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) 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.
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)
Helen Barclay (2018/19 Trailblazer) tells us about her experience of coaching during the scheme
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
SMART uses a ‘four-point programme’. These four points include:
- Enhance and maintain motivation to abstain
- Cope with urges
- Manage thoughts, feelings, and behaviours
- 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.
- looks at domestic violence
- Focusses on the perpetrator (for the victims)
- Helps them understand why it happened
Weekly timetable for alcohol recovery community (right)
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
Fascilitated By Spectrum, Wakefield 12th July 2019
Spectrum community health comprises of:-
- prison healthcare
- Sexual health
- Community substance misuse
- 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
- 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)
- 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)
- 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
- Health promotion
- Self esteem
- Access to healthcare
- Healthy lifestyles
- pressure to reduce hospital admission (due to the number of the staff it would require to do so)
- 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
- 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
- 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
- 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
- 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
- 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
- Around 50% prisoners/offenders
- 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
- Understanding pain
- Use the acronym PADABIT for reviewing records
- 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
- 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.
- 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
3rd May 2019
Migrant Health – session by Dr Andrew Lephard, GP at Bevan Healthcare.
This week we had a session on Migrant Health by Andy Lephard, a senior GP at Bevan Healthcare who has been working in this sector for over 10 years and has often done teaching sessions on this subject due to his experience of this type of general practice.
Andy talked about the different ways that people can arrive in the UK – through refugee resettlement programmes, asylum seeking, being trafficked into the country. He told us about the asylum process and where patients tend to struggle – and why. They go through an initial interview, then later on a substantive interview which can last many hours. Then they receive a decision about their asylum application (it can take many months, although is only supposed to be a maximum of 6 months), and at that point they have 28 days to get themselves sorted with “normal” benefits and amenities (housing, universal credit, bank account etc) before their asylum support is stopped. Many people hit a crisis at this point as they may still not speak English and may have mental health problems, not know the area and not be in a good place psychologically or financially to get all these things sorted. Housing takes money and time – after living on asylum seeker benefits of £35 per week it is going to be quite hard to afford a deposit.
Asylum seekers are usually not allowed to work and are given approx. £35 per week to live with. Their accommodation and heating/bills are paid for but are often in areas of the country with low rents and the standard of accommodation is often low. They are moved around the country with little notice and have to sign in frequently at the home office so are not free to move around. During the process of travelling from their home country, many families are separated. Once someone has been accepted as refugee they have the right to family reunion (1st degree family members only and there are some stipulations) so many families might consider sending only one family member (paying to get across the world is expensive) and then reunite later. However also in other cases families may get shipped to different countries and some be claiming asylum in different parts of the world. Andy talked about the effects this has on people and the frustration and powerlessness that seems prevalent in many people stuck in this situation. The feeling that they have escaped the danger but life is harder than it used to be.
We learned about VPRS and GPP refugee resettlement schemes – a lot of people at Bevan have arrived through these means and they run new arrivals clinics for these people to discuss immunisations, general check ups and to introduce people to UK healthcare systems. These people do not have to go through the asylum system as they are already accepted as refugees. They are supported fully for a year after arrival and the difference in the way they are treated compared to asylum seekers who have arrived in the UK off their own back is quite huge.
People arriving on the VPRS (vulnerable person refugee scheme) will have come from UN refugee camps and be identified as particularly vulnerable – often with children who have serious health conditions that cannot be managed in a refugee camp. The GPP scheme is similar but is for any refugee from certain conflicts only, and they do not have to be particularly vulnerable. It does make the mind boggle a bit to wonder just how people would be chosen for these schemes, given the millions of people across the world still stuck in refugee camps.
After this session I felt that I understood these common migration methods much better and understood more about how healthcare needs to adapt to fit the difficulties that people in this situation can experience. Particularly mental health and orientation to the NHS. It stressed the importance of knowledge of charities that can help support people in need, and of non-medical support services (e.g. social prescribing) in helping new arrivals to integrate into their new local community.
