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Covid-19 - Fair Health Response Racism

Black Lives Matter: the death of George Floyd, health inequalities and Covid-19

A personal reflection on racism and steps for meaningful action by Dr Mariya Aziz, GP, Keighley, West Yorkshire with input from Dr Tom Ratcliffe, Fair Health

Events over the last few weeks, from the brutal killing of George Floyd to the devastating effects of COVID 19 on the BAME community, have highlighted the racial inequalities that lie deep within our institutions and the appalling impact it has on so many.

For those from a BAME background, myself included, it has churned up memories and feelings that we try and suppress and brought them to the forefront.

I cannot pretend that my experiences of racism as a British born Pakistani are the equivalent to those of my Black counterparts. However, the impact is indelible and has shaped me into the individual I am today.

The Health Services Journal reports that 44% of NHS doctors currently self-identify as BAME.  At the height of the epidemic, of the number of doctors who sadly lost their lives to Covid-19, a staggering 95% were from BAME backgrounds. The same pattern is seen in other clinical staff groups (see resources).

Data from the Office of National Statistics (see resources) showed that people from Black, Bangadeshi / Pakistani and Indian ethnic groups were all at a substantially increased risk of death from Covid-19 compared with white ethnic groups, even once multiple other factors, such as age, gender and socioeconomic deprivation, were controlled for. The data standardised for age alone is even starker. This showed that Black men and women were over 4 times more likely to die from Covid-19 than their white counterparts: a shocking disparity that reveals the stark intersection of race and poverty in health inequality.

Risk of COVID-19-related death by ethnic group and sex, England and Wales, 2 March to 10 April 2020 (Age adjusted model)

EthnicitySexOdds ratio of Death compared to White ethnicity Lower CI Upper CI
BlackFemale4.283.814.81
BlackMale4.23.814.63
Bangladeshi/PakistaniMale3.553.134.03
Bangladeshi/PakistaniFemale3.352.84
OtherMale2.682.323.09
IndianFemale2.672.33.1
IndianMale2.392.132.69
OtherFemale2.051.672.52
ChineseMale1.931.412.64
MixedMale1.811.42.34
MixedFemale1.611.142.26
ChineseFemale1.150.721.84
Source: Office for National Statistics, UK

How do we respond? What can we do better? And what we must avoid doing from now on?

First, we must all recognise and challenge the overt and more subtle forms of racism that still exist in healthcare.

Second, we must stop assuming that “not seeing colour,” means racism will go away and adopt a stance of active “anti-racism”.     

Third, we must take extra steps to be more inclusive, recognising that people from BAME backgrounds will often have past experiences that can trigger difficult memories and feelings that can impact on their ability to engage with colleagues, organisations and leadership opportunities. There may also be cultural barriers, which we are not sensitive to, that could also impact their progression to senior positions.

Recognising the challenge of racism

Overtly racist comments and use of unacceptable racial terminology is becoming less common but is certainly not unheard of. I do still hear people ask questions or use language that is unacceptable and have challenged it. Sadly, I have not always felt supported in doing so. I like to think that this not because people condone what others are saying (in the majority of cases) but because people are not always clear about the forms racism can take and feel uneasy about calling it out.

I do not feel this is acceptable. Inaction and failing to challenge racism is to be complicit in racial abuse.

Most difficult to address are comments and actions that are borne from ignorance and form “micro-aggressions”. Insidious in effect, these can create self-doubt and a pervasive worry about the way in which one is perceived. This can be more harmful than the overt racism that most people would easily recognise.

Examples in healthcare include:

  • Patients refusing to see a BAME clinician due to their race;
  • Ill thought out comments such as “your/her English is surprisingly good” in clinical feedback;
  • Unnecessarily prefacing references to colleagues with a racial identifier that would not be used when referring to white colleague (i.e. “the Asian doctor”, “that Asian family”)
  • Asking questions about another person’s cultural or social life out of curiosity but posing these in a way that uses stereotypes disrespectfully (i.e. “are people in your culture allowed to have more than one wife?”)

Being actively anti-racist

Some people conclude that the answer to these issues is to remove race as an issue entirely. Co-workers have reached out to me with comments such as “I don’t see your colour”. Whilst well intentioned, I have never felt such an approach provides comfort or reassurance. For me, it minimises who I am. My race and culture are part of me, not something that can be simply ignored.

In her book, White Fragility, Robin Di Angelo, illustrates this point when reflecting on an interaction between a White woman and African-American man:

“His race meant that he had a very different experience in life than she did. If she were ever going to understand or challenge racism, she would need to acknowledge this difference. Pretending that she did not notice that he was black was not helpful to him in any way, as it denied his reality and kept hers insular and unchallenged. This pretence that she did not notice his race assumed that he was “just like her,” and in so doing, she projected her reality onto him.”

