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The Exceptional Potential of General Practice Conference – Glasgow – Dr Katie Burgass

14-15th February 2019

The conference was a great way to meet others interested in health inequalities, listen to the experiences of working in this area from some truly inspirational speakers and explore future challenges as well as celebrating many great achievements by GPs and their colleagues across the UK.

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One of the opening talks by Professor Allyson Pollock about how market forces affect the inverse care law was an eye opener. She discussed how the inverse care law has been shown to operate more completely where medical care is most exposed to market forces. The introduction via the health and social care act of private providers bidding for healthcare contracts has been seen to exacerbate this. This combined with the current allocation of GP funds being equal but not equitable has led to a decrease in GP services and population health. Currently 5 million people are using food banks in the UK. 11% of GP practices have closed in the last 10 years.

She went on to discuss what we can do as GP’s working at the “deep end” to help in this crisis. Patients in deprived areas are reported to have less opportunity for shared decision making, less time and felt less empathy from health care workers. Patient enablement has been shown to only occur when empathy is expressed. Continuity of care and time are the most influential factors in improving patient care.

We then went on to hear many inspirational stories from different GPs across the UK. We first heard from the Deep End in Scotland, learning about the Govan SHIP project, a program that allowed the employment of locums to free time of salaried and GP partners to focus on providing better care for those more complex patients. They also ran MDT meetings with different members of the healthcare team (social care, mental health, district nurses, health visitors, rehab, link workers) to discuss high need patients and improve co-ordination of care. The GPs were also given time to develop areas of interest and develop leadership roles. Evaluation at the end of the project showed a reduction in appointments and home visits for those complex patients. They also found that many of the locums employed stayed on at the practice improving recruitment. The success of this project echoed Professors Pollocks words about the importance of increased time and continuity of care.

We also heard from the North Dublin training scheme who have developed a specific curriculum for those training within their area focussed on deprivation. This included modules on self-care and change management as well as an arts program. The scheme included a 4th year, when a special interest post could be followed such as working in a homeless, prison or migrant health clinic.  

Dr Blane, a Deep End GP, also gave a very interesting talk on the educational challenges faced when training those in areas of health inequalities. His salient points for care of patients in deprived areas were

  • Extra time for consultations
  • Best use of serial encounters (learn a patients story)
  • GP’s as the natural hubs of local health systems (a great opportunity for linking with others)
  • Making connections across the front line (sharing learning)
  • Better support for the front line (infrastructure)
  • Leadership at different levels (at every level)

A discussion on the Wider World impact on health inequalities by Sir Andy Haines also gave a different perspective on how we think about health and our world. Environmental stewardship is a current hot topic and one which I have never considered as directly impacting on the health of the population I see. However hearing statistics such as “1 in 9 deaths globally is caused by air pollution” and that “as the % of carbon dioxide in the air increases the quality and nutritional value of food reduces”, made me think about this again. He also raised the question of whether if people think about environmental changes as impacting their health, would they care about it more?

I also very much enjoyed a break out session where medical students, foundation doctors and early career GPs met to discuss the challenges they faced and ideas they had about future developments in this area. The general feeling was people were doing similar work all over the country and opening communication channels and sharing ideas would be beneficial to everyone.

I went away from this conference feeling inspired and enthused. Although there was much discussion about the current poor state of care provided for those in deprived areas across our country, hearing about the positive steps that had been taken and the passion for development in this area from others was encouraging. The key message I took away from the conference is that the three areas that should be focussed on to provide good care in deep end practices are:

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  1. Continuity of care (getting to know patients better by improving access to appointments, better retention of regular staff)
  2. More time with patients (more staff to allow this, flexibility of appointments)
  3. Resilience of GPs and healthcare staff (the importance of self-care measures, allowing time for personal development, supporting staff to avoid burnout).

The importance of recruitment, education and retention in practices really interests me. GPs are now a scarce resource and large numbers of newly qualified GPs are now opting to locum rather than take up a permanent position. Having recently moved from locuming to a salaried position I am aware of how attractive the flexibility and financial incentive of locuming can be. I have also witnessed how brilliant GPs have become burnt out due to the nature and intensity of the work.

