Author's response

What is the NHS for? Steven and Jackson give several examples, based on ‘idyllic, rural’ north-east Fife, including counselling for patients no longer able to afford private medicine, home visiting across the country miles, providing extra support for older patients whose offspring live far way, and the general increased needs of older patients.1

All these types of issue, variously reflecting needs and demands, can keep GPs busy, but in the same way that the purpose of the NHS is not just to pay staff, neither is it just to be sure that staff are busy.

It is no news to anyone that increasing age is the main driver of consultation rates in general practice, whether in affluent or deprived areas. Successive GP contracts have been weighted to reflect this. But while GPs serving affluent areas have to cope with the multiple morbidity of ageing, GPs serving very deprived areas are dealing with higher levels of multiple morbidity and social complexity at every age after childhood. GP contracts and workload studies have taken little account of this, partly because workload can only increase so much, and after that, both practitioners and patients have to adapt to what is possible. The maldistribution of GP manpower in the UK, that is worse in England than in Scotland, is an established fact and not a hypothesis.2 The ‘Deep End’ title implies the consequent depth of unmet need within everyday general practice in deprived areas.

Many of the issues that concern general practice in the Deep End are similar to those affecting all practices, including the challenges of ageing populations. One reason for focusing on the Deep End is that life expectancy is unnecessarily short in very deprived areas, and as Julian Tudor Hart has shown, well-organised, mainstream general practice can make an important difference. General practice could be better supported to improve health and narrow health inequalities in very deprived areas – not just a ‘laudable aim’, but a major policy objective of all political parties. This is not the only purpose of the NHS, as Dr Steven and Professor Jackson describe, but the case deserves a hearing, and respect.

• © British Journal of General Practice, April 2011