The answer to racism is not to ignore race. It is to be actively anti-racist:

“One either allows racial inequities to persevere, as a racist, or confronts racial inequities, as an antiracist. There is no in-between safe space of “not racist.” The claim of “not racist” neutrality is a mask for racism,” Ibram X. Kendi (from How to be an Anti-Racist).

For most of us, adopting a stance of anti-racism, involves painful self-examination and challenging conversations. It should not need stating, but being BAME does not exempt me from this! Sadly even within my own community, there is a racial hierarchy and there is a need to look inwards and reflect on this.

I also believe that understanding what it means to be an ally is an important first step in the road to becoming an antiracist. Being an ally is not easy. It requires us to step out of our comfort zones and challenge discrimination where we see it but to also be mindful of scenarios where it is not so evident.  There is a need to acknowledge that we may have privileges not afforded to others on the basis of their skin tone and to share the benefits of this privilege.

Learning is an essential part of this process. And this means more than completing an annual mandatory e-learning module on Equality and Diversity. Whilst still worth doing, this is not even going to scratch the surface. You may find some of the resources listed at end helpful in addressing our learning gap.

Below is a chart that I have found helpful in the process of self-evaluation in my journey to becoming an antiracist.

Chart was adapted by Andrew M. Ibrahim MD, MSc from “Who Do I Want to Be During COVID-19” (original author unknown) with some ideas pulled from Ibram X. Kendi’s work.

As Scott wood, American author and poet wrote:

“Yes, racism looks like hate, but hate is just one manifestation. Privilege is another. Access is another. Ignorance is another. Apathy is another. And so on. So while I agree with people who say no one is born racist, it remains a powerful system that we’re immediately born into…It’s a set of socioeconomic traps and cultural values that are fired up every time we interact with the world. It is a thing you have to keep scooping out of the boat of your life to keep from drowning in it…”

I have no words to better this and it stresses even more that the act of being antiracist is a lifetime commitment to self-evaluation and learning.

Empowering BAME people within healthcare

Within my current role, whilst our primary care organisation (and indeed the whole medical profession), is very diverse overall, I am the only senior BAME GP working in my immediate setting. Recent events have made me reflect on the effects of this and my own empowerment.

Being placed in a group where I am in the minority as a person of colour can be paralysing. Whilst not an issue in the safety of my immediate clinical team, stepping out of this protected zone into the large business or commissioning meetings can be daunting.

At times, these experiences have rendered me acutely conscious of my race but also my culture and its variance to that of my peers. I know I speak for myself and others when I say that when placed in an ethnically homogenous environment we have all felt to some degree that we have had to compromise ourselves to blend in. In turn this leads to one feeling apologetic or the need to justify/defend certain behaviours that do not fit into the “White” norm.

I know the reasons for my response to this specific situation are rooted in my own insecurities based on past racial discriminations. The last time I was the only BAME individual in a large group was at school, which was a traumatic time due to race related bullying. Sadly, this experience was not atypical and similar feelings and experiences can be a barrier for those from a BAME background to progressing to roles of senior leadership.

Engagement with my predominantly White colleagues on this topic has not been easy. I acknowledge that race is a sensitive topic and those from a White background can feel defensive or as if they are being attacked equally those on the other side of it are perceived as “having a chip on their shoulder/always making it about race”. Hence it is imperative that we do educate ourselves and I include myself in that.

Being South Asian and Muslim does not exempt me from having my own prejudices and unconscious biases. And simply having a diverse workforce is not sufficient to resolve this issue. In fact, I am conscious that, among BAME colleagues, there is a recognised phenomenon of “pulling up the ladder” and failing to help empower colleagues or, worse still, making their progression harder than it should be.

Practical action

If we are to tackle racism, there will be uncomfortable realities that need acknowledging and challenging. We must be proactive and acknowledge a need for meaningful and sustained education and training around race and its impact within all layers of the NHS. We must translate learning from this into delivery of clinical care and consider how organisation of healthcare in culturally insensitive or inappropriate ways exacerbates health inequalities.

This will take time, effort and commitment. However, there are practical steps that we can take immediately. I have listed some suggestions below:

  • Within healthcare:
    • Leaders, including Freedom to Speak Up Guardians, should use this opportunity to specifically address the issue of racism within the NHS and invite a more open discussion of this topic
    • Primary care organisations should organise the collection of data in primary care similar to that of the secondary care and CCG WRES reports to support and ensure that BAME colleagues are being given equal opportunities.
    • Healthcare employers should ensure staff surveys specifically mention discrimination relating to race and other protected characteristics
    • Primary care organisations and educators should promote the concept of allyship as part of wider education for all staff on antiracism and the effects of unconscious bias.
    • Mentoring should be provided for BAME colleagues. For example, using the reverse mentorship programme run by Health Education England. This would pair individuals from under-represented groups with healthcare leaders from non-BAME backgrounds in the hope that alliances are created and experience and knowledge shared.
    • Proactively encourage BAME colleagues to pursue leadership opportunities. The NHS leadership academy has courses aimed at supporting BAME individuals progressing within the work place, i.e. the “ Stepping up” and “Ready Now” programmes.
    • Practical steps such as recognising a wider range of religious holidays in organisational timetables, thus empowering people and making them feel valued within the organisation.
  • For patients:
    • Use Health Equity Audit to look at the uptake of primary and secondary prevention and health outcomes by ethnicity, then take steps to address any inequities identified
    • Ensure information is provided in a range of languages and interpreters are easily accessed
    • Ensure that patient councils include a range of individuals and voices that reflect the demographic make up of the patient body, including by ethnicity
    • Ensure that the way that illness presents in different groups is recognised and that clinical staff are aware of how symptoms and signs vary across BAME and white ethnicities
    • Build alliances with organisations that already provide services for the most vulnerable members of the BAME community, for example inclusion health providers and the VCS

