Life at the Deep End

Dr Yasar Khan on the challenges and privileges of running a ‘Deep End’ practice in a deprived area

Deep End GP surgeries are those providing healthcare services to the 15-20% most deprived UK populations, as identified by the index of multiple deprivation rank. On average, life expectancy is reduced by seven to nine years in the most deprived populations compared with the least deprived.

The Covid pandemic has exposed and further exacerbated these underlying inequalities – related mortality rates are four times higher among those who are under 65 in the poorest 10% of areas in England. Meanwhile, patients aged 50 in the most deprived areas consult at the same frequency as those aged 70 in the least deprived.

Furthermore, the impact of a rise in the cost of living is disproportionately experienced by those at the lowest income decile due to a higher relative total spend on gas and electricity, reduction in real-terms pay and less pre-existing savings. Those with least incomes are having to make hard choices between prioritising eating and/or heating and paying debts to avoid a state of destitution.   

Disproportionate challenges

Deep End GP practices face numerous disproportionate challenges. Patient populations consist of multi-morbidity in younger age groups, including higher rates of mental illness and substance misuse with related polypharmacy. Patients who lack sufficient English language skills are overrepresented in more deprived regions of the UK, and a lack of proficiency in the national language is associated with difficulties navigating public services, attaining employment based on structured work contracts, accessing education and training, advocating individual rights, and using healthcare facilities – all of which result in poorer social and health outcomes.

Health literacy rates are lower among those in lower income deciles, immigrants and elderly patients. Lower health literacy is associated with higher rates of A&E attendance, hospital admissions, non-participation in primary health prevention, non-concordance with medication regimes and avoidable mortality rates. NHSE has adopted a digital transformation policy agenda whereby the ‘front door’ to NHS services is digitalised, but approximately 10% of the UK adult population are non-internet users, with those on lower incomes more likely to be non-users. 

Primary care continues to experience unparalleled challenges in relation to the recruitment and retention of GPs, with a sustained fall in the number of qualified GPs arising for the first time since the 1960s. Between 2015 and 2020, the number of FTE GPs reduced by 1,863, and areas that are relatively more socioeconomically deprived experience disproportionate GP shortages. To make matters worse, the ARRS scheme – introduced to ensure increased recruitment of allied health professionals into primary care – makes no reference to providing tailored support to Deep End practices experiencing acute staff shortages. 

Overall, GP surgeries operating within more deprived populations are allocated approximately 7% less funding per weighted registered patient compared with those serving the least deprived. The Carr-Hill funding formula is fundamentally inequitable, leading to a relative reduction of Deep End GP surgery resources; this fuels adverse health outcomes and widening health inequalities.

 Julian Tudor Hart’s inverse care law (1971), whereby a mismatch of resources to needs exists, appears systemically ingrained in the UK general practice core funding formula. 

My Deep End surgery

Lea Vale Medical Group is located in Luton, Bedfordshire. In February 2020, the practice received an overall ‘outstanding’ CQC status. Its registered patient-list size has increased by 26% – from 24,781 in January 2019 to 31,136 in October 2022. The GP FTE headcount has increased by 25% over the same period. But no additional capital infrastructure in terms of extra clinical or admin rooms have been allocated to accommodate this recent expansion. 

The practice provides bespoke services to particularly vulnerable groups, such as the homeless and those seeking asylum/refugees; 26% (8,023) of registered patients do not speak English as their first language. So, given the unique necessities of its patients as a Deep End practice, the surgery doors have always been kept open throughout the Covid pandemic.

This open access, a close working partnership with local stakeholders and recent town developments have been the main drivers of the recent growth. Strategies adopted to optimise GP recruitment and retention included: expansion as a training practice; weekly 1:1 mentoring sessions for salaried GPs; investment in training and development leading to additional professional qualifications; flexible working; encouragement of portfolio careers; and a relentless focus on medical education, including medical student teaching. 

Despite the challenges, it is a privilege to work as a GP at a Deep End practice and witness the profound potential of primary care in optimising outcomes for some of the most vulnerable individuals in society. However, UK policy requires a radical transformation whereby equitable resources are provided to Deep End GP surgeries to allow genuine ‘levelling up’ to materialise. 

Dr Yasar Khan is a GP partner at a Deep End practice in Luton, Bedfordshire