GP at the Deep End

General Practice at the Deep End Yorkshire and Humber at 5 years

A personal reflection by Dr Tom Ratcliffe, GP

I had been working as a GP in Airedale, just west of Bradford, for around 2 years when I got involved with setting up GP at the Deep End Yorkshire and Humber. Like many parts of the country, Airedale is an area of socioeconomic extremes. On one edge of our patch lies Skipton and Craven, reportedly the happiest place in the UK, and on another, Wharfedale, which hosts some of the most expensive housing in Northern England. I had completed most of my GP training in Keighley, a town closer to Bradford with a much more mixed socioeconomic outlook, and eventually took up a permanent position at Holycroft Surgery, located within one of the most deprived council wards in the UK.

As with many areas, travel across the Airedale locality and life experience, along with pretty much every other indicator of health and wellbeing, varies dramatically – an 8 mile journey can encompass a 10 year difference in like expectancy at birth for local inhabitants. However, it was not the abstract idea of health inequality and these statistical variations that got me interested in the Deep End movement. Rather, it was the shared experience of healthcare professionals working in areas of socioeconomic deprivation.

It was immediately apparent that our patients came with layers of problems and issues born out of a lifetime of disadvantage. Even something simple like a rotator cuff strain was rarely just a rotator cuff strain. How would you help get this better when the patient was working 12-14 hours a day as a carer on a zero-hours contract doing manual handling all day, did not have the money to take time off work, had the recovery rate of someone 20 years older due to a lifetime of stress and childhood trauma and struggled to remain motived to exercise due to depression and having to look after her alcoholic partner?

It was also a period when I’d watched a procession of brilliant GPs move out of my practice in Keighley to work in leafier neighbouring areas, emigrate or become unwell and retire. One GP remarked to me: “I spend a lot of my time doing social work and I just can’t carry on being here until 8 or 9pm every day trying sort peoples’ lives out. It’s making me ill”. It was around this time I read about GPs at the Deep End in Scotland. Graham Watt’s swimming pool analogy really struck a chord.

Reading through the Deep End group’s short papers, made me realise there were others out there grappling with all of the problems I was seeing and that there was this vast well of wisdom that I, a relatively newcomer, could tap into. It was also inspiring and energising to see this tough and vital work given recognition through academic and Government institutions.

From October 2015, we hosted a series of increasingly well attended meetings under the GP at the Deep End banner. We decided that the areas we needed to address were Workforce, Advocacy (for GPs and people in the communities where they worked), Education and Research.

Things developed quickly. As well as the accumulated wisdom our of colleagues in Scotland and figures such as Julian Tudor-Hart, we met amazing people like John Patterson, Laura Nielsen and the Shared Health, Focussed Care and Citadel Healthcare teams from Greater Manchester, who had set up primary care with the aim of tackling health inequalities at its heart and transformed lives across their communities in Oldham and beyond. Irish GP Austin O’Carroll inspired us all with the amazing North Dublin City Training Programme, which trains GPs to work with people living in areas of deprivation and with marginalised groups. Jonathon Tomlinson from Hackney in East London helped us learn about the role of trauma in peoples’ lives and how GPs could help through “trauma informed care”. Greg Fell, now Director of Public Health in Sheffield, has helped us focus on the role of public health in primary care and the evidence base for addressing health inequalities as GPs. Perhaps most importantly, GPs in working in Yorkshire and Humber’s major cities got to meet each other and share stories of how they’d helped patients living in communities with huge and, at times, seemingly insoluble challenges.

We set up with award-winning Fair Health website to share this collected knowledge and experience with GP trainees across the region and, now, nationally and internationally through e-learning modules, blogs and podcasts. We have “Trailblazer” training programmes specifically focussed on deprivation for GP trainees and new qualified First5 GPs. We have hosted a series of brilliant and motivated “health equity leadership” fellows in the School of Primary Care who have helped ensure every new GP in Yorkshire and Humber has received specific training around health equity and spent time out of the GP surgery in their communities.

In undergraduate education, Ben Jackson at the University of Sheffield has set up a programme of community based medical education around health inequalities. Liz Walton has set up a research network across practices in the city’s most deprived communities, increasing patient participation in designing and enrolling in medical research, and also helped write up our experiences in the BJGP and other journals.

Increasingly, our Deep End colleagues are taking on senior leadership positions or becoming involved in advocating for change across the NHS in Yorkshire and Humber. We have been lucky enough to contribute to two books: Tackling Causes and Consequences of Health Inequalities; The Exceptional Potential of General Practice, which set out approaches to workforce development and curriculum delivery.

Yorkshire and Humber GPs at the Deep End cannot and would not want to take credit for all this amazing work. But it has provided a rallying point for enthusiastic GPs. We hope it has provided some inspiration and helped us learn from each other. Perhaps most importantly, the movement has raised the profile of some the most challenging and important work in the NHS and made those people doing it feel a little less alone and a little more supported.

A summary of our work over the last 5 years can be found below.

Covid-19 - Fair Health Response

Fair Health in the Time of Covid-19

Covid-19 is emphatically not the great leveller.

It has shone a light on the great divides in our society. Everyone can catch it, everyone can die from it but the impact of the virus and the necessary measures to control its spread is not shared equally across society.

Our response will require kindness, caring and compassion. The current upsurge in these values should give us cause for hope during an otherwise very difficult time for many people. And they will be most needed where suffering is greatest.

What is interesting about the risk of death or hospital admission from the virus is that it almost perfectly tracks your current risk of death. So, if you are already sick, from a BAME background, grew up in poverty or already older you are more likely to develop serious symptoms and/or die.

