Giving Voice to the Missing or Marginalised.
Andrea Williamson is a Professor of General Practice and Inclusion Health combining teaching, research and clinical practice. Her career focus is on caring for those less fortunate.
Andrea teaches and trains about the social determinants of health, inclusion health and trauma informed care. She leads on research about “missingness” in healthcare and is involved in wider research to improve care for people experiencing severe and multiple disadvantage.
Deputy Director of the GP teaching team at Glasgow Undergraduate Medical School, she set up and runs the BSc intercalated degree specialist course “Global Health Primary Care”.
She is a founding member of the steering group of GPs at the Deep End, deputy chair of the Health Inequalities Standing Group of the RCGP, a member of the NIHR Health Services and Delivery Research Prioritisation Committee UK, the Scottish Government Primary Care Health Inequalities Research Advisory Group and the National Suicide Preventions Advisory Group. She is a past Commissioner on the Poverty Truth Commission, and was the Primary Care member of the NICE Guideline Committee for integrated health and social care for people experiencing homelessness.
Andrea is a medical officer in Glasgow Alcohol and Drug Recovery Services and was a GP in the Glasgow Homeless GP practice from 2008 until it was closed in 2023.
“Increasingly people are really struggling to get access to general practice. For people who have high health literacy, a reasonable amount of wealth so they’ve actually got money on their phone, the time, and the psychological robustness – you know, it’s not an easy thing to sit on the phone at 8.30 every morning, trying desperately to get through to your practice. And the thing is that practices don’t know who’s not getting through. Practices don’t know who’s given up.”
Cartoon by Jack Brougham
University of Glasgow. Link to: The Scottish Deep End Project.
From GENERAL PRACTITIONERS AT THE DEEP END INTERNATIONAL BULLETIN NO 9 JULY 2023
An Editorial by Andrea in the British Journal of General Practice in September 2023. “Inclusion health and missingness in healthcare: dig where you stand”
The Herald reporting a study that appeared recently in BMJOpen
The inequality of healthcare.
Cartoon by Jack Brougham
Professor of General Practice and Inclusion Health… tell us about your role, how you got there, and the importance of Inclusion Health.
Andrea Williamson: So, how did I get here? That’s an interesting question. I’ve always been interested in the care of marginalized people and even as a medical student here in Glasgow I used to be involved in running a soup kitchen for people experiencing homelessness. Then I did my GP training when I finished medical school and came back to the City of Glasgow after managing to leave for a couple of years. I found clinical medicine interesting, and I enjoy the detective work in that, but I’ve always been interested in the people who are not being well served by health care as it is currently delivered. I was lucky enough to do an academic fellowship here at the University of Glasgow and I got to choose which clinical services I went to work in. So I spent a bit of time working in alcohol and drug recovery services, and I spent a bit of time helping what was then the homeless families team, and became interested in the sort of the tricky stuff around- how do you ensure that people take up offers of care, do the health promoting things that they need to do, and that then started me on a journey. During that Fellowship I did my Master’s in Public Health and got switched on to doing research. I’d never thought in my early career that I would end up doing research but I really loved qualitative research and that led me on to thinking about my PhD as well.
About 13 years ago I was involved in the early days of GPs at the Deep End which was started by my colleague Graham Watt who was Head of Department here in Glasgow and his thing was that the GPs who serve the most social economically deprived communities don’t really have a voice in what’s going on in terms of healthcare development and delivery, so he convened that group. Now, 13 years or 14 years on were still going strong and the Deep End movement has now become well known. There are Deep End groups across the UK and beyond, and now globally. Its focused on the care of patients in socioeconomically deprived communities and that’s been really interesting for me because I always tended to think a lot about the issues that my patients encounter and, that as a health professional trying to care for the people I encounter, that that was really about extreme marginalization. What the Deep End group taught us is that, actually, it’s an issue for lots of people struggling with adversity.
