Health inequalities in Scotland and how the Deep End Project aims to balance them

Tea & Talk
Publication Date
29/07/2021
Tea and Talk with the RSE
Tea and Talk with the RSE
Health inequalities in Scotland and how the Deep End Project aims to balance them
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Scotland compares very poorly with other countries in Europe and even within the UK when it comes to health inequalities, but why? In S03E02 of the RSE’s Tea and Talk Podcast, RSE Chief Executive Rebekah Widdowfield talks to Professor Graham Watt CBE FRSE about the reasons and possible answers.

Graham is Emeritus Professor in General Practice at the University of Glasgow and a Fellow of both the Academy of Medical Sciences and the Royal Society of Edinburgh. He has written extensively on health inequalities and for over a decade has been involved in the Deep End Project, which looks at work in general practices serving the hundred most deprived populations in Scotland.

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Episode transcript

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Rebekah Widdowfield: [00:00:00] Today, I’m speaking with professor Graham Watt CBE. Graham is emeritus professor in general practice at the University of Glasgow and a fellow of both the academy of medical sciences and the Royal Society of Edinburgh.

Graham has written extensively on health inequalities. And for over a decade has been involved in the deep end project, which looks at work in general practices, serving the hundred most deprived populations in Scotland.

So who better to talk to us on the topic of health inequalities than Graham?

Graham, a lot of your career has been focused on exploring and seeking to address health inequality. So I wonder if you could just tell us a little bit about your background and what was it that really took you into that real focus on health inequalities through your work?

Graham Watt: [00:00:39] Yes. I don’t like being labelled as an expert in health inequalities, but I’ll come back to that later on. I’m an Aberdeen medical graduate; Aberdonians are improved by travel. So I’ve been around quite a bit. I was interested in keeping, staying a doctor and doing epidemiology, which was a difficult combination because there was no clear structure, and I really had to make one up. I was interested in the sort of population approach because of its inclusiveness. And also because the people who weren’t included, the non-responders, were always different from the people who did respond. And that was an interesting observation because it reflected a process of exclusion from knowledge and from evidence which I thought, was important to anyone to pursue it.

I got the tickets for general practice and hospital medicine, but went to work with Julian Tudor Hart to a well-known GP in south Wales. The author of the inverse care law. I went there as a medical student and thought, gosh, I’m going back there. This chap’s imagining and delivering the future with a population approach to working at a village and staying long enough to make a difference.

I got an MD there with community studies of salt restriction, which were astonishing and the levels of engagement and participation. And came back to Scotland, was very lucky to get the chair of general practice at Glasgow University on the casting vote of the principle.

I’d like to think I rewarded his is his faith in me that was Sir William Kerr Fraser. And then I felt at home, an academic generalist: small department on the periphery of the institution with the opportunity to put some of the things I’d learnt in south Wales, with Tudor Hart into effect.

We took a long, a long time though to find the next… a bit like rock climbing, finding the next stage to go up. The Royal College of GP’s were wanting to have a toolkit for GP’s to address health inequalities. So there’s a working group to talk about that. And we made three decisions. One was, they wouldn’t write a report on health inequalities because there were plenty of them.

We wouldn’t give GP’s a toolkit because that would be rather patronising. And the first thing we would do is listen to what they had to say. So we had a meeting at Erskine hotel about 12 years ago this year, we had about 70% of the hundred most deprived practices represented.

That seating plan was a circle, everybody in the front row, almost everything that was said was included in the report. And it got us started. It was interesting because I’d done some epidemiology with Matt Sutton, down in Manchester looking at what in effect was the epidemiology of the Deep End by aggregating general practice populations, according to the type of population being served.

So you can get the hundred most deprived and they were, of course they were scattered all over the place. And you could do that with Scottish data, but nobody had ever done that in ISD because the questions being asked were always to serve management with its geographical responsibilities. And that meant that deprivation was, was diluted and hidden.

And this, this epidemiology that we did was collating practice data, wherever they were, providing they were serving a deprived population. And that showed that there was no more GP’s in that kind of area than an affluent area. And that got us started on the idea of the deep end.

The deep end metaphor, it was actually something that Tudor Hart had talked about 10 years previously, and it immediately struck a chord with GP’s and our colleagues who are never really getting to the bottom of things, treading water in the deep end, trying to, to survive.