The economic impacts will be most acutely felt by those with the fewest resources: people in low paid jobs, people who have chronic mental or physical illness, people on temporary or “zero hours” contracts and those who are living from pay check to pay check. It is also likely that those in low paid manual jobs (e.g. supermarket, social care, construction workers etc) will be less able to socially distance by working from home and, hence, less able to minimise the risk of Covid-19 infection.  Those who are now confined to home in poor quality or cramped housing will have the most miserable experience and those living in the least affluent, vibrant and green surroundings will suffer the biggest fall in wellbeing.

These individuals are all part of the same group: the poorest in society.

Michael Marmot recently reminded us that, in the UK, the poorest 10% of households have less than 30% of their income remaining after deducting housing costs and the cost of healthy food. They also have very little wealth to fall back on in times of economic crisis. The implications are clear: loss of income due to Covid-19-related unemployment or illness will cause destitution among those who are already struggling to get by.

Health inequalities were already widening before Covid and these divides are now likely to be accelerated by another economic crisis, massively compounded by a virus that kills those already suffering from chronic illness and multimorbidity, the rates of which already follow a sharp social gradient.

Covid has taken the social determinants of health, which have insidiously been working away behind the scenes, slowly eroding peoples’ health and wellbeing, and exploded their impact into full view. Our civic, community and healthcare resources have been degraded by a decade of austerity, as have many aspects of the welfare safety net. Covid has triggered substantial reinvestment but we must not let these issues disappear back into the shadows as the crisis recedes.

The response to Covid has been to put the whole NHS on an acute footing, aimed at treating a single disease, whilst trying to also provide care to the non-Covid acutely unwell. This means that planned primary care, which can narrow the health gap by 10-20% if access is good and quality high, has been temporarily suspended (or at least deprioritised). Because the system was already at capacity, and because capacity was already inadequate in the most socioeconomically deprived communities, it will take a long time to catch up after this crisis. After Covid we will discover a massive pool of morbidity, mortality and unmet demand. Mental illness that existed before this crisis will also sharply deteriorate due to increased stress and isolation plus a temporary withdrawal of face to face primary care.

GPs also know that the aftermath of social trauma can last years or even decades and blight peoples’ whole lives. GPs have spent years trying to help people traumatised by war, tragic events, childhood neglect or mistreatment, crime or domestic abuse. Covid will leave thousands, perhaps hundreds of thousands, of people traumatised by its direct effects or as a result of vulnerable people being left isolated in toxic social situations, where the abuse or mistreatment they have suffered becomes temporarily inescapable.

The long tail of this crisis are neatly summarised here:

A close up of a map

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The Four Waves of Impact: Covid-19

Source: (thank you to Dr Victor Tseng)

So how can we respond?

If there is a positive thing to take away from the Covid crisis it is the outpouring of kindness, the renewed recognition of the contribution of people with jobs whose value may have been forgotten or overlooked, a huge injection of investment into healthcare and social welfare and a revived willingness to think about the needs of others.

We might reflect on J.B. Priestley’s words:

“We don’t live alone. We are members of one body. We are responsible for each other.”

An Inspector Calls, 1945

So how should we respond in primary care?

As our colleagues at Citadel Healthcare in Greater Manchester remind us, for general practice, we should go back to basics: “find the sickest, and give them the best care”. And we must double down on our efforts to do this during and after Covid-19.

  • We will have to catch up peoples’ chronic disease management – prioritise the poorest, who can be identified by integrating the available databases on socioeconomic deprivation with primary care records and by examining chronic disease data (time to collaborate with our wonderful colleagues in public health – at Fair Health we are also trying to create some resources to make this easier for practices, watch this space!). Also prioritise those things that have the biggest impact on health outcomes – start with cardiovascular disease prevention. Perhaps revise where to focus your efforts by working through our learning modules.
  • Now will be the time to adopt an approach based on “Trauma Informed Care”. You can read more about this in our learning modules on this site and on the “A Better NHS” blog (see resources below).
  • Use the Primary Care Network DES to invest in social prescribing to try and deal with some of the acute social issues that Covid will exacerbate and use this to build better links with your local Voluntary and Charitable Sector, who may need your support and advocacy more than ever
  • Collaborate with the “social determinants of health workforce” more than ever:
    • The social workers, teachers, school nurses and health visitors who will be helping safeguarded children during and after the crisis
    • The Citizens Advice Bureau, debt advisors and Department for Work and Pensions operatives who will be needed more than ever to help people through the multiple domestic financial crisis that Covid will create
    • Organisations providing care for people who are homeless, refugees and other vulnerable groups to ensure they can access very strained services in the post Covid world
    • Drug and alcohol services, whose users won’t have been able to socially distance and access support as easily during this crisis
    • The nurses and carers out in the community supporting our most vulnerable
  • Remember that primary care organisations are anchor institutions for many communities – just being there is so important: you can hold onto the memories of how Covid impacted your community and you can hold the NHS leadership and politicians to account for their decisions, their efforts to address health inequalities and future readiness for a pandemic or the slower health “emergency” represented by growing health inequalities
  • Try and ensure that information about Covid and the social safety net that is being created is accessible to all by providing information in multiple languages and formats (see resources for free translations of material provided by Doctors of the World)
  • As illustrated above, the Covid crisis will have a long tail, perhaps stretching out over many years, this is where health equity focussed primary care will be needed most


A Better NHS Blog: (see 23rd February 2020)

The Marmot Review 10 Years On:

Doctors of the World patient information:

Please note that we cannot verify the accuracy of information on external sites, particularly at this time of rapidly changing knowledge about Covid-19