Categories
Trailblazer GP Blogs

Healthcare in a prison setting

Spectrum Community Health CIC

by Alice Deasy (Trailblazer GP 2019/20)

I came away from our day with Spectrum Community Health CIC talking about healthcare in a prison buzzing. I was inspired by the people working in this challenging environment, hopeful for what they offered to the often complex and vulnerable individuals who found themselves in those environments, and definitely more informed about what I had thought earlier in the day ‘was another world’. 

Spectrum a not-for-profit organisation established in 2011, provides health services in 13 prison estates in the North of England as well as providing sexual health services and substance misuse services in community settings. 

A basic introduction to the prison estate, categories of prisons and how healthcare in prison operates, was a useful orientation and highlighted the differences between health care in a prison and community setting. Specifically, the contracted healthcare service being ‘the guest of the governor’, and the idea that ‘security came first and health second’. A further difference, was the importance of working with the prison regimen, which might dictate when you had your clinics, how long they might last and when a patient might be available to attend the GP or other clinic. 

The day that gave me hope. I had not considered that for some people prison might provide an environment and an opportunity to stabilise chronic health problems and work with mental health teams to improve underlying mental health problems, and ‘be healthy’. I was reassured by the statement of equivalence, which dictates that the health care in prison should be offered equivalent (but not necessarily the same) as what is offered in the community. However, the point was made that experience in the prison system is not the same for everybody. Overcrowded prisons and a stretched system mean that some people don’t have these opportunities, and difficulties in moving between prisons, uncertainty about future and leaving prison estates at short notice create added challenge. 

The Trailblazers asked questions about the interface between the prison health care system and community general practice. This raised the interesting issue about problems with providing GPs with discharge or ‘release’ paperwork which might facilitate the care of people recently released from prison. We all agreed that improvement in this area would benefit patients.

The day helped me to understand the challenges of the prison context, and the need for excellent MDT working, liaison with the prison services and a bucket load of pragmatism and creative thinking. 

Categories
Trailblazer GP Blogs

British Red Cross Session

By Julie Duodu (Trailblazer GP 2019/20)

21/02/2020

Today we were illuminated about and humbled by the incredible work undertaken by the British Red Cross. 

This session was delivered by the incredible and passionate Susan Morley, whom is a fabulous ambassador for The British Red Cross as a whole and in particular the South Yorkshire branch.

The session started with a thoughtful quiz which deftly demonstrated how the tapestry of British heritage both past and present is full of migration and how several migrants and their descendants whom would be classed as refugees today have massively contributed to our society and culture. In essence “refugees are ordinary people caught up in extraordinary situations”.

It was incredibly helpful to revise the relevant terminology and to consider the small proportion of refugees who come to the UK and the countries they have originated from in recent years.

I really appreciated how Susan broke down the asylum process, and the expectations and restrictions placed on those seeking asylum in the UK. It gives me greater insight into what some of my patients are enduring and it must take a toll psychologically. The uncertainty, the legal minefield and the threat of being detained along the way, must be greatly unsettling and disturbing to say the least. It was useful to learn about the assistance the Red Cross gives at each stage, be it linking clients up with Solicitors and accessing legal help, helping people better understand the asylum process themselves and what evidence to gather, financial or practical support to plug the gaps the £37:50 per person per week or less (or in failed asylum cases, non at all) does not reach, such as transportation to mandatory sign in sessions at the Home Office etc. It was great to learn how the Red Cross links in with other charities and organisations whom work to help people settle in the UK and navigate the whole tumultuous process of seeking asylum and beyond. This includes helping those seeking asylum to access health and social services, accessing English language lessons and activities to look after wellbeing such as involvement in volunteering.

It was interesting to find out the other arms of the organisation- family tracing, health and welfare, attestation of detention and the “trace the face” an innovative means to help people find loved ones whom have become separated and out of touch. It was heart-warming to see how the hard work of the organisation can get people back in touch with each other.