That then led me to think about how research and policy development often that happens in silos. You’ll get really great work being done about how you can best support people experiencing homelessness, or best support people struggling with problem substance use, and you can have really great policy and practice stuff going on in an interesting practice. But, actually, there’s a lot of synergy, a lot of learning, that can be gleaned from those different approaches and there’s something to be said for bringing it all together. That where the inclusion health aspect comes in and that’s why, when I was promoted to Professor last summer, we thought that was the best way to describe what my work involves. It’s about trying to think about marginalization across the piste, and to learn as best we can from lots of different disciplines, to think about how service provision for people should be different.
DMacA: You’ve hit the headlines recently. You had a headline across the national newspapers with some of your research on the time that patients have in the consultation. Tell us about that.
AW: It is chasing that Holy Grail of how you identify and quantify unmet needs. One thing that we’re really good at doing as health professionals is dealing with what’s in front of us. The Health Service is such a busy place these days that, for people to have the headspace to take a step back and identify who’s missing, what’s missing, is not always easy. We were doing a big piece of epidemiological work looking at missingness and healthcare a few years ago and my colleague Alex McConnachie, who’s the lead statistician on the team, said there’s more to this, we can use this data to think about unmet needs. We had done really careful coding of long-term health conditions in the GP record and when we looked at that we found that, actually, there is a big mismatch between the time that GPs give in more socioeconomically deprived places than in more affluent places.
…we do really have unique insights into a whole range areas of people’s lives across society. We meet people when they’re at their most vulnerable and we know things about people that many people even in their immediate family might not know.
DMacA: So the problem really begins in the consultation. Health access in the consultation is primarily a problem, even in these deprived groups.
AW: In terms of people even managing to get to see the GP, there’s a whole pathway there. There are people identifying that they have a health need that needs met; people then feeling able to seek out care, then people being able to take up offers of care if they can get that offer. And that’s become a really pressing problem since the covid pandemic. Increasingly people are really struggling to get access to general practice. For people who have high health literacy, a reasonable amount of wealth so they’ve actually got money on their phone, the time, and the psychological robustness – you know, it’s not an easy thing to sit on the phone at 8 30 every morning, trying desperately to get through to your practice. And the thing is that practices don’t know who’s not getting through. Practices don’t know who’s given up. There are the health needs that people identify that they might need met that’s causing them harm, but there’s also lots of other unidentified needs, risk factors for longer term cardiovascular outcomes, for example.
DMacA: Let me bring you back to another of your interests which clearly began when you were a medical student and that is; alcohol and drug addiction.
AW: That interest came from meeting the needs of people who were marginalized. There’s such shame and stigma still. Although there’s huge effort going in to try and shift that, there’s still huge shame and stigma around a person struggling with substance use, whether that be alcohol or other drugs which are (still) illegal. I suppose that was my initial interest and then, as my knowledge and experience developed I increasingly came to understand that, when people are using alcohol and drugs, the vast majority of people who are dependent, are using it to escape and cope. So, they’re using it to escape and cope with memories and emotions of often really terrible things that have happened to them in their past. And aside from the shame and stigma, exclusion from services then brings that firmly into the inclusion health context. One of the commonalities that many people who you would consider to be in inclusion health population share is that they’ve often, and I’m not wanting to stereotype but I think that the evidence does tell us quite strongly, that people often have had really significant adversity and difficulties across their life.
DMacA: We talk about the individual but this is a whole public health political issue and, while people think of general practices as being about the consultation, the whole politics of healthcare impinge on general practice like, for example, minimum pricing of alcohol, alcohol policy. Talk to me about your views.
AW: For many GPs their work life is about the consultation, it’s about the individual patient in front of them but, actually, it rarely is. Because most GPs help manage their practice, have some sort of control over how they run their practice, and one thing that the GPs of the Deep End group taught us is that we have quite a lot of power. Our voices are heard. Some people would say it is a bit of a cliche but actually lots of other public sector professionals have similar voices. But we do really have unique insights into a whole range of areas in people’s lives across society. We meet people when they’re at their most vulnerable and we know things about people that many people even in their immediate family might not know. That kind of knowledge of people’s lives is really important and what the Deep End group has done is to say that knowledge should be translated into advocacy and we should be thinking about the things that are really important in terms of the population, in terms of public health. I know that not all GPs are comfortable with that but, what I think we’ve shown through the Deep End movement, is that action can have power.
