Doctors in deprivation: prescribing on the frontline

By Jessica Bradley

In a windowless conference room in Oldham, a guest speaker has just finished delivering a talk over video call, projected onto the wall in front of us, when a woman raises her hand to ask a question. “A few years ago, one of our GPs died by suicide,” she begins. “It’s changed the culture at our practice.”

The woman, a GP herself, continues to talk about the stress that comes with working as a GP in a deprived area. She alludes to the idea that this stress may have contributed to her colleague’s death. And, at this precise moment, the call cuts off. We never find out what her question was. 

We’re halfway through the morning, and the conference attendees have already been asked several times by the organisers to talk among themselves about the positive aspects of working in deprived areas. There will be a ‘joyful’ feel to the ‘Doctors in Deprivation’ conference, even if some people need reminding every 10 minutes.

We’ve found ourselves here, on a Thursday at the end of June, because of a little-known principle in medical care known as the ‘Inverse Care Law’. First proposed by the general practitioner Julian Tudor Hart in 1971, the Inverse Care Law describes how “good medical care tends to vary inversely with the need for it in the population served”, as he wrote in The Lancet at the time. Clinicians working in deprived areas have more patients and have to fit more appointments into a working day, often resulting in a lower quality of care.

GP practices in more deprived areas of England — the areas that many of those attending the conference work in — are relatively underfunded, under-doctored and perform less well than those in other parts of the country, even though their patients are at higher risk of developing multiple health problems. It’s harder to recruit, and retain, doctors in poorer areas, too. In fact, Between 2018 and 2020, women in the 10% most deprived areas could expect to live 19 fewer years in good health than in the 10% least deprived. For men, this gap is 18.6 years.

Despite this, when GPs receive their training, the challenges of working in an area of deprivation is barely mentioned. It was a frustration borne out of this oversight that led clinicians from the Oldham-based Shared Health Foundation to think about how GPs can be equipped and supported to stay in these jobs at a time when so many are burning out. From a conversation in the pub one evening, the Doctors in Deprivation programme was born.

“It’s hard to recruit doctors to work in areas of deprivation,” Farvah Javed, a GP in Oldham, told me on a recent Monday. “It’s tougher… because there are more complexities with patients. So we have fewer GPs in deprived areas, which doesn’t make sense. You need more.”

The symptoms 

It’s late morning at the conference. A GP with no sign of waning energy is standing at the front of the room, clicking through to a new slide every now and then, telling us about a patient. She’s a ‘great mum’, the doctor says, but her daughter’s attendance at school is only 12%. When she is at school she gets bullied, the favoured jibe being that she smells of urine. This is because she wets the bed, but she has sensory issues, and doesn’t like going in the bath.

The woman has spent years trying to get her daughter an autism assessment, but her recent fourth attempt ended with a letter telling her that GPs can no longer refer their patients to CAMHS — that’s child and adolescent mental health services — and that has to be the school instead. But the woman’s relationship with her daughter’s school has completely broken down.

They’re living in poverty. The mum has joint pain that’s so bad she can’t carry much food back from the shops. She can’t afford to get food delivered, either, so she doesn’t eat a lot.

The GP is not telling this story because the woman is an exception among their patients. On the contrary, patients like her are pretty much the rule for the GPs in this room. Having to navigate the cross-section between health and people’s complex lives is their bread and butter.

The prescription

After medical students complete a five-year degree and two foundation years of training, they must complete a specialist training programme as graduates to become a GP. Very few will come from a disadvantaged background; just 4%, according to one study. Many GPs work in areas of deprivation with little prior knowledge of or exposure to the socioeconomic issues their patients are dealing with, nor of how this influences their health, their ability to attend appointments, and their willingness to trust and cooperate with medical practitioners.

The Shared Health clinicians designed a three-year course to bridge that gap. It is still the only deprivation programme in England. As part of the course, first-year students have three-and-a-half hours of practical learning per week, and after their first year, an additional two hours of study, including a tutorial session from their supervisor. The idea is for students to learn how to help patients deal with psychosocial issues that may be underlying or impacting their health and their ability to manage illness, so that they can better understand and treat patients in the context of their environment and the complications that deprivation is often associated with — such as insecure housing, mental illness, substance abuse and domestic abuse. 

