 Now tonight we were going to have a talk on migration from Paul Adger of Southampton University, but unfortunately he's come down really ill with follow on coded, so he can't be here. So we're delighted that one of our council members, Professor Graham Watt has stepped in to give a talk on general practitioners at the deep end. The deep end is an international movement with the beginning Glasgow, which is now extended to seven countries, which aims to reverse the fact that the availability of good medical care tends to be in inverse proportion to the needs of the local population. This particularly applies to general practice, which is often seen as a poor relation to hospital treatment, but like public health generally has probably done more to combat ill health. Graham was Professor of general practice at the University of Glasgow, and was awarded a CBE in 2017 for his contribution to medicine. He has had a lifelong interest in healthcare, and perhaps his greatest and most important achievement in that area was leading the deep end project from 2009 to 2016, based on the 100 most deprived general practice populations in Scotland. Please extend a warm welcome to Professor Graham Watt. Thank you very much. When I was appointed Professor of general practice at Glasgow University, I thought it was a big deal. And I was disabused of that very early on, giving a lunchtime talk at Bridgeston Health Centre. And the practice manager didn't know who I was but she'd been put out onto the pavement to intercept my arrival. So I wasn't the first person that she had intercepted, asking if they were the Professor of general practice at the University of Glasgow. In fact, just before I arrived, she'd accosted a man in a suit who said he was just here to lay the linoleum. But tonight I do feel important talking to the Royal Philosophical Society, it's a pleasure. On the slides, in 2018 my granddaughter received a Christmas present of two handcrafted wooden giraffes. Not only, not only giraffes, but matched pairs of zebras, tigers, crocodiles, elephants, snakes and hippopotamide, along with a boat to travel in, and an old man in a beard to steer it. And in due course, we'll explain to her that all this was made by a man in his 91st year. One of the last creative acts in the long and hugely productive life of Julian Tudor Hart, the only general practitioner to be awarded an honorary degree by the University of Glasgow, whose career spanned the first 40 years of the NHS, not only imagining but also realising what a general practitioner could achieve within the NHS. As Haslitt said of Coleridge, he cast a great stone into the pool of contemporary thought and the circles have grown wider and wider. My talk begins a long time ago in a place far away, but it will finish close to home with a topic in which everyone here has a stake. It's organised in three parts. So this is part one. Tudor Hart's best known for his 1971 essay in the Inverse Care Law in the Lancet observing, as Tony said, that the availability of good medical care tends to vary inversely with the need for it in the population served. I'll say more about that shortly. But he was also a pioneer, an epidemiologist, a researcher, a social advocate, and underlying it all, a family doctor looking after the health needs of 2000 people over 30 years. The Tudor Hart name sounds rather Elizabethan, but his paternal relatives were North American, including Ephraim Hart, a Bavarian Jew, New York merchant, a politician, and Frederick Tudor, the Boston Ice King, who made his fortune exploring, exporting ice before refrigeration from Massachusetts to Cuba and India. His grandfather Percival, on the left, was sent from Canada to study medicine in Paris, which he couldn't stomach, so he left to become a painter and cut off from parental support. He was a starving artist, a fellow student with Matisse, a neighbour of Toulouse-Lautrec, his first wife, an emigre minor polis aristocrat, died young from tuberculosis. It sounds rather like the plot of La Bohaine. His father, on the right, Alexander Bornan Florence, was a left-wing doctor on the Republican side in the Spanish Civil War. But his maternal relatives were Scottish, Norman Macbeth, born in Glasgow, educated in Edinburgh, an apprentice engineer. In 1871 he worked in the drawing office of Messers Todd and McGregor, shipbuilders and partake, before moving with his wife, Annie McNichol, from Helensborough to Bolton, where he worked for 30 years and they brought up a family of nine children. The eldest of whom was Anne Macbeth, one of the Glasgow girls, head of needlecraft and embroidery at Glasgow School of Art, and a suffragette for which she was imprisoned, put in solitary and force fed in 1912. So medicine, engineering, art and politics ran in his family. And it's a complicated background. He could have played rugby for Scotland, England, Wales, Poland, Italy, France or Canada, but never did. For the last 60 years of his life he lived and worked in South Wales, and you'll see a lot of his artwork in this talk. In 1952 he worked for five years in general practice in West London, Paul Robeson, a visiting patient, then moved to South Wales as a member of the Medical Research Council Epidemiology Unit. But he didn't like being only a researcher, observing people's problems, but not able to do anything about it. So he left. They become, in 1961, a single-handed general practitioner in the remote mining village of Glen Corrig in West Glen Morgan. Commenting later, with a quote from the book and film The Go Between, that that stage in his life he had chosen to exchange a life of facts for the facts of life. He had a clear idea about what he wanted to do. With great effort any doctor can get to know all his patients, even in a city with high turnover. Only then can he learn to think of a responsibility not only to the patient sitting in the surgery, but to the whole population for whose care he's paid and for whose health he's responsible. He can then see his role as the ultimate custodian of the public health on a defined section of a world front against misery and disease. So he left in Glen Corrig as a deprived inner city housing estate, plonked on a Welsh hillside next to a coal mine. Although there were also six hill farms. And on the right at the bottom, you can see him returning from a home visit to one of them. The work was hard with huge surgeries and visiting lists. It took five years to reach a stable position, working through the unmet need, but more significant significantly marrying Mary Thomas whom he'd met at the MRC unit. They were married for 55 years. His story was her story, and vice versa. He recognized the records putting everything in order, converting from Lloyd George envelopes to a for records, the surgery moved from a wooden hut to a small health center the first in Wales. He took full advantage of the opportunities to recruit a team of receptionist nurses and community staff. In a stable position. He became the first doctor in the world to measure the blood pressures of all his patients and wrote it up in the Lancet pioneering then orthodox now. Famously, the last man to take part. Charlie Dixon on the right only agreed to take part if everyone else had taken part first. He was the last man, and he had the highest blood pressure in the