Dr Helen Barclay
Session by Jonathan Tomlinson
Blog post by Dr Katie Burgass
Trauma is an issue that has been raised at many of the sessions we have covered through
the Trailblazer scheme so it was extremely useful to have a session solely focussed on this
We started by discussing examples of complex and difficult to manage patients we have
encountered, those that can present with many and often difficult to explain medical
symptoms. Jonathon spoke about how he had identified common problems between these
patients such as pain, fatigue, IBS, palpitations, dyspnoea, dyspepsia and incontinence.
These symptoms all are associated with sympathetic (arousal) or parasympathetic
We discussed the theory of “Hypervigilance”. The limbic system (that controls our emotion,
motivation, learning and memory) is linked to the brainstem which controls the vagus nerve
in charge of our parasympathetic and sympathetic drives. If there is trauma in early life,
people often struggle with self-regulation between “arousal” and “reduction” states. As a
result they can develop symptoms through the parasympathetic or sympathetic drive, that
could therefore be interpreted as symptoms of undischarged traumatic stress. In addition to
this the limbic system and brainstem have no link to the prefrontal lobe (involved in
decision making, planning and behaviour) so any actions coming from it are reflexes. The
patient has no control over these symptoms.
Patients suffering with symptoms of hypervigilance often use methods that result in
dissociation and disconnection to try and regain a level of control. Examples are self-
harming, using drugs or isolating themselves. It is also worth noting the impact of trauma
can be variable between different individuals. Trauma is the symptom, not the event.
We also discussed the impact of childhood trauma as well as resulting in physical and
mental health difficulties, can often result in shame. “Unlike guilt which is the fear of doing
something wrong, shame is the guilt of feeling you are a bad person”. This can be crippling
to a person.
So how best to approach a consultation if you feel someone has suffered from this in the
past? And when you have, where do you go next with it? Recovery is all about reconnection.
The 5 areas Jonathon suggested focussing on were:
1. Relationships – building a meaningful connection with another human being, this
could be done using social prescribers to access voluntary or support groups.
2. Biology – encouraging healthy behaviours, addressing diet and weight, smoking
cessation and drug use, rationalisation of medications.
3. Body – encouraging physical and mental exercise, creative activities, using outdoor
spaces and connecting with nature.
4. Mind – dealing with emotions, accessing support through talking therapies and
mental health teams
5. Social security – without this 5 th element it is very difficult to start addressing the
other 4. Having financial security and appropriate, safe accommodation is a priority.
Once someone feels secure in the environment can they start addressing changes
As doctors we often strive to find the “science” behind our patients presentations, so
hearing a theory around the impact of trauma on physical health based within a
neuroscientific context was extremely interesting.
Practical tips I picked up from the session:
– Look at the problems list and consolidate.
– Acknowledge when things have become chronic. Looks for symptoms of
“hypervigilance” as explained above.
– If you feel a patient may have suffered from trauma in the past allow time to build
rapport and a relationship before addressing this. “Where do you think your anxiety
comes from?” is often a helpful question to ask as an opener.
– Acknowledge the cause of the symptoms, this will empower patients.
– Look at the 5 areas to be focussed on for recovery. Make a plan together, addressing
things at a pace the patient in comfortable with.
– Make a crisis plan for if things were to go wrong, involve family / friends and other
professionals. Focus on triggers and coping mechanisms as well as sources of
support. Write the plan down. Review it after each crisis. Don’t change medication
during a crisis.
There are many patients I encounter at work that I am sure have experienced trauma in
their past. I now feel more equipped to address this with them, the difficulty, as always in
general practice, is finding adequate amounts of time and space to spend with these
vulnerable patients within the busy day.
There were some incredible opportunities to connect with other like-minded GP’s on an action learning set. It allowed some thinking time to explore problematic areas of practice within our new jobs at newly qualified GP’s and solve ‘wicked’ issues, where the concept of the problem is often difficult to comprehend and understand and the answers often lie in nuanced collective agreement rather than reactionary approaches. The theory is that this approach by sharing problems with like-minded peers with similar professional experience is more likely to result in making meaningful behavioural change and positive action. My session of coaching was almost a well-earned and useful time for reflection on the path I was headed in my early stages as GP.
