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As another general practice closes, new report calls for practical action to better support primary healthcare

Introduction by Croakey: General practice is becoming unviable in the areas of Australia where patients most need primary healthcare, creating “a perfect storm in the most deprived communities”, according to a prominent GP, Dr Tim Senior.

In a report published recently by the Winston Churchill Trust, Senior makes a range of recommendations to better support GPs and other primary healthcare professionals working in disadvantaged communities, often while under-resourced and under-supported.

The report describes Senior’s investigations in England, Scotland and Ireland as part of a Churchill Fellowship (previously covered in a Croakey series last year), and highlights the harmful impacts of poverty upon the health and wellbeing of communities.

Senior, a contributing editor and member of Croakey Health Media, urges the health sector to advocate during the upcoming federal election campaign for an end to policies “that keep people in poverty and make housing unaffordable”.

His report comes as an independently owned and operated general practice in rural lutruwita/Tasmania, the Bridge Street Surgery in Richmond, today announced plans to close at the end of February due to a lack of funding support and workforce burnout.

“Demand for healthcare in the region is growing, and without the ability to secure long-term GPs and the financial model to support the business, my staff and I are burning out,” said Dr Robyn Mathews in a statement.


Tim Senior writes:

After an unforgettable trip to England, Ireland and Scotland, courtesy of the Winston Churchill Trust, where I visited GPs and other health professionals serving socioeconomically disadvantaged communities, I have returned to Australia to think about what we can learn and what we can implement here.

Let’s remember that Australia does have a good health system, but where it falls down is in affordability, especially for those who need it most.

Let’s be specific about what ‘those who need it most’ means here – we mean multiple chronic diseases occurring in individuals 10-15 years earlier than in the least deprived communities; and we mean adverse social circumstances, such as access to affordable healthy food, poor quality or overcrowded housing or a lack of quality employment or education.

The current policy solution to these problems is to open more heavily subsidised “bulk billing” urgent care centres, which is fine for people who are acutely physically unwell, but does nothing for chronic disease management, preventive activities, mental health, or advocacy for housing or Centrelink.

As the cost of living crisis bites, these problems aren’t those of an aging society, they are those of an increasingly unequal society.

Key findings

In my visits to Deep End GPs and primary healthcare services in Plymouth, London, Sheffield, Dublin and Glasgow, all the communities were different. However, I saw six themes over and over, that will be familiar to many in primary healthcare in Australia.

1. Different systems keep recreating the same problems for disadvantaged communities and for the GPs working with them

So much of what I saw in all the communities I visited across three different countries and health systems was familiar from my work in Australia.

I saw people who were made to feel unwelcome in secondary care services, and who expected to be judged when they visited health practitioners.

Everywhere mental health services were non-existent or difficult to access.

GPs were managing complex multimorbidity often under-supported and always under-resourced – all the different health systems failed to direct funding towards disadvantaged communities.

2. Deep End GPs are expert, inspiring, pragmatic – and subversive

All the GPs I met were inspiring and highly skilled. They managed complex multimorbidity, acute care and preventive health in challenging settings.

They were able to intentionally engage patients and develop rapport and trust with people who were suspicious of health services.

They understood the health system and were able help patients navigate services, and advocate for them. They also frequently bent the rules so  their patients weren’t excluded from the care they needed.

3. Deep End work is embedded in communities and knowledge of local people and places

All the Deep End groups I met were different, because they reflected the communities they served.

They knew the people locally, and knew the local services and resources. They understood the geography – where housing was, where pharmacies were – and local history.

There was a wariness of national bodies coming in from outside with well-intentioned policies that didn’t understand local resources.

4. Supporting Deep End GPs to flourish

Despite the challenges, the GPs and health professionals I met were highly committed to their work, their communities and their teams.

They found sources of joy in their work, often from working in partnership with their patients, and they supported each other both inside and outside work.

5. Acting on social circumstances causing ill-health

Many areas had programs of social prescribing through Community Link Workers based in general practices, or through networks attached to several practices. They connected patients to local social agencies or helped with housing or food security.

The multidisciplinary teams in primary care broadened the care available to patients, rather than just replicating what was available from different health professionals doing each other’s tasks.

6. Health policy for Deep End work and workforce

Many of the Deep End groups are finding ways of developing their own workforces with the specific skills required to work in socioeconomically disadvantaged areas.

Medical students are being taught through particular programs and placements. GPs are being trained and placed in specific Deep End roles, such as Health Equity Fellows.

Community Link Workers and other primary care professionals are being placed specifically in Deep End practices to provide the broader range of care required. Deep End groups, especially in Scotland, have had some success advocating on policy with governments.

Inverse care law

Those themes won’t be unfamiliar to people in the Australian primary healthcare sector, and especially to those working in the Aboriginal Community Controlled sector.

As Professor Graham Watt, the GP who founded the original Deep End group in Glasgow, told me, “GPs don’t think about health equity. They think about how much more they could do for their patients if they had the resources.”

How much more could we do in Australia?

Health spending on primary care has declined. The number of people avoiding seeing their GP due to cost is increasing, and the proportion  avoiding seeking any healthcare, including from GPs, is higher in the most disadvantaged communities.

Medicare rebates don’t fund the provision of high quality care adequately – the Government know this when they guarantee “bulk billing” in urgent care centres by heavily subsidising them.

In fact, as Medicare rebates increasingly don’t cover the cost of providing care, practices are forced to charge co-payments, which has the effect of proportionately diverting primary care funding away from the most disadvantaged communities, toward areas where people can afford co-payments – exacerbating the inverse care law.

