Abstract
Background Living in socioeconomically deprived areas is associated with shorter lives and worse health. GPs working in these areas face additional challenges compared with those in more affluent locations.
Aim To establish GPs’ motivation for working in these areas, to discover the challenges that GPs face, and to gain insights from GPs on potential improvements and changes.
Design and setting An interpretative phenomenological analysis was undertaken of GPs’ lived experiences of working in the most socioeconomically deprived practices in Northern Ireland (NI), which is the most deprived country within the UK.
Method Interviews were carried out with nine GPs to find out the challenges facing them, why they work in a Deep End area, and what suggestions, ideas, and solutions they have to improve patient care and GP experience at NI’s Deep End.
Results The challenges related to wider health service failures including the increased demand on GPs and feelings of powerlessness. Patient population challenges included ‘missingness’, late or crisis presentations, alongside the clinical difficulties of a highly ‘medicalised’ patient population, as well as the high prevalence of mental health problems. However, GPs choose to work in Deep End areas because the environments were seen as clinically stimulating and rewarding, as well as giving them feelings of belonging and fulfilling a duty to ‘their’ area. Improvements focused on providing more flexible access, increased mental health provision, and future training and recruitment, particularly around widening participation in medical school.
Conclusion Improving the environmental conditions, empowering individuals, and investing in communities are essential factors to achieving health. The current model of providing reactionary acute care is leading to GPs experiencing powerlessness and feelings of helplessness at the Deep End.
Introduction
General practice in areas of socioeconomic deprivation faces additional challenges. Individuals in these areas live shorter lives in worse health.1,2 GPs face larger patient lists, increased demand, higher physical and mental health comorbidity, and shorter consultations, with current funding not matching clinical need.3–7 Alongside the demand versus resource mismatch7,8 are the large number of social presentations faced by Deep End GPs,7 concerns around the increasing roll-out of digital and remote innovations in primary care,9,10 the significant unrecognised ‘hidden’ workload,8 and the current workforce crisis.11–13 The Deep End projects, over the past 15 years, have been networks advocating for and working towards closing the health inequalities gap; however, Northern Ireland (NI) has lagged behind, despite being the most deprived of the UK nations.14
There are unique challenges to health care in NI relating to the ‘Troubles’, a recent civil conflict, spanning three decades, resulting in more than 3500 deaths, 34 000 shootings, and 14 000 bombings.15,16 At time of publication, NI has the longest secondary care waiting lists17,18 and highest suicide rate in the UK.19 It also has a political system that has been stalled for more time than it has functioned over the past 7 years. Within the UK context, NI can be seen as the Deep End of the Deep End. Unlike the rest of the UK, general practice-level socioeconomic data are not freely available, and therefore the unique challenges and needs of GPs at the Deep End are largely unseen and unrecognised. This study specifically focuses on the GPs’ perspectives in NI.
This study aimed to find out the following:
the specific challenges facing Deep End GPs in NI;
why GPs work in a Deep End area (the positive, protective aspects); and
suggestions, ideas, and solutions to improve patient care and GP experience at NI’s Deep End.
Method
Phenomenology was the theoretical perspective used, given it explores both what was experienced and how it was experienced,20,21 specifically interpretative phenomenological analysis (IPA). IPA takes an interpretative approach to the data, with the researcher(s) making sense of the participants considering their experiences.22 The participants were GPs working at the Deep End, which is defined as general practices with more than half the patient list living in the most socioeconomically deprived quintile as described in the authors’ previous work.23,24 The structure of IPA nurtures the reflexivity, allowing for identification, description, analysis, organisation, and reporting of themes that are drawn from the data.25,26 Semi-structured interviews were used for data capture, which is regarded as the exemplary method for data collection in IPA.25 The interview schedule was developed by the research team through consultation with GP representatives from the most deprived GP Federations in NI. A purposive sampling approach was taken to maximise variation with an email invitation to potential participants from the list of general practices operating in the most socioeconomically deprived areas of NI. See Box 1 for inclusion and exclusion criteria. This approach has previously been adopted in Scotland for similar work.27 The email invite and participant information sheet are included within Supplementary Information S1 and S2.
