Submission to the Strategic review of General practice
In February 2024, Deep End Ireland was invited by the Department of Health to contribute to the Strategic Review of General Practice. Our submission highlights the challenges and opportunities facing general practice, particularly in communities of deprivation, and sets out recommendations to strengthen equity, access, and sustainability in primary care. We are publishing our submission here to share our perspective and to support wider discussion on how general practice can best serve patients and communities across Ireland.
29th Feb 2024
Authored by Dr Brid Shanahan, Dr Patrick O’Donnell, Professor Susan Smith on behalf of the Deep End Ireland Group
Executive Summary and Recommendations
The Deep End Ireland group is made up of General Practitioners (GPs) working in the most disadvantaged communities across the country. Since it was established 12 years ago the group has worked to address health inequities and to tackle the Inverse Care Law – this states that people who most need good quality health care are often the least likely to receive it. Access to high quality healthcare is an important determinant of health. Inequitable access to that care is an unintentional yet powerful driver of health inequities. Currently there is a flat distribution of health resources in Ireland, and as a group we believe that those resources should be targeted with consideration of the needs of the population being served.
It is well established that there are higher health needs in areas of deprivation. Despite this, there are relatively fewer GPs working in deprived communities compared to more affluent communities. This results in higher patient to GP ratios in these areas. In order to provide more equitable care, the GP to patient ratios should be based on patient need. There are also large variations in access to other clinical and social care services including child and adolescent mental health services (CAMHS), psychology, speech and language therapy (SLT), social workers and disability services. We advocate for targeted action to strengthen primary care and general practice teams in areas of deprivation. This “equity-focused funding” would start to address the Inverse Care Law.
To increase the GP to patient ratio we need to attract more GPs to work in areas of deprivation. Positive exposure to working in deprived communities needs to begin at an undergraduate level and continue right through to the completion of GP specialist training. GPs working in areas of deprivation have relatively higher levels of stress and there is a higher turnover in GP posts when compared to their peers working in more affluent areas. More equitable funding through weighted capitation for deprivation would enhance capacity for extended GP consultations to address complex health needs for patients. This, combined with additional supports such as allocating salaried GPs to work in existing practices or funding additional practice staff hours in areas of deprivation, would both improve clinical care delivery and help to reduce stress and burnout amongst GPs in these areas.
Involving members of Deep End Ireland in policy making and the planning of services would ensure that decisions are sustainable, and equity focused. We have identified a series of recommendations to support more equitable and sustainable general practice as follows:
Support for GPs
• Provide infrastructure supports for new practices starting in areas of deprivation including the cost of premises and providing certainty around salaries of younger GPs working within practices
• Enhance capacity for extended GP consultations to address complex health needs for patients in areas of deprivation
• Introduce deprivation-weighted GMS capitation rates in accordance with increased need for patients in deprived areas and at a younger age
Expand the GP team
• Expand capacity for GP practice nursing, administrative support and other potential roles such as link workers or focused care workers in practices in areas of deprivation
GP training
• Explore measures to address the recruitment of GPs to work in areas of deprivation, starting at the undergraduate phase and continuing to the completion of GP specialist training
• Consider measures to improve working conditions for GPs in areas of deprivation in order to improve retention
Policy making and service planning
• Involve GPs who are working in the most disadvantaged communities in policy making and planning to ensure that decisions are equity focused
• Establish a Primary Care Health Equity Working Group that would include representation from all stakeholder groups including frontline services and patients living in areas of deprivation
Introduction
Health Inequities
Health inequalities are defined as unjust and avoidable differences in people’s health across the population and between different groups (McCartney et al., 2019). Many of the causes of health inequalities lie outside of the domain of health, but access to high-quality healthcare is an important determinant of health, and so inequitable access to that care is an unintentional yet powerful driver of health inequalities (World Health Organization, 2023). In Ireland, life expectancy is 5 years less for men in the most deprived areas compared to the most affluent (Central Statistics Office, 2016). People living in deprived areas develop multiple chronic conditions (multimorbidity) at least ten years before those in non-deprived areas (Barnett et al., 2012), and resulting levels of morbidity and mortality are high (Mackenbach et al., 2008, Stringhini et al., 2017). As well as living with poor health for longer, people living in disadvantaged communities have higher rates of cancer mortality, higher circulatory disease mortality and higher rates of injuries (Osborne, 2015).
Unsurprisingly given these higher health needs, consultation rates in deprived areas are also higher than in non-deprived areas, placing additional strain on health services (Boomla et al., 2014, Stirling et al., 2001, Vestesson et al., 2023, Mukhtar et al., 2018). A study of consultation rates in the UK found that they were 42% higher in more deprived areas (Roland et al., 2015). Increasing deprivation is also associated with higher rates of psychological distress and mental illness, and GPs in disadvantaged areas manage patients with more complex combinations of physical and mental health conditions (Stirling et al., 2001). Patients with more complex problems require longer consultations, but this is often not possible due to the relatively higher number of consultation rates in more deprived areas and the relatively lower numbers of GPs. This reduces opportunities for effective, preventive healthcare. The image below illustrates these challenges.
McClean et al using data from 956 practices in Scotland (McLean et al., 2015)
There is recognition internationally in both research and policy that primary care and general practice have a key role to play in alleviating the impact of health inequalities. A 2022 report from the Primary Care Health Inequalities Short Life Working Group in Scotland collated the advice of a broad range of frontline professionals and people affected by deprivation in developing a practical action plan that would start to address some fundamental inequalities in health there (Scottish Government, 2022). This blueprint is being implemented in tandem with the application of the Fairer Scotland Duty which is a statutory duty that places a legal responsibility on Scottish public bodies to actively consider how they can reduce inequalities of outcome caused by socio-economic disadvantage when making strategic decisions.