The tragic events in the USA and the Black Lives Matter movement have created huge momentum in what is most likely a once in a generation moment. I know having these conversations with our teams, calling out racism in all its forms and adopting a stance of active anti-racism will be difficult. We have to remember that this is about us coming together so that the minority can be part of the majority and receive fair and equal treatment.

Resources

Sources referenced in this blog

How to be an Anti-Racist. Ibram X Kendi

White Fragility. Robin Di Angelo

ONS – deaths from Covid 19 and socioeconomic deprivation

ONS – deaths from Covid 19 and ethnicity

Health Service Journal – analysis of deaths from Covid 19 among UK healthcare professionals

Further reading and viewing

There are many excellent books, films, documentaries covering the topics discussed in this blog. The list below suggests a few that may be of interest and/or provoke further reflection and debate. Please note that a number of these resources include graphic and distressing material that some will find difficult to read, hear and/or watch.

Books:

Non Fiction –

Why I’m No Longer Talking to White People About Race by Reni Eddo-Lodge​. Based on Reni’s blog post of the same name that went viral back in 2014. A must read book exploring what it means to be a person of colour in the UK today. 

The Good Immigrant. A collection of essays featuring people such as Riz Ahmed, Bim Adewunmi, Vinay Patel, Eddo-Lodge and many others exploring race and immigration. 

Inglorious Empire by Shashi Tharoo. Tharoo is an Indian politician and diplomat, whose book examines the effects of British colonialism on India and challenges some of the post-colonial myths about the British Empire.

White Privilege by Kalwant Bhopal. This book explores the myth of a post-racial society.

Black and British: A Forgotten History. David Olusoga. Olusoga explores how British history has been ‘white-washed’ and sheds light on the very long (right back to the Roman empire) and interwoven history of the UK and people whose origins lie in Africa.

Between the World and Me by Ta-Nehisi Coates. A letter to his son exploring questions about race in the USA today. 

Fiction –

Girl, Woman, Other by Bernadine Evaristo. Booker prize winning novel exploring the interconected stories of twelve characters raising questions about race and feminism. 

Queenie by Candice Carty-Williams. Darkly funny and candid. Covers a huge range of topics include race, mental health.

Americanah by Chimamanda Ngozi Adichie. The novel explores the story of a Nigerian woman who moves to the USA for university, caught between the two cultures and countries. 

Homegoing by Yaa Gyasi. This novel explores the story of two sisters with different destinies: one sold into slavery and one marrying becoming the wife of a slave trader.

Viewing –

13th, a Netflix documentary exposing racial inequality within the criminal justice system. Title comes from the 13th Amendment, (the abolition of slavery in the USA).

When They See Us, a mini-series from Ava DuVernay about the Central Park Five (uncomfortable viewing including detailed descriptions of rape and scenes of violence).​

Black and British: A Forgotten History.David Olusoga. Available on BBC iplayer. Olusoga explores how British history has been ‘white-washed’ and sheds light on the very long and interwoven history of the UK and people whose origins lie in Africa.  He has also presented a series exploring ‘Britain’s Forgotten Slave Owners’ which is also available on BBC iplayer. 

Selma, a film that chronicles the marches of the Civil Rights Movement. 

The Hate U Give, a film based on the YA novel offering an intimate portrait of race in America.

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Trailblazer GP Blogs

Chronic pain and persistent physical symptoms

Blog Post by Deemica Patel (Trailblazer GP 2019/20)

Write up of Trailblazer GP Education Session. This session was delivered by Suzanne Heywood-Everett, Consultant Clinical Psychologist, who has an interest in eating disorders, Autism and Chronic pain.

The session focussed on how we as GP’s can manage chronic pain and persistent physical symptoms. Frequently health professionals can feel that they are out of their depth with these issues and see patients with these problems as ‘heart sinks.’ This can create a culture where health professionals may avoid such patients, medicalise their issues, medicate the problem, and refer inappropriately for investigations and to different specialities. This in turn can make the problem worse as patients may experience further psychological issues, feel they aren’t being listened to and they may seek quick solutions.

