How to address the inverse care law and increase GP recruitment in areas of socioeconomic deprivation: a qualitative study of GP trainees’ views and experiences in the UK

Working in areas of socioeconomic deprivation is challenging but has many advantages

Participants were asked about their experiences of working in areas of deprivation, including the challenges and positive aspects they encountered.

It was clear trainees experienced challenging clinical scenarios during their time working in areas of deprivation. Examples included complex multimorbidity and drug and alcohol addiction leading to difficult, time-consuming consultations for the GP:

'People who use drugs regularly don't consult through the normal routes often, they often have a very fixed agenda that I can't meet safely.' (Participant 8, year 3 of training, female, had never worked in a Deep End practice)

Clinical issues combined with complex social issues led to feelings of frustration and powerlessness:

'I feel that I've been trained to recognise and see how [social issues] impacts on health, but I don't feel very equipped to sort that problem out as a root cause and so feel a little bit powerless.' (Participant 9, year 3 of training, female, had never worked in a Deep End practice)

Frustration was also shared by many of the participants relating to lack of motivation and engagement by patients, which increased the workload and levels of stress. Safeguarding concerns and frequent use of translators were also highlighted as challenges:

'I found the safeguarding issues are a very, very frequent problem and they are time-consuming. It’s stressful, it feels risky.' (Participant 4, year 3 of training, female, had never worked in a Deep End practice)

'I have had a lot of consultations via translators and that’s really challenging. That’s a huge thing that I find difficult because you're not getting to the real issue. It feels like at times medicine with a total blindfold on.' (Participant 10, year 3 of training, female, had never worked in a Deep End practice)

Participants also highlighted the difficulty of managing complex consultations in 10 minutes:

'I feel as though if you had 15 or 20 minute appointments for these situations you could actually feel as though you could sort of ease into it. Whereas the thought of managing these situations in 10 minutes would fill me with a bit of fear.' (Participant 12, year 3 of training, female, had worked in a Deep End practice)

However, although challenging, this was not a deterrent for most participants who enjoyed working in a DE/DAP. Many participants highlighted the rewarding nature of the work and the positive relationships with patients who were grateful for their clinical care. This also included acting as a role model for younger patients:

'Being a role model for young people in deprived areas. So patients can think my GP is actually a real person. I think you could be more instrumental as a practice of improving opportunities for young people.' (Participant 9, year 3 of training, female, had never worked in a Deep End practice)

Participants also felt they were being allowed to make more pragmatic decisions with less anxiety about making mistakes:

'There’s a lot of stuff that you kind of have to accept that you can't do anything about or reverse. And for me, I find that easier. It’s clearer to see the things that I can help with.' (Participant 10, year 3 of training, female, had never worked in a Deep End practice)

Good teamworking was a frequently mentioned experience when participants had worked in DE/DAPs:

'I think it feels more "teamly" in a way because I think the staff know it’s hard and they understand that the patients are tricky to manage. So you kind of feel like you're in it together and it has a nice feeling.' (Participant 11, year 2 of training, female, had worked in a Deep End practice)

It was also highlighted that DE/DAPs offered innovative solutions to help their patients. For example, practices were tuned in to the issues facing their patients:

'We have got quite a lot set up in our practice. It’s not signposting people to apps and websites, it’s directly handing out clothes for the kids and that kind of thing.' (Participant 10, year 3 of training, female, had never worked in a Deep End practice)

The availability of a wider multidisciplinary team was also widely praised by a number of participants and was often targeted specifically to the needs of the local population:

'They've got like, mental health link workers and social prescribers and different types of receptionists who they've recruited from the local population. So there’s a couple of people who are [ethnicity] and they've got a really unique insight into the population.' (Participant 13, year 2 of training, male, had never worked in a Deep End practice)

The practices also were good at managing difficult clinical scenarios, such as drug and alcohol addiction, and clinical work was medically interesting:

'The stuff that I've seen in practice A and B has been medically quite interesting. You see people presenting much later with illness. There’s much more pathology like when I get my list of bloods in the morning.' (Participant 4, year 3 of training, female, had never worked in a Deep End practice)

Trainees are willing to work in areas of socioeconomic deprivation but clinical experience is important

Participants who had no prior experience of working in a DE/DAP were asked about their perceptions of working in such areas and whether they would be willing to work in such practices post-training. Those participants who had worked in deprived areas were asked about their plans post-training and what factors would influence their plans to work in a DE/DAP. All trainees were also asked about their familiarity with the Deep End concept.