This was an incredibly informative session. I previously had been aware of the work of the British Red Cross on the ground in places of conflict or in refugee camps. It was interesting to learn about the hard work which takes place here in the UK in the various strands of the organisation. This session and the improved comprehension of what those seeking asylum have to endure is bound to pay dividends through my increased awareness and empathy towards patients for whom this is a current inescapable reality. I am grateful for this and hope to further put into practice the message of the British Red Cross and its message about the power of kindness.

With thanks to the Susan Morley and the South Yorkshire British Red Cross team for facilitating this session.

Categories
Trailblazer GP Blogs

Psychotherapy

Managing patient’s with borderline personality disorder (or emotionally unstable personality disorder) is something that myself and I know many of my colleagues find extremely challenging within the limits of primary care. I was therefore really looking forward to this session to gain a further understanding of the condition and learn from the experience and advice of two experts in this field.

The session was run by Dr Harriet Fletcher, a local consultant psychiatrist, and her colleague Annie Mason.

We began by discussing our thoughts on the definition of border line personality disorder (BPD). An extreme trait, often related to trauma, resulting in a difficulty in adapting to social situations, was agreed upon. It was also agreed that this label, although useful in allowing needs to be classified and defining allocation of services,  can often be unhelpful for both medical staff and patients, as can lead to stigma and a feeling of helplessness. We discussed how this may reflect the fact that we often feel there is nothing we as clinicians can do to help. Encouragingly we learnt there has been studies that have shown those with symptoms of BPD can improve with treatment of rates reported up to 50%. Perhaps the frustration therefore is around accessing the right treatment for these patients in a timely manner. The controversy around labelling was similarly raised in the personality disorder consensus statement, that also highlighted the poor care and lack of access to services that patients often have to face, reflecting the groups experiences.

The aetiology of BPD appears to be complex and still unclear. There is a question around whether genetics play a part or whether it is purely developed based on early life experiences. There are clear links with issues with attachment at a young age, adverse childhood events and childhood trauma. There has also been recent evidence in neurobiology suggesting those with BPD may have structural changes resulting in a functional deficit in brain areas central in affecting emotional regulation.

There seems to be very limited research into BPD globally. In mental health services in the UK the prevalence is reported at around 50%. It is often assumed there are higher rates in women but numbers are in fact equal in the community. It was interestingly raised that there was no clear evidence of higher rates of BPD within areas of socioeconomic deprivation, although it was hypothesised this could be due to a lack of research, reporting or formal diagnosis in these areas.

We discussed the frustrations we felt in primary care, trying to access the appropriate services and support for these patients in the different areas we work in across Yorkshire and the Humber.  There are very few BPD clinics across the UK, although in the NHS long term plan it outlined new funding for community mental health, including specific BPD services.

One area that we felt as GPs caused us significant anxiety when consulting with these patients was the management of their risk when assessing potential self-harm or suicidal episodes. 60-70% of those with BPD are reported to attempt suicide with 10% being successful. Those with a dual diagnosis such as personality disorder and drug dependence had higher rates of suicide.

We moved on to talking about treatment. Psychotherapy is the process of teaching people to regulate their emotions. It involves stepping back, looking at situations from the outside and challenging what could be changed. We discussed the psychosocial factors that can be implemented in the development of BPD such as abuse, or biparental difficulties such as an absent father or over bearing mother. Interestingly the care givers response to abuse may be more important than the abuse itself in long term outcomes.

IMG_2151.jpg

Attachment theory is also important. A useful analogy was used describing emotional health as an “elastic band” that needs testing in early life, but not too much! It is unsurprising people can develop difficulties in managing their emotions if they have never been taught how to do so. Often people can lack a sense of who they are and, as an infant gets older, the importance of an attachment figure as a secure base is paramount. The good news is however there is evidence that having a supportive attachment figure can override the effects of adverse childhood events. 

CBT can also have a role in the management of those with BPD. This can take up to 36 sessions to be effective so is an intense commitment for the patient. It challenges the maladaptive schemas developed in childhood to cope with dysfunctional relationships with family members.