Shared Health Foundation says the course — which is free for trainees — is competitive. The trainers look for people who are passionate about social change in healthcare and tackling the barriers people in deprived areas face, and who want to build their careers in an area of disadvantage. Ultimately, they’re asking GPs to lead change in their communities. 

The programme now takes on eight new students every year, most of whom go on to work in a GP practice in Greater Manchester. Alongside placements, the students have weekly informal teaching sessions in a community hub in Rochdale, which often include expert speakers from paediatrics, psychology and homelessness. They also study for two exams over the three years. All of this helps the students understand their patients’ behaviour in and around their appointments, says Lindy Bolzern, who is currently on the course.

“Generic GP training doesn’t equip people with situational awareness, such as how to perceive someone not showing up to their appointment,” she says. “They could think nothing of it. Or, they could understand the situational factors preventing them from turning up, such as being moved to temporary accommodation that’s three buses away from their GP surgery.”

Bolzern says that the course is also equipping her with the support network she’ll need to help her patients with issues such as housing applications and benefits. She tells me she wanted to be a GP because it’s one of the areas of medicine where you’re most able to treat health issues in the context of the patient’s environment. “When you work in challenging circumstances, it’s really important to know what things work,” she says. “If I can find the things I need to help make a change, you feel okay at the end of the day. I can’t give them a house, but I can tell them it’s not their fault they don’t have a house.”

A few years after qualifying as a doctor, Emily Gaines, 30, was working in an A&E department and studying for a master’s degree in healthcare management in an attempt to understand how the NHS actually works. “I became increasingly aware of health inequalities, and frustrated in feeling like I had an inability to do anything about [the causes of them]. I saw what should be a widely accessible, equal service be completely not that,” she tells me.

In her second year, Gaines worked on a placement with homeless families and was encouraged to reflect on the emotions it stirred up. “Life-changing sounds a bit dramatic — it was impactful,” she says. “I was completely ignorant of the housing process. The placement helped me create a context of patients I would’ve otherwise just seen in the practice, now I understand why they’re not showing up to an appointment when the most important thing that day is getting food.”

She learned a lot about patients who are labelled as ‘difficult’ and shunned by healthcare professionals — because they’re aggressive, for example. “There’s a reason for it, 99% of the time,” Gaines says. “If you have time to explore that, it helps you understand them better. I can then adapt how I work to support them in the best way I can. A lot of health professionals will roll their eyes and just say they’re really difficult.”

But it can take months, even a year, before it clicks with her patients. “I can know something is going on, but they won’t open up, so I’ll sit with them along their journey and then they’ll tell me they’re experiencing horrendous domestic abuse, and the penny drops,” she says.

Gaines graduated from the scheme this February. She describes her upbringing as privileged, with a loving family and a feeling of safety. “I didn’t realise how much these things are either beneficial or detrimental, depending on which side of the coin you’re on,” she says.

Holistic health

By midday, everyone seems to be warming up to the conference’s positivity agenda. There are some hopeful stories from attendees — one GP shares how she went to visit a patient who was dying of cancer and said she needed to see her to feel at peace.

“It was two days before Christmas,” the GP says. “She burst into tears and said she felt she could die after seeing me. Sometimes we don’t realise the difference we make to people.”

Bolzern — who attends the deprivation programme part-time while working both in a GP practice and with Salford’s inclusion health service for people experiencing homelessness — feels this acutely, and often.  

“I’m surprised by how much explaining something, and giving patients a level of empowerment, can change their behaviour,” she says. “They really perk up if I say ‘Well done, you’re doing well,’ as if they’ve not been told that for ages. It makes you feel really powerful… and a bit sad.”

But is this satisfaction enough, when these GPs are so exposed to the bigger picture of the socioeconomic determinants of health every day? Bolzern tells me the problems can feel overwhelming. “There are things I still find shocking every day that are difficult to accept. Someone is living in a mouldy house and can’t breathe, or sleeping in accommodation with 30 people on the floor because they don’t have appropriate housing. It’s shocking, and it should be.”