Chronic pain

Chronic pain is pain experienced for more than 3 months duration and is due to changes in the state of the individual’s tissues and influenced by other external factors.

Some key points around chronic pain management:

  • It is important to elicit cultural norms and health beliefs as these can lead to somatisation.
  • It is normal for health professionals to medicalise problems and they have a tendency with patients experiencing chronic pain to over investigate in case they feel that something is missed
  • Take ownership – patients can see lots of different professionals and sometimes this may be due to unavailability of appointments with a particular health professional, certain health professionals may not feel comfortable/ experienced seeing patients with chronic pain so do not actively encourage follow up with them.
  • It is important for continuity to be established.
  • Referrals to other services may make the problem worse.
  • Quick fixes can reinforce health beliefs
  • Admit that you don’t always have the answer
  • Patients should take responsibility for their pain- empower them
  • Role for GP to challenge a patient’s narrative around chronic pain

Points during the consultation

  • Try to explore the impact of the pain and pain medication on their life and the impact of medicalisationOften pentinoids/ opiates can cause multiple side effects and patients may be prescribed medications to counteract these
  • Explore their experience of investigations and referrals
  • Patients commonly feel worse as the referral and investigation culture can make them feel that something is being missed
  • Ask about psychological trauma- this can help you understand when and why the pain began
  • Be mindful of your reaction to the issue – e.g. using negative words (ouch, oh no), negative body language can reinforce a patient’s perception of the problem
  • Think of way you explain terms e.g. degeneration and trapped nerve are unhelpful words
  • Patients with chronic pain can be reluctant to change a certain behaviour
  • Exercise: think of a behaviour that you have found hard to give up. How would you feel if we were asked to give it up and what would the best way would be for somebody to ask you to give it up.
  • Most people minimise the negative aspect of the behaviour e.g. I know I shouldn’t drink more alcohol but it helps me to relax and I have had a stressful week at work, therefore I deserve a drink to help me relax
  • Understanding this highlighted that it would be difficult to make changes if you are not in the correct mind-set
  • Patients need to be self-motivated and either pre contemplating or contemplating making changes before embarking on this journey
  • Offer a follow up appointment when they are ready to make changes

Going forward

  • Acknowledge pain is real and about protection e.g. twisted ankleà swollen and painful, cannot walkà restà symptoms improve 
  • Advise management is not a quick fix and will take time
  • Need to learn about pain and why it occurs and why the body responds to this- a useful tool are videos on chronic pain. 1. Tame the beast, Lorimer Moseley: https://www.youtube.com/watch?v=ikUzvSph7Z4 2. Understanding pain in less than 5 minutes and what you can do about it: https://www.youtube.com/watch?v=C_3phB93rvI

For chronic pain need to retrain an individual’s pain system

  • Learn about pain
  • Learn about body
  • Retrain pain system: emphasis on scientific approach and why medications not working  
  • The way you think about pain changes it  

Patients will admit to still being in pain despite medications and getting side effects. Encourage them to gradually reduce to see if pain gets worse and if side effects improve

This cannot be achieved in one appointment- advise patients it will take time!    

Persistent physical symptoms

There is no organic medical reason for this, despite investigations and there may be a psychological component

Can be more than pain e.g. any physical symptom

Delayed symptom onset –usually occurs post stressful period

Should be viewed as part of the recovery process of chronic stress and trauma  

The management is very similar to chronic pain – see above

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Trailblazer GP Blogs

Imposter syndrome: Just clouds in the sky…

12th June 2020

We have just finished a Trailblazer session with Susy Stirling exploring ideas around the Imposter Syndrome and how this might show up in our lives and affect our thinking and decision making. In the latter part of the session we considered how we might understand and manage these thoughts.

I have been deeply affected by the session and wanted to share my thoughts. Firstly, to reflect that I never imagined that three hours over an online platform, even with a skilled facilitator and eleven excellent colleagues, could allow for such rich thinking, self realisation and understanding. These are grandiose words, but I use them deliberately.

I have been aware of the concepts around Imposter Syndrome (‘the self perception of intellectual phoniness despite consistent external validation’) for some time. I knew I experienced it to some extent but I have previously been reluctant to be labeled with it. I certainly experience thoughts and behaviours related to imposter syndrome such as; ‘one day they will discover I am not as good as they think I am’ and, ‘other people make better decisions that I do’ and I do have a tendency to ‘overwork or ‘polish’ something beyond requirements’ (which may mean this blog never gets finished!). Today gave me the opportunity to unpack and understand these thoughts, and recognise that it probably plays a greater role in my thinking that I had previously wanted to acknowledge.

