How can the NHS address health inequalities when resources continue to flow away from the poorest patients with the greatest need?

It is a question that has resurfaced this week amid the backlash over plans to cut the number of community link workers for GP practices in Glasgow.

What's the problem?

Community link workers – also known as community link practitioners (CLPs) – are increasingly embedded in GP practices to bridge the gap between medical needs and the social determinants of health.

These might be problems with debt, housing, food or fuel poverty, benefits, or loneliness. Patients can be referred straight to the CLP in their practice for help, sometimes getting access to hour-long consultations.

Aberdeen is one of the few places in Scotland to have a CLP in every practice, but in other parts of the country – such as Glasgow – they have been prioritised to Deep End practices, which are located in the most deprived areas.

This makes sense when the goal is to reduce health inequalities.

What makes much less sense is the Glasgow Health and Social Care Partnership's (HSCP) plan to cut the number of full-time CLP roles it funds from nearly 70 to 42 as of April 2024, in the midst of a cost-of-living crisis.

Those who left are likely to be spread across two or three surgeries, meaning larger caseloads with less time available per patient and less opportunity to make an impact.

At the same time, it means that something which helped to boost the appeal of Deep End surgeries in terms of doctor recruitment and retention – the promise of having a full-time CLP embedded in the practice to help with complex patients – is eroded.

What's to blame?

Glasgow's HSCP leaders have pointed the finger at Holyrood, insisting that they are "only able to agree contracts based on our known income from Scottish Government" and that they have had no guarantee that the £1.35 million they received for CLPs this year will be repeated in 2024/25.

However, it is understood that the Scottish Government considers this "top up" cash and expects the HSCP to continue funding CLPs from a separate pot of money, known as the Primary Care Investment Fund. In a statement, a spokesman said that the Government is "clear that Community Links Workers must continue to provide a vital service in disadvantaged areas".

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At present, Glasgow is the only HSCP threatening to cut community link worker numbers, which only adds to the controversy facing the city's health leaders.

Those on the frontline do not care where the money comes from, but they have long criticised the system of rolling annual contracts under which CLPs are employed. As well as making them an easy target for cuts, it has driven some to quit jobs they loved simply because they were unable to obtain mortgages.

There is an argument to be made that if tackling health inequalities really is a national priority, then funding for CLPs should be set centrally, ring-fenced and assured long-term.

The Inverse Care law

It is also worth reflecting on why CLPs are so badly needed in Deep End practices in the first place. One of the most important reasons is the "inverse care law", a phenomenon first described in 1971.

In basic terms it sums up the problem of unmet need, whereby healthcare resources tend to distribute unevenly in a way that disadvantages poorer communities despite their need being greatest.

Take general practice in Scotland.

Research has shown that rates of premature mortality (dying before the age of 75) and multi-morbidity (living with several chronic illnesses) are roughly 2.5-fold higher among patients in the most deprived areas compared to the least, yet funding per patient is basically static across the spectrum.

At the same time, practices in the most deprived areas were found to be carrying out roughly 20% more consultations than those in the most affluent areas, despite having a lower GP-to-patient ratio.

Mortality and morbidity (blue and red) increase in line with deprivation but funding per registered patient (black) does not; the number of GP consultations per patient (green) is around 20 per cent higher in the most deprived areas (Image: BJGP)

In order to manage that demand, appointments were found to be one minute shorter on average – a situation which is completely at odds with the levels of complex and chronic disease being seen.

The boon of CLPs is that they helped to correct some of this imbalance by freeing up GP time and delivering practical, effective support to patients to improve their overall wellbeing.

Cutting their numbers for the sake of a £1.35m saving is a false economy that will cost Glasgow dear in the long run.

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