The NHS must be at its best where it is needed most

David reflects on the impact of the pandemic on general practice and the importance of targeting resources to mitigate health inequalities.

The Covid-19 pandemic has shone a spotlight on the stark inequalities that exist in our society. We have seen how certain groups in the population – ethnic minorities, care home residents, and those living in areas of socio-economic deprivation – have been hit hardest by the disease.

Health inequalities – the unfair and avoidable differences in health status seen within and between countries – have been around since records began. But they are not inevitable, and policies can make a difference, even during a global pandemic (this link will take you away from our website).

The conditions in which people are born, grow, live, work and age (“social determinants of health”(this link will take you away from our website)) are shaped by the distribution of money, power and resources at global, national and local levels. However, despite decades of policy reports and rhetoric about health inequalities, the inverse care law (this link will take you away from our website) and the distribution of NHS resources is rarely mentioned. This needs to change.

In the recent Deep End GP report 36 (this link will take you away from our website) on ‘General Practice in the time of Covid’, twelve General Practitioners working in areas of concentrated socio-economic deprivation in Glasgow and Edinburgh describe some of the challenges that Covid-19 has presented to general practice and the “invaluable” support provided by community links practitioners.

Challenges

The immediate response to lockdown involved practices moving online and the NHS protecting itself by putting much of its work on hold. The report outlines GP concerns during this period, about “missing patients”, vulnerable children and families who have had their support networks withdrawn, and the increasing burden of financial and mental health issues.

There are also new types of inequality arising from increased use of remote consulting by phone or video, and the implications for women’s mental health and child wellbeing as more women stay at home to look after children, losing their financial security and independence.

Staff and patients adapted rapidly to telephone and video consultations. However, there were difficulties: although the video software was easy for us to use, we found many of our patients’ smartphones were not up to date; others had no credit on their phones; and some just don’t have phones.

The report describes new and continuing challenges ahead include the clinical backlog, the complications of neglected conditions, and an epidemic of financial and psychological distress, set against endemic issues of multimorbidity (the presence of multiple health and social problems) (this link will take you away from our website), health care fragmentation, inequity in health care provision (this link will take you away from our website) and the workforce crisis in general practice (this link will take you away from our website). Yet despite the many challenges ahead, Deep End GPs believe there is hope for the future.

Building back better

The essential element of efficient and equitable primary health care is unconditional, personalised continuity of care for all patients, whatever conditions they may have. Without such care, complications occur sooner and patients present earlier to out of hours, A&E and other emergency services. High quality and equitable health care in the community protects emergency services from overload.

Generalist clinical care linked to local services and community resources also reduces health care fragmentation – that is, care lacking continuity and coordination. The Deep End report highlights how good team working, peer support, and improved communication with secondary care colleagues and community pharmacists have made a difference. But community link workers and practice-attached financial advisors have been “invaluable” in Deep End practices.

How do practices in areas of deprivation manage without a Link Worker when so many patients are struggling with mental health and isolation issues? Link Workers are better placed to connect with community organisations that have quickly adapted to offer support with food and prescription delivery, and activities to counter isolation and mental health problems during lockdown.

The recent Scottish Government report “Re-mobilise, Recover, Re-design: The Framework for NHS Scotland” (this link will take you away from our website) outlines NHS priorities for getting back to normal and preparing the NHS for the winter season. It also includes a commitment to address inequity in health and health care.

As GPs working in areas of socio-economic deprivation, we welcome this commitment. The inverse care law continues in Scotland as the difference between what practices can do and what they could do with more time and better connections. While we recognise that the underlying social and structural determinants of health inequalities are deeply ingrained and institutionalised, the Deep End report highlights four immediate actions to reduce inequity:

• Increasing the provision of community link workers from 50% to 100% of Deep End practices in Glasgow;
• Embedding financial advisors in general practices as part of the new Scottish Social security system;
• Expanding the model of embedding mental health workers in general practice; and
• Establishing new metrics to inform, monitor and evaluate policies to improve health equity.

Health inequalities are not inevitable, even during a pandemic. But if the NHS is not at its best where it is needed most, then health inequalities will inevitably widen.

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