So we have a… the logo is based on that metaphor and it’s a slightly naughty metaphor cause it implies that GP’s and the shallow end are twiddling their thumbs. And of course they’re very busy dealing with older patients. More educated and demanding patients. In many ways their work, their life is more difficult than treating an undemanding, but iller population. Anyway, the attraction for me for the deep end was, you know, there are so many people who write about health inequalities that have no connection with policy or practice.

So what they do has very little effect. You can even see that now with some of the big players in health inequalities, they’re not connected with the decisions at local or national level. And that’s one of the explanations, why the story of health inequalities in Scotland is really one of failure.

I can remember being at meetings thirty years ago, very similar to meetings now. And it’s not for lack of data. It’s not for lack of reports. You know, if those were Olympic sports, we would be medalists, you know? Cause we’re very good at producing Scottish reports on health inequalities.

But they’re not getting better. We compare very poorly with the rest of Europe and the rest of the UK. And so although health inequalities are regularly rediscovered by the media, they never asked the question of why is it being rediscovered? You know that question never seems to… I think it’s because there’s no memory in the media of what they reported six months previously. It is a question, you know, we keep on discovering and reporting and being appalled and making commitments to do something about it. But don’t, I think one of the, I mean, this is a personal view, but I think one of the problems has been the sort of specialist nature of the discipline by making health inequalities, the subject with its own experts, it’s taken non-experts out of the game. And in a sense that has, it’s symptomatic of the issue being on the margins, not being mainstream. I think that’s one of the explanations. Why inequalities in health is never a mainstream issue.

It’s always something that can be done episodically on the side, usually with small projects that don’t last long. I think that’s a kind of a structural problem and an expectation of how Scotland has learned to live and accept differences, which are not acceptable in other countries.

Rebekah Widdowfield: [00:07:56] I was going to ask you a little bit later about other countries, but one of the things that struck me with what you were saying there, Graham was you previously commented about the transformation that science has had in terms of our understanding as a world, but its application being frequently an exercise in political choice and, and human values.

And that very much mirrors the sentiment that we had from Dame Professor Anne Glover in an earlier episode. But I mean, what do you see as the sort of consequences of that for the delivery of health services and health outcomes. I mean, I think you’ve alluded to the fact that one of the reasons we’re not making as much progress as we might be doing in addressing health inequalities because of that sort of interface, if you like. So how does that play out for you?

Graham Watt: [00:08:35] Well, I think there has been a dearth of research. My colleague, Stuart Mercer, who’s the director of the Scottish school of primary care, I describe as the David Livingston of primary care himself because he’s one of the few people who’s gone into this dark areas of the healthcare system, outside the institutions to describe and explain what’s going on here.

He showed that, you know, consultations in general practice and deprived areas are generally shorter than other areas. Although the needs and complexity, are greater the expectations are lower, on both sides of the table. Outcomes are poorer, especially for patients with mental health problems, which is the commonest comorbidity.

And the GP’s are under stress. And until 2007, when that was published in an American journal, there had been nothing like it produced. And it’s not that you can’t do the search in very deprived areas. It’s just difficult to do it and it hasn’t been done. So that’s one of the areas, but, but even if you produce the evidence our experience in the deep end is that the world doesn’t automatically fall into place on the basis of the new evidence.

If it was a drug that was curing a particular disease and particularly had a mass market available to, to pharma, it would run like a hare. But this is more, more difficult. I mean, Stuart, my colleague, he did a study called Care Plus, which involved longer consultations for patients selected on the basis of GP’s knowing that the patients could do with a longer consultation, there was support for the GP’s and patients as well.

But what if it was a randomised trial, which is almost unheard of, and the kind of practices where it took place and it showed that quality of life, which is a measure you can’t… the trouble with looking at health inequality, through research is that the outcomes are long term. You know, you’re doing things today that might not affect mortality statistics for 20 years.

So you use soft outcomes and this study showed that, two things. One, if you’ve got extra consultation time your quality of life improves, but if you didn’t, it got worse. So there’s two things going on there and we have a health economist on board and the health economy statistics were carried out, which showed that this was an intervention that came well within the NICE threshold. There was 13,000 per colleague, whereas the threshold is 20,000. Now, if our technology was evaluated with those kinds of data, it would, it would sail into practice, especially if there were interest behind it.

