GP training and education in the Deep End Dr David Blane Academic GP, University of Glasgow @dnblane

Overview Context What are we doing in Scotland? What are the particular GP training and education issues for the Deep End? What are we doing in Scotland? At undergraduate level At postgraduate level For continuing professional development (CPD)

Inverse care law “The availability of good medical care tends to vary inversely with the need for it in the population served” Not the difference between good and bad care, but between what general practices can do and what they could do with resources based on need. The inverse care law is a policy of the NHS which restricts care in relation to need. “This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.  The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.”

Inverse care law today % Differences from least deprived decile for mortality, comorbidity, consultations and funding From BJGP (dec 15) “General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland”   4

Distribution of training practices Russell M, Lough M. Deprived areas: deprived of training? BJGP 2010; 60(580): 846-8.

Deep End issues ISSUES AFFECTING DEEP END COMMUNITIES Unemployment Benefits sanctions Cuts to services Drugs and alcohol Child protection Asylum seekers Vulnerable adults Bereavement KEY POINTS ABOUT DEEP END ENCOUNTERS Multiple morbidity and social complexity Shortage of time Reduced expectations Lower enablement Health literacy Practitioner stress Weak interfaces

GP practice hubs Stronger population focus Expanded workforce New roles (e.g. physician associate) More admin support More time with pts New models of care Better use of IT Improved premises

GP training and education

Undergraduate training Population concepts Health systems Marginalised patient groups Cultural diversity Ethics What are the core competencies we wish new medical graduates to have so they are equipped for working as an FY1 (doctor in training in the UK) and for lifelong learning? What are the knowledge skills and attributes that UK medical students interested in learning more about health inequalities could cover?

Undergraduate training Student Selected Component (SSC) in Social Determinants of Health Teaching and community placements: addictions personality disorders refugee/asylum and other marginalised groups Deep End GPs Intercalated BSc in Global Health Global Burden of Disease Socio-Economic & Environmental Determinants of Health Health Systems & Policy Global Health Governance Human Rights & Ethics Cultural Diversity & Health

Postgraduate training GPST1/2 twice yearly learning day on inequalities, addictions, multimorbidity GPST3 placements in Homeless Health Centre Post-CCT Health inequality Fellowship The practical requirements of a training practice, in terms of organisation, record keeping and IT, are considered less of a barrier, now that all practices have addressed such issues, as part of the Quality and Outcome Framework (QOF).   It was felt that training practices have to be particularly well organized to include training activities within the generally intense nature of general practice in very deprived areas.   Training status is highly valued by trainers, allowing expression of professional values, and providing a constant stimulus for improvement, regular contact with colleagues and protection against burn out.

CPD needs 11 Learning needs 4 Learning resource gaps: Addressing low engagement and increasing health literacy Maintaining therapeutic optimism working in areas of high deprivation How to use EBM effectively when working with patients with high levels of multimorbidity How to meet the health needs of migrants including people seeking asylum and refugees. 11 Learning needs identified: 1. Engaging with patients (autonomy/health literacy/screening) 2. Promoting GP tenacity/realistic optimism 3. Drugs and alcohol 4. Safeguarding children 5. Asylum seekers/migrant health 6. Multimorbidity 7. Poverty 8. Vulnerable adults 9. Evidence-Based Medicine (EBM) and unhealthy populations 10. Previous sexual abuse 11. Homelessness

Deep End Fellowship proposal More training practices in deprived areas Additional support for Deep End training practices Implement practice rotations for GP trainees Expand NES Health Inequality Fellowship Scheme 12 Fellows, 50:50, 2 years Release time for cadre of experienced GPs

Learning from others? Tailored curriculum Social Medicine Module Self Care Module Change Management Module Research Module Arts Programme Training for Primary Care in Areas of Deprivation and with Marginalised Groups

Summary Particular training issues in the Deep End Linked with GP recruitment crisis and new ways of working Including more part-time, portfolio careers Different needs at UG, PG and CPD stages The next generation are up for the challenge… … though need more support, particularly with leadership roles (e.g. Fellowship scheme)

Group discussion What 3 things are most important for medical students to understand about Deep End GP? How should we help GPSTs appreciate the nature of Deep End GP work? What are the CPD needs of Deep End GPs?