So, as a group, we’ve been actively supporting the minimum unit pricing strategy in Scotland. We’ve recently been involved in the call to have that increased because we feel that the amount needs to be increased as it has been shown to have positive public health outcomes. In fact, we would go further as way more needs to be done in terms of alcohol policy in Scotland to help reduce the harms. The flip side is that we also need to be thinking better about how we provide care for people who are struggling with alcohol dependency, who get tipped over. At the moment there’s lots of action and lots of policy interest in moving things along but really, in terms of services for people, it is still a bit of a postcode lottery when it comes to being able to access alcohol treatment services. We’re still not great at providing care that’s permeable and easy to access for people. Linked with that, and it has been said for decades now, that the link between struggling with problem substances, and then getting care and treatment and support for mental health issues, is still not good at all.
One thing that we’re really good at doing as health professionals is dealing with what’s in front of us. The Health Service is such a busy place these days that, for people to have the headspace to take a step back and identify who’s missing, what’s missing, is not always easy.
DMacA: Let me talk to you about another aspect of this problem at a higher level, and it’s an equally a problem on both sides of the Irish Sea, and that’s the whole area of the culture of alcohol in our society.
AW: That’s one of the really interesting things. It even comes up when you’re teaching undergraduate medical students and we have students from other country settings who come into the UK, and when we have discussions about alcohol it just becomes obvious so quickly. It’s the same in professional settings as well. That culture, that alcohol is a pleasurable thing, is across everything that we do; when we think about socializing, relaxing. It’s really interesting when you’re trying to encourage students and practitioners to be reflective. That’s one element, and the other element is to do with issues around how you can structure social space, the places where people can go and meet. Again, back to that escape and coping, how is it as a society that we escape, how is it that we cope with the challenges and difficulties of life. For sure, life is very hard for a lot of people at the moment and, for me, one of the things that I’m always struck by when I’m thinking about inclusion health and of the Deep End is often of the sort of resources for people so that they can socialize or manage life more easily in other ways. Those resources are just not as available in our Deep End communities and it’s harder to do things. So it’s all of those, there are so many factors.
There is something really powerful about having your tribe and that’s one thing that the Deep End does. It enables people who have may have been plugging away on their own, or within a small practice or setting. When they come together that means they’ve got this backup and they’ve got encouragement, they’ve got the collective skills.
DMacA: I’m so impressed with what you do with the Deep End communities, what Graham Watt started and what you folk continue and that’s so positive. But, I’d like you to share some insight into how you keep going when sometimes things go wrong- positive encouragement in keeping the whole machine moving.
AW: The really short answer is that that no clinician is alone in this. What we learned from our predecessors is that collective action is really really important. That is what keeps us all going. For sure, each of us have times where either individually or collectively things get really tough and feel like we’re having to say the same things over and over and over again. But what we’ve learned, and its been it’s been a fascinating learning curve for us all as a group, is that politicians change, civil servants change, the policy framework changes, health colleagues within management change, and so you have to keep saying the same thing but actually perseverance is a skill and is a really effective strategy. So, even within the Deep End group, we’ve had people over the years who’ve either dipped out for a short time or done a bit of work and then moved on, but there is that core collective of people who re-energize each other. There is something really powerful about having your tribe and that’s one thing that the Deep End does. It enables people who have may have been plugging away on their own, or within a small practice or setting. When they come together that means they’ve got this backup and they’ve got encouragement, they’ve got the collective skills. Because that’s the other thing about the Deep End groups, and they are all distinct, they are basically a collection of various individuals with a range of skill sets who come together to try and make things better for Deep End patients. That’s it in a nutshell really. It’s that collective action and perseverance that makes the difference.
DMacA: Andrea, has been fascinating talking to you; moving from the personal and continuing care of the individual to the collective health activism and health advocacy. Continue with your fantastic work. Thank you very much for sharing it with us today