But if the intervention is longer consultation time, which means you have to provide more manpower. And that means that it’s possibly coming from somewhere else. Then you’re immediately into cultural and political problems, you encounter an establishment of power and resource which is reluctant to give any of it up.

So the evidence is a tender plant in this forest that you’re trying to negotiate your way through. There are much stronger influences on what decides what happens including of course the inertia of the status quo. We were sidetracked a bit by the First Minister saying this will be dealt with in the GP contract and she didn’t know that it couldn’t be because the GP contract does two things that pays GP’s and it provides resources for practices and interfering with the way that GP’s are paid is a very tricky path to go down if you’re trying to redistribute resources. And what we learned was that that’s a non-starter, you need to find another way of getting the resources to where they’re needed.

It’s complicated now because general practice is under pressure. Not just because of Covid, but because of, I think underfunding and you know, GP manpower in Scotland has been flat for 10 years. The consultant establishment is increased by a sixth and that’s, that’s the wrong direction. We don’t need more specialists. We need more people who can deal, provide unconditional support for patients, whatever problems that they’ve got.

On the advocacy side. I mean, the government has recently announced that they’re going to put financial advisors into general practices on the basis of work that we’ve done showing that in Parkhead and Carntyne in Glasgow, this increases the uptake of benefits by people who are entitled to them, but haven’t claimed.

And the average benefit per year for someone who, who takes it up is about £7,000 . Very few things in medicine help people as much as that. But it’s taken us five or six years to get that. Into a policy and Kate Burton in public health and myself, who’ve sort of led the lobbying have been told more than once by civil servants, “please stop asking for this. It’s not going to happen.” And you just, you just have to keep going and eventually a door opens and you jump through it and it does happen. So what we’ve learned is that advocacy, isn’t a sprint, it’s a marathon and you just need to be ready for it. And so we’ve made progress on the financial advice.

The method is, it is simply if you embed the advice in a practice, then you increase uptake because the resource is available locally, quickly in a familiar place. And it’s all based on relationships and it works so. We want lots of people to be embedded in that way, because in deprived areas, the referal links need to be local, familiar and quick if they’re going to be taken up, because if they involve two bus rides across the city and back again, it’s not going to happen.

Rebekah Widdowfield: [00:15:08] It reminded me actually, and just interesting how things maybe don’t happen as well. And this is, this is in the Northeast of England, but my mother worked at Citizens Advice Bureau debt service in the GP practice for very similar reasons. Yeah. And that included about the take-up of benefits as well, because what was coming through from the GP practices had an underlying poverty dimension.

Graham Watt: [00:15:32] Yes, well that illustrates a few things. One is, but there’s nothing new under the sun. You know, what we were doing in Glasgow in the deep end had been done previously in Dundee. The new thing was, was to connect all those up in there to create a bit of a collegiality and solidarity between isolated initiatives because the citizens advice bureau is part of the existing establishment.

So from our point of view, we wanted to get some of the resource for the new Scottish social security system diverted. And in a sense that was just the same as trying to get resources out of mainstream general practice, people defend what they have. But I remember we had a meeting in Glasgow, a joint meeting with GP’s and the advice system in Glasgow, where one of the managers was talking about how, because of resource constraints that was going to be necessary to centralise the offices – exactly the wrong solution. A sensible managerial solution, but a bad practical solution because in that what you’re essentially doing is you’re taking resources away from where they’re needed in a community.

Rebekah Widdowfield: [00:16:51] And I think you’ve talked quite a bit about previously about the, sort of the importance of both unconditional and the continuity of care for people. And I guess we’re seeing this to some extent with the vaccine uptake as well, actually, the importance of who is giving the messages in terms of trust and local, maybe defined in different ways, but the, sort of the importance of the peer community, I guess, as well as people on the ground who are trusted.

Graham Watt: [00:17:17] Yes. Well, I’m not sure of data on that. But I think most GP’s will be saying to their patients, you know, I’ve got my family vaccinated and that tends to be an influential thing to say, especially if it’s true. I think that trust is often spoke about, you can’t assume it has to be earned and it’s based on positive experiences and confidence that they’ll be repeated.