One thing I found particularly interesting was to understand what experiences might have contributed to this ‘imposter’ thinking. For me, though it may already have been part of me, I think my insecurities increased at medical school. Medical school was a very impersonal environment where there were lots of very bright individuals who I felt all seemed to know more and understand more than I did. External validation such as passing exams and getting good grades did little to challenge this narrative in me which persisted through early years as a doctor. I wonder if my current narrative would be different if there had been more opportunities during medical school and early career years for personal reflection and development, helping me understand my strengths and value. Medical school was also the time that I had few or no persistent mentoring relationships (which I am lucky to have had in the latter part of my career), and, though I had good friends I did not have a significant other to challenge my narrative or my sense of self.

During the second half of the session we discussed ways to challenge any unhelpful narratives that we carry. We considered some of the techniques from ACT (Acceptance and Commitment Therapy) about how to distance ourselves from unhelpful and negative thoughts, moving from fixed ideas to fleeting thoughts. One lovely analogy that I will take forward was thinking about our thoughts as moving clouds in a sky, they are constant, they pass over and we can let go of them.

Finally we considered the importance of self awareness and purpose. ‘When we know and understand what we are here for we can better manage our feeling of being an imposter’. We considered how our core values might align with our current roles. In my case more recently my sense of being an imposter has diminished by working with a friendly, skilled, committed team in a place with a vibrant multicultural population with significant health and life challenges. A place I feel fits with my core values.

Dr Alice Deasy (Trailblazer GP 2019/20)

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Trailblazer GP Blogs

Wellbeing for GPs during the Covid crisis

Trailblazer GP blog

Dr Charlie Coffey (Trailblazer 2019/20)

Charlie going open water swimming

On the 17th April the Trailblazers attended a Zoom meeting led by Jaimee Wylam, a Public Health doctor and Martin Billington, a GP. The seminar couldn’t have come at a better time whilst we are all in lock down as the emphasis was placed on how, as doctors, we can take better care of ourselves.

I found that the openness of Martin and Jaimee really helped facilitate how we are all feeling during the COVID pandemic. Initial discussions unfolded the general feeling that we all felt quite restricted, anxious and caged in. As GP’s we are doing mainly telephone consultations and when needed will see the patient face to face.  This is an unprecedented working environment and with that brings it’s own stressors, the main one being managing more uncertainty. We discussed how stress impacts on us both physically and emotionally and whether we had good awareness of when we were stressed.

Martin took us through a lovely breathing exercise “square breathing” as collectively we were starting to feel a little stressed just by the very nature of discussing the impact of it.

Something that had a positive impact on me personally was the category setting in light of the pandemic. Martin asked us to categorise things that we enjoyed doing into 3 groups. Group 1-things that we could do now without restrictions, for example gardening or going for a walk. Group 2-things that we could do with some modifications, for instance swap the swimming pool and go open water swimming -this is something I have enjoyed so much and I intend to keep it up even when the pools are open.  Group 3-things that we couldn’t currently do such as eat in a restaurant or go on holiday

I found this a particularly beneficial exercise as it displayed still so many things I could still do and also how many new things I had placed in the first category. Prior to this pandemic I rarely stayed at home doing arts and crafts with my 2 young boys, instead we would be out in parks, spending money on lunches or expensive days out. Our life now was slower and more simple and in some ways less stressful. I enjoyed just being at home with them not feeling like we “had” to go out. I am also one of the fortunate ones-we have garden. I have never felt more grateful for this

To continue with the positive theme we talked about things we were grateful for. For me, it was again, having a garden and my health, to still be able to go running, enjoy my children. Having a support network we all felt was quite fundamental in how we dealt with stress. We reflected on how we could improve our support networks-some of us were leaving jobs to hopefully move into a more supportive environment. We were helpfully given links to the NHS and BMA sites available to NHS workers who may need additional forms of support for their mental health. Zoom has also provided us with a form of support, through this technology, which was new to most of us, we are able to stay in contact and keep the trail blazer program going.  Up and down the country family and friends are taking part in quizzes, chatting to their grandchildren, work colleagues, taking part in exercise challenges.  The NHS has also become more tech savvy, video consults were alien to me prior to this pandemic but now it is the new normal.

We agreed that self care and being kind to ourselves during the pandemic was vital. Yes the majority of us are going to gain a little “Corona weight” but is now really the time to place pressure on ourselves or to start restricting our treats? Well done to those who are perfectly home schooling their children, or have learned how to play a new instrument, my sense of achievement is getting through each day, perhaps with the help of Disney Channel (best £5.99 I’ve ever spent) or if feeling inspired, some arts and crafts. I have learned to stay away from baking, it rarely ends well.

Arts and Crafts in the garden

This discussion on well being made me feel less alone and very much part of a strong connected group of individuals who were honest about how they were feeling and managing during this really difficult time both personally and professionally.  I ended the meeting feeling more confident due to the new techniques and exercises that we were shown that we could utilise when felt stressed or anxious. Thank you Martin and Jaimee for your time it was a truly valuable experience.

Further Resources

To find out more about wellbeing sessions like these check out Jaimee or Martin’s website

Also please see our Surviving and Thriving at the Deep End e-learning Module

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Trailblazer GP Blogs

Online patient access and triage, can it help to improve health equity?