| GPs working in the highest need, socioeconomically deprived areas — the Deep End — face additional challenges compared with those in more affluent locations. This study looks at the Northern Ireland (NI) context and explores why, despite the challenges, GPs choose to work in these areas. The main issues relate to wider healthcare failings and the challenges of patient populations, some of whom generally frequently use (‘medicalised’ group) and those who underuse (‘missingness’ group) health services. GPs tend to relate to Deep End areas, either owing to personal connections or feelings of duty and social responsibility. No amount of funding focused on general practice will ‘solve’ the issues; instead, a far greater holistic approach, improving the physical conditions in which people are born, live, and work in, is needed. |
| Inclusion criteria | Exclusion criteria |
|---|
| Must be fully qualified with a Certificate of Completion of Training (CCT) | GP registrars |
| Willingness to communicate in English language | GPs who do not work in areas of significant socioeconomic deprivation |
| Willingness to sign the informed consent form and partake in a one-to-one online interview | |
Box 1. Inclusion and exclusion criteria
The interviews took place remotely using Microsoft Teams, enabling GP engagement uninhibited by location. Interviews were conducted and manually transcribed by the first author, a GP, who had undergone formal qualitative research training as part of their postgraduate studies. Data analysis followed the IPA steps as directed by Smith et al.25,28,29 The steps were as follows: data familiarisation; note-making on interesting parts of the data; theme identification from notes (see Supplementary Information S3 and S4 for the interview schedule and example interview with notes and themes);25,28 and a coding framework iteratively developed in NVivo (version 20) for each participant and transcript. The first author completed these steps for all participants; the other members of the research team reviewed transcripts, re-coded, and were part of the development of the coding frameworks. The number of interviews was not pre-set, and interviews would stop once the research team felt theoretical sufficiency had been reached within the data.
Discussion
Summary
This study explored the following three areas: the specific challenges facing Deep End GPs in NI; the reasons why GPs work in a Deep End area (the positive, protective aspects); and the suggestions, ideas, and solutions from Deep End GPs to improve patient care and GP experience at NI’s Deep End.
The main challenges facing GPs were the overwhelming patient demand, the ‘revolving door’, or recirculation of repeat presentations owing to overstretched secondary care services and excessive waiting lists, disproportionately impacting patients with the least financial means. Patient population challenges related to how people use general practice, including frequency of crisis presentations and a perceived pressure to prescribe. The social, geographical, and historical context of the area, particularly around the impact and legacy of the ‘Troubles’ and intergenerational trauma, provide additional complexity to the GP’s caseload.
Despite the challenges, the participants did report positive and protective factors that encouraged them to continue working in Deep End areas. These were the personal job satisfaction and the feeling of making a difference, alongside the clinically stimulating type of work. Personal feelings of belonging, duty, and connection with a geographical area were protective and motivational.
Deep End GPs, from their experiences, raised areas for improvement including flexible, drop-in style primary healthcare access, focused GP training and recruitment in socioeconomically deprived areas, increased mental health service provision, and increased investment in community and social support.
Strengths and limitations
The strengths of this work are the NI focus, the post-conflict society context it resonates with, as well as the incorporation of both urban and rural Deep End practices not commonly seen in Deep End literature. The sample size, while small, is in keeping with phenomenological studies.29 Nine GPs, with a range of experience from 1–23 years, represented 20% (n = 9/45) of Deep End practices. Given the work pressures, a 20% representation of Deep End practices was thought reasonable. This was further strengthened by interviews eight and nine not raising new themes and data fitting within the coding framework, which suggested theoretical sufficiency had been met through these nine interviews. The data collection process was strengthened by the interview schedule being developed by the whole research team, using input from stakeholders within the four most socioeconomically deprived GP Federations, with the consistency of interview approach afforded by a single researcher (the first author). This semi-structured approach allowed for a richness and depth to the data, which are required when exploring GPs’ lived experiences and perceptions. Rigour was achieved by the methodological approach set out by Smith et al for IPA,22,25,28,29 including the research team being involved in transcript coding and development of the coding framework.
Following the first three interviews, preliminary results were shared with academic GP colleagues at a national conference. The feedback and questions led to an amendment in the interview schedule with the addition of a ‘silver bullet’ or open cheque-book question around potential improvements.
The work is limited by the time gap between interview collections, which may have implications on the results and data, meaning different pressures were facing general practice at the times of data collection. However, it has given the results more depth, moving beyond the immediate COVID-19 implications, to providing more transferable data looking at the post-COVID-19 transition period. The research team tried to mitigate the time gap between data collection by adding additional steps to strengthen the rigour of the work, with individual review of coded transcripts, and subsequent research team discussion. The lead researcher, who conducted the interviews, was known to three of the interviewees prior, which, given the relatively small size of NI, is to be expected. While the interview guide and semi-structured nature helped ensure consistency, these prior relationships could have impacted the collected data. Finally, as described in the introduction, the context of NI is distinctive compared with the rest of the UK, and therefore application of the results to UK-wide practice should be approached with caution.