The seminal 2008 WHO World Health Report advised that strengthening primary healthcare and making it universal would ensure that “health systems contribute to health equity, social justice and the end of exclusion” (World Health Organization, 2008). This report and the subsequent 2010 WHO Europe report reinforced the significance of the role that health systems and primary healthcare have in addressing social exclusion and improving the health status of populations. They summarised that “action to improve the health of disadvantaged populations should …. be grounded in a human rights approach to health and the values and principles of primary health care” and highlighted the need to include “communities experiencing poverty and social exclusion in the design, implementation, monitoring and evaluation of policy and practice”.
Professor Barbara Starfield when writing about the benefits of a robust primary care system described it as having the potential to be a key access point for relatively deprived population groups to high-quality care in their communities, and this in turn could lead to improved rates of early diagnosis, enhanced prevention activities, and the avoidance of the need for secondary care engagement (Starfield et al., 2005). This has been echoed in a recent realist review paper in the Lancet Public Health journal on the specific role that general practice can play in reducing health inequalities (Gkiouleka et al., 2023). The authors included 159 papers in their final synthesis and found that for general practice to be effective in striving to reduce persistent inequalities, it needs to be well connected, it needs to work on an intersectional basis, and it must be flexible, inclusive and community centred. The paper also included recommendations on the engagement on front-line professionals and people from disadvantaged areas in relevant policy development, the consideration of schemes to promote the recruitment and retention of local healthcare staff from disadvantaged areas and that funding should be distributed taking the specific needs of the populations served into account. It calls this “equity-focused funding” and says it must integrate the socioeconomic status and ethnicity of patient groups in general practice funding calculations, with a higher weighting for practices in disadvantaged areas.
The Deep End group in Scotland have identified the GP as having a central role in the care of so call “hard to reach” populations (Watt et al., 2012). Ease of accessibility to GP services means that these patients are more likely to present with acute medical issues to their GP than to other services. They also have high levels of trust in their GP and are more likely to engage with other services if referred on.
Reducing health inequalities through general practice. (Gkiouleka et al., 2023)
Impact on Health Services
Despite this increased health need, there are relatively fewer GPs working in deprived areas than working in affluent areas. This is known as the Inverse Care Law – the availability of healthcare is often least where it is needed most.
“The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”
In 2019 in Dublin’s North Inner City, for example, there was one GP for every 2,500 patients, compared to the national average of one GP for 1,600 patients (Osborne, 2015). There is also often high staff turnover of allied health professionals due to the pressured nature of work in these areas. The Social Deprivation Practice Grant Support Grant introduced in 2021 represented a first step in providing additional support to Irish GPs working in areas of deprivation to assist them with the challenges they face. This grant represents important but modest additional support for practices, and it does not replace the need for a systematic approach to the needs-based allocation of resources, for example, using deprivation weighted capitation for PCRS contract. The current grant needs to be effectively targeted at practices in the most deprived areas and it needs to be multiannual to allow effective planning and retention of staff supported by the grant. It will be critically important to ensure that all funding is focused on areas of greatest deprivation and becomes a stable ongoing support to ensure planned and agreed enhanced services for the areas and practices identified through detailed deprivation analysis. The existing model of sustained and targeted supports provided to schools in deprived areas under the Delivering Equality of opportunity In Schools (DEIS) programme provides an exemplar of a model that could be used to support primary care delivery in these areas. Medical card patients who cannot access private healthcare experience long waiting times for secondary care services. There are also large variations in access to other vital clinical and social care services including child and adolescent mental health services, psychology, speech and language therapy, social workers and disability services. Unlike more affluent patients, these patients generally do not have the means to pay out of pocket for care. These delays add to the later diagnosis and effective treatment of conditions across the lifespan and contribute to higher mortality from cancer that occur in more disadvantaged areas in Ireland.
Deep End Ireland
The Deep End Ireland group is made up of GPs working in disadvantaged communities across the country and it is affiliated with the international Deep End group. Over the years we have engaged in many initiatives to advocate for our patients by meeting politicians, policymakers, the Irish College of General Practitioners and the medical unions. Deep End Ireland workshops and reports have focused on the Inverse Care Law and incorporating link workers into practices in areas of deprivation and learning from Scottish and Irish pilot initiatives. We have also focused on advocacy to support children with complex needs and their parents living in areas of deprivation who need to be referred for early intervention support.
Relevance to the Strategic Review
GP Workload in Disadvantaged Communities
The wider workforce challenges affecting all general practices will severely impact practices in deprived areas. As GPs working in these areas, we are advocating for targeted action that we feel is urgently needed to strengthen primary care and general practices in areas of deprivation that will enhance our capacity to address well-established health inequities. The resources provided to general practices and primary care services across the country should take into account the level of need in the communities they serve. This “equity-focused funding” would start to address the Inverse Care Law.
