Iain Gray: Government must throw GPs in at Deep End

In THE same week that the animated film Brave’s depiction of a mythical Scotland of the past generated much press coverage and attention from politicians, statistics painting an all too real picture of present-day Scotland slipped out largely unremarked. Scottish life expectancy improved, but continues to be the worst in the UK, with the average Scottish man living for 75.9 years compared to 78.6 for his English counterpart.

Even worse are details showing that the difference in life expectancy between the best and the worst neighbourhoods in Scotland is as much as 30 years. Of course this is largely explained by differences in rates of smoking, drinking, drug addiction and diet, but most people would agree that things like poor housing, unemployment and hard physical work take their toll too.

Yet when the Scottish Parliament’s audit committee considered a report by the Auditor General into NHS cardiology services, we found a puzzle there not explained by any of this. The report was very positive, noting that death rates from heart disease have fallen by 40 per cent in ten years. Treatments like angioplasty and bypasses are improving in quality and quantity.

However in the most deprived areas of Scotland 20 per cent fewer of these treatments are performed than should be expected, while in affluent Scotland 60 per cent more procedures are carried out than we would expect to see. To be clear, there is more heart disease in deprived areas, and so more treatments there overall, but less than there should be, given those higher levels of illness. The Auditor General said: “This…implies a lower level of access to treatments for people in more deprived areas.”

This inequality turned out to have been discovered over ten years ago, and there appeared to be no explanation forthcoming. Is the NHS really excluding poor people from treatment? At the suggestion of Mary Scanlon MSP, we agreed to look further into this, and to do so by going to where the problem largely lies – moving the committee to Glasgow for a day. This was the kind of thing committees of the parliament used to do regularly, but it has become much less common.

The committee has still to produce its report, but for me the key evidence came from Deep End. This is a network of GPs who work with the 100 most deprived GP lists in the country. The project, led by Professor Graham Watt of Glasgow University, is the only attempt to share the experience within which must lie some of the answers to Scotland’s health inequalities. After all, GPs are the gateway to the NHS, the first and regular point of contact for patients.

From Deep End’s experience explanations do begin to emerge. First, their patients are more likely to display co-morbidity, doctor-speak for having so many things wrong with you that neither you nor your doctor spot the specific signs of say, heart disease. Such patients also feel that they overuse the health service, and are reluctant to “bother” the doctor, a reluctance not shared by more affluent citizens. Deep End’s patients sometimes just do not report chest pains. For one thing, they do not want to be told off again for their lifestyle. Even worse, Prof Watt’s paper “Socioeconomic variations in responses to chest pain” reveals a stunning degree of fatalism. For many of the Deep End patients, chest pain and a heart attack is just what happens to everyone, and it is their fault. GPs call this “normalising chest pain”. In fact, it is people who believe they deserve to die young. As one says: “You only get what you deserve. The books tell you that, and the telly and the papers tell you that.”

I think there is a degree of GP complicity. Watt quotes a patient from an affluent area describing visits to the GP as including a chat about “this interesting paper in The Lancet” while a patient from a poorer area says of her GPs: “They don’t like me asking questions.” The GPs we met also acknowledged that if some patients were referred to cardiology consultants, a bureaucratic appointments system would prove too much for people with a chaotic lifestyle. They would not see it through to treatment.

None of this is new to the GPs involved, and they all believe that what they need is more time with their patients and more willingness to deal with non-medical issues such as benefits problems, housing or domestic abuse, alongside health issues. But it is news to most politicians, especially when Prof Watt produces what he calls his “killer diagram”. This shows three indicators of poor health plotted against levels of deprivation. All three rise steeply as deprivation increases. Below them is a line representing GPs per head of population. It is completely flat. Scotland already has more GPs per head than England, but they are spread evenly without regard to deprivation or the inequality of need.

The message from Deep End GPs to politicians is: “You have been bold on smoking, and bold on alcohol, you need to be bold on GPs.” The fact is that we never have been bold when it comes to targeting NHS resources at areas of poorer health. Affluent communities do not just assert themselves in the GP’s surgery; they do so at the ballot box as well.

Nonetheless, I know that Labour’s Scottish leader Johann Lamont takes health inequalities seriously, so perhaps it is time for Labour to be brave enough to grasp this thistle. It is not enough to shift resources from one huge health board to another, though. The targeting has to be much more focused than that. We should beware of an NHS too much in thrall to consultants and hospitals. GPs may not be the most popular professionals right now, but Prof Watt and his colleagues show that they might hold the key to finally doing something about that 30-year life expectancy gap, if we are brave enough to throw more of them in at the Deep End. • Iain Gray is Labour MSP for East Lothian and convenor of Holyrood’s Public Audit Committee. He writes here in a personal capacity