Social accountability and serving all communities

Purpose and context

Socially accountable healthcare focuses on the reduction of health inequalities. Health inequalities are unfair and avoidable differences in health across the population, and between different groups within society. These include how long people are likely to live, the health conditions they may experience and the care that is available to them.

Such differences are striking. For example, life expectancy between the richest and poorest patients differs by approximately 20 years, and there was a significant decrease in life expectancy among the most deprived areas of England between 2015 to 2017 and 2018 to 2020 (Office for National Statistics, 2022). The COVID-19 pandemic brought the reality of health inequalities into stark awareness as the most socioeconomically deprived in our society were disproportionately affected.

GPs are uniquely placed to understand the communities they serve, given their intimate knowledge of their patients’ circumstances and the social, cultural and medical factors that influence their health. As trusted figures in patients’ lives, GPs have variable power to identify and improve determinants of health that are having an adverse impact, and to influence changes in behaviour. For many patients, help in finding a job can have a more uplifting effect on their health than prescribed medication.

To care for patients holistically, GPs need to understand that the person sitting in front of them is as healthy as they are not just because of what medical condition they may or may not have diagnosed, or how well that condition is treated, but because of a complex interaction of various health determinants, many of which are outside their control. They need to understand the reasons that outcomes differ, and where they can exert influence to reduce inequality.

GPST is an opportunity to address inequities in care. Through this element of the GPST reform programme, we seek to ensure that GPs are supported in their role as catalysts for social change, and that the best care is offered to those most in need.

We heard...

Trainees and educators told us that many of them entered medicine and general practice to do good for individuals and communities, and that many of them aspire to care for those least well-served.

Some we spoke to were concerned that changes to the delivery model of general practice might exacerbate inequalities, and that learning from the pandemic and our collective response to it must address such unintended consequences.

Those we engaged with supported the following application of social accountability.

A model for socially accountable GP Specialty Training (Patterson & Blane, 2021)

Socially responsible

• Offering high standards of training, producing ‘good GPs’ to meet the health needs of society
• Every GP trainee receives training in the social determinants of health and health inequalities
• GP educators have access to teaching and resources to enable them to support health equity-focused training

Socially responsive

• Local GP training programmes identify needs of their populations and deliver specific training to meet these, e.g. care of homeless patients, cultural awareness, language/communication
• Trainees can access opportunities for more advanced leadership training
• Out of programme opportunities are available to trainees, e.g. HEE employed Health Equity Fellowships

Socially accountable

• Workforce and other initiatives are targeted at areas of socio-economic deprivation, e.g. post-CCT schemes
• GP training is co-created and delivered alongside community/third sector partners and patients
• Availability of a formal programme of opportunities for trainees to spend time in community social placements, e.g. with charities
• Engagement with academic community and other organisations locally and nationally working in the area of health equity, e.g. Deep End GP, Fairhealth

Given the evidence that training practices deliver higher quality care (Ahluwalia, et al., 2020)

respondents advocated for expansion in GPST capacity to prioritise underserved and underdoctored

areas, especially those with high indices of multiple deprivation.

A place-based pilot in Yorkshire and Humber helped future GPs develop skills and awareness in deprivation medicine and inclusion health, allowing trainees to spend between six and 12 months in practices in the most deprived areas or those which target vulnerable patients.

Trainees also did a placement at another organisation, such as mental health or homelessness services, to gain complementary skills. The pilot found that trainees are inspired by opportunities to work in tough areas and make a difference.

Priorities and action

Many general practices cover areas of socio-economic deprivation and serve disadvantaged and excluded patients and populations. These patients have particular needs and GPs working in such practices need particular experience, knowledge and skills in order to support them.

HEE’s primary care deans have created 165 Health Equity Focused Training (HEFT) programmes, providing three-year pilot programmes in areas of deprivation, and continue to identify opportunities for the development of additional HEFT programmes. HEFT consists of a shared national online education programme for all HEFT GP DiTs, combined with training posts in deprived areas, inclusion health, and as part of local communities of practice, local support and networking.

We will further develop post-CCT deprivation-themed fellowships, including the trailblazer scheme, with access to a monthly national trailblazer education programme. There are currently 52 GPs in these fellowships.

We are determined that GPs who complete specialty training are equipped to serve all in our society, including those most disadvantaged. We will work with colleagues in integrated care boards and the new NHS England to support prioritisation of areas of deprivation within primary care estate plans, to ensure sufficient training estate capacity. We will prioritise training capacity expansion to areas of deprivation, including urban estates and remote and rural areas. The HEE redistribution work will support this both regionally and intra-regionally.

We will work to ensure that all GP DiTs gain experience across the spectrum of deprivation, including geographical rotations and longitudinal placements where possible. This reform programme aims to tailor training delivery to the needs of communities within the bounds of the curriculum. Such training will utilise common content and standards while enabling meaningful local application.

When GPs relocate after CCT or later in their careers, they will be supported in continuous professional development by the workforce education and training directorate of the new NHS England and our Integrated Care System-level Primary and Community Care Training Hubs, to understand the needs of patients and populations locally, recognising how these vary across the country.

All GP DiTs will receive training in the social determinants of health and health inequalities, and in advocacy and population health (see below), through the provision of health equity training materials to training programme directors.