Often GPs working in areas of deprivation have relatively large patient lists and the workload of providing care for these patients is compounded by complex health and social needs (Teljeur et al., 2010). People living in areas of deprivation often need to attend their GP more frequently and can require longer consultations due to the complexity of their problems (McLean et al., 2015). The current housing crisis disproportionately affects people living in areas of deprivation and this can add to GP workload as we know there is poorer health amongst homeless patients and there is additional time needed for GPs to advocate for the accommodation needs of these patients (Grotti et al., 2018). There is also extra workload for practice teams in trying to keep track of the addresses of these patients in order to ensure that they are linked to appropriate services despite frequent moving. New migrants coming to Ireland are more likely to live in areas of deprivation and so the GPs may need to navigate cultural and language barriers (Maître and Privalko, 2021). This can take quite a bit of time and requires professional interpreting which is not always available. The provision of interpreters to GPs in recent years for work with Ukrainian refugees is a step in the right direction, but it must be made available freely for GPs to use with other migrant groups and it should be acknowledged that consultations with patients who have limited English are longer (HSE, 2009). Patients with limited English and those who have literacy issues can face barriers to secondary care access, sometimes being required to respond to written communications such as validation letters for out-patient clinics and other services that require them to opt in (e.g. counselling in primary care CIPC). This again can create extra work for their GPs and practice teams who may need to complete forms for the patients, make re-referrals for them following missed appointments or to advocate for them to avail of these services. The role of the gatekeeper in terms of health service access is one that GPs are trained for and accustomed to, but this can be hugely challenging when trying to support patients in areas of deprivation. GPs working in disadvantaged communities are expected to overcome these and other challenges while providing the same high-quality healthcare as more affluent areas, but with no additional funding or resources .
GP Training
In order to encourage medical graduates to consider becoming GPs, positive exposure and explanation of the benefits of being a GP need to be conveyed to students across the continuum from undergraduate to GP trainee, and efforts to do this have been reported on by the ICGP and AUDGPI (ICGP and AUDGPI, 2023). The quality and length of these placements in GP practices can be very influential on the decisions of students and qualified doctors (Butler et al., 2022). Work carried out in the UK including Northern Ireland showed that most GP practices involved in the education of GP trainee were located in affluent rather than deprived areas, and this was subsequently described as an “inverse training law” (Rees et al., 2016, Russell and Lough, 2010, Blane, 2018, Butler et al., 2022). The authors felt that the reasons for this imbalance in the availability of GP training placements were likely resulting from the increased pressure GPs in deprived areas faced and their lack of time to devote to teaching due to the inverse care law (Blane et al., 2013). They also noted certain characteristics of practices in deprived areas – namely being run single-handed – making it more difficult to accommodate GP trainees (Blane et al., 2013). Evidence synthesis has shown that the potential consequences of these imbalances in placements and training can include the fact that students and trainees would feel less confident about working in GP practices in areas of deprivation if they had no experience of them during their training (Crampton et al., 2013). More recent work in Scotland has borne this out and GP trainees described the major challenges they perceived they would have to face if they worked in deprived areas including having smaller practice teams, the patients being sicker, having to deal with addiction issues more frequently, having difficulties communicating with patients and poor levels of patient health literacy (McMahon and Cunningham, 2022).
In the Irish context, it is known that more GP training places are required to meet the needs of the increasing population of Ireland. The ICGP will increase the number of new trainees by 20% in 2024 alone. It is important that these new trainees are exposed to both the challenges and rewards of working in areas of deprivation in a supported and constructive way. The North Dublin City GP (NDCGP) training scheme has demonstrated an appetite among medical graduates for dedicated training in areas of deprivation and with socially excluded groups (O Carroll and O’Reilly, 2019), but the exposure and skills taught in that particular scheme should be available for GP trainees all over the country. The NDCGP was established in 2011, and by 2019 they found that 97% of their graduates were either working as GPs in areas of deprivation or doing work that included providing care to marginalised populations (O Carroll and O’Reilly, 2019). This is a success story that shows the level of interest among younger medical graduates when given exposure in a supported way to the clinical management of patients from marginalised groups and working in areas of deprivation.
GP Recruitment and Retention
We know from international evidence that GPs working in areas of deprivation have relatively higher levels of stress and higher turnover than their peers working in more affluent areas. A 2021 study in the UK found that practices in the most deprived areas had a higher turnover of GPs than practices in other areas (Parisi et al., 2021). This was likely a result of the increased levels of multimorbidity in the patient populations being cared for and the resulting high levels of healthcare need (Parisi et al., 2021). Research from Denmark has also shown that GPs working in deprived areas had higher levels of burnout compared to GPs in less deprived areas (Pedersen and Vedsted, 2014). This resulted in lower numbers of GPs working in those deprived areas and they found that the GPs who continued to work in these areas had high risk of burnout and may not have been performing their job optimally (Pedersen and Vedsted, 2014).
In England and Scotland specific schemes have been created to provide continued training, guidance and support to newly qualified GPs working in areas of deprivation, i.e. after specialist qualification and finishing their GP training schemes. The Scottish Deep End Pioneer Scheme gave newly qualified GPs working in Deep End practices weekly protected time for continuing education and service improvement projects specific to practice in areas of deprivation (Dhanani and Blane, 2023). It also gave the senior lead GP in each of the participating practices weekly protected time to work on the service development project. An evaluation of the scheme carried out in 2022 found that “all GP fellows interviewed expressed a desire to continue working in Deep End general practice and felt more equipped to do so after the Pioneer Scheme” (Dhanani and Blane, 2023). In England more recently, the Catalyst programme has been established to provide similar support and guidance to newly qualified GPs there (https://www.hyms.ac.uk/continuing-education/catalyst#course). Initiatives such as these could work to improve the recruitment and retention of GPs working in areas of deprivation in Ireland.
Supporting GP Capacity
The flat distribution of resources that is a feature of the Inverse Care Law means that the only way GPs can currently deal with the increased demand in deprived areas is to have shorter consultations, rather than the longer consultations that are often warranted in view of the complexity of issues encountered. This can lead to missed opportunities for preventive care, cancer screening and chronic disease management during these consultations. The Care Plus research study carried out in 2016 in Scotland showed that longer consultations for patients with complex problems in deprived areas were associated with better outcomes after 12 months and that it was a cost-effective adaptation to make (£12,224 per QALY) (Mercer et al., 2016). Another recent study from the UK found that having more GPs per capita in deprived areas resulted in lower emergency department admission rates for that population (Nicodemo et al., 2021).