But being shocked is the privilege of doctors who have a support system, she says; those without that will just blank these things out. Still, she has to manage her emotions, and says that sinking into despondency is a real risk.

There are two things that help: having a network to tap into for practical advice (like how to contact a particular social worker or phrase a letter), and being able to think realistically. “You have to be aware of what you can do, and what you can’t do,” Bolzern says.

The cure?

Lunch is out of the way at the conference, and two GPs are proudly sharing clips from a short film they’ve made based on their research programme, which involved a group of GPs getting involved in their communities and reporting back on their experiences. 

They ask everyone to stand up, and then sit back down if they disagree with the next few statements. The first: “It’s right to work with people in the local community on service improvement.” It doesn’t create any movement. Then they ask if GPs, specifically, should have a responsibility to do this. A few people sit down. Then, they ask if GPs get enough resources to be able to do this. All but one or two audience members sit down. That chimes with warnings, stretching back over the last decade, about how stressed and overworked GPs are. Today, the average GP consultation lasts only 10 minutes.

Shared Health’s deprivation programme has a huge emphasis on equipping trainees with an awareness and support system so they can prevent burnout, both on the course and later in their careers. This is especially important now, as just a couple of months after it was announced, mental health support for NHS medical practitioners is potentially being pulled for GPs. 

Gaines didn’t feel like burnout was a risk when she was on the course. “The programme is the only experience I had [during medical training] where I actually felt like someone genuinely cared about my well-being,” she says. Gaines was catapulted into real, working life again earlier this year, and she now balances working in a GP practice in Heywood, near Rochdale, in a deprived area, with working with homeless families on a research project.

“I’m not supported as much now,” she says. “If I was struggling, I could get support, but true well-being is not getting to the point of struggling. It’s easy to look around and see colleagues burnt out and struggling, so it’s something I worry about. My life is simple at the moment, I don’t have children, I have work and that’s about it. As it gets more complicated, I worry about my ability to manage my work/life balance.”

Gaines still experiences frustrations with the healthcare system. While she now understands the drivers and consequences of health inequalities much better now, she says the only way to make the healthcare system work better for patients in poverty is to draw on her colleagues. “Getting clinicians and people working in the NHS to help change the whole system is the way forward,” she says. 

She wants to eventually take on a management role that will allow her to change things systemically, from the top down. “I can get a lot of job satisfaction, but on a wider basis there are things I want to change.”

The plaster

By 5pm I feel like I’ve spent half a day in Disneyland, and the other half in a puppy graveyard. It’s been a cocktail of forced positivity and conversations about how healthcare is failing the most vulnerable.

In the breaks, I hear GPs defying the instructions to keep it light. Under their breaths, they swap stories about the pressures, the unintuitive ways the system works, the unfairness of it all. There was going to be an opportunity for people to air their views to the room, right at the end of the day, we were promised. A timed rant, but a rant nonetheless. But the last talk of the day wraps up to light applause and the quiet shuffling of bums. The door opens, and we’re encouraged to take leftover slices of cake home. The opportunity to vent never comes.

I’d expected disturbing stories and statistics, and genius solutions rousing the room into rallying cries — not skirting around reality with awkward jokes, ice-breakers and small talk about the cakes on offer at lunchtime. These are the people, after all, who aim to make healthcare equally accessible, boost social mobility, end the cruel trappings of poverty across Greater Manchester and beyond.

But it would be wrong to suggest that the attendees have the same fuzzy denial that helps the rest of us mortals get through our days. These people are GPs; GPs who’ve chosen to work in deprived areas, no less. They’ve chosen a challenging career where the rewards of the job are hard-won.

No one GP, or GP programme, can solve the drivers of health inequalities, and doctors — and students — in deprived areas know this. I wonder if confronting this every day is the biggest driver of burnout. Perhaps it’s enough to know they’re making positive changes in their local communities, and that, one day, they could have a wider influence. Until then, there’s cake.