Salaried jobs need to become more attractive to younger GPs. By improving GP numbers and resilience by offering more time and space to both consult but also explore areas of self-development (as illustrated by the govan SHIP program) will lead to better retention of staff , continuity of care and ultimately better patient outcomes. Practices need to be able to give GPs the space and time to develop other interests and to do that they require appropriate financial backing from the government.

Dr Katie Burgass

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Bevan Healthcare

A social enterprise revolutionising primary care delivery for vulnerable groups

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Trailblazers at Bevan Jan 2019

The day encompassed a full day practice visit to Bevan Healthcare GP practice in Bradford. Bevan Healthcare is a social enterprise, with a vision of providing healthcare to disadvantaged vulnerable groups. These patient groups may include the homeless, refugees, asylum seekers, victims of abuse, trafficking or those with drug or alcohol problems. The practice offers longer appointments, link workers, drop in clinics for patients, GPs with special interests in addiction and an outreach service which include a health ‘bus’ which provides a ‘street doctor’ service once a week on an evening for vulnerable patients including those involved in prostitution.  

The practice works with third sector partner organisations to provide wellbeing groups, such as art or cookery classes, for vulnerable groups. On the day we were shown an art and textiles class ran for women who have been unfortunately been the victim of domestic violence in the past, with the focus on healing and recovery via supporting one another. We then met two GP’s who have a special interest in associated branches of medicine, for instance addiction. We discussed at length the reasons behind the majority of presentations for addiction problems. As per my previous learning on the subject, adverse childhood experiences were paramount in the majority of cases where alcohol and drugs were misused and the use perpetuated into addiction and the social problems that often arose. I learnt that more than three adverse childhood events was linked with higher levels of the likelihood of addiction and subsequent homelessness, including break up of parents, bereavement, experiencing sexual abuse and substance misuse within the family being the most common ACE’s. This was useful in thinking about the patient’s I see in practice who present with addiction, and did give me a new found empathy for them. We also discussed the various theoretical models which cover addiction and that suffering ACE’s is actually linked to neurophysiological changes that make addiction and sensitive the dopamine cascade involved more readily. We also discussed the various studies that have demonstrated the link between social environment and addiction. The two major studies discussed were Rat Park (1970) and Mintz’s 1979 work on looking at opiate use in soldiers returning from the Vietnam war. In both, the absence of a fulfilling and stimulating social environment perpetuated the use of opiates, whereas the opposite was true when subjects were given environments in which they felt safe, secure and had opportunities to engage with others readily. Again this helped me understand and empathise with those patients in a cycle of addiction and homelessness or difficult living circumstances and has certainly changed my attitude towards them.

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Practically the day was really helpful in providing certain tips on how to manage such patients who are involved in addiction, for example the holistic care for someone with an opiate addiction may involve considering their dentistry, looking at injection sites for infection, prescribing PPI + antiemetics for nausea and vomiting, prescribing antihistamines and mentho-derm for pruritis and obviously laxatives for constipation secondary to the opiates. More tips included the widespread vitamin b and magnesium deficiency commonly found amongst these patient groups and also practical ways in which to ensure that patients can avoid malnourishment. We also heard of ways in which health care has been shaped by the patients, for example sexual health clinics for women involved in sex work, and the way this has reduced the number of cases of sexually transmitted infections amongst this population.

The day was extremely useful in shaping my attitudes and practice. It has given me more empathy and understanding towards patients who are battling addiction and the theoretical basis of adverse childhood events and sensitising the addiction pathways in the nucleus accumbens resonated with me as a clinician to easily understand the ways in which addiction can take hold and perpetuate, especially when people are exposed to the wrong social circumstances. The visit was helpful to see how a practice run as a social enterprise is run and how without the constraints of GMS, services can be set up to meet the demands of the patient population in a reflexive and timely way. This has also helped me reflect as I move forward in my career the potential for working with partner organisations and third sector agencies as healthcare provider.

Date of visit 18th Jan 2019

Dr Mathew Fortnam

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Health Inequalities

21st December 2018

This was a great introductory session to Health Inequalities and the research and theories behind some of the great work that is done in Deep End GP practices across the country.

We started by discussing the social determinants of health, and how it is harder to be healthy when someone lives in a deprived area, with fewer resources and more social challenges throughout life. These might include living conditions, financial security, employment conditions, social exclusion, gender, early child development, addiction, family support, and many other factors. We looked at Maslow’s hierarchy of need, and also at the difference between equity and equality.