The 2022 report on the Chronic Disease Burden in Ireland shows that GMS patients aged 18 to 44 years have higher incidences of asthma, congestive heart disease, stroke and diabetes than their non-GMS counterpart (Kearney et al., 2022). It also acknowledged that patients living in deprived areas are more likely to develop chronic diseases than those living in affluent areas. The report also included international data indicating that patients in deprived areas develop chronic diseases and multimorbidity at a younger age than patients in affluent areas. These differences in morbidity are not reflected in the flat distribution of resources using GMS capitation across different socio-economic groups in the Irish context.
The Irish Longitudinal Study on Ageing (TILDA) uses highest level of education attainment as a well-accepted proxy for socio-economic status. In a 2020 report, they found that for 58- to 64-year-olds frailty was twice as prevalent amongst people who had only attained primary school education versus those who completed second-level education (O’Halloran et al., 2020). They also found that frailty was three times as prevalent in those with primary education versus those with third level education. The 2016 Census showed that men in the most deprived quintile have a life expectancy which is 5 years less than men living in the least deprived quintile (Central Statistics Office, 2016). Currently there is a significant jump in GMS capitation rate for patients aged over 70, and this is to reflect the higher health needs of older patients. In deprived areas patients have these high health needs at a younger age. GPs working in disadvantaged areas are trying to provide this rigorous care at present without adequate resources. This increased level of capitation needs to occur at a younger age for patients in deprived areas if we are to provide effective care for these high-risk patients in primary care settings.
The major barrier to longer consultations in the Irish context at present is a uniform approach to GMS panel size regardless of the needs of the patient population. Currently, the expansion of GMS panel sizes in areas of high need leads to longer waiting times for patient appointments and likely reduced opportunities for effective and efficient preventive care. There is a need to identify a mechanism for the better resourcing of care with smaller list sizes that reflect the level of deprivation and need in the patients served. The current capitation-based GMS contract incentivises GPs to take on as many patients as possible. These large lists are necessary to ensure the financial survival of practices in deprived areas where there is very little income from private patients. This can result in longer waiting times for patients to get appointments with their GPs. In the North East Inner City in Dublin there is one GP for every 2500 people. The national average is one GP for every 1600 people (ICGP, 2016). We know that patients in deprived areas need to attend their GP more frequently and have more complex presentations, thus we need to aim for an even lower ratio of patients per GP in these areas. Instead, we currently have a situation where maximising GMS panel size is incentivised and this could result in poorer outcomes for people in disadvantaged areas and increased pressures on the hospital system. An increased capitation fee for patients in the most deprived socio-economic groups is essential to providing adequate levels of care. Increased capitation would give GPs working in areas of deprivation the means to increase the GP to patient ratio and work towards improving the standard of care and outcomes for these patients.
GPs could be supported in other ways such as allocating salaried GPs to work within existing practice clinical governance structures, or by funding additional practice nurses or administrative support hours for practices in areas of deprivation. Deep End Ireland GPs have embraced the Social Deprivation Practice grant, but it is currently dispersed very widely and provides a very modest level of additional resource to each practice (max €16,000 annually). While the existing deprivation payment has established the principle of targeting resources based on need and it has started to address health inequities in a small way, a data-informed resource allocation model working multiannually is now needed to ensure the funding is distributed based on the needs of the population being served by each practice.
In line with Sláintecare policy, the GP practice teams could be expanded to ensure more efficient and effective service delivery with all members working as closely to the top of their licence as possible, with particular focus on the role of GP nursing, administrative support for practices and the consideration of the value that other potential roles could play in improving service delivery while taking account of the development of wider community services through the Enhanced Community Care (ECC) programme. The initial implementation of the Social Deprivation Practice Grant by Deep End Ireland members highlighted the potential benefits that such additional supports could bring, with some employing practice-based link workers to support vulnerable patients. There is also evidence from Scotland outlining the positive impact of having practice-based financial advisors in primary care settings (Egan and Robison, 2019). While we welcome the expansion of the GP practice team, it is important that patients still have continuity of care with their preferred GP. New team members should support patients and improve practice efficiency but the therapeutic relationship between the patient and their GP cannot be replaced. Continuity of care has been shown to improve patient outcomes, including reduced all-cause mortality, but patients in areas of deprivation are less likely to have continuity of care with their GP than in more affluent areas (Gray et al., 2018, Jeffers and Baker, 2016). This is yet another example of the inverse care law.
Co-location of services is critical for the most vulnerable patients. They are familiar with GP services so are more likely to attend or be seen opportunistically if in a known and trusted location. This should include not just the GP practice and the primary care team, but also integrated care hubs and other services such as social prescribers, addiction services and community mental health teams. Lack of transportation is a known barrier to healthcare, and it disproportionately affects those living in areas of deprivation. In urban areas, the distances involved may be relatively short, but they can form very real barriers for patients with complex issues to try and overcome (Syed et al., 2013).
Infrastructure support for GP practices in areas of deprivation is critical. GPs should be supported to work in HSE primary care centres, particularly in areas of deprivation and consideration should be given to doing this on a rent-free basis to encourage the establishment of practices in these areas. The needs of the local population need to be taken into account when building these primary care centres. At present, many GP practices located in primary care centres are limited by a lack of space for additional doctors and so cannot take on more patients. There is an urgent need to review issues around rent in primary care centres with potential for expansion and hosting of ECC team members without compromising GP space and capacity.
