3. QUESTION WHY DO YOU ROB BANKS ? ANSWER BECAUSE THAT’S WHERE THE MONEY IS WILLIE SUTTON

4. WHERE ARE THE MOST DEPRIVED POPULATIONS ? The problem of concentration (BLANKET DEPRIVATION) 50% are registered with the 100 “most deprived” practice populations (from 50-90% of patients in the most deprived 15% of postcodes) The problem of dilution (POCKET DEPRIVATION) 50% are registered with 700 other practices in Scotland (less than 50% in the most deprived 15% of postcodes) The problem of non-involvement (HIDDEN DEPRIVATION) 200 practices have no patients in the most deprived 15% of postcodes

5. HEALTHYYEARSTOTAL LIFE IN POORLIFE EXPECTANCYHEALTHEXPECTANCY yearsyearsyears MENST 10%76581 RICHEST 10%76581 POOREST 10%571168 DIFFERENCE19613 WOMEN RICHEST 10%78684 POOREST 10%611576 DIFFERENCE1798

6. WHERE ARE THE 100 PRACTICES? CHPNo of top 100 practices SIMD 2009 Glasgow East CHCP27) Glasgow North CHCP18) Glasgow West CHCP14) 76 Glasgow South-West CHCP13) Glasgow South-East CHCP4) Inverclyde7 Edinburgh 4 Tayside4 Ayrshire 5 Renfrewshire 1 Fife1 Grampian1 Lanarkshire1 TOTAL100

7. ASPECTS OF THE 100 MOST DEPRIVED PRACTICES 43% of male deaths and 24% of female deaths occur under 70 (compared with 25% of male and 14% of female deaths in the most affluent 100 practices) A large majority of practices are in Glasgow 60% have three or fewer WTE general practitioners Average list size is 4300

8. QOF POINTS 2007 TOTALCLINICALNON-CLINICAL Most affluent practices984645339 Mixed practices979643336 Most deprived practices977641335

9. ADDITIONAL ACTIVITIES Undergraduate teaching45 Postgraduate teaching27 Research (SPCRN)66 Primary Care Collaborative (SPCC)67

10. INVERSE CARE LAW “The availability of good medical care tends to vary inversely with the need for it in the population served”. The inverse care law is a policy of NHS Scotland which restricts care in relation to need. Not the difference between good and bad care, but between what general practices can do and could do with resources based on need.

11. NOT ONLY Evidence-based medicine (QOF, SIGN) BUT ALSO Unconditional, personalised, continuity of care, provided for all patients, whatever problems they present.

14. IS THE NHS FAIR? i.e. equitable based on need In providing emergency careYES In providing non-emergency careNO In providing primary careNO

15. Percentage differences from least deprived decile for mortality, comorbidity, consultations and funding “Over 2 million Scots in the most deprived 40% of the population received £10 less GP funding per head per annum than over 3 million Scots in the most affluent 60%”

16. CONSULTATIONS IN DEPRIVED AREAS - 1 Multiple morbidity and social complexity Shortage of time Reduced expectations Lower enablement (especially for mental health problems) Practitioner stress Mercer SM, Watt GCM Inverse care law : clinical primary care encounters in deprived and affluent areas of Scotland Annals of Family Medicine 2007;5:503-510

17. CONSULTATIONS IN DEPRIVED AREAS - 2 Patients showed less desire for shared decision-making GPs perceived as less empathetic GPs displayed less patient-centred verbal and nonverbal behaviours Outcomes worse at 1 month (MYMOP) Perceived physician empathy predicted better outcomes Mercer SW Higgins M Bikker AM Fitzpatrick B McConnachie A Lloyd SM Little P Watt GCM General practitioners’ empathy and health outcomes: a prospective observational study of consultations in areas of high and low deprivation Annals of Family Medicine 2016;14:117-124

18. Applying the CARE measure and Patient Enablement Instrument (PEI) after general practice consultations YOU CAN GET EMPATHY WITHOUT ENABLEMENT BUT YOU NEVER GET ENABLEMENT WITHOUT EMPATHY Mercer SW Jani BD Maxwell M Wong SYS Watt GCM Patient enablement requires physician empathy: a cross-sectional study of general practice consultations in areas of high and low socio-economic deprivation in Scotland BMC Family Practice 2012, 13:6

19. RELATIONSHIPS ARE THE SILVER BULLETS OF GENERAL PRACTICE AND PRIMARY CARE Especially for the 15% of patients who account for 50% of the workload

20. 87 : 13 86 : 14 85 : 15 84 : 16 GATEKEEPING

21. THE SECRET OF GATEKEEPING THERE IS NO GATE (at least, to unscheduled care) ONLY A GATEWAY (that patients can go through at any time)

22. Number of emergency admissions (all specs, all ages, all stays) at GG&C sites, 1995/6 - 2014/15. Source: SMR01 data from J Gomez. SEE : Report of 3 rd National Deep End Conference www.gla.ac.uk/deepend Change Fund

24. BJGP, June 2015 Ubiquitous, endemic complexity The value of previous encounters Empathy and trust A “worried doctor” Setting the bar high Every patient matters

25. CARE PLUS: a whole-system approach Time, continuity, person centredness and self-management support Patient Practitioner System Professional Patient Longer consultation time with continuity Support meetings and structure for long person- centred consultations CD and written guide on mindfulness Plus CBT guide Community activities recommended

26. Effect size = 0.35 CARE Plus prevents decline in QOL (EQ5-DL)

27. CARE Plus is very cost-effective Cost < £13,000 per QALY NICE currently supports a cost of £20,000 per QALY

28. BRIEF ENCOUNTERS SERIAL ENCOUNTERS

29. RELATIONSHIPS WITH PATIENTS Initially face to face, eventually side by side Julian Tudor Hart A NEW KIND OF DOCTOR

30. SCHEHEREZADE TELLING 1001 TALES

31. Payne R, Abel G, Guthrie B, Mercer SW. The impact of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study. CMAJ 185 (e-publication ahead of print): E221-E228, 2013, doi:10.1503/cmaj.121349 10% of patients with 4 or more conditions accounted for 34% of patients with unplanned admissions to hospital and 47% of patients with potentially preventable unplanned admissions.

32. MEASURING OMISSION THE RULE OF HALVES 50% were diagnosed 50% were treated 50% were controlled i.e. 12% get best care THE IMPORTANCE OF GOOD INFORMATION

33. Listen to the patient He is telling you the diagnosis SIR WILIAM OSLER Listen to the patient She is telling you her treatment goals PROFESSOR JAN DE MAESENEER

34. GENERAL PRACTITIONERS AT THE DEEP END

35. PARTICIPATION IN DEEP END MEETINGS AlwaysSometimes TotalParticipating (%) in thein the Deep End Glasgow 6987761 (79%) Inverclyde55101 (10%) Rest of GG&C28101 (10%) Edinburgh 3365 (83%) Dundee3251 (20%) Ayrshire3471 (14%) Lanarkshire0330 (0%) Aberdeen0111 (100%) Fife0110 (0%) TOTAL853512071 (59%) 63 (74%) of the 85 consistent practices took part in at least one Deep End meeting 13 (37%) of the 35 occasional practices took part in at least one Deep End meeting