Australia prides itself on being the land of the opportunity. Unlike the American paradigm, we put equality and access to a leg up within our world view around opportunity. But what does this mean in terms of healthcare funding?
Scotland’s demography has long been acknowledged as less affluent than the rest of the UK. The Thatcher reforms hit towns like Glasgow especially harshly, creating what is now known as the “Glasgow Effect”. This captures the inter-generational hopelessness and corresponding desire to have a right to work seen in that town. More than half of all of the general practices in Glasgow support patients in areas of severe disadvantage.
The disadvantage scale of relevance to healthcare has been developed at the University of Glasgow. It clearly shows an inverse relationship between postcode, presence of multi-morbidity and life expectancy. Along the train line which runs east to west in the city, life expectancy deteriorates by over a year every time the train stops. The gap is over 18 years between the best and worst performing areas.
In response, the University has facilitated “GPs at the Deep End”. It represents the top 10% of practices as inferred by their comparative disadvantage. With just on 1000 practices in Scotland, the assignment makes intuitive sense too. Patients in these areas are either hard to reach or easy to ignore, depending upon your perspective.
Auspiced by the College of General Practice, the group has managed to spearhead a range of interventions targeted at bridging the gap in health outcomes and also attracting more general practitioners to work in these catchments. One of their keynote initiatives is the Link Worker project. Underpinned by a strong evaluation and replication agenda, the project deploys full-time community liaison workers within practices. They work with patients who resist therapy, would benefit from multiple health and social welfare interventions or are simply more psychologically complex than an ordinary medical consult can unpack.
The result is that GPs are more prepared to open the Pandoras Box associated with these patients and get to the bottom of what is holding them back from better health. They know that in doing so they have a complementary resource who can follow through with the patient. The process overcomes the “medicalisation” of the symptoms so many of these folks have when really what is required is integrated health and social care. The Link Workers are paid the equivalent of an entry level nursing salary. They are accompanied by half their salary in project support funds to provide opportunity to instigate other actions which will address the seven objectives of the project.
In another project, each practice has been assigned a dedicated Social Worker from existing provider resources. Social Workers in Scotland only deal with patients in real crisis, so where Link Workers and Social Workers co-exist, there is little overlap in patient cohort. Strong calls are being made, based on preliminary data, to extend this process across the country.
Both initiatives go a long way to addressing the Inverse Care Law associated with disadvantaged populations. In other words, if we deliver the same level of care across the population, we in fact reduce the health outcomes of those with the highest needs. In the interests of a fair go, it would appear that Australia needs to broaden its “Closing the Gap” approach, now fruitfully entrenched for indigenous peoples, to other communities suffering the results of disadvantage.
The Irish have just started to embrace the lexicon of “Deep End” medicine to support policy conversations in their context. I would be happy to fall off into the Deep End too. It actually represents a step up from the circumstances our practice finds itself in right now!
Tracey Johnson, General Manager, Inala Primary Care