The figures are stark enough but don’t tell the whole story – cancer rates in lower socio-economic groups are more than double the rate in better-off populations; males living in the poorest neighbourhoods will on average die 4.3 years earlier than those living in wealthier neighbourhoods; circulatory diseases are 120% higher in the lowest occupational class.

The reality of daily living for many in areas of deprivation is even starker; people struggling through chaotic lives, often made worse by the recent recession, with multiple health and social problems. Their plight is worsened by a lack of access to the medical and social services they need, which have also been subject to recessionary retrenchment.

At the coalface of dealing with these patients are GPs in the disadvantaged areas. While they find the work they do to be rewarding, they struggle in treating and advocating for their patients against a backdrop of poor infrastructural and practice resourcing.

A GP perspective

According to Dr Edel McGinnity, who practises in Mulhuddart in north-west Dublin: “Practically your whole day is spent firefighting acute medical and social problems. It’s difficult to get to do smears, to talk to people about smoking, diet, etc. 

One-in-five of our medical card patients over 40 has diabetes. 

“One of the critical things about GPs in deprived areas is that relatively speaking our practices would tend to have less income. This means we often do not have adequate resources to provide the services needed. Roughly speaking, our income under the medical card scheme would be only 70% of the national average, because our practices would tend not to have large numbers of elderly patients, who attract higher capitation rates.

“Our income is lower even though our patients get much sicker at a much younger age than the average. A 50-year-old patient in an area of great disadvantage consults at the same rate as a 70-year-old in the most affluent area.”

Recent report 

Brian Osborne’s recent report on doctors in disadvantaged areas, carried out for the ICGP,¹ showed that where Dr McGinnity practises, the ratio of GPs to population is one to 3,600. In north Dublin as a whole, it is one to 2,500, and nationally it is one to 1,600.

Not only is the workload greater for GPs working in these areas, but as the payment is below the average, this is often one of the reasons it is difficult to find GPs to work in disadvantaged locations, Dr McGinnity points out.

“Even if everything was equal, and the same number of GPs practised in every area of the country, the GP workload in disadvantaged areas would still be much greater. This is because you have twice the number of chronically sick and prematurely dying people.

“To put it another way, because general practice in disadvantaged areas is not resourced and staffed properly, then GPs are effectively only offering half the service, because you have twice as many patients as the average GPs and twice as many of those patients would have a higher number of illnesses than the national average.”

The effect of austerity

Looking after patients in disadvantaged areas has become more of a challenge during the recent period of austerity, which hasn’t really gone away as far as primary care is concerned. 

Says Dr McGinnity: “Austerity caused huge problems, because people’s social issues worsened, and because the services deteriorated. The recruitment embargo in the health service caused major difficulties, because the turnover of staff in deprived areas can be quite high due to the work being so tough, so staff would leave in greater numbers but couldn’t be replaced. Austerity had a disproportionate effect in disadvantaged areas, with services becoming depleted due to shortages of staff.”

She points out that until recently, the local family therapy service In Mulhuddart had not been taking referrals at all from general practice. 

“Worse still, the local CAHMS (Child and Adolescent Mental Health Service) is not taking referrals at all at the moment, and this is a serious issue for public patients in disadvantaged areas. 

“I had a troubled young person in today and that patient needed a referral. CAHMS have told me they are short of consultants, they can’t get locums, they are not taking referrals, we will keep your patient’s case details on file and if you have any concerns send the patient to the hospital ED, which is of course, ridiculous. I’ve had to make numerous phone calls trying on behalf of these young patients, often in serious distress and in need of help.”

Setting up Deep End Ireland

It is with a view to finding solutions to the many issues facing health and social services in areas of deprivation that Edel McGinnity was instrumental in setting up the Deep End Ireland project.

“The group is not about lobbying for doctors, we are lobbying for better patient services in deprived areas. And it’s not just a case of poor access to ancillary services outside the GP practice. A typical GP in such an area will have twice as many challenging patients (in terms of their health) on their list than they would have in middle class area of south Dublin. 

“For example, we might have a patient coming in their fifties with diabetes, chronic lung disease, depression; they might have a social/medical problem with their child who’s just been expelled from school, and maybe older child who has addiction problems. Despite the best efforts of GPs in deprived areas, patients don’t always get the same level of GP service they might get in better off areas, simply due to work pressures and poor resources.”

Poor access to hospital services for public patients is a national problem that impacts greatly on people living in deprived areas. “Earlier this year there was an 11-month wait for an ultrasound at the local hospital, Connolly in Blanchardstown, versus two months for a public patient at St Michael’s in Dun Laoghaire. Since then, the local waiting list has improved, mainly because of pressure put on the HSE, which is now outsourcing the waiting list elsewhere.”