Identification of E-Health requirements is needed, including support to provide necessary infrastructure and IT with recent examples of the capacity to use GP data to identify additional patient needs. For example, a recent study used GP data from practices in one particular area of deprivation to identify a higher prevalence of asthma in residents of Oliver Bond House in Dublin 8 compared to the surrounding community (Mc Carthy et al., 2024).
Addressing infrastructural challenges is critical both for practice establishment and succession planning. There have been other potential GP service delivery models piloted including GPCareForAll. This is a non-profit organisation that aims to support general practice development in the most disadvantaged communities. It provides centralised supports to developing practices, including financial advice, human resources support, property management and other support services allowing GPs to focus on clinical practice, while also maintaining clinical autonomy. The pilot project in Dublin’s North inner city was established in 2015. It now has a GMS list of 2600 patients, most of whom did not previously have a GP. It is a model that can be used to inform HSE development of capacity in general practice in disadvantaged communities.
There is also a need to identify the requirements necessary to reform Out of Hours (OOH) GP services to ensure the delivery of accessible, high-quality emergency care throughout the country. This is a particular issue in high-needs populations living in disadvantaged communities where there is a likelihood that overstretched OOH services may not be able to meet demand outside normal working hours and this could lead to potentially inappropriate attendances at Emergency Departments. In some areas at present the OOH model for GPs is structured that they must work a number of sessions that is dictated by their practice patients’ use of OOH services. This means that the more attendances your patients have at the OOH service, the more GP sessions your practice must provide to cover these services. This places further stress on GPs already dealing with higher workloads during normal working hours.
Policy Making and Service Planning
Policy makers and those who design health services need to consider the scope of service to be provided to patients on a universal basis and develop the support model necessary to underpin the provision of GP services that are sustainable and in line with Sláintecare. The ECC programme has resourced chronic disease management, and this is a welcome development. This won’t be as effective and efficient as possible, however, without recognition of the need to target vulnerable patients in disadvantaged areas who develop multimorbidity earlier with a more complex mixture of physical and mental health conditions. This group of patients have the highest numbers of avoidable emergency admissions to hospital, and services need to be designed to address this key health system challenge.
Primary Care Teams have been a pillar of primary healthcare policy for over a decade, and they are particularly important in disadvantaged areas where teamwork is a key part of delivering effective care. During the current period of recruitment embargoes, service planners need to ensure that vacancies on primary care teams in disadvantaged areas are prioritised and that staffing levels can match the needs of the population served – i.e. more frontline staff needed per person in areas of deprivation. For example, currently community disability network teams are distributed based on population size and not on the needs of that population in Ireland (Health Service Executive, 2021). A study done in Northern Ireland in 2018 found that the rate of autism in the most deprived decile of their population was 31% higher than the Northern Ireland average, meaning that more services were required in deprived areas for children with autism (Department of Health, 2018). Similarly, child and adolescent mental health service (CAMHS) teams in Ireland are distributed based on population size, and not the level of need in the population served by those teams (Mental Health Commission, 2023). The Millenium Cohort Study in the UK found that children from low-income families are four times more likely to experience mental health problems than children from higher-income families (Gutman et al., 2015).
The Sláintecare scheme of ECC programmes has the stated aim of allowing “health and social care services to manage care at a local level and prevent avoidable referrals and admissions to acute hospitals, where safe and appropriate to do so”. Unfortunately, many of the physical programme hubs that patients are called to are not based in deprived areas, and in some instances they are further away and less accessible by public transport than local hospitals are, making them very inconvenient for patients without private transport. This highlights the importance of examining the context of communities, and deprived communities in particular, when establishing new services aimed at keeping people well and close to home.
The policy development that allows all GPs direct access to diagnostics in the community has greatly improved the management of patients in the community, and this is particularly true in deprived areas. The populations we serve would have been nearly exclusively reliant on the public system for diagnostics prior to this welcome initiative, as rates of private health insurance cover or ability to pay out-of-pocket would have been very low. We encourage the HSE to invest in community diagnostics based on population need and ensure ongoing access to these facilities for patients in the most disadvantaged areas.
Link workers providing Social Prescribing have a key role to play in providing a community-orientated resource in which human contact and support is given to an individual to address their social and psychological needs, including linking patients in with the GP and other health and social services (Kiely et al., 2022). They have the potential to make a difference in deprived areas, but the role is only one part of the solution as relevant community resources need to be in place for them to be able to work and they cannot address structural determinants of health on their own. Link workers guide patients to appropriate services and resources in their own community, and they can either be based in primary care services or within GP teams. Irish Deep End GPs have voiced a preference for the latter model where link workers are embedded within the practices (Smith and O'Donnell, 2018). This contrasts with the current HSE Healthy Communities model where there is a social prescriber in each designated Sláintecare Healthy Community, covering a large population with no clear targeting of those most in need of the intervention. Deep End Ireland has recently completed a randomised controlled trial examining the impact of link workers who were placed directly in practices, and the final results of this will be published soon (Kiely et al., 2021). Another service innovation we propose for consideration is the use of Focused Care Workers to support families that are experiencing stresses that can lead to very high health and social care needs (SQW, 2019). Our international Deep End network colleagues have created a programme tailored to the needs of these families and they are currently building an evidence base for its effectiveness (www.focusedcare.org.uk) Focused care workers have been found to reduce the inappropriate use of services such as emergency care (SQW, 2019).