village with a diastolic of 170 and assist all that couldn't be recorded on the machine. It was so high. He would have been dead in two years, but lived another 25 with treatment. It's an important teaching lesson, the last person as important as the first. The key to doing this for a whole population was what he called the measurement of omission screening the records not patients identifying what he hadn't done and flagging the notes, so it will be done next time. In this way he could address what's called the rule of halves. The tendency in any system for people to leak out. It's shown that 50% of people with high blood pressure weren't diagnosed 50% of those diagnosed weren't on treatment and 50% of those on treatment were not controlled. A half times a half times a half means that only a eighth of patients were getting evidence based treatment. The measuring omission and flagging the notes was the way to close the circles, and all this was predating computers, email answering phones, mobile phones. And what he did for patients with high blood pressure, he did for every patient. In the last five years, involving 210,000 patient encounters about 180 per week. You could show a 30% reduction in premature mortality compared with a neighbouring population, receiving conventional care, as reported in the British Medical General. She achieved partly by delivering evidence based medicine, such as the control of high blood pressure, but also by providing unconditional personalized continuity of care for all his patients, whatever problems or combination of problems they might have. And he showed that long term commitment to a particular community could improve health, length in lives, nano health inequalities, and he did this in the most deprived community in West Glamorgan, confounding his own inverse care law. In his book, A New Kind of Doctor, he looked back at the care of a man, invalidated out of the steel industry, with a list of problems which we now call multi morbidity. He'd had a leg fracture, he couldn't work anymore, he had no use for his big muscular body, it rather went to seed. Overall, the story is a success. For the staff at our health centre, it was a steady unglamorous slog through a total of 310 consultations. For me, about 41 hours of work with the patient, initially face to face, gradually shifting to side by side professionally. The most satisfying and exciting things have been the events which haven't happened. No jokes, no corny heart attacks, no complications and diabetes, no kid they fail you with dialysis or transplant. This is the real stuff of primary care. And it's a challenge to measure quality when your outcomes are known events. By his own admission, he began as an authoritative paternalistic doctor but he changed because he had to change. The word initially face to face, gradually shifting to side by side. He was talking about writing about what we now call co-production and the pace at which it could be achieved in a deprived community 20 years before it became a policy cat's word. He was a prolific writer of over 150 research papers, articles, books. He was translated into several languages including Spanish and Chinese. He lectured widely and was at his exhilarating best when speaking impromptu. In this slide bottom right he sketches his meeting with Italian colleagues. What he offered GPs was an image of themselves as important members of the medical profession, alongside specialists not beneath them. The meeting was important, finding a language that described the work of general practitioners, not only as it was, but also as it could be. He was humble in himself but ambitious for his ideas. The work of a general practitioner is immeasurably enhanced by working in with and for a local community for long enough to make a difference. The last as important as the first and the work isn't done until everyone's on board. You've heard of the worried well. He was the worried doctor. Anticipating patients problems not waiting for them to happen and then avoided them by joint endeavor. Drawing on marks because that was his politics. He saw healthcare as a form of production producing not profits, but social value, shared knowledge, confidence, the ability to live better with conditions achieved not by the doctor alone, but by doctors and patients working together. Patients were partners, not customers, not consumers. The NHS should never be a business to make money, but is a social institution based on mutuality and trust the ultimate gift economy like blood transfusion getting what you need, giving what you can, a model for how society might run as a whole. In the rebuilding society, he argued that that cooperation would trump competition, not marginally, but as steam once surpassed horse power. In 1975, as an Aberdeen medical student I traveled 500 miles to the colleague for my general practice attachment. A career changing experience seeing life and work at such a high level. And five years later I returned as a GP assistant and research registrar. To begin with, I wondered how sensible it was to start my career in the back of beyond. But on reflection, I've never worked anywhere more central. Unfortunately, that would be another talk. If you've read the book or seen the film of AJ Cronin's The Citadel. I have some idea of what it felt like as a young Scottish doctor arriving to work in South Wales in the special environment of a mining community. And I'm going to just stop for a couple of minutes to show you something that might give you an idea when I first arrived. And the first Friday night to meet the team. Dark night rainy nights in a local pub. So there we were sitting around a table two or three pints. And in the pub was a choir of 30 or 40 men singing in the background chorus of the Hebrew slaves, Dom Jones Delilah Welsh hymns, spirituals, all on the background. So I went back with a surreptitious recorder. And so that was quite an unusual thing. Last year in South Wales, 40 years after I made that recording I finally tracked down the singer Leon Evans, a retired engineer who could have been a professional singer as you heard but with a mortgage and a young family didn't have the option. That was the idea he'd been recorded. So I sent a clip to radio three, and it was played on Saturdays and radio three breakfast. So I sent them another one that the carol holy night sung by the whole choir. And if you were listening to radio three breakfast last Christmas day, you might have heard it. I never tire of sharing this wonderful collection of recordings, but I digress part two. The inverse care law is alive and well in Scotland. This slide divides the Scottish population along the bottom into 10 groups of just over half a million people most affluent on the left most surprised on the right. Premature mortality in blue top line premature multi mobility in red second line, they increase to over two and a half fold across the spectrum. But funding in black is broadly flat, especially in the more deprived half of the population. Consultation rates in green rise a little in deprived areas about 20% but with no extra resource. That's only possible by having shorter consultations are working a longer day. Indeed, a research study showed that GP consultations in deprived areas were shorter dealt with more multi