Advocating on behalf of patients

Edel McGinnity stresses that advocating on behalf of your patients is a key component of working in deprived areas; “Really, most of the patients we treat are very inspiring. Some of the traumas they go through would be unimaginable for most of us. That they can even get up in the morning is an achievement. And the work we do can make a difference. We spend a lot of our time writing letters looking for things on behalf of our patients. We could be writing letters to the probation service, to the prison service, or looking for a clothing allowance in any given day. I’ve even been asked to write a letter to a money lender on behalf of a patient in difficulty. This type of advocacy can really make a difference.”

Edel believes properly functioning primary care teams (PCTs) can work particularly well in areas of disadvantage. She accepts that there are problems with GP engagement with PCTs, but says this may not always be the fault of the HSE or Department of Health.

“I don’t think a system will ever work properly if some GPs will say: ‘I want my patients to get physio, OT… I want this service and that service, etc from the HSE, but at the same time saying ‘no, I’m not going to a meeting with other PCT members or administrators’. I’m not going to engage with the local PCT because I don’t like the HSE’. Admittedly, that’s not the only reason why the primary care team system hasn’t been an unqualified success, although it has worked well in our case and in many other cases. But at the same time I don’t think we can just blame the HSE for everything and walk away from any responsibility to help provide a better primary care system.

“Having said that, I appreciate that there will always be a tension between your relationship with the HSE and your relationship with your patients.”

Social work on behalf of patients

“I would firmly believe that being essentially a social worker on behalf of your patients is part of our job, although I realise many GPs would feel it isn’t. The most common feeling among patients in deprived areas is of exclusion, of alienation. Their GP is one of the few people they can go to where they won’t be ‘frozen out’; told they don’t have the right address, the right documents, the right information etc. We are always there for them, and we never send people away.”

Dr McGinnity says in campaigning for better services, doctors involved in the Deep End Ireland project would point to the need for initiatives like a grant for an extra salaried GP or nurse in practices that need them, and a deprivation allowance similar to the rural practice allowance. 

“This would help us get the resources to find additional time to deal with the complex patient cohort we have. If we were to be granted a ‘wish list’ of the most urgent things we need, I would list these as: Support for developing premises; a grant for additional practice staffing; and supporting the hiring of necessary staff for primary care teams and the recruitment of additional public health nurses, who are totally overwhelmed at the moment.”

As to difficulties encountered in getting GPs to work in deprived areas, Dr McGinnity says in her experience, most young GPs who train in deprived areas would want to go back to work in these areas, but they need to be encouraged to do so through better resourcing of general practice.

Dr McGinnity says working in areas of deprivation, despite the many challenges, can be interesting and rewarding. “If you, for example, succeed in ‘turning around’ a young person who has major addiction problems, that’s very satisfying.”

The swimming pool analogy

“The reason we called the project ‘GPs at the Deep End’ is partly because this is a ‘swimming pool’ analogy. On the surface of the water, everything looks level, but underneath there are hidden depths – this is how we feel resources are distributed at present – a uniform level of resources cannot deal with the depth of problems in some areas.

“We initiated the Irish project after the example of the Scottish Deep End Group. GPs in the Scottish Deep End project work in 100 general practices serving the most
socio-economically deprived populations in that country, and work to highlight the medical and social needs of these populations and to campaign for better resources for the practices that serve them.

“As GPs who have formed Deep End Ireland, we can’t officially say we represent the most deprived practices until we have mapped out and identified exactly where those patients are. We need this type of data in order to have the evidence to allow us to campaign effectively for improved resources. Getting this information, however, is proving to be a difficult exercise due to data protection issues,” Dr McGinnity says. “We would hope, however, to have the data available later this year. 

“The research is being carried out for us by Susan Smith, Professor of Primary Care Medicine at the Department of General Practice in the RCSI, with Trutz Hasse of the Pobal Group, who has been instrumental in drawing up a deprivation index.

“The Deep End Ireland project is not about lining GPs’ pockets, but about getting better services in place. Obviously, with a new contract set to be negotiated this year, resourcing GP services in deprived areas needs to be a key component of this,” Dr McGinnity says.

“Most of the GPs working in deprived areas would be aged 50 plus, so many of these will be retiring in the not too distant future. Unless proper infrastructure is put in place to encourage younger GPs to work in areas of deprivation, we could turn out to be a dying breed.” 

For more information about the Deep End project in Ireland, contact susansmith@rcsi.ie

References

1. Irish General Practice: Working with Deprivation. Brian Osborne, ICGP Assistant Medical Director- available on www.icgp.ie