Other community services such as children's disability services and child and adolescent mental health services providing care to patients from disadvantaged areas are particularly under-resourced and struggling to function. These have been identified by the Deep End Ireland group as priority areas for targeted improvement to improve long term outcomes for our young patients. Service provision should be based on population needs and weighted for higher rates of illness and disability in the most disadvantaged communities. We would like to emphasise our commitment to the focus of Sláintecare Healthy Communities. We note that some of the populations covered are very large – up to 50,000 people. There may be a need to target specific vulnerable groups within these areas to achieve maximum benefit.
Recommendations
The following are our main recommendations for the Strategic Review of General Practice:
Support for GPs
Provide infrastructure supports for new practices starting in areas of deprivation including the cost of premises and providing certainty around salaries of younger GPs working within practices
Enhance capacity for extended GP consultations to address complex health needs for patients in areas of deprivation
Introduce deprivation-weighted GMS capitation rates in accordance with increased need for patients in deprived areas and at a younger age
2. Expand the GP team
Expand capacity for GP practice nursing, administrative support and other potential roles such as link workers or focused care workers in practices in areas of deprivation
3. GP training
Explore measures to address the recruitment of GPs to work in areas of deprivation, starting at the undergraduate phase and continuing to the completion of GP specialist training
Consider measures to improve working conditions for GPs in areas of deprivation in order to improve retention
4. Policy making and service planning
Involve GPs who are working in the most disadvantaged communities in policy making and planning to ensure that decisions are equity focused
Establish a Primary Care Health Equity Working Group that would include representation from all stakeholder groups including frontline services and patients living in areas of deprivation
References
BARNETT, K., MERCER, S. W., NORBURY, M., WATT, G., WYKE, S. & GUTHRIE, B. 2012. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet, 380.
BLANE, D. N. 2018. Medical education in (and for) areas of socio-economic deprivation in the UK. Education for Primary Care, 29, 255-258.
BLANE, D. N., HANNAH, H., MCLEAN, G., LOUGH, M. & WATT, G. C. M. 2013. Attitudes towards health inequalities amongst GP trainers in Glasgow, and their ideas for changes in training. Education for Primary Care, 24, 97-104.
BOOMLA, K., HULL, S. & ROBSON, J. 2014. GP funding formula masks major inequalities for practices in deprived areas. BMJ : British Medical Journal, 349, g7648.
BUTLER, D., O’DONOVAN, D., MCCLUNG, A. & HART, N. 2022. Do undergraduate general practice placements propagate the ‘inverse care law’? Education for Primary Care, 33, 280-287.
CENTRAL STATISTICS OFFICE 2016. Census of Population of Ireland - Mortality Differentials in Ireland 2016-2017. Dublin: Central Statistics Office. https://www.cso.ie/en/releasesandpublications/in/mdi/mortalitydifferentialsinireland2016-2017/.
CRAMPTON, P. E. S., MCLACHLAN, J. C. & ILLING, J. C. 2013. A systematic literature review of undergraduate clinical placements in underserved areas. Medical Education, 47, 969-978.
DEPARTMENT OF HEALTH 2018. Estimating Prevalence of Autism Spectrum Disorders (ASD) in the Irish Population: A review of data sources and epidemiological studies DoH. https://assets.gov.ie/10707/ce1ca48714424c0ba4bb4c0ae2e510b2.pdf.
DHANANI, S. & BLANE, D. N. 2023. The Deep End GP Pioneer Scheme: a qualitative evaluation. Aust J Prim Health, 29, 155-164.
EGAN, J. & ROBISON, O. 2019. Integrating money advice workers into primary care settings: an evaluation. Glasgow Centre for Population Health.
GKIOULEKA, A., WONG, G., SOWDEN, S., BAMBRA, C., SIERSBAEK, R., MANJI, S., MOSELEY, A., HARMSTON, R., KUHN, I. & FORD, J. 2023. Reducing health inequalities through general practice. The Lancet Public Health, 8, e463-e472.
GRAY, D. J. P., SIDAWAY-LEE, K., WHITE, E., THORNE, A. & EVANS, P. H. 2018. Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJ open, 8, e021161.
GROTTI, R., RUSSELL, H., FAHEY, É. & MAÎTRE, B. 2018. Discrimination and inequality in housing in Ireland. ESRI and the Irish Human Rights and Equality Commission. https://doi.org/10.26504/bkmnext361.
GUTMAN, L. M., JOSHI, H., PARSONAGE, M. & SCHOON, I. 2015. Children of the new century: Mental health findings from the Millennium Cohort Study. Centre for Mental Health Report. London, UK: Centre for Mental Health.
HEALTH SERVICE EXECUTIVE 2021. CHO Governance of Children’s Disability Network Services. HSE. https://www.hse.ie/eng/services/list/4/disability/progressing-disability/pds-programme/documents/community-healthcare-organisation-governance-of-children-s-disability-network-service.pdf.
HSE 2009. On speaking terms: good practice guidelines for HSE staff in the provision of interpreting services. Health Service Executive Social Inclusion Unit. https://www.hse.ie/eng/services/publications/socialinclusion/emaspeaking.pdf.
ICGP 2016. Submission to the Oireachtas Committee on the Future of Health Care. Dublin: Irish College of General Practitioners. https://www.icgp.ie/speck/properties/asset/asset.cfm?type=LibraryAsset&id=CC712748%2DB46E%2D8F4A%2D84B162337E2081A7&property=asset&revision=tip&disposition=inline&app=icgp&filename=Submission%5Fto%5Fthe%5FOireachtas%5FCommittee%5Fon%5Fthe%5FFuture%5Fof%5FHealth%5FCare%2Epdf.