The session was very engaging with many experiences shared and much discussion around the topic. One of the questions raised was why as a population we seem to accept long waiting lists for mental health issues when they would be seen as inappropriate for physical issues. There was also debate around whether there should be space for an interim service between primary and secondary care mental health services as there was such a large gap between what can be provided by the two.

I found the session useful as it not only deepened my understanding of this topic but also taught me about the potentially positive outcomes for those with BPD. I often think about the prospective impact of traumatic life events on the future health of the young patients I see in surgery but learning about the positive effect a stable and supportive care giver can provide has left me feeling more optimistic. We need to continue to feedback to CCGS and other governing bodies about the need for wider and more accessible mental health services in our areas.

Useful resources:

–          MIND – ebsite has a helpful, accurate patient information leaflet on BPD

–          Oxford Mindfulness Centre – Free 8 week mindfulness course, accessible on website or through an app

–          Headspace – Mindfulness app on monthly subscription

Dr Katie Burgass, Trailblazer GP 2018/19

Categories
Trailblazer GP Blogs

Top Tips for new starting Trailblazers

Mat, Katie and Saira (Trailblazers 18/19) tells us what they enjoyed most about the scheme and give some advice for the newly starting Trailblazers this month

Dr Mat Fortnam (Trailblazer GP18/19)
Dr Katie Burgass (Trailblazer GP 18/19)
Dr Saira Khan (Trailblazer GP 18/19)
Categories
Trailblazer GP Blogs

Action Learning Sets

Dr Sam Wild (Trailblazer GP 18/19) tells us his experience of being part of an Action Learning Set of GPs working in areas of deprivation as part of The Trailblazer Scheme in Yorkshire.

Dr Sam Wild (Trailblazer GP 18/19)
Categories
Trailblazer GP Blogs

Action Learning Sets Video

Dr Sam Wild (Trailblazer GP 18/19) tells us his experience of being part of an Action Learning Set of GPs working in areas of deprivation as part of The Trailblazer Scheme.


Categories
Trailblazer GP Blogs

Medically Unexplained Symptoms

Session 27th September 2019- Bradford.

Session ran by Suzanne Heywood-Everett

Medically unexplained symptoms (or persistent physical symptoms as can be the preferred term) is a common consultation within general practice and these can be some of the most challenging cases to manage. This presentation is often more prevalent in areas of deprivation and can be exacerbated by difficult social circumstances.

This teaching day was very beneficial in discussing consulting in these cases along with management strategies. This built very nicely on previous teaching we have had regarding chronic pain. There were certainly plenty of learning points I could apply to my patients and will hopefully aid my management in these cases.

We considered potential pitfalls that general practitioners can face in managing these patients including our own unwillingness, trying lots of different treatment methods or searching for a cure, talking/persuading too much, coercion, being ‘right’/sounding smart, forgetting to observe and act curious, loosing track of own values. These are important to bear in mind when faced with patients with persistent physical symptoms as are likely to be barriers to effective management.

It was helpful discussing an approach to persistent physical symptoms (where an alternative diagnosis was felt to be ruled out). This was useful overlap with the chronic pain session; in particular breaking the initial consultation in two (the first being getting the pain story then the second considering management).

In the first session asking about the pain story, when it started, validation, how managed so far, what’s worked/not worked, what they think is going on and what they think might help, what else is going on in their life. Following this a pain/symptoms diary might be helpful (however recording what they did to help and how successful it was – rather than just the pain/symptom itself)

In the second consultation then review the diary if this has been used, build rapport and engagement. An important thing I took from this was then considering where the patient was in terms of changing and how this would change the management strategy from here. For example, if they were pre-contemplative then risk management would be sensible (ie not escalating medications if they are not going to help). If the patient is contemplative then focusing on validating, seeing what else may be going on, distracting from pain, tapping/breaths. At the preparation stage then they may be ready for more information like research (new approach to pain, excited about this), considering pain as a chronic condition in itself.