morbidity and social complexity, had lower expectations on both sides of the table and poorer outcomes, especially for patients with mental health with commoners co morbidity and were associated with higher GP stress, because after one complicated patient was another and another patients with complex problems and affluent areas got 25% more time than similar patients in deprived areas. These are all data before austerity before COVID and the cost of living crisis, all of which have made it worse. And that starkly is inequity in health care, not as an as an abstraction, but as a daily reality for practitioners and patients. The Scottish deep end project, which I will want to describe has given identity, a voice shared activity shared learning policy impact to this previously neglected group of general practitioners, and by proxy, the patients they serve. Turn that slide upside down. And you see where we got the idea of the deep end of a swimming pool. And from this the deep end logo with the deep end of a swimming pool, the steep slope of health need, the flat line of resource, a sunrise or a sunset depending on your personality. The pool for Scotland top left a spiritual down the side. This is one of the few audiences in which I don't have to explain what a spiritual is for. It's a stirring instrument. And the whole thing is a flag for rallying under. Deep end GPS do and what can be done to help them. The first step was to listen to what they had to say at a conference at Erskine in 2009, involving GPS from practices serving the 100 most deprived populations in Scotland, mostly in Glasgow but also Edinburgh, Ayrshire and Eastley. That's about 10% of Scottish practices. Two thirds were represented. Locom fees to help them out of practice for the day. The first time they'd ever been convened or consulted. The seating plan was a circle with everyone in the front row. The conference report captured their experience and views. That set the agenda for a series of roundtable discussions on specific topics, all with short and long reports on our website at Glasgow University. Forty reports now the latest covering COVID homelessness, climate change, and prison health care. Some reports have been about austerity, welfare benefits, alcohol pricing, using the experience and voice of general practitioners to highlight social issues as they affect patients. But deep end advocacy has mainly been about health care. Health care is not at its best where it's needed most inequalities and health will widen as health care has become more effective and better organized the implications of inequitable care or become important for public health. There may rise to a six point manifesto more time for consultations addressing the inverse care law, better use of serious encounters that's continuity, staying long enough to make a difference. Building local health systems around general practices I'll talk about that better sharing of experience and learning better support stronger leadership especially at ground level, a simple enough agenda, it sounds. Every point is a challenge to current distributions of power and resource, and not every GP signs up for this for her PhD my colleague Brianna Babel from Oregon interviewed GPs working in deprived areas in Glasgow. All of them saw their role in the green circle in clinical consultations. You saw no further than that was others tuned into patients social situations, view the local community as a resource saw the social and political determinants of poor health being played out in front of them and wanted to do something about it. Here's the steering group of the Scottish deep end project meeting recently. Lots of young GPs, mostly women. They're helping each other to make the future to happen they're helping each other to make the future they want. Now of course advocacy isn't just what you say it's what you do. So very quickly, I'll describe five deep end projects. Our program provided an extra person in the practice team, acting not only as a signpost to community resources sometimes called social prescribing, but also working one to one with patients, especially those struggling to cope with a complicated and fragmented health and social care system. That scheme is now being rolled out to 150 Scottish general practices. The health center in the shadow of the Celtic Stadium financial advice workers who were embedded in the practice, not simply working nearby, increased the number of new referrals for welfare benefits with an average financial benefit per refer patient of over 7000 pounds per annum. The scheme is also now being rolled out with First Minister support. The deep end GP pioneer scheme puts young GPs into deprived practices partly to add capacity, but also to release the time of experience GP so they can apply their knowledge and experience to service development. The GP fellows are also engaged in service development and they release scheme to meet the educational needs for GPs in the deep end that conventional training doesn't provide. This scheme not only introduced young GPs to the deep end, it also revived the enthusiasm and delayed the retirement of host GPs. The governship project had nothing to do with ships, although government is where some famous ships were built. Long term GP locums made it possible to give every GP in the practice, one protected session per week to use as they saw fit and most use their knowledge to select patients who needed more consultation time, sorting and prioritizing their problems, re-coordinating their care, driving integrated care from the bottom up via multidisciplinary team meetings with attached social workers and link workers. In that way on 8% of patients in the practice reduced the workload of the practice at as a whole, because these were high users of the service whose problems were never being fully dealt with. It's a model of good integrated care. And finally, in a randomized controlled trial, the care plus study, it showed that extending consultations for selected patients with complex problems is cost effective. It not only improves patients quality of life on the left. It also prevents its further decline, as observed in the right in the control group. In this way, we've been working through what are considered the active ingredients of effective primary care, especially longer consultations, GP protected time, embedded co workers, community links, academic support, collegiality. But a consistent theme has been the importance of clinical generalism, providing unconditional personalized continuity of care for patients, whatever problem or combination of problems they present. As I said, like workers and embedded financial advisors have been rolled out nationally. We're still lobbying for the other changes. The primary motivation of most deep end GPs is not to address inequalities in health. That's an abstraction produced by statisticians and public health colleagues comparing groups. The motivation of GPs is to improve patient care, closing the gap between what they are able to do, and what they could do with more time and more support. And that's partly about evidence, but it's mainly about values. A GP in Scotland, Scotland's most deprived general practice. This is Petrus and ballet in fossil. She's a German GP now naturalized in the UK. I observed