'We’re all in the same boat … some of us just have more holes in their boat': a qualitative interview study of primary care staff views of Deep End Cymru

Treading water: experiences of providing care in Deep End practices

Participants discussed the complexity of the population they served with high rates of mental illness, drug and alcohol abuse, domestic violence, and complex chronic illness. Patients often experienced poor housing, unemployment, and low income, all of which contributed to their health issues:

'You’ve kind of got the baggage of a life lived in deprivation and all the impacts that has on your quality of life, and your physical health and your mental health, and multimorbidity.' (Interview 5)

Most clinicians felt the complexity of the consultations was too much to manage within 10 minutes:

'There is absolutely no way that you can deliver adequate care in a 10-minute appointment for somebody. You have a patient who, you can see there are issues that need to … that you need to look at, but you’re almost frightened to open that up.' (Interview 10)

A few felt that they had developed a particular expertise in managing complex patients. However, most felt there was a general lack of resources, and those who needed the help had the least access:

'We’re all in the same boat … some of us just have more holes in their boat.' (Interview 4)

Many Deep End practices reported proactive approaches to support patients. Many used mental health workers and community connectors. Some practices reported additional services for patients experiencing homelessness and asylum seekers, some had reached out to the community to improve vaccination rates, some changed their websites so it could be accessed in different languages, and many had upskilled in areas such as contraception and substance misuse.

There were mixed feelings towards working in clusters (groups of practices that work together locally to develop services).¹³ Those who found it helpful tended to work with practices that had a similar population. There was a general feeling that services worked well when set up locally, but services were often regional rather than local:

'... they can’t afford the bus to get over there, they can’t afford a taxi so no one goes … people can’t access the health care they need.' (Interview 6)

Participants reported a mismatch between supply of appointments and demand, leading to frustration and sometimes abuse from patients. The demand was felt by both clinicians and administrative staff. Many participants felt helpless and were seeing high rates of burnout. This made it harder to recruit and retain staff, leading to even further staff shortages:

'There are high levels of burnout in the GP population in general, but I think it’s particularly intense in Deep End practices, where you know, GPs are struggling, and they’re massively under-resourced.' (Interview 16)

There were ongoing concerns that often there were only one or two GPs holding practices together:

'I do worry even more now, about these sort of Valleys practices and these ones are all struggling, um, how the future is going to be for them.' (Interview 15)

Some practices reported being actively involved in research, a few found it helpful financially, but often the motivation was contributing to research that benefitted their patients. They viewed their population as enthusiastic and willing to take part in research. Other practices felt that it was not a priority stating they had too much on their plate.

Diving into the deep end: motivations for working in a Deep End practice

All participants gave altruistic reasons for working in Deep End practices. They described their desire to help and reflected on the moral imperatives that everyone was entitled to equal health care:

'I’ve always sort of been brought up to have that sense of like everyone’s equal … I just think like morally, everyone should have that access to health care that they need.' (Interview 4)

Almost all participants felt it was rewarding to work in a Deep End practice, and they would not necessarily get the same job satisfaction from working in more affluent areas:

'A lot of the time it’s, you feel like you’re actually making a difference ... which I guess is what we all want to do in this world isn’t it.' (Interview 1)

Although in some practices there had been challenges dealing with frustration from patients and sometimes abuse of staff, many participants enjoyed working with their population usually finding patients very grateful for the help they received. Many participants also enjoyed the diversity of the populations they served, and the range of problems they encountered, finding they were usually seeing patients that needed help.

Many participants enjoyed working at their practice owing to the practice culture and a supportive environment. A few mentioned they trained at the practice and decided to stay on once qualified; this was also seen to aid recruitment in these practices:

'I think there’s a reason I wanted to stay is because it’s got a particular culture of support and it’s a training practice, we’ve got students so the whole thing is positive even in difficult circumstances.' (Interview 6)

Providing a life jacket: support from the Deep End Cymru community

Most participants were from practices that had engaged in some way with Deep End Cymru. Three participants mentioned limited or no involvement.