ICGP & AUDGPI 2023. Medical Student to General Practitioner - An urgent call to action Irish College General Practitioners & Association of University Department of General Practice in Ireland. www.ucc.ie/en/media/academic/epidemiologyandpublichealth/pdfdocs/ChronicDiseaseBurdeninIreland.EPICCReport.May2022.pdf.
JEFFERS, H. & BAKER, M. 2016. Continuity of care: still important in modern-day general practice. British Journal of General Practice, 66, 396-397.
KEARNEY, P., BUCKLEY, C., FITZGERALD, T., GAJEWSKA, K., MCHUGH, S., PALMER, B., O'KEEFFE, L. & STAMENIC, D. 2022. Chronic disease burden in Ireland. Evidence for Policies to Prevent Chronic Conditions (EPICC) School of Public Health UCC. www.ucc.ie/en/media/academic/epidemiologyandpublichealth/pdfdocs/ChronicDiseaseBurdeninIreland.EPICCReport.May2022.pdf.
KIELY, B., CLYNE, B., BOLAND, F., O'DONNELL, P., CONNOLLY, D., O'SHEA, E. & SMITH, S. M. 2021. Link workers providing social prescribing and health and social care coordination for people with multimorbidity in socially deprived areas (the LinkMM trial): protocol for a pragmatic randomised controlled trial. BMJ open, 11, e041809.
KIELY, B., CROKE, A., O'SHEA, M., BOLAND, F., O'SHEA, E., CONNOLLY, D. & SMITH, S. M. 2022. Effect of social prescribing link workers on health outcomes and costs for adults in primary care and community settings: a systematic review. BMJ open, 12, e062951.
MACKENBACH , J. P., STIRBU , I., ROSKAM , A.-J. R., SCHAAP , M. M., MENVIELLE , G., LEINSALU , M. & KUNST , A. E. 2008. Socioeconomic Inequalities in Health in 22 European Countries. New England Journal of Medicine, 358, 2468-2481.
MAÎTRE, B. & PRIVALKO, I. 2021. Technical paper on the measure of basic deprivation and consistent poverty in Ireland. Department of Social Protection. https://www.esri.ie/publications/technical-paper-on-the-measure-of-basic-deprivation-and-consistent-poverty-in-ireland.
MC CARTHY, N., HAYES, C., CREANE, D., O CIARDHA, D., SMITH, S. M. & CAMPBELL, A. 2024. Health data to support local communities. The Robert Emmet Community Development Project and Oliver Bond House case study within Optimizing Data to Integrate Health and Social Care in Dublin 8. Trinity College Dublin. https://doi.org/10.25546/104420.
MCCARTNEY, G., POPHAM, F., MCMASTER, R. & CUMBERS, A. 2019. Defining health and health inequalities. Public Health, 172, 22-30.
MCLEAN, G., GUTHRIE, B., MERCER, S. W. & WATT, G. C. 2015. General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland. Br J Gen Pract, 65, e799-805.
MCMAHON, A. & CUNNINGHAM, D. E. 2022. GP training in affluent practices in Scotland: the experiences of GP trainees and implications for their future practice. Education for Primary Care, 1-8.
MENTAL HEALTH COMMISSION 2023. Independent Review of the provision of Child and Adolescent Mental Health Services (CAMHS) in the State by the Inspector of Mental Health Services. Deep End Ireland. https://www.mhcirl.ie/sites/default/files/2023-07/Mental%20Health%20Commission%20Independent%20Reviews%20of%20CAMHS%20services%20in%20the%20State.pdf.
MERCER, S. W., FITZPATRICK, B., GUTHRIE, B., FENWICK, E., GRIEVE, E., LAWSON, K., BOYER, N., MCCONNACHIE, A., LLOYD, S. M., O’BRIEN, R., WATT, G. C. M. & WYKE, S. 2016. The CARE Plus study – a whole-system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: exploratory cluster randomised controlled trial and cost-utility analysis. BMC Medicine, 14, 88.
MUKHTAR, T. K., BANKHEAD, C., STEVENS, S., PERERA, R., HOLT, T. A., SALISBURY, C. & HOBBS, F. R. 2018. Factors associated with consultation rates in general practice in England, 2013–2014: a cross-sectional study. British Journal of General Practice, 68, e370-e377.
NICODEMO, C., MCCORMICK, B., WITTENBERG, R. & HOBBS, F. R. 2021. Are more GPs associated with a reduction in emergency hospital admissions? A quantitative study on GP referral in England. British Journal of General Practice, 71, e287-e295.
O CARROLL, A. & O’REILLY, F. 2019. Medicine on the margins. An innovative GP training programme prepares GPs for work with underserved communities. Education for Primary Care, 30, 375-380.
O’HALLORAN, A., MCGARRIGLE, C., SCARLETT, S., ROE, L., O’SHEA, M., ROMERO-ORTUNO, R. & KENNY, R. 2020. Living with Frailty in Ireland 2018. The Irish Longitudinal Study on Ageing. https://tilda.tcd.ie/publications/reports/pdf/w5-key-findings-report/Chapter%203.pdf.
OSBORNE, B. 2015. Irish General Practice - Working with Deprivation. Irish College of General Practitioners. https://www.lenus.ie/bitstream/handle/10147/617214/Irish_General_Practice_-_Working_with_Deprivation.pdf;sequence=1.
PARISI, R., LAU, Y.-S., BOWER, P., CHECKLAND, K., RUBERY, J., SUTTON, M., GILES, S. J., ESMAIL, A., SPOONER, S. & KONTOPANTELIS, E. 2021. Rates of turnover among general practitioners: a retrospective study of all English general practices between 2007 and 2019. BMJ Open, 11, e049827.