her day she invited me. She said she picked me up at seven o'clock in the morning. I tried not to convey that this was an unusual time for me to get up. It wasn't unusual for her until seven in the evening. She still had things to do. I wrote, I wrote the experience up in the British Journal of General Practice. I saw multi morbidity in large measure, presenting as a series of complicated stories. So the importance of prior knowledge, allowing consultations to start at the higher level and without which much less could be achieved in a short consultation. The importance of empathy and trust that patients placed in the doctor who knew them well and who cared what happened to them. I saw no worried well patients but I saw a worried doctor using her better knowledge to anticipate and try to prevent complications. She was ambitious for what might be achieved. Not immediately but over time. What mattered in the tales of a thousand and one nights to her as Ada you may recall had to invent a new story every day, her life depended on it. The Sultan wasn't going to chuck off her head. That's also the task of primary care, helping to create strong patient stories, experiences, and every practice is a compendium of such stories. The Sultan knows whether they're long stories or short stories or horror stories or fairy stories. That kind of information is not collected and reviews. An important part of story building is boosting patients knowledge, confidence and agency, the ability to take charge of their affairs. The point at which self help and self management are destinations not starting points despite rhetoric. It's a shared journey at an appropriate pace. In Julian Tudor Hart's words initially face to face gradually shifting to side by side. Now not every patient needs that it's perfect possible to reach a great age without any help from doctors I acknowledge that. But in Scotland, the 10% of patients with four or more conditions who account for a third of unplanned admissions to hospital and a half of potentially preventable unplanned admissions, they certainly do need unconditional personalized continuity of care. Patients with multi mobility and that means lots of conditions. There's no simple case definition because they're all different. But their needs are the same. Unconditional personalized continuity of care from a small team of providers whom they know and whom they trust. Relationships are the silver bullets of general practice and primary care, but not just relationships with patients. And the strength of general practice. First contact continuity population coverage coordination flexibility doesn't have to be done everything at the same time, long term relationships and trust these features are not exclusive to general practice. There are two public services that have them in such large degree. And that makes general practice the natural hub of local health systems, because they have the point of contact and they have coverage. But hubs go nowhere unless connected via spokes to other services and community resources, each spoke a relationship that needs to be built up and looked at. Realizing the potential of general practice requires competence, not only in clinical consultations, but also into practice based building programs, neither based on bricks and mortar or fancy architecture, but on relationships the first building a compendium of patient narratives. The second building strong local health systems based on general practice hubs. In 2019 in Glasgow we had a conference, not ready to celebrate the life and work of Julian Tudor Hart. Who envisaged it often, partly to note the publication of a book the exceptional potential of general practice I've been talking about that. We share the experiences of deep end projects in other places. The logo has been copied by deep end projects going across the top in Ireland. In Yorkshire there's the white rose in Manchester that's meant to be a bee, a busy bee in Canberra that's one of the colorful birds you see in Australia. Second line is northeastern North Cumbria. Nottinghamshire Robin Hood. Who had an interesting way of dealing with the financial redistribution remember you may recall. And then on to London with the leaf of a plane tree and the course of the River Thames. And then there's the East of England along the bottom. And then Denmark, very exciting this is the first deep end project that has started with institutional investment at a national level. And then Northern Ireland did agree. Apparently it's very difficult to draw the flag in Northern Ireland because of the sensitivity it looks as though they've put the flag into the North Sea. And what you'll notice about all these logos. And I think there are three more to come from Cornwall Merseyside in Wales. They all have a swimming pool, but only the project from Yokohama and Nagasaki has a wave machine. And this spread has been spontaneous, largely fueled by the passion of practitioners. The support has come second, their local regional or national networks of GPS and practices serving to private areas with a wider vision, what they can achieve and sharing activities spanning workforce education advocacy research. And the fast spread of the deep end movement from its beginning in Scotland, that the marginalization and neglect of the pride groups is common to many health systems. The experience of the various deep end projects is shared via the six monthly bulletin I'm just editing the eighth one. No one is trying to replicate the work of Julian Tudor Hart and the microcosm of a small Welsh mining village half a century ago. It's going to be crazy. Rather the challenges to apply his values and principles in today's context, retaining what's elemental and essential but continuing to be imaginative, innovative and productive. By what I mean, inclusiveness, looking after everyone, the last person as important as the first imaginative use of information, especially measuring what you haven't done. It's easier to measure what you've done. The importance of clinical generalism, unconditional personalized continuity of care commitment, working with in and for a local community and perseverance, staying long enough to make a difference, which brings me to the third and final part of this talk in the here and now. I don't need to tell you that the NHS is in trouble, and we may be at a tipping point. Most people now live 15 to 20 years longer than people at the start of the NHS in 1948. And as they get older, don't need to tell you they acquire and learn to live with an increasing number of health problems, what we called multi morbidity. In the years of age, multi morbidity is always higher and occurs 15 to 10 years earlier in poor areas that the top line, as opposed to the bottom line. And in poor areas, it's not so much the frailty of old age. As organizations begin to fail, rather it's the number, the severity and complexity of health and social problems within families and households. So here in the future is going to continue to deal with emergencies, large and small, provide specialist investigations and treatments help families negotiate pregnancy birth and childhood help people die with dignity and comfort. But increasingly, the challenge is to live well in later life with multiple diagnoses. So the Commonwealth Fund in New