Blog post by Dr Esme Lawy (Trailblazer GP 2019/20)

I work in a large two-site inner-city practice serving an extremely diverse population of patients many of whom live with deprivation, many of whom are migrants to Sheffield, many very recent arrivals. It is a population of patients who are not necessarily brilliantly served by the wider health service. We have adapted to some of the challenges we face in terms of sheer workload by moving in the past year to entirely clinician first triage with patients greatly encouraged to use our online consultation system AskmyGP. The (sometimes enormous) list of patient contacts and queries is then shared around the available clinicians with a great emphasis being placed on continuity, if it can go to the doc who knows that patient then it will. We then decide whether to engage with the patient online using the messaging system, phone them, bring them straight down for a face-to-face appointment or triage it elsewhere eg. Straight to a physio assessment or another service. They can send photos easily as long as they have a smartphone with a camera (I have found through asking my patients that most but clearly not all do have one in the household).

I have been at this surgery for a year and throughout this time we have been adapting and getting used to the system and, more to the point so have our patients. Some are instant converts. One 80 yr old woman who chuckled when I asked if she had a smartphone and said ‘yeah, but I can only use messenger’ was pretty impressed when I explained that it was pretty much the same thing but she could speak to her doctor, within a few hours, without having to be on hold on the phone at all.

Screenshot of the patient facing side of the system

There are drawbacks, I have had questions in my mind throughout the process along the lines of does this make things better for our patients? Does it makes things better for our staff? Does it make things better in terms of reducing health inequity? I don’t think the answers here are simple. The first thing to say is that we have always actively been intending to improve and not to create a barrier to access, people can still also reach us in exactly the same way as they always did before, via the phone line from 8:30-10am and they will be prioritised in exactly the same way (ie clinically), reception just create an AskmyGP query on their behalf.

There have been some serious questions raised and discussed in our meetings about how this system impacts our patient’s who have low literacy or little English. Our feeling is that the requirement for English is no greater than that required to speak to a receptionist and ask for an appointment. If anything I have probably found many patients are happier this way. They can use Google translate, they can ask a family member who can create the query for them as a proxy, and they always have the option to just fall back on the old system and phone to speak to reception or pitch up at the desk (well, in simpler, pre-COVID-19 times they could anyway). The literacy side of things is interesting, since learning recently that the average reading age of adults in the UK is somewhere in the region of an 11 yr old I have adapted the way I use the system. It’s the same old com-skills that we all know and use automatically but you just have to remember them as an absolute priority. Keep it simple, don’t use jargon, keep it brief and wait for confirmation that you have been understood. If we don’t get that indication using the online messaging we would almost always phone them or bring them down to ensure things have been understood and their issues fully tackled. And one strength with online communication is that the information is there for them to go back to later, with a phone call or face to face appointment it is gone unless you also gave them some written information or they had the where with all to take notes.

Figure showing how queries flow through the practice

A big concern is the use of the system by perpetrators of coercive control to further distance their victims from a professional who might be able to spot something amiss and offer help. Other concerns would be for those who don’t speak or write English or possibly vulnerable older people who might find that some of their communication with their doctor is taken over by a very ‘helpful’ partner or family member or friend who is more fluent in English or more computer literate. Again there is something about the system that has the potential to distance the individual from their clinician. I answer to this I can only vouch for the fact that everyone I work with has their radar switched on when it comes to spotting these problems. I’m not saying it is perfect but I do think that used judiciously and by highly trained clinicians who are not out to turn a blind eye to these scenarios I think it can work. At least as well a telephone based doctor first system. And the idea really is to free up time, if you have been able to deal with a simple UTI in a 23 yr old with a quick back and forth message you have time and, more importantly the thinking and emotional capacity to take something potentially bigger on and ask the uncomfortable question, use a professional interpreter instead of a family member even though it will take much longer, ask to see the patient alone, start to build a bridge.

And then I come finally to the current situation we find ourselves in. I do worry immensely about the disproportionate effect of the current COVID-19 crisis on patients like ours whose lives and health are not always as secure as they would like. I am alarmed by the emerging figures showing the disproportionate number of deaths amongst health professionals from a BAME background. Ten of the first eleven doctors who have died from COVID-19 in the UK were of a BAME background. It would appear that this virus does discriminate in the same way that so much ill health does. Even the experience of self-isolation/lockdown/being shielded clearly is very different for those who live in inadequate or overcrowded housing or those who live with serious long term mental illnesses. This has all been spoken about very informatively by Tom Ratcliffe in his recent blog entry below.

