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

2. 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)

3. 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  The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.”

4. 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

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

6. 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

7. 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

8. GP training and education

9. 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?

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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)

16. 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?