York, nothing to do with the British Commonwealth, compared health systems in high income countries, and it rated the NHS. The second column from the right, where all the ones are as the best health service amongst high income countries. The ones in the final column, that's the United States, which spends far more than anybody else, and has poor rankings in this comparison. We've got very little to learn from that country. But 10 years on, we've slipped still second column from the right, the fourth in the table now behind Norway behind Netherlands behind Australia, having lost ground in terms of access, investment and equity. Small wonder when you consider the underfunding of the NHS during the first seven years of the last decade, when the budget increased by 1% annually compared to 4% annually in the previous decade. That's not been enough to keep pace with the growing and aging population. And then along comes COVID, from which the service is still recovering and creaking. General practice is working harder than ever seeing 10% more patients than before the pandemic. And with the backlog of care for a whole range of conditions, the new problem of long COVID, the mental health burden from increasing financial security insecurity, and the challenge of new ways of working finding the right balance between face to face and telephone consultations in the Indian newspaper, the new head of the Royal College of GPs Camilla Hawthorne writes the number of GPs is falling and the number of patients we're seeing is rising becoming a GP, being a GP is becoming untenable and workable and doable. It's such a grind that people are retiring as quickly as they can. In Scotland, a third of general practices have GP vacancies they cannot fill. It's harder than ever, it's hard to be demonized by the Daily Mail and the Daily Express, if you read such things as the cause of increasing problems with access in general practice, especially in England, where there are fewer GPs, the head of the population. And it's a NHS staff doctors and nurses from the top of this ranking of the public's trust of different professions, politicians and government ministers at the bottom might seem a tall order but the Daily Mail and right wing press are doing their best. The ranking of the NHS could be seen simply as part of the austerity policies, which the current Westminster government favors both then and now, but there's another consideration. When the party in power has seen the COVID pandemic as an opportunity for friends and supporters to make a lot of money. And at least 70 of its MPs including many members of the cabinet of links to private healthcare companies seeking NHS contracts, producing public disaffection with the NHS could be a marketing strategy. And certainly, private healthcare has made substantial inroads particularly into the English NHS in the last decade. In Tudor Hart's cartoon here the anesthetist is asking the operating surgeon say, What are you doing this for the surgeon replies $60,000. No, I meant what is the patient got the surgeon replies $60,000. In his essay on the inverse care law to the heart warned the inverse care law operates more completely by medical care is most exposed to market forces, and less so for such exposure is reduced the market distribution of medical care is a primitive and outdated social form and any return to it would further exaggerate the maldistribution of medical resort. Specifically, private healthcare concentrates on profitable patients. It avoids patients with complex problems. It over provides for the worried well. It can't deal with emergencies. With the money out of the system that we better spent inside. It doesn't pay for the training of the people it's employees, and it promotes social exclusion of two groups, people who can't pay and users of private medicine who no longer feel part of the community. The minister's family is registered with a private GP service in London, which charges 250 pounds for a 30 minute consultation, 80 pounds for prescription, 150 pounds for a telephone conversation, and 500 pounds for a home visit. Of course, you can afford it. Perhaps the Prime Minister needs special arrangements. The worry is that decisions about the NHS are being taken by people who do not use it, and who have a financial interest in its decline. As we've seen this week, the political and media treatment of this issue is messy and dispiriting, but I agree with Helen McArdle. This is a time for the Herald's health correspondent in yesterday's Herald that we face a choice and honest debate about the future of the NHS, or an inevitable slide into privatisation by stealth. So I'm finishing this talk with three main questions. First, how will the rescue of the NHS be paid for. In one way or another, preferably paying taxes rather than fees for service. Bear in mind that the UK spends less on health care and five other G7 countries and raises less tax as a portion of GDP than any other Western European country, mainly due to lower national insurance contributions. If we want it. The second question is what will the additional funding be spent on. It's not just a question of restoring order. This slide shows in purple at the top, the increase in the number of clinical specialists in the last decade in Scotland, England, Wales and Northern Ireland. The trends in blue below show corresponding data for the numbers of general practitioners hardly rising at all. The resulting imbalance between specialists and general services has consequences could simply services in the community are less available and less able to keep patients in the community by preventing delaying or lessening disease complications. So any departments are busy. And you'll have seen and heard their call for more resources. But when a ship is listing to one side, it isn't the side nearest the water that needs more weight. Or to use another analogy. Why build emergency services at the bottom of the cliff, but a simpler strategy is to build a fence at the top. The suffering of specialist services with the referral criteria waiting lists and ability to discharge patients is also a problem for patients. At any age multi mobility imposes on patients a treatment burden that's what it's called now the work that patients have to do understanding their conditions and treatments, accessing services, finding ways to live well with their conditions. Specialist services are important, often brilliant and what they do, part of many patients package of care. But for many patients with multi mobility having to find their way through an archipelago of specialist services for each of their conditions is a burden. Spike Milligan brilliant brilliantly described this mushrooming of specialist services. This invented a machine that does the work of two men. Unfortunately, it takes three men to work it. If you had an outpatient department in Glasgow recently. Your appointment letter will have reminded you that each outpatient department cost to service 135 pounds. Every NHS spends on your general practice care in Scotland is 144 pounds per annum. That's 5% of the 2,900 pounds it spend on you in total. It would take relatively little to make a huge difference to general practice and primary care. At the symposium held in Glasgow in 2017 to mark Tudor Hart's 80th birthday. I