Very understandably coronavirus has our patient’s stressed and scared. So suddenly there is a different feel to all these online and telephone triage conversations, people are very onboard with anything that avoids them coming down to the surgery, we are now having to negotiate with people who really do need to be seen to get them in. Clearly this a frightening time for all but do think that out of this could come some positive behaviour change. More of our patients are using the online system, many many more are happy to engage with online consulting using messaging, photos or video. And we as doctors are suddenly more motivated to use it to its full potential and iron out any glitches which might have been holding us back slightly. Most of this move to online and telephone consulting is entirely appropriate. There will be non-coronavirus related fall-out from this crisis; worsening of people’s mental health, delays in diagnosis of serious disease and increased risk to those living in precarious or abusive situations. But I think used judiciously and by those who have already developed skills around it I think our system is a force for good through this time. A piece in this months edition of The Doctor cautions against a rushed move to the use of online systems. And I think there is a crucial distinction to be drawn between systems like ours and those that are designed, perhaps with AI capabilities to divert patients away. I feel fortunate to work in a practice where using this technology is an embedded part of how we work. I think that out of this appalling crisis will come a further positive shift in how we and our patients use and value the system. I think that together we are using it to build better and closer relationships.

Links

Furore as asian covid 19 death toll rises

BMA- A virtual revolution

Ask my GP- How it works

Categories
Covid-19 - Fair Health Response

Fair Health in the Time of Covid-19

Covid-19 is emphatically not the great leveller.

It has shone a light on the great divides in our society. Everyone can catch it, everyone can die from it but the impact of the virus and the necessary measures to control its spread is not shared equally across society.

Our response will require kindness, caring and compassion. The current upsurge in these values should give us cause for hope during an otherwise very difficult time for many people. And they will be most needed where suffering is greatest.

What is interesting about the risk of death or hospital admission from the virus is that it almost perfectly tracks your current risk of death. So, if you are already sick, from a BAME background, grew up in poverty or already older you are more likely to develop serious symptoms and/or die.

The economic impacts will be most acutely felt by those with the fewest resources: people in low paid jobs, people who have chronic mental or physical illness, people on temporary or “zero hours” contracts and those who are living from pay check to pay check. It is also likely that those in low paid manual jobs (e.g. supermarket, social care, construction workers etc) will be less able to socially distance by working from home and, hence, less able to minimise the risk of Covid-19 infection.  Those who are now confined to home in poor quality or cramped housing will have the most miserable experience and those living in the least affluent, vibrant and green surroundings will suffer the biggest fall in wellbeing.

These individuals are all part of the same group: the poorest in society.

Michael Marmot recently reminded us that, in the UK, the poorest 10% of households have less than 30% of their income remaining after deducting housing costs and the cost of healthy food. They also have very little wealth to fall back on in times of economic crisis. The implications are clear: loss of income due to Covid-19-related unemployment or illness will cause destitution among those who are already struggling to get by.

Health inequalities were already widening before Covid and these divides are now likely to be accelerated by another economic crisis, massively compounded by a virus that kills those already suffering from chronic illness and multimorbidity, the rates of which already follow a sharp social gradient.

Covid has taken the social determinants of health, which have insidiously been working away behind the scenes, slowly eroding peoples’ health and wellbeing, and exploded their impact into full view. Our civic, community and healthcare resources have been degraded by a decade of austerity, as have many aspects of the welfare safety net. Covid has triggered substantial reinvestment but we must not let these issues disappear back into the shadows as the crisis recedes.

The response to Covid has been to put the whole NHS on an acute footing, aimed at treating a single disease, whilst trying to also provide care to the non-Covid acutely unwell. This means that planned primary care, which can narrow the health gap by 10-20% if access is good and quality high, has been temporarily suspended (or at least deprioritised). Because the system was already at capacity, and because capacity was already inadequate in the most socioeconomically deprived communities, it will take a long time to catch up after this crisis. After Covid we will discover a massive pool of morbidity, mortality and unmet demand. Mental illness that existed before this crisis will also sharply deteriorate due to increased stress and isolation plus a temporary withdrawal of face to face primary care.

GPs also know that the aftermath of social trauma can last years or even decades and blight peoples’ whole lives. GPs have spent years trying to help people traumatised by war, tragic events, childhood neglect or mistreatment, crime or domestic abuse. Covid will leave thousands, perhaps hundreds of thousands, of people traumatised by its direct effects or as a result of vulnerable people being left isolated in toxic social situations, where the abuse or mistreatment they have suffered becomes temporarily inescapable.

The long tail of this crisis are neatly summarised here:

A close up of a map

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The Four Waves of Impact: Covid-19

Source: https://pbs.twimg.com/media/EUX2TipWoAMa_19.jpg (thank you to Dr Victor Tseng)

So how can we respond?

If there is a positive thing to take away from the Covid crisis it is the outpouring of kindness, the renewed recognition of the contribution of people with jobs whose value may have been forgotten or overlooked, a huge injection of investment into healthcare and social welfare and a revived willingness to think about the needs of others.

We might reflect on J.B. Priestley’s words:

“We don’t live alone. We are members of one body. We are responsible for each other.”

An Inspector Calls, 1945

So how should we respond in primary care?

