GPs at the Deep End

The ‘GPs at the Deep End’ have the laudable aim of reducing health inequalities. Watt hypothesises there is an inequitable distribution of GPs in deprived areas.1 He suggests that deprived areas require more GPs than affluent areas because the high disease prevalence in deprived areas leads to greater GP workload. We would like to challenge the assumption that deprivation is the main influence on GP workload. We believe at least four other factors influence this and that the four factors have complex interactions.

First, in the same issue of the BJGP, Salisbury et al found that age is associated with disease prevalence and also with consultation rates with GPs in England.2 Therefore, GPs working in affluent areas may have an equally high workload as those in deprived areas if they have a large proportion of older patients. In Monifieth, Scotland, we not only have a large proportion of older patients but also a large proportion of patients living in care homes. The care homes we look after include a home for those with high care needs, such as survivors of head injuries. In the past these very sick patients would have been looked after in secondary care. Today, they require us to make more house visits than the average.

Second, people in affluent areas are likely to have higher social mobility. This results in families being more geographically widespread and less able to help one another. This may lead to increased dependence on health professionals such as GPs.

Third, distance from the GP and poor transport links may increase the number of house visits required of GPs in leafy affluent areas compared to their colleagues in more tightly-knit urban deprived areas. Additionally, in rural or semi-rural areas it can take well over an hour to do just one visit, and visits in a single day may be spread out over a large geographical area.

These factors may interact. For example, professional people often retire to northeast Fife to an idyllic rural location. They may have few friends and family in the area and rely on their car for transport. As they age they may become ill and require home visits due to lack of family support and poor transport links.

Finally, GPs are widely acknowledged to have an important ‘gatekeeper’ role. We suggest that educated, professional patients are more likely to be informed about their health and about potential treatments for illness. Retired professionals or affluent groups have often also been used to having private health care attached to their work that they can no longer afford because premiums rise with age. They expect the same service now that they have more need of health care, from the NHS. This may lead to a higher rate of requests for referral to secondary care. It can take a lot of time, patience, and repeated visits to try to educate this group to have more realistic expectations of the service and to keep patients away from unnecessary and expensive secondary care.

In conclusion, we believe that population age, the availability of family support, rurality, and patient expectations may have as much, if not more, of an influence on GP workload as population deprivation. Furthermore, any reduction in GP funding may lead to an inadequate gatekeeper role and increased use of expensive secondary care. We're all GPs and we're all in at the deep end paddling hard to keep afloat.

• © British Journal of General Practice, April 2011