So a lot of general practice I think, is about building positive experiences. Continuity is quite a difficult entity to evaluate. Denis Pereira Gray in Exeter is still trying to do that in a systematic way. It’s increasingly difficult to provide continuity with an individual, but with good record keeping essential information can be available.

But with them, the short consultations, if you don’t have a memory bank of prior contact and shared knowledge, much less can be achieved. I have often written about the day I spent with Petra Sambale, a German doctor in the most deprived practice in Scotland, in Possilpark, from seven in the morning to seven at night. Saw all her patients, and they were all based on immediate recognition and moving to a higher level. You know, there was no groundwork to do in knowing the patient’s name, their background, their problem. She could never have done what she did in a day from a cold start. It all had to be based on a moving stream of information.

And when I worked with Tudor Hart in south Wales a key thing of his example – showing over 25 years, premature mortality was 30% lower than the neighborhoods – was staying long enough to make a difference. You know, that’s, that’s increasingly difficult.

The mega practices popular in England. There’s a few in Scotland. They, they don’t provide that. And it’s a weakness of the system. It’s not that everybody needs the same kind of continuity of care. But there’s a paper by Rupert Payne that says that the 10% of people in Scotland with 4+ conditions account for 50% of potentially preventable hospital admissions.

So there’s a very important minority of patients, in whom an investment of time and continuity has the potential to keep them out of hospital for longer. And some of the deep end projects have gone down that road – the pioneer project, the ship project – that it’s always based on the GP’s knowing the patients, they know who would benefit from the extra time and who wouldn’t and of course that’s drawing on information that only exists in their heads. It’s, you know, you wouldn’t get an MD for it. But that kind of accumulated knowledge of patients is a huge undervalued resource with great efficiencies for the health service, because if you take it away, you have a whole lot of impersonal consultations, which almost by definition are risk averse because there isn’t the confidence to do anything else.

Rebekah Widdowfield: [00:20:58] But just, just to say a little bit more about the deep end project. So it’s been going since 2009 now, I think. Yeah. And, and it sort of brings together lots of different projects, but how has the deep end project supported what you’re saying earlier about the need for that connection with policy and practice and the need to connect with evidence, with decisions at local and national level, do you feel, do you feel it’s made some headway in that regard?

Graham Watt: [00:21:22] I think it has, it’s quite a long story. We had some huge examples of good fortune in terms of resource, you know, a new professor of public health was appointed in Glasgow and pinched my research fellow. And I’d, I’d £30k that I couldn’t spend. And Carol Tannahill whom you may know, was Head of the Glasgow Centre for Population Health and she gave me permission to use it to connect with deep end practices. So we had a kind of a war chest that’s allowed us to get GP’s – we always paid locum fees to get GP’s out of practice for a half-day roundtable, because otherwise you just get the kind of people who can go to a half-day meetings, which is an atypical group.

And that gave us 30 or 40 reports on particular topics that are manifestable, but it also gave us a network of practices who were ready to engage with opportunities for projects when they arose – Pioneer, SHIP… financial advisors – and that, that gave us the rollout of the projects.

Link workers have been rolled out. Interestingly, the initial roll out of link workers was on the basis of a cabinet secretary for health who just thought that it was a good idea and he didn’t wait for the evaluation. We didn’t object to that. He thought they were a good idea, financial advisers.

Other embedded workers we’re still arguing on: extra time for consultations, protect the time for GP’s, embedded mental health workers. You know, there’s a tendency of mental health to cut patients off at the neck and just deal with the bits above the neck. And of course, most mental health problems are connected with other issues.

So the solution is, is to embed the mental health workers in practices so that they’re available. And there’s a good example of that at Craigmillar health center in Edinburgh, which the Glasgow GP’s kind of drool over, they would like to have that, that arrangement.

In terms of the main resource has been the sort of energy and enthusiasm, the passion, even of the participating GP’s. The deep end is essentially a pre institutional network fueled by passion, connecting people in the same situation for shared activity and shared learning and shared identity, shared voice. And what’s been very positive, has been the spread of that model initially to Ireland. Then to Yorkshire, Humber and then greater Manchester.

