GPs in Scotland see themselves playing a role in tackling health inequalities through both individual clinical care and community advocacy. However, they face constraints like large workloads and complex patients. GPs negotiate these constraints by prioritizing patient autonomy over bureaucratic guidelines. They advocate for patients through involvement in clinical care, addressing social issues, and developing community links. Some GPs also advocate for policy change by flagging inequalities and their impacts. A practitioner-led group called Deep End has successfully advocated for policy changes to improve services for deprived populations in Scotland.

1. Breannon Babbel, MPP, MPH
Urban Studies
University of Glasgow
31 May 2016
Tackling health inequalities in
primary care: an exploration of
GPs experience at the frontline

3. Outline
• Background context
• Scottish healthcare vs. US healthcare
• Scotland’s health inequalities
• GPs working in areas of deprivation
• Lipsky’s street-level bureaucracy
• Methods
• Findings
• GP role in tackling health inequalities
• GP as SLB
• GPs and advocacy
• Implications for the US

4. BACKGROUND CONTEXT

5. Types of Healthcare Systems
1. Traditional sickness insurance
2. National health insurance
3. National health service
4. Mixed system

6. Three Dimensions

7. Health Coverage in the US

8. Health Coverage in Scotland

9. Scotland’s Health Inequalities
Source: The Scottish Government, “Long-Term Monitoring of Health Inequalities”
(2014)

10. Jordanhill-
75.8 years
Bridgeton-
61.9 years
Glasgow’s Health Inequalities
~ 6 miles
apart

11. Social Determinants of Health
‘Rainbow Model’
Dahlgren & Whitehead (1991)

12. Role of Healthcare in Tackling Health
Inequalities
• Healthcare can:
– Reduce the severity and delay progression of
disease (Starfield, 2004)
– Mitigate health inequalities via population health
coverage which focuses on socially disadvantaged
and marginalised populations (Gilson et al., 2007)
• Universal healthcare can ameliorate the health
damage caused by disadvantage (Macintyre, 2007)

13. Patients in deprived areas
 Multiple morbidity
 Mental Illness
 Addiction
 Unemployment
 Lower Income
GP Challenges Related to Deprivation
Complexity

14. 100 most deprived
practices in
Scotland
87 located within Greater
Glasgow & Clyde

15. Lipsky’s Street-Level Bureaucrat
SLBs are characterised by
their:
• Large caseloads
• Inadequate resources
• Need to process work
expeditiously
• Non-voluntary clients

16. Lipsky’s Street-Level Bureaucrat
SLB ‘dilemmas’ result from
trying to meet
bureaucratic goals and
patients’ needs:
• Autonomy vs.
bureaucratic control
• Responsiveness vs.
standardisation
• Demand vs. supply
(Lipsky 1980, 2010)
Professional
Autonomy Organisational
Guidelines

17. RESEARCH QUESTIONS &
METHODS

18. * Possilpark Health Centre- 1st, 4th, and 25th most deprived practices in Scotland
24 semi-
structured
interviews
Glasgow
& Lothian
Health Boards

19. Research Agenda
• What role (if any) do they see in tackling health
inequalities?
• What are their constraints?
• How do they negotiate the conflict of professional
autonomy vs organisational control?
• How do they view their role
as potential patient advocate?

20. FINDINGS

21. GPs: Social Constructions of Patients
Negative Constructions
• Victim blaming
“A lot of it is I think they just basically like to abuse
drugs [rather than change lifestyles]. It’s the same
with alcohol, they just like to abuse alcohol and
that’s it.”

22. GPs: Social Constructions of Patients
Positive Constructions
• Patient empathy
“The problems people have, just trying to live their
lives never mind look after their health…I mean
they also are aware that they should be changing
the lifestyles, should try and stop smoking or they
should be drinking less or whatever.”

23. GPs: Health Inequalities
Negative Constructions
• Focus on lifestyle and
health behavior
“Cultures of smoking and drinking…”
“Most people actually prefer sweet things and crisps,
and they don’t want to have an apple...”