Given the challenges of working in a DE/DAP, trainees highlighted the importance of gaining clinical experience of working in such practices. While the majority of the participants had encountered patients experiencing some form of socioeconomic deprivation during their general practice training, one participant had no experience and two participants had limited experience. One of the major concerns was fear of the unknown:

'My thoughts about going to one of these Deep End practices would be, would I be able to do it? Would I enjoy it? Would I want to commit to a job there having never worked in that type of practice before? So I think I would feel a bit apprehensive about it getting a job there initially.' (Participant 2, year 3 of training, female, had never worked in a Deep End practice)

This lack of experience was the main driving factor to not wanting to work in a DE/DAP on completion of training:

'It’s really difficult because I might fit in really well, I've just never done it. So maybe I should just kind of stick with what I know.' (Participant 2, year 3 of training, female, had never worked in a Deep End practice)

For those trainees who had clinical experience in a DE/DAP, level of deprivation was not an important factor when considering where to work post-training:

'I don't actually have a preference because I think every population will come with its own challenges and unique things. Ultimately, I see it as that doesn't have a huge bearing on my work. Ultimately the medicine doesn't change dramatically.' (Participant 13, year 2 of training, male, had never worked in a Deep End practice)

Indeed, the majority of participants stated that they would prefer to work in an area of deprivation:

'Your aim really should be using your skills in the place where you potentially need it most and that there is a real benefit to doing that and job satisfaction and interest.' (Participant 12, year 3 of training, female, had worked in a Deep End practice)

The most commonly cited reason for choosing a practice post-training was having already worked in the practice during training. Knowing the team is supportive and being familiar with the practice was important:

'I've obviously chosen to work where I'm trained and I think a lot of people do the same because they know what they're getting in for and they know the team. That will probably always be the case.' (Participant 8, year 3 of training, female, had never worked in a Deep End practice)

This was also applicable to working in practices in areas of deprivation:

'I’ve invested 18 months into getting to grips with all their systems and getting to grips with the complex patients. And I think it would just be a real shame to not carry on building on that really.' (Participant 12, year 3 of training, female, had worked in a Deep End practice)

Participants highlighted being familiar with the challenges of working in an area of deprivation was important:

'If you are exposed [to deprived areas] it might make you likely to actually apply to those places or not be put off [by] it because of the unknown.' (Participant 4, year 3 of training, female, had never worked in a Deep End practice)

Given the importance of training when choosing a practice to work in, participants were asked about their thoughts on training in a DE/DAP. All participants described the importance of training in both DE/DAPs and affluent practices to gain a wide range of experience:

'It makes you a more well-rounded doctor. Just because you work in an affluent area doesn't mean you're not going to have patients who have had similar problems to those in a more deprived area that you've worked in before and vice versa. So yeah, I think it should definitely be a compulsory part of training.' (Participant 5, year 3 of training, female, had never worked in a Deep End practice)

Knowledge of the Deep End concept itself was low among trainees. A number of participants had never encountered the concept of the Deep End, including a participant who was working in a Deep End practice. Other participants understood it related to the level of deprivation and extent of health inequalities but only one participant was aware of its aim to tackle the inverse care law. In light of this, and the need to improve awareness of the concept among trainees, participants were asked about their thoughts on an integrated training programme in the Deep End. This would allow allocated time to work on projects relating to the Deep End or experiencing work in a Deep End practice. Participants thought this would be a good idea but added this would likely appeal to those who already have an interest in socioeconomic deprivation and thus may not improve general recruitment.

Financial incentives are not an important attracting factor but support and development opportunities are

Participants were then asked about factors that would encourage them to work in a Deep End practice post-training.

The most important draw to working in a DE/DAP was knowing the practice had adapted to help mitigate the known challenges. Commonly mentioned priorities were 15-minute appointment times, a fixed number of patients per session, and a supportive team. Seven participants stated protected CPD time to develop a special interest would be a big incentive:

'Opportunities for CPD for development as an individual [would be a priority]. That probably comes from having an area of special interest, whether that’s women’s health or education, and that would attract me more to a Deep End practice.' (Participant 9, year 3 of training, female, had never worked in a Deep End practice)

The majority of participants highlighted the importance of having support or supervision to help the transition from trainee to qualified GP. This supervision did not necessarily need to be formal, rather an informal support network to help alleviate the stress and pressure associated with working in a DE/DAP practice:

'I guess even more than supervision you need it for the blatant purpose of it just to be like "hey, this made me feel awful" and they'll be like "yeah, don't worry, that’s normal".' (Participant 11, year 2 of training, female, had worked in a Deep End practice)

Money was not a major driver to attract participants to work in the Deep End. However, given working in Deep End practices is known to be hard, participants would want to feel they are being sufficiently compensated. A number of participants also highlighted that offering high pay or a ‘golden handshake’ may not attract doctors who are likely to stay working in the Deep End:

'If somebody was only attracted to that job because of the pay then is that the kind of doctor that’s likely to stay long term?' (Participant 3, year 1 of training, male, had worked in a Deep End practice)