The session gave many useful examples for explanations of persistent physical symptoms. This included using danger receptors instead of pain receptors and how context changes this (e.g. nail in the hand, no pain on way to hospital then bad pain once there – stimulus hasn’t changed. Lorimer snake example. Amanda Spratt pain cycling uphill after accident when cycling uphill). As with the chronic pain teaching we discussed chronic pain as a different condition to acute pain hence not responding as acute pain to analgesia. These examples (and others) could be useful, depending on the patient – as mentioned above they are more likely to be successful with patients in the preparation stage.

The importance of giving hope about the management of symptoms was also a feature of the teaching, for example in being excited about a new way of thinking about chronic pain and giving credibility to yourself when talking about chronic pain management. Being realistic that for the patient improving symptoms and quality of life may not be quick or easy, but may be quicker and easier than they think. We also discussed the importance of the language used and to be careful with this; the classic detrimental example being crumbly spine.

The key learning points from this session will benefit my future practice in me feeling more confident and prepared to manage patients presenting with these symptoms. I recognise these will not be easy consultations but I will feel more equipped in my approach and management. In particular, considering where a patient may be in considering change; for example not trying to go into metaphors and explanations where the patient is pre-contemplative.

Notes by Dr Sam Wild (Trailblazer GP 18/19)

Categories
Trailblazer GP Blogs

Coaching

Helen Barclay (2018/19 Trailblazer) tells us about her experience of coaching during the scheme

Categories
Trailblazer GP Blogs

Project 6 Visit Sheffield

Session ran by Jan Mayor, Waypoint 

Blog write up by Dr Saira Khan

13th September 2019

Project 6 is a voluntary sector drug and alcohol charity based in Keighley, West Yorkshire and Sheffield, South Yorkshire. They help people reduce the risks associated with substance misuse and we offer highly effective, evidence based support to drug and alcohol users and their families.

Sheffield Alcohol Support Service (SASS) came together with project 6 to help local communities. 

There are 2 types of support for alcohol abuse, one is the conventional alcoholic anonymous, and the other is SMART Recovery. 

  • AA originated in America. 
  • SMART stands for Self Management and Recovery Training 
project 6 2.jpeg

SMART uses a ‘four-point programme’. These four points include:

  1. Enhance and maintain motivation to abstain
  2. Cope with urges
  3. Manage thoughts, feelings, and behaviours
  4. Balance momentary and enduring satisfactions

This framework encourages participants to map out their own path to recovery. SMART shifts participants’ ‘locus of control’ to an internal position and therefore allowing them to shape their own destiny. AA, on the other hand, encourages members to seek the help of a ‘higher power.’ 

  • This is why in Americans in general prefer AA, as patients are more religious than in the UK. 

SMART is less that that the patient is an ‘alcoholic’ and more that he has developed a ‘addiction’. 

  • SMART considers addiction to be the physical act of drinking alcohol or taking drugs, and once an addict is in ‘recovery’ the ‘addiction’ ceases to exist. 
  • AA holds that an addict is always an addict for the rest of his or her adult life. 
  • Which is why SMART instead focuses on highlighting irrational beliefs that risk a relapse episode in the present.

This was conveyed by a former addict, he himself preferred the SMART process and was not an advocate for AA. However it was acknowledged that everyone is on their own journey, and this new trainer understood that not everyone was like him. 

Smart believes drinking is a learnt behaviour which can be unlearnt. Similar to cbt. Saying the story again can be counter-productive.  Whereas AA is normally saying it’s a higher feeling that makes you more likely to drink, therefore you need to stop it. There are 12 steps. Making them admit they have lost power over their addiction.

“I’m not fixed and you’re not broken”

Some people needed to fill the gap that was used for drinking with something else. There is a Northern College, Wakefield for people with benefits is free, has childcare, they will have transport. Another programme called Fresh start, this is for women who have had children removed. 