And now we’ve got them in the Northeast England – north Cumbria, Nottinghamshire. London, Plymouth – there’s a deep end project in Canberra in Australia. And there are stirrings in Denmark, Norway, Canada, and even the U.S. So there is something about the marginality of healthcare in poor areas and the sort of exclusion of patients that isn’t particularly Scottish, it’s kind of ubiquitous because healthcare left to its own will naturally specialise, centralise, privatise. All moves in the wrong direction in terms of the multi-morbidity that we, we face.

So I think that’s why there’s common cause across the deep end projects. And I think that the main success has been one of almost sort of creating a resistance movement. You know, the government has been very good to us in Scotland. They’ve always given us a core budget. Which because we had no address or infrastructure the RCGP had to handle the money. But that, that allowed us to have meetings and pay locum fees, have occasional conferences. We were always outside the local NHS. It was always a difficult relationship because we were across boundaries. And we weren’t beholden to them.

It was an enormous strength actually to be outside the system. Eventually it was a weakness because you want the system to change. Well, the principle of sustainability is that there has to be joint ownership. And if you haven’t built that in the beginning, it’s quite difficult to add it on later on. But the new chair of the Scottish deep end project is Carey Lunan, a GP at Craigmillar in Edinburgh who was previously the chair of RCGP Scotland.

And she has brought the whole thing up to a new level of engagement with policy. And I think that’s very encouraging.

Rebekah Widdowfield: [00:26:37] you talked earlier about the sort of the rediscovery of inequalities. And I think sometimes it feels a bit like that with Covid, that Covid has sort of rediscovered or the media has rediscovered and shone a light on and amplified existing inequalities. Or the pandemic itself has amplified existing inequalities. I mean, in terms of health inequalities, has there been anything that has particularly surprised you in the way that the pandemic has played out across different communities and sections as a society or, or has it been from your perspective actually fairly predictable in terms of what has happened on the back of a shock like a pandemic.

Graham Watt: [00:27:15] I think perhaps one of the surprises down south was being the extent to which it’s affected Asian doctors. So almost all of the deaths in doctors have been Asians. I’m not sure whether that’s because the jobs they have or susceptibility or living in communities where there’s quite crowded family living. I don’t know. I think it is obviously a colossal problem on top of the existing landscape, which hasn’t gone away. And when Covid gradually fades, the problems that it leaves are all going to be compounding the problems that we really weren’t dealing with very well beforehand.

And that includes the mental health consequences especially allied with the financial hit too, which hasn’t really started yet. And there’s there’s the move to remote consulting. Initially it was either phone or video, I think video has been put to one side largely, but being able to consult, you know, phone consulting has got a place. It’s good for some things, it’s not good for things, and it certainly can’t replace the face-to-face consultation. But especially for this group of patients with multi-morbidity and in spades, you know, multi-morbidity for an epidemiologist is just two conditions. But with the commonest condition in an old person is high blood pressure. So they only need one other thing to be multi morbid. But that’s a completely different issue for the patient and the doctor from the kind of multi-morbidity that occurs on average 10 to 15 years earlier, in poor areas. And this, I characterise it by the number, complexity, severity, and continuing nature of health and social problems within families.

And of course there are no data that capture that. The interesting thing about Covid is it takes something like Covid to create the circumstances for a rediscovery of collectivism and social solidarity and the idea that nobody’s safe unless everybody’s safe. And the best way of protecting your family is for families to be protected. It takes something like Covid to get us back to that.

But I’m not sure to what extent it’s going to have a transformational effect. People talk about things not being the same again, but there’s a sense in which we are returning to where we were not trying to reimagine the future.

Rebekah Widdowfield: [00:30:08] Graham you were talking there about actually how the pandemic might have stimulated a new sense of collectivism. I guess collectivism also connects with compassion, which you’ve also quite often spoken about in terms of it’s importance in terms of how people are treated within the health system and, and more widely, can you, can you say a little bit more about that and, and why it’s so critically important you feel for, for health outcomes?

Graham Watt: [00:30:35] Well, there’s a study by Stuart Mercer again, based on 3000 GP consultations in Scotland and it included two instruments. One was his care measure, a 10 question instrument, which asks the patient about the doctor’s perceived empathy. You know, did the doctor care and knew who you were, listened, et cetera, et cetera?

