal and has contributed essays to many other medical journals across the world. She has been particularly interested to explore the nature of general practice, the importance of medical generalism, issues of justice and liberty in relation to health care, the corrosive influence of the medical
industrial complex and the commercialisation of medicine, and the challenges posed by disease-mongering, the care of the dying and violence within families.
Stewart Mercer is an academic General Practitioner, having worked clinically in a range of settings including the Deep End. He was a researcher at Glasgow University for 20 years studying inequalities in health and health care and the importance of empathic, patient-centred care. Since 2008 he has led a programme of research on the needs of patients with multiple complex problems (multimorbidity). He has expertise in the development and evaluation of complex interventions and has been the Director of the Scottish School of Primary Care since 2014. In 2019 he is moving to a chair at the University of Edinburgh.
John Montgomery has worked in the David Elder Medical Practice, Govan Health Centre since 1987, initially as a registrar, as a partner since 1989 and now as senior partner. He became a GP trainer, developed an interest in diabetes with the SCI Diabetes Group, had a spell in medical broadcasting with BBC Radio Scotland, was elected chair of the South Glasgow GP Committee and now has the Lead Clinician role in the development of the Govan SHIP project.
Anne Mullin has worked in Govan for 24 years as a GP and “I am exactly where I want to be in my career”. She chairs the Steering Group of General Practitioners at the Deep End.
Austin O’Carroll, General Practitioner in Dublin, founded several initiatives addressing health inequities: Safetynet primary-care service for over 6000 marginalized patients annually; GMQ, primary-care service for homeless people; Partnership for Health Equity, a research, education, policy and service delivery collaboration; Curam Healthnet, creating new GP practices in areas of deprivation; and the North Dublin City GP Training programme. He completed a Doctorate in ethnographic research into the health service usage behaviours of homeless people. He received the Irish Health Professional of the Year Award in 2015.
Patrick O’Donnell graduated from a rural vocational training scheme in 2012, competed a master’s degree in global health and now works as a GP and Clinical Fellow in Social Inclusion at the University of Limerick. He is currently doing a PhD on social exclusion and primary healthcare. As well as working as a GP in a disadvantaged area of Limerick city, he runs clinics for marginalised groups who do not have access to mainstream medical care.
John Patterson is a General Practitioner and Medical Director of Hope Citadel Healthcare, a NHS Social Enterprise running nine practices covering 31,000 patients in hard-pressed neighbourhoods around Greater Manchester. Their response to the demands of the ‘Deep End’ was to design a ‘Focused Care’ model to bias healthcare access to the most vulnerable and needy households. Three of their practices have been rated ‘Outstanding’ by CQC. From 2018 he was appointed CCO of Oldham CCG.
Allyson Pollock is Professor and Director of the Institute of Health & Society at Newcastle University. A public health physician, she is a leading authority on the fundamental principles of universal health systems, marketisation and public private partnerships, and international trade law and health. Her current research is around access to medicines, pharmaceutical regulation, and public health; and child and sports injury. Her book NHS plc: the privatisation of our health care was published by Verso, and she is currently working on a book An Anthem for the NHS.
John Robson has been a GP in Tower Hamlets, East London for 37 years, has a longstanding interest in cardiovascular disease, chaired the NICE guideline 2008 on lipids and CVD risk estimation and was a co-author of the QRisk and QDiabetes scores. He is CV lead for University College London Partners and Tower Hamlets CCG and Clinical Effectiveness Group lead at Queen Margaret University London (QMUL). He has carried out a range of research studies on the evaluation of quality improvement in equitable health service delivery.
Petra Sambale has worked in both the UK and her native country Germany. She qualified as a GP in Glasgow and has been a partner in Keppoch Medical Practice since 2000. She values the principles of the NHS and enjoys being a GP trainer in an area of concentrated deprivation. She believes GPs have an important part in addressing health inequalities. Her involvement in the Deep End Steering Group led to her current role as Lead GP of the Deep End Pioneer Project.
Elizabeth Walton is a Clinical Lecturer in primary care medicine and a GP in the most deprived area of Sheffield at the Whitehouse Surgery. Her NIHR funding is to develop research and teaching skills with a focus on health inequalities. Her passion to work towards health equity for communities and to support professionals working with vulnerable groups was inspired through witnessing the contrasts in the social determinants of health for patients throughout her career.
Graham Watt is an Aberdeen medical graduate and after hospital jobs in Shetland, Leicester, Aberdeen and Nottingham worked as MRC Research Registrar at Glyncorrrwg in South Wales with Julian Tudor Hart. After GP training at Ladywell Medical Centre in Edinburgh and Townhead Health Centre in Glasgow, he completed public health training with posts in epidemiology, health services research management and academic public health. Despite this circuitous route, he had the great good fortune in 1994 to become Norie Miller Professor of General Practice at the University of Glasgow. He retired in 2016 and is now Emeritus Professor.
Chair Biographies
Khairat Al Habbal is a family medicine specialist in Beirut and Clinical Instructor of Family Medicine and Social Medicine at the Lebanese American University, Beirut .
Richard Horton graduated in medicine from the University of Birmingham in 1986. Since 1995 he has been Editor-in-Chief of The Lancet.
Mayur Lakhani is President of the Royal College of General Practitioners and a General Practitioner in Sileby, Leicestershire.
Carey Lunan is a GP at Craigmillar Health Centre in Edinburgh and is Chair of RCGP Scotland.
Andrew Lyon, after working in shops and factories, studied Sociology and Economics at Edinburgh University. With the International Futures Forum, he worked to restore effectiveness in times of rapid change. He chaired the Deep End Steering group from 2009-16.
Helen Stokes-Lampard is Chair of the Royal College of General Practitioners and a General Practitioner in Lichfield, Staffordshire.
A Better NHS 