Introduction by Croakey: In June this year, Dr Tim Senior launched a Croakey series sharing stories from a Churchill Fellowship that supported him to visit general practices in the United Kingdom with the aim of answering this question: what can we do in Australia to support GPs providing care in socioeconomically disadvantaged communities?
In the latest article in this series, he goes back to where it all began: Glasgow, the birthplace of General Practice at the Deep End, and he also visits a general practice in Edinburgh.
While his Fellowship may have wrapped up, the journey continues, writes Senior.
Tim Senior writes:
The final leg of my Churchill Fellowship takes me to Glasgow, where General Practice at the Deep End was born. Here I am at the Keppoch Medical Practice, which serves the most deprived community in Scotland, and is familiar from the initial GPs at The Deep End series in the British Journal of General Practice.
I’m a bit surprised at how normal the Keppoch medical practice is, as it is quite different to some of the other practices visited on my Fellowship. It’s on the first floor of a large purpose-built building, shared with a few other health services, including other GP practices, in Possilpark, a suburb in the north of Glasgow.
Elsewhere in my Fellowship I’ve seen general practices do outreach to the homeless, or in-reach to the hospital, I’ve seen special clinics set up for Roma communities, or for asylum seekers and refugees.
This is a mainstream practice, embedded in its community doing things that all GPs would recognise as good general practice. They are very well organised, though, in being able to use the information technology to audit and plan care beyond direct face-to-face patient care. (In Australia the incentive is just to see patients, there’s no funding – or almost none – for activities outside patient care that is face-to-face or on the telephone/video call. Yet being able to coordinate care, and do quality improvement activities is so crucial.)
I was able to sit with Dr Petra Sambale, one of the practice partners, on a process of medication reviews, which was able to look at individual patient files and create alerts to have discussions about recommended medication changes. In fact, this was a preventive health or monitoring activity.
I also learnt more about the role of the Community Links Worker. This is someone funded by the Scottish Government and attached to Deep End practices whose role is specifically to see people referred by the GP and link them to community activities, such as gardening, or education, or mental health peer support.
I spent time talking to Nikki Smith, the Community Links worker at the Keppoch practice, and she showed me around Possilpark. While the most visible part of her role is linking patients of the practice to third sector organisations, Smith explained to me the two other parts of the role that are essential to making it work.
These are Community Asset Mapping – the Community Links Workers have to know what is available in their local communities, and they go out to meet them, to develop relationships. This makes referrals much more personal. The third component to the role is meeting with other Community Link Workers for education and resource sharing, and for peer support.
This is a really good example of a role designed for social prescribing, and one which is well constructed to address the need specifically in deprived communities. This really expands the possibilities for what GP practices are able to offer their patients.
In the Australian context, it is worth noting that this promotes multidisciplinary teamwork, and expanding what the team is able to offer, which is very different to task substitution.
Making connections
Outside Glasgow, I paid a visit to Dr Nora Murray-Cavanagh at Wester Hailes Medical Practice, in the western suburbs of Edinburgh. We met in the small local shopping centre, which reminded me very much of the shopping centre in Airds near my own workplace in NSW.
The practice itself, like Keppoch, is in buildings owned by the National Health Service, and shared with other organisations, including mental health and dental services. This helps collaboration and referrals, and the practice team itself includes another Community Links Worker and a pharmacist.
Through the afternoon I sit in with Dr Peter Cairns doing an opiate substitution clinic, and I am unsurprised at how familiar the patient experiences feel – their cautious welcome of a primary care professional who treats them like humans, and listens to their concerns, set against under-funded, health services, and unwelcoming or inconvenient social services.
Dr Murray-Cavanagh shows me around the local area and the practice, and again I am struck by the drive from Deep End GPs I’ve seen across my whole trip. They are highly skilled in medicine, but also understand that this isn’t enough without social action at whatever scale. As well as encouraging collaboration across practitioners, sometimes just by bringing food in for everyone, she’s started up a supply of baby clothes and a small community library in the practice.
So, as I’m thinking about the Deep End GPs I’ve met on my travels, I have two more GPs to tell you about.
First, Dr David Blane is the current leader of the GPs at the Deep End network in Glasgow. He’s now a GP at Keppoch Medical Practice and Senior Clinical Lecturer at Glasgow University. His presence has bookended my trip, as he led the Deep End Research Interest Group at the Society of Academic Primary Care conference in Bristol.
Blane’s pathway to this position has come through the development of specific Deep End Fellowships, providing additional GPs to Deep End practices, with additional opportunities for quality improvement or research, and also (in some cases) specific time for maintaining wellbeing and preventing burnout. His journey and leadership is a testament to this long-term support and thinking.
A continuing journey
And finally, I get to meet Professor Graham Watt, now retired. We walk through the streets of central Glasgow (“You must look up in Glasgow. The buildings were designed to reflect classical architecture”) as we look for a local café to talk in.
I’m thrilled to meet him at last. He has the broad knowledge of a true generalist, a GP, a public health physician and a researcher. He is the GP who started the GPs at the Deep End groups.
He worked with, and was friends with Dr Julian Tudor Hart and his family. We discussed Tudor Hart’s book, The Political Economy of Health Care, which I was reading as I travelled (“All the best bits are in the footnotes, Watt told me, correctly).
One of the principles of my Churchill Fellowship has been that I am looking at general practice – the provision of healthcare, seeing people face to face – rather than public health, which is about looking at populations rather than individuals.
Watt sums this up beautifully for me: “GPs don’t think about health inequalities. They think about how much more they could be doing for their patients, if only they had the resources.”
This is it. All the GPs I’ve met have been grappling with this. Of course we see inequities, we see the maldistribution of resources, but always it comes back to the people we see face to face, whose stories we hear.
As a GP, our role is to work with the people we meet, as Tudor Hart said, “initially face to face, eventually side by side”.
To some extent the policy solution is simple, as Professor Graham Watt and colleagues wrote back in 2012: “The contribution of general practice to improving health and narrowing inequalities in health is not so much via the learning of new tricks and delivery of externally devised toolkits as by increasing the volume and quality of what Deep End practices do.”
But this is a brave solution too. Do we trust the evidence on the importance of primary healthcare in improving health? Do we trust the evidence on the importance of continuity of care?
My Churchill Fellowship journey has finished. But my journey – to support GPs at the Deep End, and to encourage policy makers that supporting GPs at the Deep End will have really important outcomes – is only just beginning.
I invite you all to continue journeying with me. Share these articles, look out for my Churchill Fellowship report, connect with me on Twitter, Bluesky, Mastodon, or LinkedIn. And, most importantly, know who your local Deep End GPs are, and look after them well.
See previous articles in the #ChurchillDeepEnd series