PEDERSEN, A. F. & VEDSTED, P. 2014. Understanding the inverse care law: a register and survey-based study of patient deprivation and burnout in general practice. International Journal for Equity in Health, 13, 121.
REES, E. L., GAY, S. P. & MCKINLEY, R. K. 2016. The epidemiology of teaching and training General Practices in England. Education for Primary Care, 27, 462-470.
ROLAND, M., BARBER, N., HOWE, A., IMISON, C., RUBIN, G. & STOREY, K. 2015. The future of primary health care: creating teams for tomorrow: report by the primary care workforce commission. Health Education England.
RUSSELL, M. & LOUGH, M. 2010. Deprived areas: deprived of training? British Journal of General Practice, 60, 846-848.
SCOTTISH GOVERNMENT 2022. Report of the Primary Care Health Inequalities Short-Life Working Group. Scottish Government Primary Care Directorate. https://www.gov.scot/binaries/content/documents/govscot/publications/independent-report/2022/03/report-primary-care-health-inequalities-short-life-working-group/documents/report-primary-care-health-inequalities-short-life-working-group/report-primary-care-health-inequalities-short-life-working-group/govscot%3Adocument/report-primary-care-health-inequalities-short-life-working-group.pdf.
SMITH, S. & O'DONNELL, P. 2018. Role of Links Workers & Social Prescribing. Deep End Ireland. http://deepend.ie/wp-content/uploads/2018/04/Deep-End-Ireland-Link-Workers-Report-2018.pdf.
SQW 2019. Qualitative evaluation of Focused Care - Final report. SQW. https://focusedcare.org.uk/wp-content/uploads/2020/11/FC-Qualitative-Eval.pdf.
STARFIELD, B., SHI, L. & MACINKO, J. 2005. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly, 83, 457-502.
STIRLING, A. M., WILSON, P. & MCCONNACHIE, A. 2001. Deprivation, psychological distress, and consultation length in general practice. British Journal of General Practice, 51, 456-460.
STRINGHINI, S., CARMELI, C., JOKELA, M., AVENDAÑO, M., MUENNIG, P., GUIDA, F., RICCERI, F., D'ERRICO, A., BARROS, H., BOCHUD, M., CHADEAU-HYAM, M., CLAVEL-CHAPELON, F., COSTA, G., DELPIERRE, C., FRAGA, S., GOLDBERG, M., GILES, G. G., KROGH, V., KELLY-IRVING, M., LAYTE, R., LASSERRE, A. M., MARMOT, M. G., PREISIG, M., SHIPLEY, M. J., VOLLENWEIDER, P., ZINS, M., KAWACHI, I., STEPTOE, A., MACKENBACH, J. P., VINEIS, P., KIVIMÄKI, M., ALENIUS, H., AVENDANO, M., BARROS, H., BOCHUD, M., CARMELI, C., CARRA, L., CASTAGNÉ, R., CHADEAU-HYAM, M., CLAVEL-CHAPELON, F., COSTA, G., COURTIN, E., DELPIERRE, C., D'ERRICO, A., DUGUÉ, P.-A., ELLIOTT, P., FRAGA, S., GARES, V., GILES, G., GOLDBERG, M., GRECO, D., HODGE, A., IRVING, M. K., KARISOLA, P., KIVIMÄKI, M., KROGH, V., LANG, T., LAYTE, R., LEPAGE, B., MACKENBACH, J., MARMOT, M., MCCRORY, C., MILNE, R., MUENNIG, P., NUSSELDER, W., PANICO, S., PETROVIC, D., POLIDORO, S., PREISIG, M., RAITAKARI, O., RIBEIRO, A. I., RIBEIRO, A. I., RICCERI, F., ROBINSON, O., VALVERDE, J. R., SACERDOTE, C., SATOLLI, R., SEVERI, G., SHIPLEY, M. J., STRINGHINI, S., TUMINO, R., VINEIS, P., VOLLENWEIDER, P. & ZINS, M. 2017. Socioeconomic status and the 25 ×25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women. The Lancet, 389, 1229-1237.
SYED, S. T., GERBER, B. S. & SHARP, L. K. 2013. Traveling Towards Disease: Transportation Barriers to Health Care Access. Journal of Community Health, 38, 976-993.
TELJEUR, C., O’DOWD, T., THOMAS, S. & KELLY, A. 2010. The distribution of GPs in Ireland in relation to deprivation. Health & Place, 16, 1077-1083.
TUDOR HART, J. 1971. The Inverse Care Law. The Lancet, 297, 405-412.
VESTESSON, E. M., DE CORTE, K. L. A., CRELLIN, E., LEDGER, J., BAKHAI, M. & CLARKE, G. M. 2023. Consultation Rate and Mode by Deprivation in English General Practice From 2018 to 2022: Population-Based Study. JMIR Public Health Surveill, 9, e44944.
WATT, G., BROWN, G., BUDD, J., CAWSTON, P., CRAIG, M., JAMIESON, R., LANGRIDGE, S., LYON, A., MERCER, S. & MORTON, C. 2012. General Practitioners at the Deep End: The experience and views of general practitioners working in the most severely deprived areas of Scotland. Occasional paper (Royal College of General Practitioners), i.
WORLD HEALTH ORGANIZATION 2008. The World Health Report 2008: Primary Health Care Now More Than Ever. Geneva: World Health Organization.
WORLD HEALTH ORGANIZATION. 2023. Social determinants of health [Online]. WHO,. Available: https://www.who.int/teams/social-determinants-of-health [Accessed 20/12/14].