We discussed the politico-social determinants of health as well – the Inverse Care Law and the importance of the GP’s role as an advocate for patients who are suffering due to social conditions and exclusion.

As it was the session before Christmas, Rachel had us playing a game of Health Inequalities Pictionary Team Relay – I can’t really describe this but it was an absolutely inspired idea!

The session reinforced to me that as GPs we have a unique opportunity to advocate for these patients and to strive to provide the right sort of care to patients whose health is adversely affected by social factors. Hospital colleagues do not have the continuity of care or the link to community organisations that it is possible to develop as a GP, and by working specifically in one community as we do GPs, we can develop community links that will affect the health outcomes of our patients in the long term, through social means rather than medical.

I don’t think at any point through medical training did we have such a clear lecture or seminar on the social determinants of health – this session really made me think about our goal as doctors – we need to treat medical conditions as they arise but when such huge disparities exist in rates of disease between the richest and poorest in society, it makes far more sense to reduce these inequalities so that a huge proportion of health problems do not occur in the first place. Prevention is always better than cure – we should be encouraging policymakers to look at the facts and to make policies for health and social care which address this enormously important issue.  

However you could take this to mean that all doctors should give up and go into politics or public health – I don’t think that! By treating patients and getting to know our local populations, we can gather our own evidence of what social policies do to health outcomes. And by being aware of this, we can tailor our treatment to the individual patient and communities, so that we can influence change this way as well as advocating on a national level or through organisations that we support (e.g. the RCGP has some activity on the subject of health inequality).

I found this session incredibly useful and inspiring – and I would encourage anybody who is interested to know further to look at the learning modules on the Fairhealth website as they cover a lot of this material very concisely. Unfortunately you can’t play “Health Inequalities Pictionary Team Relay” on the website, but I would encourage Rachel to make this game commercially available one day…

Dr Helen Barclay

Location: The Hepworth, Wakefield

Session facilitator: Rachel Steen

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Effective Meetings

This was a useful day as meetings and involvement in meetings is something I feel I can struggle with and find participation in meetings is not something which comes naturally to me.

As my career progresses I am more likely to have an increased involvement in meeting/teaching and so this day gave helpful pointers in how to make meetings more valuable.

Key learning points:

– Consider place – tidy/clean environment, maybe drinks/food and be well prepared. This will make people feel more valued and more likely to engage

– Attention – the attention you pay to someone in aim to enhance there thinking (demonstrated and practiced in thinking pairs, while listening paying attention to content, response, environment. Not interjecting often, remain more neutral, allowing silences)

– Equality – aiming to allow everyone to have there say/give their ideas. Especially when chairing asking those are not as involved what they think (ok for them to agree with previous points/have no different thoughts)

– Issues to questions – think what’s the issue, what is the outcome wanted and what is the question, that if we could answer it, would get us closest to our outcome. Have an agenda of questions, this will help people have ideas on solutions.

– Send details around the agenda questions out in advance so the details do not need discussing in detail first

– Giving a minute for people to jot down their thoughts on the question before starting the discussion I found was helpful to structure discussions and responses.

– Consider using rounds – everyone getting a chance to discuss, then asking next person what they think. Can go around again after initial thoughts if this has changed any opinions or prompted new points

– Thinking council; presenter presents issue, then questions to clarify questions, then in a round everyone gets a change to respond to the question, no interruptions

– Appreciation – should do this more in general, and in meetings. Sincere, succinct, specific

Following on from this teaching I have had opportunity to put this teaching into practice. I organised and run a mental health MDT meeting with secondary care and IAPT to discuss difficult mental health cases which we were not sure needed referral or how to manage best.

I found this intimidating, but the above knowledge helped me greatly in structuring the meeting and making it run smoothly
In particular, sending out information in advance and ensuring the cases we were discussing had specific questions to answer was very beneficial.

I didn’t formally use rounds in the discussion, but I more actively tried to involve everyone in the discussions and give good attention to all

I also ensured I was familiar with the room being used and that tea and biscuits were available (although the take up for these was surprisingly poor!)

My confidence in running meetings have developed greatly, this is something that I still find less natural and less comfortable with, but the above learning has really helped and I will be using further in future.

Dr Sam Wild

Date of teaching 23rd November 2018