Freedom programme

  • looks at domestic violence
  • Focusses on the perpetrator (for the victims) 
  • Helps them understand why it happened

Weekly timetable for alcohol recovery community (right) 

Patient Experiences

A lot of feeling of being self-aware and internalised judgement. So any hint of judgement would be ruined in the relationship. This patient did think it was the depression that was making him drink and making him feel like he wasn’t quite right. But it was actually the drinking. He didn’t want to go to the SMART meetings, instead just met general people informally. 

He felt that blood tests can come as a realisation to the patients. As they thought they’d been “getting away with it” the whole time.  “Create that crisis with bad blood tests”

If raised GGT with alcohol use, shouldn’t be driving at all, at least 6 months. At least if 60units a week then for DVLA. Are stated as a hazard.

He stated:- “Define what normal is.”

This stayed with me when he would say people would want him to go back to normal, he said what exactly is normal. 

Another person wanted to join the session, however he felt that GP’s didn’t understand, and immediately reverted into saying his credentials. He already felt that without us saying anything that we had looked down on him, and felt that we were judging him. This would have been based on all of his prior experiences with medical professionals. Ultimately he should’ve felt that the GP was a safe place and he didn’t.

It made me realise that being judgemental can come across in body language, and in small cues that you say. Sometimes it doesn’t accumulate to us being judgemental, but how one person described that he felt ashamed every time he saw a health professional, and he projected this onto them. 

Five ways to well-being

5 ways to wellbeing.jpg
Categories
Trailblazer GP Blogs

Prison Medicine

Fascilitated By Spectrum, Wakefield 12th July 2019

prison pic.png

Spectrum community health comprises of:- 

  • prison healthcare
  • Sexual health
  • Community substance misuse 

Spectrum background:- 

  • Previously run by PCT
  • Runs up to north Tyneside down to Barnsley
  • UK registered charity – spectrum people
  • multiple partnerships all across north west – 
  • Good values based culture

Prison categories:- 

  • Range from Cat A to Cat D 
  • Cat A is closed, high risk crimes
  • Cat D is open low risk
  • Others in between 

Constraints of Prison

  • operational (medication timing, differences)
  • Access (so many other priorities eg. Education /work (even though low pay))
  • Other priorities (eg. Legal visits can take priority for some patients in cat A particularly or visits from family and gym is very important)
  • Security 
  • Escorts (some prisoners may need 6 officers before even opening the door, and going to hospital appt)
  • Bed watches (need 2 officers, therefore need to keep prison safe- staffing) 
  • Transfers
  • Prescribing (more acute medicine in cat A eg. Pcm overdose/ drug seeking/ can even manipulate use of nicotine patches)
  • All prisons on system one now
  • Ethical dilemma with prescribing psychoactive substances 
  • Breaking confidentiality with patient to prison officers eg.illicit substances, not allowed on the wings. 
  • Important for MDT approach 

Opportunities 

  • Health promotion
  • Self esteem
  • Access to healthcare
  • Continuity
  • Healthy lifestyles

Ethical dilemmas

  • pressure to reduce hospital admission (due to the number of the staff it would require to do so) 
  • Confidentiality
  • Prescribing for pain vs substance misuse 
  • Every death in custody goes to coroner 
  • So many implications from actions 
  • Need good record keeping 
  • Some only have 7am-7pm health care cover 

Healthcare in prisons consist of:- 

  • Primary care providers
  • Substance misuse
  • Secondary care mental health eg. Psych ,palliative care
  • National Shortage of prison medicine drs
  • Can compromise services too 

Forensic psych beds

  • Difficult to issue
  • Hard to move those with severe psychosis for example to a forensic psych bed
  • Big pressure on the system and normally the pt is on a segregation unit not suitable

Access 

  • Morning urgent triage from 8am, then an evening triage 
  • Still have clinics and a waiting room, majority are consulted 1:1 (without police) 
  • 95% men 5% female in prison
    • women more smaller group and can be difficult behaviours 