As our colleagues at Citadel Healthcare in Greater Manchester remind us, for general practice, we should go back to basics: “find the sickest, and give them the best care”. And we must double down on our efforts to do this during and after Covid-19.

  • We will have to catch up peoples’ chronic disease management – prioritise the poorest, who can be identified by integrating the available databases on socioeconomic deprivation with primary care records and by examining chronic disease data (time to collaborate with our wonderful colleagues in public health – at Fair Health we are also trying to create some resources to make this easier for practices, watch this space!). Also prioritise those things that have the biggest impact on health outcomes – start with cardiovascular disease prevention. Perhaps revise where to focus your efforts by working through our learning modules.
  • Now will be the time to adopt an approach based on “Trauma Informed Care”. You can read more about this in our learning modules on this site and on the “A Better NHS” blog (see resources below).
  • Use the Primary Care Network DES to invest in social prescribing to try and deal with some of the acute social issues that Covid will exacerbate and use this to build better links with your local Voluntary and Charitable Sector, who may need your support and advocacy more than ever
  • Collaborate with the “social determinants of health workforce” more than ever:
    • The social workers, teachers, school nurses and health visitors who will be helping safeguarded children during and after the crisis
    • The Citizens Advice Bureau, debt advisors and Department for Work and Pensions operatives who will be needed more than ever to help people through the multiple domestic financial crisis that Covid will create
    • Organisations providing care for people who are homeless, refugees and other vulnerable groups to ensure they can access very strained services in the post Covid world
    • Drug and alcohol services, whose users won’t have been able to socially distance and access support as easily during this crisis
    • The nurses and carers out in the community supporting our most vulnerable
  • Remember that primary care organisations are anchor institutions for many communities – just being there is so important: you can hold onto the memories of how Covid impacted your community and you can hold the NHS leadership and politicians to account for their decisions, their efforts to address health inequalities and future readiness for a pandemic or the slower health “emergency” represented by growing health inequalities
  • Try and ensure that information about Covid and the social safety net that is being created is accessible to all by providing information in multiple languages and formats (see resources for free translations of material provided by Doctors of the World)
  • As illustrated above, the Covid crisis will have a long tail, perhaps stretching out over many years, this is where health equity focussed primary care will be needed most

Resources

A Better NHS Blog: https://abetternhs.net/ (see 23rd February 2020)

The Marmot Review 10 Years On: https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on

Doctors of the World patient information: https://www.doctorsoftheworld.org.uk/coronavirus-information/

Please note that we cannot verify the accuracy of information on external sites, particularly at this time of rapidly changing knowledge about Covid-19

Categories
Trailblazer GP Blogs

Health Coaching

Julie Duodu (GP Trailblazer 2019/2020)

27.03.2020

Today, through the wonder that it is Zoom, Dr Tim Williams delivered an excellent session on health coaching. For many, it was our first time utilising the zoom technology for video conferencing and it was the first time to explore this topic.

The technology worked extremely well- it was clear and crisp and uninterrupted. The format enabled slides to be presented, large group working and working in pairs in “breakout rooms” to practice the techniques of health coaching which was great to reinforce the theory presented.

In the session we explored what coaching is and made the distinction between coaching and counselling. We discussed important factors required to be a good coach.

Dr Williams introduced the “S.T.OP.I.T” and “ D.O.I.T” models which can be utilised as a coach to help our patients work out what it is they wish to change, discover the true motivation for this to act as meaningful tools to fuel that change and also to devise realistic outcomes and a plan of attack to make the changes they wish to see in their lives.

We were introduced to the concept of patient activation measures to gage how motivated or engaged a patient is with the process of change or improvement. An excellent example from the practice of Dr Hart- also a Director in Peak Health Coaching, illustrated how by finding out a patient’s activation measure, apt resources can be directed towards them to help them manage their health needs and goals. Some patients with a low activation score but complex health needs may have a more effective outcome if social prescribing is utilised first to increase their activation levels before having more intensive health education for example with a practice nurse for example.

I found this session to be extremely useful. It was a great introduction to this fascinating topic and I can see how the models shared can be utilised for life coaching as well as life coaching. I can appreciate how useful it could be to adopt a coaching mindset with all patients and I think that with practice, skill and care, a clinician could apply some or all of the model within a routine consultation depending on the patient, the topic and the rapport one has with a patient. It was also great to have the time and opportunity to practice these concepts on each other- I think it takes great skill as a coach to give people the space to think and to think well without feeling the need to interject, fill silences or to offer advice. It is quite rewarding assisting someone to arrive at an answer which they had within themselves all along.

Thank you Dr Tim Williams for all your efforts to adapt your session to be compatible with the technology and for your determination to deliver it as scheduled albeit in a virtual capacity. It worked extremely well and it was informative and helpful and something which will hopefully improve our clinical practice.

Dr Tim Williams teaching the Trailblazers about coaching via Zoom (March 2020)
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