In a rich discussion with Dr Ruth Bromley, GP and former Chair of Manchester Health & Care Commissioning (MHCC), Harry Blacklock, Research and Policy Analyst for Curia’s NHS Innovation and Life Sciences Commission, asked about her work in primary care and tackling health inequalities across the UK.
Starting our discussion, I asked Dr Bromley about her background in the wide range of health and social care that she has worked in throughout her career. Dr Bromley explained that she practices as a GP in a deprived area of Manchester, which faces long-standing issues of poverty and a lack of opportunities for the community. She noted the impacts of these socioeconomic factors “with patients having multiple illnesses that you wouldn’t ordinarily have been taught to expect until their sixties or seventies”.
However, with the financial crisis of 2008 and subsequent austerity, her patients were the “first hit” by economic hardship. It was the resulting noticeable depreciation in health that inspired Dr Bromley to the South Manchester CCG board, which later became MHCC. Dr Bromley was then substantially elected by GPs as Chair of the MHCC in July 2018, where she has worked with multiple local authority leaders on social determinants of healthparticularly homelessness.
Current conditions in primary care
Asking Dr Bromley about the current pressures on NHS services and her experience as a primary care clinician, she explained that the number of patients and subsequent paperwork has increased “exponentially”. Many GPs are working till late into the evening, despite the profession being proposed as a “family-friendly career path” for clinicians. This is all alongside a well-documented decline in the number of GPs in the UK.
She added that ongoing tensions exist between what GPs might want to be able to deliver for their patients, what is humanly possible on any given working day and what is safe for patients to receive and clinicians to provide. It is easy to frame this through the challenge of getting a GP appointment or to describe this as a tension between primary and secondary care. She explained that this is sometimes how it plays out, but in reality, “There are too few people trying to do too much work in an ever-increasingly complex healthcare system.” GPs are frequently blamed for responding to contractual arrangements despite working well above and beyond their contractual duties and core working hours.
Dr Bromley stated her worry for the coming years with regards to the rising NHS backlog and the patients who are waiting years for operations that directly impact their ability to work and therefore provide for their families. She added, “The NHS will feel the impact of a socioeconomic crisis this winter that will adversely affect the health of those living in deprivation for years to come.”
Integrated Care Systems
Following the arrival of Integrated Care Systems (ICS) on 1st July 2022, Dr Bromley was asked whether she believes the new system is a genuine opportunity for more coordinated treatment and care. She explained that the potential for improved outcomes was real but that the impact of ICS will be significantly constrained by the current conditions facing the NHS, which will create tension with the focus on preventative health. Dr Bromley added that “NHS and social care employees have worked relentlessly to deliver care throughout the pandemic; they are exhausted but prepared to do their very best. We need to think carefully about the demands we continue to place upon our colleagues.” Furthermore, broader integration with other public sector services, such as housing, education and the criminal justice system, akin to the devolution model originally pioneered in Greater Manchester, is, she believes, necessary to create the maximum gain for communities.
On integrating NHS structures, Dr Bromley explained that a lot of senior time has been spent delivering the NHS transformation agenda and that “This energy now needs to be directed back towards community provision and providing frontline care.” The new structures potentially create a stretched hierarchy and close attention will need to be given to delegating decision-making power to communities and even closer to where patients receive their care. She explained that this is essential to achieve the stated goals of the NHS Long Term Plan.
Dr Bromley has undertaken inspiring work tackling health inequalities, particularly as the Clinical Lead for Homelessness in Greater Manchester. She detailed her experience working with Mayor of Greater Manchester, Andy Burnham, where they fostered a holistic approach to tackling homelessness, which encompassed understanding the impact of psychological trauma upon adult behaviour. On the cyclical nature of homelessness, she added that the high number of families and children in temporary accommodation was a deep concern as “Being homeless as a child is one of the biggest risk factors for being homeless as an adult.”
Dr Bromley re-emphasised the need for all public services to tackle these issues, detailing her experience of schools and healthcare services being unaware of children being homeless. This creates missed opportunities to act to mitigate the significant impact homelessness has on physical and mental health, educational attainment and quality of life. She explained that there simply is not enough resource available to ensure that young people are consistently protected from the long-term harm that homelessness can cause.
Asking which social determinant had the biggest impact on health inequalities in Greater Manchester, Dr Bromley noted that early-years experiences were the most influential social determinant. Having seen first-hand that early adversity and psychological trauma have life-long impacts on life expectancy and opportunities, she explained that as Chair of the MHCC, she advocated for discussing and promoting best care for children a “third of the time”, given the large young person and student population in Manchester.
Improving women’s health
Following the publication of the Women’s Health Strategy for England, Dr Bromley outlined her thoughts on the strategy and her experience in dealing with women’s health inequalities. She explained the need for ongoing attention to women’s health issues, stating “We need to wonder why women aren’t always diagnosed with heart attacks when they present with chest pain.” and asked, “Why it took so long for the law to accept that the place women are most unsafe is in their own homes.” She added that there are other issues that need to change, particularly cultural tendencies for women to place themselves at the “bottom of the list” within their households, for treatment and care.
Finally, I discussed with Dr Bromley her experience of health inequalities in those from minority ethnic backgrounds and the potential solutions to address disproportionate outcomes. Dr Bromley explained her experience of working with colleagues who have experienced racism working within the NHS and the need to ensure their voices are heard. She emphasised the need for diversity within the decision-making structures of the NHS, given the diversity in society and the different healthcare needs of communities. During the restructuring of ICS, the NHS has been granted an opportunity to rethink the diversity in board structures across the country, but there remains further work to be done.
In our concluding remarks, Dr Bromley reflected that whilst difficulties exist in the health system, there is a genuine opportunity for change to transform population health. She noted the proud legacy of MHCC in tackling inequalities and the potential for the country to come together to achieve these goals.