Safeguarding in the secure environment 

Women 

  • Drug use in women is double the percentage of the number of female prisoners than the Male
  • This is most likely due to childhood traumas in women
  • Women are normally controlled with their drug use whereas men more likely to be independent and do drugs with their male peers
  • Also perinatal health/Street sex workers/pregnancy
  • Sometimes can keep baby on a mother and child unit 
  • Also mixed categories due to small number of women harder to keep all categories separate

Adult at risk vulnerable prisoner 

  • learning disabilities
  • Elderly/dementia/alcohol induced 
  • Poor access for wheelchair uses due to older facilities
  • Increasing age in prison due to historical crimes 
  • Elderly in prison >50 (as the prison process can add 10-15years)
  • Each year spent in prison can reduce the life expectancy by 2 years for every year spent

Learning disabilities

  • 7% of prisoners have learning disabilities compared to 2% of the general population
  • There’s no specialised provision in prisons 
  • 36% have a physical or mental disability
  • Literacy skills similar to 11 years old 

Other safeguarding:- 

  • Substance misuse
    • majority opiate use 
    • Spice use makes people more vulnerable 
    • High number of physical abuse/sexual abuse
  • Mate crime:- form of grooming 
  • Institutional abuse- just overall poor practices and behaviours of the team
  • important not to be judgemental
  • Unexplained injuries – just report through security systems 
  • Refer through safer custody department rather than adult social care
  • Complex cases can be sought from the local safeguarding board

Self harm

  • seen a lot in personality disorder
  • 87 suicides in 2018
  • Ingestion of batteries (problems as battery vapes) 

Concerns about children

  • Male a disclosure about children on the outside

Personality disorders

  • Around 50% prisoners/offenders 
  • Problematic/persistent/pervasive 
  • Normally onset’s in adolescence, with issues around attachment and security 
  • Borderline commonly seen with unstable relationships
  • Paranoid PD linked to offending, easily provoked into feeling unfairly treated and attacked
  • Obsessive compulsive struggle more in prison given lack of control 

Trade-able medications 

  • Understanding pain 
  • Use the acronym PADABIT for reviewing records 

Prescribing

  • Use prison formulary- can be slightly different mental health and pain medication
  • Try to give longer acting preps, need an ECG, don’t use liquids. 
  • Mirtazipine – Suicide risk 10x higher than ssri
    • the sedative effect wears off after a few weeks 
    • Buscopan- psychoactive if smoked 
  • Venlafaxine- give a high like amphetamine
  • Opiate- good to write morphine equivalent 
    • not effective for chronic pain 
    • Be objective eg. If hip pain stopping you from up the stairs, with the morphine now you should get up the stairs
    • Unlikely to respond to different opiates 

Managing intoxication

  • Alcohol, do breathalyse and can tell the level, can speak to hepatology if concerned, lactulose use
  • Spice, cannabinoid agonist, sprayed onto letters normally, normally smoked. Increases risk of serotonin syndrome , long term use can cause withdrawal.
  • Opiate overdose can affect 45% of opiate users 
  • Naloxone given to pt, being used a lot to reduce overdose. 
  • Methadone/buprenorphine/suboxone
  • Depot injection of buvidal- steady dose, not lots of information on polypharmacy, going into hospitals and needing further analgesia.
  • Espranor- dissolving wafers of buprenorphine, not easily removed after 15sec.

Preparing for Coroner’s court

  • Palliative care don’t need jury 
  • Good report, get indemnifier to read it
  • Full name, qualifications (bachelor of medicine not MB) status (GP for 1 year salaried)
  • Factual account, explain medical terminology, seen alone, nhs reason, report should be standalone, wrote in first person and be specific, don’t just quote what the pt said, interpretation of your examination into context, say what you found and what you failed to find. But explain why you didn’t do it. 
  • If you cannot recall the case, then state what your usual or normal practice will be. Specify what you can remember from memory.
  • Read the records prior, know your report, speak to mps, 
  • Remember confidentiality, confirmation
  • “I don’t recall this can I review?”
  • Can watch on YouTube cross examination 
  • Ask for clarification 
  • MDU website

Blog by Dr Saira Khan