Many participants involved in Deep End Cymru felt it was a validating experience:

'We all know that this has been going on for a long time. But I think for the Deep End project, it’s you know, it’s got a name and … and we can all sort of … I don’t know, you’re stronger together, with these things.' (Interview 4)

There was a sense that being able to come together with people who understood the challenges was a source of support and one of the main positive impacts:

'Some of the ideas coming through are easily transferrable and really good, and what other people are doing. For me, it’s more about the community I think, and that sharing of things that have worked really well, or you know, the outcomes for the individuals as well.' (Interview 2)

Many voiced how important they felt Deep End Cymru was, and that by having a network, even in its early days, was a source of hope and support. They explained that it made them feel less isolated and gave hope that things may improve. There was also a sense that they were coming together with like-minded professionals who all wanted the best for their patients:

'The sort of want for, for helping the people, their patients and getting the best for their patients I think, was the, one of the biggest take-homes from it.' (Interview 8)

There were barriers to engagement. Participants felt they were ‘firefighting’ every day, so some did not feel they could spare staff to attend meetings. Participants voiced they had no ‘headspace’ to think about improvements. Another barrier was money. Deep End Cymru provided payment to allow a member from each practice to attend meetings. Many said this was not enough to provide cover and that these barriers would affect the practices that were struggling the most. Those that had not engaged with Deep End Cymru may be the ones that needed the most help:

'It’s a ‘Catch 22’ isn’t it, a network always means that you are engaging, that always means time and we are asking time of practices which are the ones struggling the most.' (Interview 13)

Swimming to shore: the search for work-based effectiveness

All participants discussed the need to change how primary care is funded with many feeling that the current Carr-Hill formula¹⁴ did not take into consideration levels of deprivation adequately. This was felt to be inequitable when considering the increased workload and how often practices struggled to meet their targets:

'The Carr-Hill formula does not work for us. It’s making us look like we do less work, but we do more.' (Interview 11)

Participants felt one important way in which the network could support practices was in advocacy. It was felt there was a general lack of awareness (including from Welsh Government, other practices, academics, and the public) of the difficulties they faced. Some participants also felt it would be helpful to get the public involved when advocating for Deep End practices:

'I think one of the most positive things it can do is campaign to get better funding because unfortunately money makes the world go round.' (Interview 1)

With increased funding, participants felt they would be able to offer better services including more and longer appointments. Many spoke about administrative support to allow practices to be more proactive at contacting patients about chronic health reviews and vaccinations. Others discussed employing other staff, such as mental health workers or link workers, to allow a more holistic approach to patient problems. All practices felt that they could spend time improving health literacy. Practices with a high proportion of patients who do not speak English as a first language wanted extra funding to offer patients longer appointments and resources in different language.

'If you’ve got a link worker, and say right, let’s look at the housing, let’s try and support you through that bit, and it might not work, but at least when we get through that, we can do the kind of broader piece.' (Interview 5)

Many participants wished for more protected time and headspace to implement solutions rather than firefighting. In order to achieve this, they wanted help with recruitment and retention of staff. They feared that some practices are unable to continue and are resigning their contracts. Some felt this could be done by increasing student placements and GP trainees to Deep End practices. Many were enthusiastic about the prospect of research, but would need protected time for training of staff, and time and funding to do the research itself.

Most participants were enthusiastic about Deep End Cymru and what it may achieve. However, a few were more cynical. There was a feeling that keeping practices engaged may be difficult unless they saw the benefits of the network and, as part of this, clearer objectives were needed. Others suggested short-term and longer-term outcomes. One suggestion was a measure of the proportion of practices engaged in Deep End Cymru. Many participants suggested staff-related outcomes such as feedback on whether workload had improved, measuring burnout among Deep End staff, and the numbers of practices that resigned their contracts.

'One big thing is staff, so kind of staff retention and recruitment, so monitoring staff levels in these practices, perhaps you could look at you know, the number of patients per partner, and if that’s rapidly rising, that suggests that practices are struggling.' (Interview 16)

Patient-related success outcomes suggested were repeat appointment levels, which may indicate that patients’ needs are being met within one consultation, and rates of behaviours such as smoking, drinking alcohol, or immunisation uptake. Longer-term outcomes discussed were life expectancy of patients in Deep End practices, and whether chronic illness rates had improved. Other suggestions were looking at whether practices were financially better off.