Comparison with existing literature
The distinction between individuals being perceived as ‘overusing’ or ‘underusing’ GP services in this study is consistently seen in Deep End literature. ‘Overusing’ or medicalisation is demonstrated by the high social presentations reported at the Deep End,7 the high unrecognised and under-resourced workload,8 as well as long waiting lists resulting in reliance on primary care for medication and social supports.30 ‘Underuse’ is similar to themes around ‘missingness’, described by Lindsay et al as the ‘repeated tendency not to take up offers of care, such that it has a negative impact on the person and their life chances.’ 31,32 The theme of avoidance has previously been described in similar Deep End populations.33,34 Both avoidance and missingness have resulted in worse morbidity and mortality outcomes.35
While the trauma of ‘the Troubles’ is well documented,16,19,36–38 this study describes the ongoing implications in general practice, namely the legacy of trauma on health and the intergenerational link. The epigenetic risks associated with the ‘Troubles’ have been described in the Commission for Victims and Survivors report, Towards a Better Future: the Trans-generational Impact of the Troubles on Mental Health,39 and the transgenerational epigenetic changes offer a theory for the increased physical comorbidity and early mortality experienced by GPs at the Deep End. Furthermore, ‘learnt helplessness’ theories, whereby persistent adversity creates negative behaviour change, acceptance, and powerlessness,40 appear consistent with the GPs’ experiences. The consequences of growing up in an area seen as a ‘Troubles’ hotspot anecdotally correlates with increased generational trauma and the role of adverse childhood experiences (ACEs).41 The intergenerational legacy of this trauma is particularly evidenced by the mental health prevalence, the overmedicalisation of some patients, and the perceived disempowerment or acceptance of poor health by others.
Regarding positive and protective factors, the rewarding aspect of the work and potential to make a positive difference in an individual’s life has previously been documented as providing powerful motivation and resilience to Deep End GPs.8 Participants identifying with and feeling a connection to an area were seen as motivational and protective, supporting the development of initiatives that seek to widen participation in medical schools as one way to reduce inequities within health care.42
Once qualified, the experience gained working in particular clinical settings influences future career choices.43,44 This study supports this finding, with many of the participants having completed their postgraduate training in areas of socioeconomic deprivation, suggesting one way to increase workforce is through focused postgraduate training in Deep End areas, in keeping with existing literature.23,42
Implications for practice
Regarding learnt helplessness and the social determinants of health, the wider social and environmental context of Deep End areas can lead to GPs experiencing powerlessness, disengagement, and a learnt helplessness. Issues such as material poverty, poor housing conditions, low educational attainment, lack of accessible health services, generational poor health, and intergenerational trauma meant that the wider social determinants of health were the focus of GPs when making sense of their experiences and discussing possible solutions and improvements. Achieving ‘health’ by empowering people and communities requires focused attention on the wider social determinants of health. Failure to do so will maintain the focus on reactionary acute care, leading to greater pressure on primary healthcare services, GPs, and patients.
Regarding mental health prevalence and provision, the high mental health prevalence within NI is influenced by the recent civil conflict, generational trauma, ongoing adversity, and high prevalence of ACEs. The findings are transferable to societies and populations that have experienced recent trauma. The study highlights a clear focus for healthcare policymakers around mental health provision for those living in Deep End areas, where the mental health needs of individuals are significant and complex.
General practice policy should incorporate the ‘Deep End’. The medical complexity of the patient populations in Deep End practices, from those who present late or in crisis, to those who are highly medicalised, means that health policy must be adapted to the community-specific context to be successful. General practice policy or initiatives need to consider the specific challenges faced by colleagues in Deep End areas, not doing so will likely increase disillusionment, burnout, and negatively impact morale within the Deep End workforce.
Regarding GP training and medical recruitment, with NI being the most socioeconomically deprived part of the UK and the high number of Deep End practices involved in training,24,45 considering measures to increase GP registrars’ exposure to Deep End areas for at least one placement on their training journey seems feasible. This would have educational benefit for postgraduate doctors, while increasing personal confidence, likely having positive downstream implications on early career recruitment in Deep End areas.
Finally, identifying with the patient population is a strong protective and positive factor to working as a Deep End GP. Widening participation into medical school has long been described as a measure to reduce health inequalities. This study shows how it is also a positive and protective factor in becoming a GP in a socioeconomically deprived area.
In conclusion, despite the challenges raised by GPs at the Deep End, there are strong positive, protective, and supportive aspects to the work. Highlighting these, and building on them, is essential to develop the GP workforce and improve care for those in society who need it most.