He narrowed it down to 10 questions and they also asked John Howie, Professor John Howie’s patients enablement instrument, which is after seeing the doctor are you better able to cope with life and your condition? And what Stuart showed in his study was that you could get empathy without enablement, but you never got enablement without empathy.

If a patient thought you didn’t care, whatever that meant to the patient, then they were unlikely to feel empowered by anything else you said to them and it’s, it’s almost a black and white observation. And it’s enormously important because it makes the point that you know, the silver bullet in general practice is a relationship.

And as Tudor Hart said, it starts face-to-face and it only shifts gradually to side-by-side because self-help and self-management aren’t starting points, with patients who lack knowledge and confidence and, and agency. So that’s an essential part of the building block, if you like of the patient experience and story.

So we talk about the need for three building programs, none of them based on bricks and mortar or fancy architecture. And that the first one is building a compendium of patient narratives. That’s what happens at present. And nobody knows whether the patient’s stories are long stories or short stories or fairy stories or horror stories. If you made it your business to find out, you’d find examples of them all.

So that’s one set of relationships. Another is building the capacity of the local care system around the general practice hub because general practice has the intrinsic properties of contact continuity coverage, the flexibility and trust.

And it’s not the only public service that has those features, but it’s by a long way, the public service, which has them in most degree. And most other services are weaker for not having the contacts, the continuity, the coverage and the trust. So that’s why bringing other people next to the practice, embedding them is a sensible move.

And it’s not because doctors are necessarily the best people to lead or certainly not to be in control, but they do have the contact and the knowledge. And that’s the, that’s a starting point for lots of things. And the third building program is to connect these local systems so that we’re not building with isolated, pioneering examples by extraordinary people, we’re talking about something that is extraordinary in its nature, but not through its content, if you can accept that.

So that needs infrastructure to build the connections, to share learning and experience. And especially as Benson hospital has that infrastructure in large measures, but general practice, primary care, it’s much more diffused. I suppose one of the advantages, the plus side of Covid is that we’ve learned to connect much more effectively electronically. So the deep end has always benefited from being able to connect electronically with practices and therefore to have communications, which we wouldn’t normally have been able to, to have.

So these are all types of relationships that need to be built up. And the difficulty is that there’s a time cost apart from other costs to build up relationships. They take time, take investment, emotional energy. How many of these can you do at one time? So it’s not an overnight thing. It’s a cultural thing over a period of time.

You asked about compassion, I would link compassion to caring in Tudor Hart’s sense, caring is giving a damn you know, it’s not a soft emotional thing. It’s the opposite of indifference. And that’s a worrying sign in the health service when people are so overwhelmed that their coping mechanism is to be indifferent to the patients in front of them. So that’s really a red flag of a warning sign when indifference starts to creep in.

I had a PhD student, Breannon Babbel who came from Oregon and has gone back to Colorado, but she spent the interim interviewing deep end GP’s in Glasgow, not necessarily just the ones in the project but randomly. She baked them cookies, which is a really smart thing to do to get their cooperation. And, and she discovered, her study neatly showed that every GP is interested in the clinical consultation. But not all of them are looking outside the consultation to the social factors that are going on in the background. Not all of them see the community as a resource that they want to connect with. And not all of them see, you know, the social and political trends being played out in front of them through the lives of their patients and wanting to do something about it. So I wouldn’t argue for a minute that every GP wants to be engaged in the way that deep end GP’s are, but they are an important and growing minority.

And the challenge is to, is to normalise what is currently abnormal and extraordinary. And it sometimes just requires connecting people. But the attraction of the deep end has been that everybody was in the same boat and they immediately knew that. And they’d never been in that boat before. The first deep end conference was the first time the most deprived GP’s in Scotland had ever been convened or consultant by anybody

Rebekah Widdowfield: [00:37:03] That says something in itself, doesn’t it?

Graham Watt: [00:37:05] Well, yeah, we thought, “gosh, is this, is this going to be the first meeting, is this going to be another meeting where GP’s whine and complain and are negative about everything?” So we, we organised it, so that there was nobody else at the meeting that they could complain to. It was unnecessary because the first meeting was immediately on the front foot, immediately positive and never looked back.

