The GP 5 Year Forward View, the importance of inequality and the Deep End

So we are all doing responses to the GP 5 Year Forward view
Who knows whether there’s any REAL investment fund. Meanwhile the world keeps revolving.

General Practice, you know the bit that everyone says is the jewel in the NHS crown, gets ever more fragile.

The point re General Practice in the most disadvantaged parts of our communities, you know the bit of the narrative everyone manages to forget, isn’t going away anytime soon.

The amazing Deep End group keep shining a light on it.

Here are some thoughts as we finalise where we are re the GP5yFV.

Regular readers will recognise rehashed material (sorry, but got to say the same thing again and again)


The slice of the NHS £ going to primary care and in particular General Practice

GP funding seems like it’s going down not up

General practice funding has fallen to 8% of total NHS spending (Appleby BMJ2014;349:g6814)


Also see here some of the slides – taken again from Prof Watt

Share of NHS £ to GP going down

The above two points are NOT, I REPEAT NOT, a hospital = bad / GP = good point,

Merely a reflection of the investment in demand management is going down not up. This was Scotland.

Maybe in England it’s different.

I don’t know, I’m writing a blog not a PhD thesis. Someone may prove me wrong.


And a big hike in activity

Hobbs et al –

16% increase in workload – more, longer consultations.

Then add in the nasty issue of consultation length in multi morbidity between practices with affluent vs deprived population profiles. See Mercer et al

RESULTS In affluent areas, patients with multimorbidity received longer consultations than patients without multimorbidity (mean 12.8 minutes vs 9.3, respectively; P = .015), but this was not so in deprived areas (mean 9.9 minutes vs 10.0 respectively; P = .774). In affluent areas, patients with multimorbidity perceived their GP as more empathic (P = .009) than patients without multimorbidity; this difference was not found in deprived areas (P = .344). Video analysis showed that GPs in affluent areas were more attentive to the disease and illness experience in patients with multimorbidity (P < .031) compared with patients without multimorbidity. This was not the case in deprived areas (P = .727).

CONCLUSIONS In deprived areas, the greater need of patients with multimorbidity is not reflected in the longer consultation length, higher GP patient centeredness, and higher perceived GP empathy found in affluent areas. Action is required to redress this mismatch of need and service provision for patients with multimorbidity if health inequalities are to be narrowed rather than widened by primary care.

Message = 

GP is like the demand management part of the NHS. 

Getting busier and % of NHS £ to GP is going down.

It’s no surprise we struggle to control demand then.
NB the findings of the Hobbs paper on deprivation & consultation rate:

“There was little association between consultation rates and deprivation at the practice level, which might have resulted from the aggregation step. We therefore did an exploratory univariate analysis of Index of Multiple Deprivation scores at the patient level, which showed a strong association between deprivation and overall consultation rate (appendix).”

Table 8 of the appendix to the Hobbs paper

d) pharmacy

I might summon the will to live to also add in something about the cut in the pharmacy contract. Nobody quite knows who will be affected. I’m not sure the equity impact assessment was done (happy to be proven wrong) or any regard was made of Pharmacy Needs Assessments. Either way cut of 6% also sends a message re primary care more broadly.


GP and inequity

There’s little to no local data, so I’m reliant on published research. The below is from Scotland and E London.

I’ll bet a months pay that your patch is no different.

Some of the pics are from slides I did for a room full of GPs at the launch of the Deep End Yorkshire group. Email me and you can have the slides.


It’s about ageing

I’m often told …..ahh but as well as thinking about deprived (mostly younger) populations you’ve also got to remember the more affluent (often older) populations with lots of multimornidity.

Accept point b), all populations need and benefit from general practice.

I don’t accept point a)

It’s not about ageing, it’s about morbidity

Age is a poor proxy for morbidity

(if you needs any more persuasion check slide 11 of this analysis of a 500k person real world dataset in Somerset
My full explanation here –

And this paper

What is the relationship between age and deprivation in influencing emergency hospital admissions? A model using data from a defined, comprehensive, all-age cohort in East Devon, UK | BMJ Open
At age 60, the risk of admission in the most deprived social group equates to the risk of emergency admission at age 71.5 in the least deprived group (age-equivalent effect=11.5 years)


These pics from the Deep End set go into GP supply inequity
Prof Watt in Glasgow uses this slide to explore the steep slope of need and the flat line of resource commitment.

The slope of need is quite steep looking at both physical & mental comorbidity, and for SMR (i.e. Age structure of pop taken out of equation) early mortality across deprivation deciles

The consultations per 1000 registered fairly flat across those deciles and funding / 1000 flat as a pancake

I.e. There is (considerably) more need in practices with more deprived pop list but no more £ per head and > consultation rate in those practices.


The Prof Boomla data on age adjusted consultation rates across deprivation quintiles

This is well worth a look

Only made a letter in BMJ but it’s astoundingly important

A 33% diff in age adjusted consultation rates between most and least affluent in E London.

This work highlighting the deficiencies of the GP funding formula was further developed by Levene et al :-

Population health needs as predictors of variations in NHS practice payments: a cross-sectional study of English general practices in 2013–2014 and 2014–2015 | British Journal of General Practice.

Message =

GPs in poorer parts of town have higher consultation rates than those in less poor parts of town. 

(But we know no more resource to deal with that – then add in a load of social complexity)  


Lastly you can nick some of the stuff out of this if you want

My take on a simply amazing piece of work from Glasgow

Message = 

GPs are like the heat sink in your computer. You don’t know it’s there till it’s broke then your system is stuffed.

It’s more stuffed in poor parts of town than rich parts. Hence inequality likely to worsen.



  1. Thanks so much for this Greg, I’m trying to write s’thing similar for my blog and a teaching session on sdoh for GP trainees and med students. Shocking how few docs / policy makers don’t get this

    Liked by 1 person

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