remember him recalling that in a lifetime of clinical practice he'd never come across a case of parents throwing their baby out with the bath water. But in the case of NHS general practice that is what the system has been doing. It's a combination of inattention neglect complacency and false reassurances from those in power. The result is that the deep end is getting deeper and becoming a bigger part of the whole system. The deep end projects have highlighted what we need to preserve and build on not only the deep end but much more widely in primary care. And when we've addressed the first two questions is whether we shall be generous enough to ensure that the NHS is best where it's needed most abolishing the inverse care law. It's a big ask, especially when all parts of the system are under pressure. It emerged from austerity, COVID, the cost of living prices, as we must surely do, but only slowly. What will the future look like. The three questions I've asked, how will it be paid for, what will it be for and will be addressed in equity are each a challenge and a test of the type of society we want to have, and what we want to pay for. And the politician who led the introduction of the NHS was asked how long he thought it would last. He said, for as long as there are people prepared to fight for it. Well, our parents and grandparents fought for it. In World War Two, with their shared experience of bravery abroad and solidarity at home, not to go back to the unfair society that existed before the war. They accepted that the best protection for individual families was for all families to be protected. Bevan described it as a new path entirely. We're still on that path, but the way ahead isn't clear. The challenges have to be made. So, a final question, and the end of this talk, what will our children and grandchildren say when they reflect on what happened to the NHS in the 2020s when it was 75 years old. Thank you. We'll now have a very brief pause for anybody who has to leave and leave before we have questions to Graham. Questions, will people raise their hand. We have two roving microphones. So, gentlemen here first. Thank you so much for a wonderful talk. I'm sure everybody enjoyed it as much as I did. It was a wonderful recollection of meeting and listening to Harry Burns, who was Glasgow's chief medical officer of a great repute. Do you feel that the work that you're doing at Depend consolidates his work or in any way conflicts with it. I think Harry Burns has been a very impressive CMO in Scotland. Not a quiet man behind the scenes, but somebody who leads from the front. And he's been very effective in the story that he tells about the importance of early life in setting a pattern. That influence policy in that way. You know, having said that Harry was directed at public health and Glasgow for a number of years and then CMO and health inequalities are not really buzzed during that time. So I think there is a disconnect between the expertise we have in this country and describing and analyzing health inequalities and our ability to do anything about it. In terms of the deep end, well, the general practice is not the whole story, obviously the social determinants of health are the things that Harry talked about. But general practice is important because it has contact and coverage with the population and it's dealing with people who have inequalities and health now. The best in policies to improve the health of children, it won't affect the health of adults for 30 or 40 years. Whereas if you turn your efforts to deal with people who have got poor health now, there's the potential the student heart showed of postponing delaying preventing complications and improving lives. So the deep end has taken a long time to get traction in policy circles. I think there are reasons for that. What one is that general practice is organized rather differently from the managed part of the health service. And it's not thought about at the higher levels of policy and management. And if you look throughout the publications of health, much of what they actually describe themselves but the NHS Health Scotland, the public health information wing of it. I don't think they've ever published a report which mentions the inverse care law. It's a major feature and it's a particularly it's a feature in Glasgow this under resourcing of general practice and the effect it has on hospitals but you find a report from the health board or even the Royal College of Physicians and Surgeons which acknowledges that this is an important part of the classical scene. And I'd like to know about it. So I think the situation is better for the deep end now because we've not only got the language into the vocabulary of policymakers but but the wheels are beginning to turn. The chair of the current deep end group has now got a government position, a lead role for health inequalities, which is a very important sign. But these things do take time. You know, when you're trying to shift power and resource, nobody gives it up lightly. It takes time. A question from online from Rona chain. How can we as patients assist the work of reversing the inverse care law. You have a vote, and you have an interest in what happens to the NHS. I think that the, you know, there was the story earlier in the week about what the NHS managers were thinking in their brainstorming meeting about how they could meet the funding shortfall. The government were very quick to say we were not into privatized services at all. I think it's important that the politicians, more than the managers are aware of public feeling on particular issues. I think that the, the, the, the drift towards the increase in specialist services and the diminution of general services in the community which is taking place over the last 20 years I think it's just a function of the strength of the managed part of the health service and it has become more and more resource for itself. Some calling out of that, and the need of patients with multiple conditions to have someone, not for their exclusive use because I imagine this audience has 150 different packages of care which is a combination of the NHS outpatient visits, you can see the nurse going to the GP, but if you've got someone you know and trust who knows who you are, with whom you can have a conversation every so often, I think that's hugely valuable in, in managing your own care. It's, the question is, what can patients do to address the inverse care level? Is that patients acting individually, or collectively? My, my answer has been really the collective root is that the voice being, being heard. Individually, I think just being respectful of services, not overusing them, not taking your, more than your fair share of resource, but I think I'm struggling to find a neat answer to your question. Thanks, Graham. Is, is this difference done deliberately, or is it a case of, say, unconscious bias? So which, the specialist generalist? The, no, the difference, this, the deep end. Yeah. I think that there are more resources in better off areas and than in poor areas. Is it, is it a conscious thing, or is it unconscious in that many people are perhaps unaware that they think who are people where they spoke too much they drink too much to bring it on themselves. Well, the, and it would