All political parties understand the importance of tackling NHS waiting lists and workforce shortfalls. But another crucial – and much less talked about – challenge is the unequal care patients receive from GPs depending on their socio-economic status.
In general, health outcomes are worse in less affluent areas, with larger numbers living with multiple long-term health conditions . But despite having greater health needs, poorer areas have lower levels of funding and fewer GPs per person. This follows what is popularly termed the ‘inverse care law’, where those most in need are least likely to receive care. And data suggests that patients are feeling that difference in their interactions with GPs.
People living in the most socio-economically deprived fifth of postcodes in England are less likely than their counterparts living in the wealthiest areas to report having their needs fully met (50% vs 60%) in their most recent GP appointment (from the 2023 GP Patient Survey). Patients in those areas also have poorer relationships with their doctors than in the most affluent areas, being less likely to report full confidence and trust in their healthcare professional (57% vs 68%), and less likely to feel they were “very good” at treating them with care and concern (44% vs 53%).
Could a better understanding of patient-doctor relationships, and how social and economic factors play into them, be key to improving care?
Several studies from the 1980s to now, have found that patients with higher socio-economic status, such as higher education or income, receive more health information and more explanation from their doctors. They also had more control over treatment decisions versus their less educated and less well-off counterparts.
One recent study of cancer review appointments in Liverpool found that doctors made more small talk and engaged in more humour with their more privileged patients. Conversely, patients with lower socio-economic status are less likely to report receiving enough information to make decisions, and more likely to feel that doctors didn’t give them understandable explanations.
Research has also found that this same feeling is shared by doctors. A study of three GP practices in England from the 1990s found doctors themselves felt they listened and gave advice less to patients in lower social classes versus their counterparts in more prestigious jobs. When specifically asking less privileged groups what makes a good GP consultation, patients focus on easy-to-understand communication, genuine empathy, and relatability.
As with all interactions between people, power and status play a key role.
One analysis of patient-doctor interactions in the USA found that white male GPs dominated conversations more with racially minoritised or female patients, but were more collaborative with patients of the same race or gender.
Doctors are the single most privileged profession in the United Kingdom. Data from 2014 showed only 4% of doctors came from working-class backgrounds. The compares to 18% for people employed in other traditionally prestigious jobs such as lawyers and investment bankers, and 35% across the general population.
Without data on the socio-economic backgrounds of NHS staff (despite guidance from the Government’s Social Mobility Commission), we can’t look in detail how socio-economic differences between doctors and patients play into experiences of care. Nevertheless, it’s conceivable that doctors more representative of their patients are more relatable. They are certainly more likely to have personal experience of the wider difficulties faced by patients outside of the consultation room that also impact health. Challenges such as fitting in doctor’s appointments around caring responsibilities, managing stress caused by unstable employment, or living in damp conditions known to worsen conditions like asthma.
Indeed, there is growing focus on holistic care that considers how the social and economic circumstances we live in impact our health.
Could increasing diversity of GPs in the UK’s poorest areas improve patient-doctor relationships and reduce inequalities in care?
While initiatives to increase diversity in medical school students have existed for over 20 years, and gender and ethnic diversity has increased, data has shown little to no change in the socio-economic diversity of admissions.
NHS England’s aspiration that “…the NHS workforce is representative of the communities we serve…” is welcome and supported by a new medical degree apprenticeship scheme with 2,000 places by 2031.
University-specific initiatives like the Extended Medical Degree Programme at King’s, will also play a role. The scheme is open to non-selective state students only, takes account for each applicant’s socio-economic background, and provides added academic and pastoral support throughout study.
But schemes like these are likely still not ambitious enough to achieve full representation. Work is also needed to address social conditioning and attitudes that makes potential students from under-represented backgrounds often feel like medicine “isn’t for people like them”. When these minority of students do get in, they are more likely to go on to work in under-served areas that need doctors the most.
Supporting the entry of under-represented groups into medicine, and putting them on course to be future GPs is therefore crucial. This should be a priority for whoever forms the next government. Not only because doctors should be representative of their communities, but because it has the potential to improve the quality of care for our most vulnerable groups.