The Action learning set in Sheffield really provided me with the head space to reflect on my learning as a newly qualified GP. Other GP’s who attended brought other difficulties they were having in practice. These included inter-professional difficulties with the managing partner, perceived workload inequity, payscale differences with another newly qualified GP who had negotiated a higher wage, difficulties in considering how to request more admin time to perform a job description and how to deal with the feeling of not being able to meet the demands of the administrative side of the job with the time made available to do so. I left feeling more able to understand the common difficulties we all face as newly qualified practitioners working in a primary care system under strain from under-funding and from being over-subscribed. I also felt the comfort in understanding the problems others face on a daily basis and how we were able to tackle these as a collective has changed my practice in the way that I am now committed to using this learning style to help solve future ‘wicked’ problems, or tease out problems that I find it difficult to articulate. I will also be able to apply this method of problem solving when working within practice teams and partnerships to work more collaboratively and achieve greater shared understanding.
My coaching session was nothing short of a revelation as it provided insight into my career that I had never really had before. The beauty of the coaching was that little advice was actually offered and in the two hours offered of self reflection and learning I was able to address some of the nagging issues that had previously been concerning me. This was mainly in relation to the feeling I had of inertia within my early career and that I hadn’t set the ‘new’ challenge.
My coaching allowed me to identify what I was feeling was a lack of validation in my new job and a lack of openness with my new practice management team as to how I was settling in and what opportunities I might be able to get involved with. I quickly made assertions to make contact with my mentor to make a mid-year progress meeting to ascertain how the practice thought I was doing (it was better than I thought!) and also to ascertain what opportunities the practice may hold in store for me and my scope of experience. This has taught me the importance personally of ensuring I not only consider my own performance, but I obtain the feedback of others as to how I am getting on to obtain some kind of objective measure which in turn helps drive motivation. As a potential future employer, this is something I have really taken on board and it will change my practice of giving regular feedback to others in my team.
Dr Mathew Fortnam (Trailblazer 2018/19)
Session ran by Dr Lucy Chiddick, Leeds
May 3rd 2019
This was a morning session with Lucy Chiddick (Health Inequalities lead in Hull CCG). I have found commissioning an intimidating topic which I find difficult to understand. The session was valuable in demystifying this topic and giving practical examples of how new ideas and changes can be made (the example used being the pathways project in Hull)
Below are my notes and key learning points from the session
– Changes in structures common and confusing for everyone! Currently CCGs – commissioning and provider arms (wide spectrum of community services). Regarding commissioning more collaboration (health sector, local authority, mental health), over bigger area, was STPs then healthcare partnerships now ICS (integrated commissioning systems)
– Population health – aim to target services to specific populations
– GP networks developing – practices with similar populations and needs – more likely to know what intervention will help for that population (30 to 50 thousand in total). Mentioned in GP forward view (developing workforce, working at scale, networks). Long term plan pushed forward networks (and now in new GP contract)
– Translating ideas into practice can be tricky
– GP contract/NHS plan; bringing more secondary care into the community (ca, resp, MH, stroke, CHD), workforce and diversifying workforce (inc looking after staff), IT, Indemnity, QOF changing. ??how to measure health inequality
– GPs in CCGs – read papers, advocate (eg for vulnerable groups) – comment on specs for stuff coming in (but ?not really changing or adding new things)
– Working in CCGs – build relationships with people and get people on side. Look everywhere for funding, along with the political climate. Also new roles can be created eg health inequalities lead. Example being pathways and resources and services for homeless people. Homeless strategy 2018 from gov helped as was in political view at that time, persuading people that this was a good idea, putting healthcare for homeless in the housing strategy for the city, need to make business case and finance – ask business analysis people for stats.
– Practicalities of this work – self directed and set own agenda. time management important (freedom to get to meet people and know what is happening). Different work to clinical – goal is long term – changes take long time
– Things to consider, does the PCN need sub-clinical lead eg in health inequality.
How the above has developed my understanding of commissioning – the most important part for me was demystifying this topic – knowing the structures are changing and confusing even to those involved makes it less intimidating – it would take time for anyone to understand when working in these roles. The change to Primary care networks is something I had heard about, but it is more clear now.
This has given me more confidence on how I could be involved if an opportunity came up to have some involvement (before I would feel under-qualified and intimidated by this area, but I do have experience and skills coming from my practice and also the teaching I have been having on Fridays)
Dr Sam Wild