take a while to go into the funding reason that the formula. I mean Scotland in the last 20 years has been very effective in shifting hospital resources to where the need is. And that's partly because the data exists that tell you where the need, the need is if you have an emergency admission to hospital it's recorded and it can be counted and you know where the needs are. And you can do the sheer formula over a period of time you can incrementally shift resources around that's been done. In the deep end, the problem is one of unmet need. Things that aren't being done aren't being recorded so there aren't the data to tell you what's not being done. And that's been a problem, one of the problems in getting the formula change. I remember that that slide that I showed you the tense of Scotland, the blue line and the red line that was published. And it was a murder of Fraser that the Conservative MP who asked a question in Parliament what the First Minister was going to do about it and she said well, don't worry it's going to be all done through the contract, because there's a new GP contract and that the first minister didn't know then that there weren't the data to inform the contract. So the profession would agree with it if there were data, because if you have a system like general practice funding, which is a computation system where the practice gets a certain amount of money per patient a bit more for the elderly a bit more for other groups. And then it's left to the practice how to spend the money, whether it's spent on what's the balance between income and expenditure on the service. That's left to practices. If you start talking about redistributing a pot of money, which includes how people are paid, then you will get resistance if you try and change it. So we have stopped arguing for trying to get a formula through the GP contract and arguing for dedicated funding for practices to do agreed programs of work. But it's very difficult. I'm sure you know to argue for resource redistribution when resources are tight. It's very much easier when you know you find oil on the North Sea or it should be. And you can spend the new money. The, you know, I said, in 2009, that group of practices have never been convened or consulted. And the strength of the meeting was everybody was in the same boat. We worried that there would be too much negativity they'd express but actually it was such a novel experience to get people in the same boat that there was a huge buzz that was never left the project. But these are GPs who if they ever meet in a, in a local medical committee meeting or a college meeting that always in a minority. Most practices are dealing with a socially mixed population, not a deprived population. But in the beginning of deep end project because we based on practices. It's a whole step, because actually most deprived patients are not registered with deep end practices scattered throughout Scotland. There's hundreds of practices who have a small areas of deprivation within them. So the deep end project now lobbies for patients not for practices, because patients are distributed much more widely than the deep end practices. Good evening. Can I say I really enjoyed your talk tonight. It was very informative. But as a person who always is suspicious of what politicians tell me is the position with recruitment of new GPs and medical students coming through. You're wondering if straight from the horses mouth, as it were, you could tell us what the actual position is, are we recruiting more young doctors or young doctors coming through qualifying and moving on, or are we actually building up more GPs possibilities. Well, you know, just a warning, I'm not completely up to speed on those data, but but there are new students coming in. You know, there's a new medical school based at St Andrews with mature students coming through the all the medical schools are taking some more students. The leakage at the other end is premature retrial, which is an understandable reaction to the workload pressures that people have. That's why one of the deep end projects which retains GPs for longer is potentially so important. But it takes 10 years to produce a GP, you know, six, five or six years, five years to graduate couple years in hospital and then specialty training. So there's no quick fix for the manpower shortage. I think it will happen, but it'll happen slowly. In the meantime, there are other things that can be done to just work within the practice, you know, the using link workers to take over some of the genderless function is important. There's a lot that nurses can do, et cetera, et cetera. We are going to have to manage our way through that problem and people will manage it through, through 101 different local solutions that they will do because they have to. I have a question if I may in this World Cup season, your vice chairman of the Scottish Professional Football League Trust, which includes I understand all 42 professional clubs, and you've said that many conventional health promotion activists have added effectiveness when combined with the emotional attachments that people have to a particular football club. Can you say a bit more about that? Well, the 42 professional football clubs, I think 90% of people living in deprived postcode in Scotland live within three miles of a professional football club. So the new strategy for the trust is to harness what it calls the social power of football, in order to address the health and other implications of poverty. And I liken it to the deep end because essentially what the trust is trying to do is to provide central support for a network of local activities, which are stronger through being connected. The group study for the trust is called fit football fans in training. And it recruits men with the waste accompanies of 38 inches of more to a series of evening evenings at a football club of their choice. Half of it sexist life, half of it is nutrition, and it's done in a group. It's been evaluated by Glasgow University and the men and now the women because it's being extended the project, they not only lose weight, but they keep the weight off. And that's very unusual for an obesity program. And the only thing that is novel about the intervention is the attachment to a football club. And the explanation of it as far as we know is that doing it that way harnesses motivations within people in a group context that make the other things more effective. It's not the only thing that the trust does it does festive friends which is Christmas lunches for elderly and lonely people at the football club of their choice. And I'm on mental health in young men, which is a sort of a difficult area. And, but it's, it's in, it's completely different from the dependent lots of ways but it's similar in that it's trying to develop local connections and to connect local activities on a national basis. Perhaps you'll correct me if I picked you up incorrectly. Did you say that in Scotland 2,900 pounds is spent per person on health, and yet only 144% of pounds is actually given to GP practices. Is that correct. That's what I said. That's what you said. So surely the fault lies with the medical profession. I live in the mountains very affluent part, but I went to the suffering general or southern general for an