I am never comfortable with the phrase “hard to reach”, which is sometimes recognised as a synonym for “easy to ignore”. We often have contact; the issue is what happens or does not happen with that contact. That is certainly the case for deep-end practices, which involve plenty of contact with patients, although they often lack the resources, the consultation time and the links to other services in order to address need. There is a big mountain of unmet need there.
You have asked so many questions, Sandra—we could spend the whole morning answering them. The links programme is an important and topical development. There is a story behind it. As regards the deep end, we started off asking practices about the extent to which they were involved in social prescribing, or using local community resources. Practices varied according to what people knew. In the past 10 years, general practice has become introspective, for all sorts of reasons—it has not been looking out. However, we moved on, with Government support, to do a links project, which tried to build on the previous work.
Then there was the bridge project, which was carried out in three practices. It sought to link a practice’s knowledge of elderly patients with community resources for social and physical activity. Two interesting things were learned from that, one of which was that every locality is different. The project has to be imagined and developed locally; it cannot be done from a centre.
I will share this anecdote. A GP in Ruchazie identified six elderly patients who she thought would be ideal for the project, but none of them thought that it was a good idea. That makes the point that it is not just a question of shifting people along. There is a relationship, and there is a person. Because the doctor was working in general practice, it was not a once-and-for-all opportunity. The relationship exists, and it can be returned to, although the link to community resources did not happen on that occasion.
It is a bit like smoking—everyone wants to give up smoking, but sometimes they are not ready so we come back to it in six months’ time. It is important to have the continuity and to have a service that has the flexibility to work in that way. If we have an outreach programme in which everything is determined by someone whose job it is to go out, we may lose that flexibility.
I turn to the links worker programme, which the Government is sponsoring and evaluating in seven practices. The programme implants a community links practitioner within general practices that are in the deep end. Their job is to do what their practices cannot do, which is to spend time making links with the community resources. The practices are finding their own ways of using those links.
The important issue is that this is not just about information. Some people just need information to be signposted—people with agency and education just need to know where something is and they will go and find it. However, particularly in deprived areas, people often lack the knowledge and articulacy to do that, especially if they have mental health problems, which are twice as common in deprived areas. Many people have attachment issues throughout their lives, because of emotional damage early on. Such damage is characterised by difficulties of attachment, never mind with services but with friends and family. Those people need a long-term relationship to enable them to make a bit of progress. It is not just about links, signposts and information, but is about relationships over a period of time.
My understanding is that a lot of what the links workers do is not signposting, but is helping patients who are floundering to deal with rather impersonal, dysfunctional and fragmented services. The way in which services are configured often makes it difficult for patients to find their way around them, especially if they have more than one problem. That is called a treatment burden.
I have a slight worry that the links worker initiative is not addressing the fundamental problem, which is that services are fragmented, dysfunctional, impersonal and difficult for some patients to find their way around. If a practice has a links worker, that may solve the problem for the individual patient without solving the problem in the system.
It is early days for the links worker initiative. In a sense, every practice should have one, but it is an expensive solution, so every practice could not afford one. The challenge is to translate what is being learned through that project into something that is sustainable at every level. Essentially, that is building social relationships within local communities, not necessarily with expensive professional salaries, which is unaffordable. As I said, because of the contact, continuity and coverage, general practice is a very good place to start, but it is not a good place at the moment, because it is under such pressure. I can talk about that more if you wish.