Recommendations

What do we need to do in Australia? I’ve made five recommendations in my report.

1. Recognise and support Deep End GPs in Australia

Every Primary Health Network, every academic unit of General Practice or Primary Care or Public Health, every State Local Health District, anyone involved in health policy or delivery should know who are the Deep End practices in their area. What support do they get? How is resourcing directed toward them? Are they noticed and acknowledged? These are the GPs and health professionals in your area most likely to be overwhelmed or burn out.

2. Recognise the expertise of Deep End GPs

This shouldn’t really need saying, but it really does. There’s an assumption that the GP job is easy – just issuing a prescription and a referral letter – and can be done by almost anyone. Every guideline, every research article, every expert seems to start their recommendations with “GPs should….” Everyone wants to deliver extra training to GPs to upskill in the things they likely are already doing.

If you think GPs should be doing something different, ask them what they think. It’s likely a system issue, not an educational gap. It’s likely they don’t need another toolkit or another report.

3. Support local action on broader social circumstances affecting health

Support and fund measures that act locally on social determinants of health, particularly for Deep End communities. This may be through formal social prescribing programs and Community Link Workers placed in practices, or through services serving a number of local practices. Primary Health Networks might be ideally placed to do this, but they wouldn’t be the only option.

4. Develop the Deep End GP workforce

We need to train, recruit and retain a workforce specifically for Deep End Communities, in the same way we do for rural and remote communities, and, to some extent, for Aboriginal and Torres Strait Islander communities. There’s a lot of overlap here, but we need to explicitly develop skills for working in communities where poverty affects all decisions and options open to someone.

There is scope for novel programs, such as Health Equity Fellows, salaried – perhaps by Primary Health Networks or academic departments – and placed in Deep End practices.

5. Develop health policy and funding that promotes health equity

All our health policy needs a socioeconomic lens applied.

Who is our ‘paradigm person’ when we are (re)designing a health service or system? Is it the person without money, who struggles to access health care, or good food? Will the service be welcoming? Will it make their life more difficult? We need to direct funding and resources where it is needed most – not just geographically, but economically. We need to measure and report the effects of health policy on the most disadvantaged communities, and whether they worsen or improve health equity.

None of this is new or surprising. We know that Australia’s health system struggles in providing care to those who can least afford care.

Without a specific focus on a health system that works for those who need it the most, we are condemned to repeat the policies that work well for those who already access the health system – people like me!

This can’t do anything more than make marginal gains – the health of people like me is already good, we are subject to beneficial social determinants, and we already have access to the health system. People like me make health policy, and we make it convenient for people like me.

But as Victor Montori, Professor of Medicine at the Mayo Clinic, told us in his keynote at the Society of Academic Primary Care conference in Bristol, “Who is your paradigmatic patient when designing services?”

We know that community health outcomes are better with more primary care, generalist physicians, and when health systems are based around primary care – comprehensive, co-ordinated, community-based, person- (not diagnosis-) centred. Health systems are also more equitable.

Leading the way

The answers are right in front of us. I have returned to Australia with a renewed appreciation of the strength of the Aboriginal Community Controlled Health Organisation (ACCHO) sector.

They exhibit the themes I saw in England, Scotland and Ireland in effective Deep End practice. They are flexible and capable of being subversive to navigate a health system that doesn’t serve Aboriginal and Torres Strait Islander people well.

The health professionals and GPs work with a profound respect for their patients, and work to enable their patients to have choices and control in their lives. They operate with multidisciplinary teams that manage complexity well, and they have specific community programs that operate on local social circumstances that cause ill health.

My own service offers subsidised fresh fruit and vegetable boxes, runs community arts groups, sporting groups and dance groups, for example. Even the choice to employ GPs on a salary is unusual in Australia, but widespread across the ACCHO sector, separating personal income from Medicare billings to support high quality clinical care in complex settings.

Their governance model is what brings about their success and ensures the community responsiveness of these services more systematically than the patient participation groups seen in UK general practice.

If we are to act effectively on supporting Deep End practice in Australia, then we must surely start from where this is already done well, the ACCHO sector.

Photo provided by author.

Calls to action

The upcoming federal election is an opportunity for advocacy at a national level.

We currently have policies that keep people in poverty and make housing unaffordable. As the cost of living crisis deepens, the most vulnerable are being left without support. In the health sector we can advocate on these issues, as individuals and as organisations.

We should also advocate for health policies that serve the most vulnerable, and for action on the social determinants of health. At its most basic, this means recommending policy that funds health services according to the needs of the communities they serve, and ensure they have adequate workforce to do this.

We also need local action, and for this we don’t need to wait for politicians or elections.

Primary Health Networks are the best placed to take local action, but anyone working in the health system, in academia, or even in local councils and not for profit services can take some of these actions.

  • Identify the Deep End services in your area. What could your organisation do to support them? (Ask them – don’t tell them what to do, don’t decide they need a webinar or a toolkit without asking!)
  • When improving services in your area, ask the people who most need the services how it should work.
  • What can you do to improve the social determinants of health in your area? Who could you collaborate with on housing or food affordability?
  • How could you attract workforce to your area? Who can you employ? Could you even trial social prescribing or Health Equity Fellows?

These are some thoughts I’ve had up to this point, but many people will have their own ideas. Try them locally. Politicians will soon be keen to be associated with any successful ideas!

• Tim Senior’s Churchill Fellowship report can be downloaded from the Churchill Trust website.  Please share it with your networks.


The #ChurchillDeepEnd series

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