operation, and it was reasonably handy and carried out very well 10 years ago. For the last three years, I've attended an 850 million pound disaster, which is a death star, the hospital Queen Elizabeth, sorry, Queen Elizabeth Hospital. They amalgamated hospitals without consulting people like me, or people on the Eaglesham who've got to travel all the way across Glasgow to get to a hospital. So perhaps if the medical profession, I go up off their backsides and said we don't want the Queen Elizabeth. We want smaller hospitals closer to the people who would have a better service. I think I think you exaggerate the power of the medical profession in the decisions that were taken. And I did show a picture of the Queen Elizabeth Hospital. And I contrasted it with the, the I was meant five hands to saying that the, in the sense of, I've often talked to myself it's a relief that that building has been built. Because now we can get on with more important building programs in terms of relationships within communities, which is a much more difficult thing to plan and achieve than building a multimillion pound hospital. I mean, it was a rationalization of Glasgow's hospitals which were Victorian and out of date. But I must admit when you go into it, it's like going into the atrium of a huge American hotel, isn't it, which makes you feel small. It's, I don't know what the architect had in mind when he designed that. I think the people in the Queen Elizabeth, in my experience, are wonderful. That's generally true isn't it that the people you meet are in the health service. It's not the people that's the problem. Because the NHS, at the end of every financial year, wind up sitting on a huge pile of unspent money, based on the fact there's 100,000 vacancies, a lot of which that money is not being paid out. But the corollary to that would be if they're not sitting on a big pile of unspent money, would they actually have the funding to recruit these 100,000 vacancies. I don't know the answer to your first question. Thank you very much really enjoyed your presentation. I'm interested to hear more about actual outcomes that your project could also be going for quite a few years to demonstrate how it has made a difference whether that's about retaining more GPS or general health outcomes being improved as a consequence of your interventions please. Yeah. Well, it's a good question, and it can be answered in several ways. Early on, when I asked colleagues on the steering group, what they thought of the deep end. And I was thinking, I was wondering whether they would value it as a change agent. But actually most people replied in terms of a support mechanism. Previously isolated not connected. It was morale boosting to be connected. So that that in one sense is an outcome. The, to produce the evidence on outcome that would persuade a cold hearted economist, you require the resources to carry out such research. The deep end was a project that started at ground level with practitioners and only acquired relationships with institutions subsequently, we were awful playing often playing catch up with the evaluations. But the link worker program has been evaluated by Mr Stuart master the director of the Scottish School of Primary Care. And it's a showed mental health benefits to patients who are seeing a link worker. And these were patients not with sufficient mental health problems to get on to a mental health waiting list. They just had it as another part of their problem. And our conjecture is that simply sitting down with someone who paid you attention and listened and care was beneficial to mental health so that was an important bit of learning. The governship project has been evaluated in terms of routine data. And it did show that the GP workload was reduced in the governship practices compared to practices in Scotland and basketball seven similar populations. But the hardest evidence came from the care plus study which I which I briefly, which was giving extra consultation time to patients who had been selected by their GP's as being likely to benefit from consultation time. But that's an interesting thing because it, it drew on information in GP's heads. Well, the calling said it's not information that's that it's that a statistician could give you in a printout with a list at the top. It valued the relationships and knowledge that GP's had with patients. And it was only an hour more in a year, which is probably doubling what people would get. And most of it was spent with a long initial consultation. And although GP may have felt that the new patients well they didn't know them that well. And that allowed things to be addressed in a more ordered kind of a way. And I showed the evaluation which showed that it improved quality of life and measures of health and well being. So all you're going to be able to achieve in the short term. And when you have a whole variety of patients with multiple, multiple morbidity, they're all different. So if you try to measure the outcomes in terms of disease outcomes, it would be impossible to imagine a study big enough to do it. But insofar as it measured well being. So subject subjected to an economic analysis, which showed that it was cost effective. And below the nice threshold for what the health service considers to be a cost effective intervention. I think that's about 20,000 pounds per quality. And it was below that threshold. Now if we had evaluated a drug or a bit of kit that was cost effective that would sail into practice. But if the cost effective intervention is more time in general practice. It's a much more difficult thing to roll out. So, the answer to your question is that we've got bits and pieces of research. My personal feeling is that the main achievement of it has been rather an existential one has been the creation of a group which didn't previously exist. It may not be a change agent, but it's definitely a support network and increasingly we think of it as a resistance movement. We're waiting for better times and being prepared for better times. So one final question over here. I go to the same church as the Chief Deputy Chief Medical Officer for Scotland. Is there any one message you would like me to give him over coffee next Sunday. His boss, Gregor Smith is a good guy. I think I ask his boss. I would say Gregor Smith used to be a GP in Lanarkshire. I would say Gregor Smith now it's easy to be that professors were rare things but now they certainly be very, very frequently. Anyway, Professor Sir Graham, Sir Gregor Smith demands boss. I think his hearts and minds in the right place on this. But I wasn't expecting that question so I'm not really proud of Beardwood answer. I was accosted by one of your friends who's left who accused me of accusing the Prime Minister of having an interest in private mention, which wasn't exactly what I said. I raised that as something for you to consider as a possible explanation of what's happened. Well, I think we'll all agree that Graham gave a wonderful talk tonight. We've all learned a lot and we all want to support the principles that he's advocating. And I think we'll all do our best to use our votes and our voices to do that. Let's thank Graham in a normal way. And perhaps you'll join us for a drink outside on the way out. And I'll see you next week. Thank you.