I’ve always found that in speaking in other places you suddenly – there’s a letter from a Dublin GP, Edel MacGinitie saying that when she read our stuff, she felt like a patient who had found a support group, you know, because her work in Dublin was the same as working in Possilpark and Muirhouse in Edinburgh.

Rebekah Widdowfield: [00:38:01] Which also, I guess, connects with resilience and what you’re saying earlier about when people, you know, get to a point of indifference because that’s a coping mechanism. If they’re overwhelmed with what they’re seeing and experiencing.

Looking maybe into the future, say 10, 15, 20 years, I mean, you’ve talked about, obviously Covid compounding some of the existing inequalities and the impacts of Covid, you know, sort of falling on top of those existing in a quantities, but where do you see the trajectory as we move forward? Are we on a trajectory of improvement and narrowing inequalities and narrowing health inequalities, or is there more we should be doing? I mean, how, I guess, how positive do you feel about the future Graham?

Graham Watt: [00:38:38] I feel there is a, there’s a Palestinian expression, a pes-optimist, you know, which combines the two where it is appropriate in some ways. I think I’m, I’m very positive about the colleagues that I’ve met through the deep end projects and the way that it’s growing. And I’m not positive about the system as it is. I think that’s unlikely to reform itself, it’s got a number of challenges to take on. One is to stop thinking of health inequalities as something that’s marginal and on the side that you, that you can deal within a small project, but it’s actually a mainstream issue because although you can highlight the big social differences between the top and bottom decile, there are also differences between the most deprived decile and the next decile, and the next decile. That’s why Michael Marmot argues about proportional universalism needs according to proportion.

And that’s a big policy step because the distribution of healthcare resources – in hospital that meets that, but in primary care it doesn’t. So the challenge of mainstreaming it to make it proportionally universal is a big issue. And I don’t know whether there’s a political party bold enough to do that. Certainly not before a referendum. I think that’s unlikely to be the case, but I think that is the challenge we’ve lived with health inequalities for so long and accepted them that the best predictor of future behaviour is past behaviour.

What’s to say that we aren’t going to be here in 20 years time, and we’ll be trying to explain it away again. I think that the big question mark for me is whether we’re on the cusp of something, you know, post Covid , maybe with independence. I don’t know. It’s difficult to imagine it without independence but that takes us into another area entirely.

I think that is the big challenge. Cause you know, there’s there’s Covid, there’s climate change. There’s the health inequality that results from social and economic division. These are all huge challenges. They’re going to require policies based on the notion that nobody is protected unless everybody’s protected.

You know, the vaccine roll out is the immediate test of that. Not sure that the test is being passed well. But if we can’t pass that test, how are we going to pass the climate test? There’s a strapline we put under a poster of deep end logos, “Inclusive healthcare by excluding exclusions and building relationships is a civilising force in an increasingly dangerous, fragmented and uncertain world”.

And I subscribe to that, that it is a civilising force because of its inclusivity. And so many things are exclusive. Being excluded from care services, being excluded from the evidence-base, excluded from many educating… increasingly the world is becoming a dark place based on division and exclusion and demonisation of the other.

And the only hopeful prospect is to find ways of being more inclusive, I think. The deep end project is a worked example of trying to do that. And a small example. So I think as part of that, and it’s for the participants, I think it not only chimes with what they’re doing, but it connects them with something larger than themselves, a very important part of professional morale.

You know, you need to be… autonomy is important, competence is important, but being part of something bigger than yourself is also important. And I suppose to some extent I’m being disparaging of the existing institutions, which used to provide that covering thing, but I think we’re, we’re in dire need of institutions that aren’t past their sell by date and are reflecting future needs, not past histories.

Rebekah Widdowfield: [00:43:37] And if you look globally, are there any countries that you think are getting this right? Or that, I mean, clearly from what you’ve said, there’s a huge amount of learning in Scotland that we can learn from and a huge amount of learning that we can apply to practice and policy. But when you look around the world and if you were talking to politicians, are there particular countries you would be saying, “go and look at X”?

Graham Watt: [00:43:59] Well, to some extent if where you are, is looking at having to deal with health inequalities then you’re already behind the game. You know, all the work on the Gini coefficient, which shows… is a measure of the distribution within society, so you look at averages that hides the range. And the UK is not well-placed in Europe or amongst economically advanced countries in terms of its Gini coefficient.

