GPs at the Deep End: Identifying and addressing social disadvantage wherever it lies

Julian Tudor-Hart described the inequalities that exist across communities, with the most disadvantaged populations often receiving less and lower-quality healthcare than those from more advantaged communities.¹ The Inverse Care Law has been the driving factor behind GPs at the Deep End, a Scottish movement that brings together general practitioners (GPs) working in the most deprived communities in Scotland.² The ‘Deep End’ refers to GPs who work in the deeper end of the social gradient of health. Founded in 2009 by Professor Graham Watt, this powerful peer-to-peer advocacy and support organisation is expanding as similar groups worldwide.³

GPs at the Deep End started with academic leadership seeking to understand the experiences of GPs working with deprived populations and to enable the practitioner voice.² Based on Scottish datazones (similar to the Australian Socio-Economic Indexes for Areas [SEIFA]), GPs working in either blanket or pocket areas of deprivation were invited to a co-design process to establish a group that would meet the needs of GPs working in areas of socioeconomic disadvantage.² The Scottish project has always been about engagement (sine qua non), identity, voice, common purpose, profile, collegiality, advocacy and joint projects. From these early beginnings, the group has grown to be a powerful advocacy group in Scotland able to influence GP training, local health policies, and, importantly, provide peer support for GPs working in challenging environments.

Initially, the Scottish GPs at the Deep End only focused on practices serving blanket deprivation with their particular challenges, but they have recently moved to also include practices with ‘pocket deprivation’ as they have found that is where most patients living in deprivation are being cared for. The most important Deep End messages are the need for generalism, which is most needed by patients with complex multimorbidity; and collegiality, the power of practices ‘marching in the same direction’.^4,5 These messages resonate broadly, hence the need to engage with all practices and not be seen as a completely separate group.

In 2016, inspired by this successful model, a group of Canberra GPs came together to form the Deep End GPs of the Canberra Region (ACT). Although Canberra’s population is relatively wealthy and well-educated, the region still has pockets of significant deprivation. These pockets are commonly distributed within areas of wealth following the longstanding ACT policy approach of ‘salt-and-pepper’ distribution of social housing.

Initial contact with the Scottish Deep End’s Professor Watt (facilitated by Twitter) was welcoming and enthusiastic with his only request being that we quantitate the deprivation experienced by patients in the communities that we serve and adapt a Deep End logo for our local region (Figure 1). The Deep End GPs of the Canberra Region is a grassroots organisation of GPs who work with at-risk people in Canberra and the surrounding region. Our objectives focus on advocacy, peer support and learning (Box 1).

Figure 1. The Deep End in the Canberra region logo

Facilitating a Deep End group

The Deep End GPs of the Canberra Region welcome all GPs who identify as working with disadvantage in their practice – we have more than 20 GPs who work with low-income groups, substance dependence, sexually diverse, refugees and asylum-seekers, prisoners and detainees, and Aboriginal and Torres Strait Islander peoples. We initially agreed that we wanted a space for GPs to meet exclusively as a professional group as there were diminishing opportunities locally for GP networking and support. GPs were invited to attend ‘as themselves’ and not representing the organisations where they work. We continue to honour this by not using titles or places of work in communications from the group – we label all communication as from the ‘Deep End GPs of the Canberra Region’.

There is no funding associated with the group and GPs attend in their own time. We meet on a six-weekly basis and the venue rotates between different clinics, including the local youth prison. The rotating meeting venue is important for improving networks between the GPs and to develop an understanding of each other’s work. The 1.5-hour meeting is followed by dinner at a nearby restaurant – not everyone is able to stay for this, but the informal dinner provides a source of collegiality and support. Between meetings, we stay in touch through an email list where meeting minutes, agendas and local issues are circulated. One of our GP members keeps records of attendees who would like to claim Royal Australian College of General Practice Continuing Professional Development points and these are submitted at the end of each year.

Early success and areas of focus

We developed our own objectives (Box 1) and these have informed the areas we have concentrated on as a group. Despite existing for just over two years, we have started to develop some core areas of interest and have been approached by policy and government groups for advice.

Research

Our initial dilemma came from Professor Watt’s request to quantitate the deprivation we see in our GP practices. Existing measures of deprivation contain data that are not routinely collected in standard GP records. Professor Christine Phillips and Dr Peter Tait carried out research projects in which medical students developed a survey that could be undertaken within a general practice setting. This work also highlighted to local medical students the depth of deprivation in our Canberra community. The next phase of this work, to administer the survey in ACT general practices, is ongoing and we hope to have an answer about the level of deprivation soon.

We also surveyed the GPs in our Deep End group to understand the main areas of concern for patients in their practice. We compiled a list of issues that we see across the practices (Box 2). Some practices see more of certain issues than others and most mirror issues in other Australian communities. This list also provided a good discussion point for the group to learn about the work we are each doing.

Advocacy

One of the most impressive features of the Scottish Deep End movement is their ability to engage with policy makers and advocate for change for at-risk patients. We have prioritised being visible to our local health department and our Primary Health Network. Early on, we wrote a letter supporting a new government policy that makes bus transport free during the day for people with low income and used this opportunity to emphasise the barrier that transport can be for accessing healthcare. The government minister responded to our letter and they were then aware that our group exists. It was also helpful to be able to start a positive conversation with our local government in relation to policy.

We have also facilitated a stakeholder meeting to discuss access to opioid substitution treatment (OST) in our local area that was attended by multiple community and service delivery groups. This led to the Canberra Deep End group making a budget submission for an additional OST dosing point that can support patients with high-level needs to enable better access for those having difficulty accessing the single current service. We also met local government health advisors and tertiary treatment committees to advocate for this proposal. The group has successfully lobbied for improved access to fully publicly funded cataract surgery, with the local health system developing new pathways of access in response to our approach and description of the barriers. We have found that the unaligned nature of the Deep End group is an asset for engaging with policymakers.

Peer support and learning

Burnout is a recognised problem for GPs working in areas of disadvantage.⁶ The Deep End group gives GPs a space to meet other GPs, debrief, learn new approaches and about existing and new services, and identify areas needing advocacy. The peer-to-peer support is one of the most valuable elements of the group. At each meeting at least one GP presents a case study and we have a group discussion about the medical care, local service delivery and lessons for the future. We also circulate articles of interest on the email list between meetings.

Evaluation

Evaluation was explicitly part of our group objectives. We use the end-of-year meeting to discuss each of our objectives and how we have worked to achieve it over the year. We also see the success of the group as GPs continue to engage with us (despite no funding to attend) and increasing requests for the group’s involvement in other committees and policy groups.

Conclusion

From its beginnings in Scotland, the Deep End movement is growing. The values that underpin the movement – reducing inequity and supporting practitioners in areas of disadvantage – hold across international healthcare settings. Our Canberra group has found the framework to be valuable for peer support and advocacy. We hope that other Australian GPs will be encouraged by our experience and develop their own group in their region. Establishing a national group of Deep End GPs in Australia would take us to the next level of engagement and follow in the steps of the Scottish movement.