24. GPs: Health Inequalities
Positive Constructions
• Wider SDH and
structural determinants
“Many of our patients are on such a low wage I
don't know how they survive…”
“Where's the incentives to stop smoking, if your life
is falling apart around you?”
“If we don’t deal with [wider structural inequalities]
we’re stuffed...the real determinants [of health] are
getting worse and worse.”

25. GPs: Health Inequalities
More convergence on individual role:
1. Health improvements via prevention, protection and
promotion strategies
“If you invest more money in general practice, then
patients will get seen quicker, we should pick up health
problems quicker and cancer survival statistics and
everything else should improve.”
2. Continuity of patient care
“We’re a constant in their life and we’re always here.”

26. GP Scope
Individual Clinical
Care
Politics
Community
Individual Social
Issues
Policy

27. GP as SLB: Workload Constraints
Constraints primarily stemmed
from:
• Shortage of time
• Complexity of patients
• Contractual obligations

28. GP as SLB: Workload Constraints
“Let's say you're very efficient, and you give yourself ...2
minutes to type things up. So it's 8 minutes for an
appointment. If somebody comes in, very typically, with
2 or 3 separate issues, you're then thinking, okay, you're
giving yourself 2.5 minutes per issue…that's just gonna
be, from the patient's side of things, so ridiculously
rushed and haphazard. And from my side, you might
miss things.”

29. GP as SLB: Autonomy vs Control
“It’s about an 89 year old who’s got a cholesterol of 5.1.
Well, it really doesn’t matter whether her cholesterol is
4.9 or 5.1, she’s 89…
You know clinically I am able to make the
judgement, and I should be able to
…I probably shouldn’t increase their statin because it will
just make them have nasty side effects. And it’s probably
4.9 when I do it next week anyway.”

30. GP as SLB: Negotiating Dilemmas
For GPs, professional autonomy overrides bureaucratic
guidelines if:
1. They perceive ignoring the guideline to be in the
best interest of the patient and
2. The financial loss is minimal
Independent contractor status viewed as vital for
allowing GPs to determine individual patient and
practice priorities
 SLB doesn’t explain GP role outside of practice

31. GP Scope
Individual Clinical
Care
Politics
Community
Individual Social
Issues
Policy

32. GP Advocacy: Clinical Care
• Involvement in secondary/specialist care
“And they might come in with a plastic bag full of
different letters, all the different services they’re involved
with. And it might be, ‘I’ve missed these appointments’,
and I’ll pick up the phone and try and deal with
that.”
“We are advocates in the sense that we just sort
everything out for people.”

33. GP Advocacy: Individual Social Issues
• Addressing the ‘non-medical side of practicing in a
deprived area’
“You think, right, this person gets chucked out of their
house, their mental health is gonna deteriorate, their
physical health is gonna deteriorate, and I’m gonna have
a bigger problem on my hands and I’ll have a more sick
patient, so it makes an interest for me to actually
write that letter for free to give them a help.”

34. GP Advocacy: Community
• Developing links within the community
“So most of what’s making our patients come to the doctors
are those lists of life threatening conditions which are well
understood – social isolation, mental problems, poor
parenting, drug and alcohol issues, unemployment,
deprivation. Now, most of those are not a straight health
issue, so the answer is not going to be a medical practice,
but the answer will be a medical practice linking with
other services.”

35. GP Advocacy: Policy & Politics
• Flag where inequalities exist
• Bear witness to the damaging effects political
decisions have on patients’ lives
• Advocate for policy change
“We don’t have the resources to give people jobs or give
people better housing, or more money, or deal with child
poverty—that’s a political and social issue. And we can
only advise what we see and what the effects of that is on
patients’ health.”

36. Deep End Group
• “Very much guided by frontline GPs and their working
experiences…”
• Successful in “[getting] the ear of the government”
GP Advocacy: Policy & Politics
Key Outputs
• Advocacy on policy
• Pilot projects including:
improving linkages with
community services, connecting
primary care to social work

37. Implications for the US
Importance of GP empathy; ability to identify need
Ability to shape policy through the use of local knowledge
and community engagement:
1. Patient advocacy
2. Improving connections with local services (FQHC)
3. Influencing policy
Value of a practitioner-led, academic supported group,
which has successfully advocated on behalf of the patients
it serves

38. Thank you
b.babbel.1@research.gla.ac.uk