Dr Chris Williams
Joint Chair of Scotland Council Royal College of General Practitioners (RCGP)Dr Chris Williams discusses the challenges and inequalities within Scotland’s healthcare system
Inequalities weigh heavily on the health and overall wellness of Scotland’s population. The origins, causes and effects of these are varied and complex, and the starkest measures of health inequalities, including life expectancy, are not narrowing. Carefully considered and targeted action is needed to address and reverse these as a matter of urgency.
Access to healthcare is increasingly recognised as a social determinant of health, but although activity can be described in terms of numbers of appointments, it is less easy to demonstrate unmet need, the term ‘inverse care law’ was coined fifty years ago, but this disparity is still an issue in deprived areas of Scotland- those individuals and groups who are most in need of health care are the least likely to receive it. A rather exhaustive body of evidence, for example Stewart Mercer and Carey Lunan’s study from last year, outlines the implications of deprivation on general practice outcomes in Scotland.
General practice delivers universal, local, comprehensive, and holistic care, and these attributes imbue it with some of the necessary tools to address inequalities on the frontline of healthcare. The Scottish Government states that tackling health inequalities is a priority; in order to achieve this, an appropriately resourced and staffed general practice must be at the forefront of healthcare policy.
Scotland’s general practice workforce faces crisis in both the dwindling number of GPs and unmanageable workload. At the same time as our population has grown and with a demographic shift ongoing, we endure a reduction in the estimated whole time equivalent GP numbers in Scotland. We simply have not seen the strategy or investment necessary to achieve appropriate staffing levels, and unfortunately, this can have real effects on patients and services. Targeted action to recruit and retain more GPs to work with deprived populations or in ‘Deep End’ practices are crucial. It is vital that our medical professionals are well versed in the effects of health inequalities, and learning should be embedded at all stages of medical study. GPs and their teams should all have supported protected learning time, with resource to allow them to undertake reflective practice in recognition of the high emotional labour of this work.
Another significant opportunity to understand and improve outcomes is with better data gathering within primary care and drawing intelligence from this. The data capabilities in secondary care keep its challenges at the forefront of policy makers minds, while the workload and impact of general practice is obscured. The data deficits also impose limitations on the ability of policy makers to effectively undertake strategic workforce and workload planning. We cannot know what we cannot measure, and so the enhanced collection and analysis of data around consultations as well as immediate measures such as health service usage, chronic disease parameters and the mental wellbeing of patients is crucial to enable the effective deployment of resources. Sub-analysis of Scottish GP workforce and workload data in terms of practice deprivation status should also be routinely undertaken to demonstrate the complexity and requirements associated with deprivation.
GPs know the value of being able to offer longer appointment times to patients in some situations, especially to those with complex needs who would benefit from careful, holistic conversation. It is often the more deprived communities which experience greater deficits in GP staffing levels- disparity where resourcing and workload issues intersect to the detriment of these communities.
It’s important to recognise that while the dialogue around health inequalities in Scotland has tended to focus on socioeconomic deprivation, other inequities also deserve consideration. Language barriers, for example, contribute to differential health outcomes. Translated appointments take longer, and there is a risk of missing nuances. The elderly, also, face challenges, with over-stretched care services and digital exclusion. We know that LGBTQ+ people face discrimination and have higher levels of mental health difficulties. These needs must be considered holistically to ensure Scotland is able to treat its whole population in an equitable and effective manner.
In short, Scotland needs a fully staffed and resourced general practice, particularly in areas of profound socio-economic deprivation. The Scottish Government’s commitment to reducing health inequalities is very welcome, but the implementation gap must be closed. The good news is that there is clear evidence that interventions can help – the wellbeing of our GPs, the sustainability of our NHS, and the health of our population.