Most of the countries in Northern Europe are better placed in that respect and that’s because they have more generous and more fair social policies, you know, their educational provision, their unemployment support, their maternity support, their pension levels are all at a different level from the UK, which is much more in tune with the U.S. You know, that, that kind of approach.

So one doesn’t have to look very far, but when what one is looking for is not examples of success in dealing with health inequality, you’re looking for successful examples of inclusive, generous, and fair policies, which result in less societal difference and therefore you don’t have the same problem to solve.

So I think that’s… and there is something to borrow from a. The U.S. And that’s a quote from Oliver Wendell Holmes, Jr. He used to be a chief justice, and above the entrance to the inland revenue in Washington they’ve chiseled in stone this quote that “taxes are the price we pay for a civilised society”.

You know, and as people have often said, you can’t have Scandinavian or Northern European levels of service with U.S. levels of tax.

Rebekah Widdowfield: [00:45:59] That takes me actually to my last question. And you’ve touched on this in some ways already, but you know, if you were going to point to two or three things as having the potential to transform health inequalities, or actually indeed inequalities more generally. I mean, you’ve talked about finding ways to be inclusive and looking at the system, and you’ve just then talked about taxes. Are there particular things if you could just do two or three things, what is it you would do if you could wave a magic wand?

Graham Watt: [00:46:25] I was asked this question at a student conference in Wales recently. And I, my answer was the financial advisor project, you know, gives people money in their pockets, but that’s a very short term solution for individuals. So it’s not the bigger question.

I think that there’s a quote from Aneurin Bevin who was the political instigator of the national health service. I’ve never been able to find it, I wrote it down at the time, but I can’t find the source. But what he said, or wrote, was that he never argued from statistics. This was in the 1950s when there was much fewer statistics and his idea was that whatever statistics he used, somebody else could find other statistics that would say the opposite.

So his line was, he argued on principle. And once you won the argument on principle, everything else followed. I’m not sure how exactly that translates 70 years later, but I think the principle he’s talking about is that some value based decisions need to be taken. And statistics can inform those judgements, but they can’t necessarily make them.

And I think the NHS was a decision of that type. It was a value based commitment to inclusiveness and to simplicity in the sense that if everybody is included you don’t have to assess them at the point of entry, a very important and simple procedure.

There are things like the food rationing in world war two, where food wasn’t rationed in one sense, it was rationed in the sense that everybody got the same. And that was found subsequently to have been beneficial for the public health. And it wasn’t based on evidence. It was based on the value of inclusiveness. And more recently, you know, the current government has established the baby box scheme. And I’ve often been asked, you know, where’s the evidence for that?

Well, I think if you’re looking for grade A randomised control trial evidence of effectiveness, then you’ll be disappointed. But I’m very much in favour of the baby box initiative because of the values that it communicates, which is that every newborn child matters and that everybody is on the same boat.

And I think that’s worth investing in from a public policy point of view and to wait to see what the effects are. So a long time ago and more recently, I think there are some examples of things that need to be done because they’re the right thing to do. But it needs politicians who… and perhaps, perhaps we have some politicians who can do that. I don’t know, plenty of them can’t I’m sure of that, but maybe there are some.

Rebekah Widdowfield: [00:49:20] So I think that thread of inclusivity has really, or inclusivity and making a difference, I think has run throughout this conversation today. And just thank you very much, professor Graham Watt.

Graham Watt: [00:49:30] When I did my inaugural lecture in ’94, it was called “include me out, exclude you in”, include me out is a quote from Darryl Zanuck, the Hungarian film producer, that couldn’t speak English. So that was, he said, include me out. So I added exclude me in, but that was, I went into the department with my sort of vision and it’s very much to do with the inclusivity. And I mentioned it to a great aunt of mine who was a hundred at the time, Dr. Dorothy Younie in St. Andrews. And she said, that’s very general practice, which I liked very much.

Rebekah Widdowfield: [00:50:10] Very very necessary. Thank you so much, professor Graham Watt for talking to us today about health and health inequalities.

Graham Watt: [00:50:17] Thank you.