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Medically Unexplained Symptoms

Session 27th September 2019- Bradford.

Session ran by Suzanne Heywood-Everett

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

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

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

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

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

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

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

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

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

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

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Prison Medicine

Fascilitated By Spectrum, Wakefield 12th July 2019

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Spectrum community health comprises of:- 

  • prison healthcare
  • Sexual health
  • Community substance misuse 

Spectrum background:- 

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

Prison categories:- 

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

Constraints of Prison

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

Opportunities 

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

Ethical dilemmas

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

Healthcare in prisons consist of:- 

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

Forensic psych beds

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

Access 

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

Safeguarding in the secure environment 

Women 

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

Adult at risk vulnerable prisoner 

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

Learning disabilities

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

Other safeguarding:- 

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

Self harm

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

Concerns about children

  • Male a disclosure about children on the outside

Personality disorders

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

Trade-able medications 

  • Understanding pain 
  • Use the acronym PADABIT for reviewing records 

Prescribing

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

Managing intoxication

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

Preparing for Coroner’s court

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

Blog by Dr Saira Khan

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Migrant health at Bevan

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

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Commissioning

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

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Hope Citadel Visit – Hill Top Surgery

I found our visit to Hope Citadel very inspiring. We met with Dr James Matheson, Dr Jon Patterson, 2 of the GPs working within the practice, and Dr Laura Neilson the CEO of the group (who had initially set up the foundation as a medical student) along with Lisa, a focussed care worker. They shared their experiences of how they set up the group and how they approached and developed their ideas about caring for patients in a very deprived setting. We also discussed the role of the focused care worker, the difference in their role between a social prescriber/community advisor and the impact they have had on patients in the practice. We learnt about the Manchester GP training scheme and how they are integrating opportunities to learn about health inequalities into training from medical school to post CCT. We were also treated to some delicious home-made soup for lunch, made from the produce from the practice’s vegetable garden that is run by their patients.

It was really helpful to speak to Lisa, the focussed care worker, about her job. Having watched “Frontline Care: Saving the NHS?” a program shown earlier in the year on ITV covering what work they do, and having heard about their role at the Health Inequalities conference in Glasgow, it was interesting to hear about practical aspects of how the role works such as what training they have and how they are supported. There seems to be a  number of advantages of this role compared to the role of a social prescriber. Social prescribing seems very concentrated on supporting through signposting whereas focussed care seems to have the scope to go one step further than this e.g. taking patients to appointments, filling in forms, organising transport, attending and running community projects within the practice for patients to get involved in. I can think of many patients I see in surgery with complex physical and social problems that I feel could benefit from a member like this in the practice team.

The discussion from the GPs who had developed the group was also very interesting. Having heard Laura speak at a Next Generation GP lecture previously I was aware of the amazing story of how they started and developed. We learnt more about the difficulties they had faced and how they had approached tackling them. Focussing on the right staff in the practice seemed critical. They demonstrated an increase in smear uptake by 50% over 5 years through improving access to appointments, ensuring all members of clinical staff were trained in smears and the encouragement of opportunistic smears. We have a lower percentage uptake of screening in our more deprived branch surgeries and the discussion offered some interesting ideas as how we could approach this as a practice that I will feed back.

Date of visit – 22nd February 2019

Dr Katie Burgass

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The Exceptional Potential of General Practice Conference- Glasgow- 14-15th February 2019- Dr Helen Barclay

This conference had a collection of truly inspiring speakers and I learned a lot. I’m not sure that this is reflected in the notes I made, as I was often too engrossed to really write down that much – but below are the things that I did jot down about the two days. The first day was more theoretical, talking about the potential of GP to effect change, and also about the life and work of Julian Tudor-Hart, who was a dedicated GP to a practice in rural Wales, a very deprived area, and whose work contributed enormously to the body of evidence about health inequalities and about the benefits of continuity of care, and who is most celebrated for his work on the Inverse Care Law.

Day 1 Learning points:

The life of Julian Tudor Hart and his development of GP mixing research and patient care in rural Wales.
The inverse care law is inextricably linked to the marketisation of healthcare.
Deep End GP as an evolving concept and the development of the subspeciality in Glasgow.
The history of socialism in medicine. The development of the NHS and the GP role in shaping it over the last 60 years. Late to agree to it but soon took it on. Partnerships, CCGs, alternative models of GP provision. Encroaching privatisation, marketisation of healthcare, bringing technology into GP.
Talking informally to retired GPs and academic GPs about activism and advocacy, service development and effecting change – focussing on preparing for the future.

Reflections from Day 1:

GPs are uniquely placed to effect change in patients’ lives and improve health and social inequalities.
It is a privilege to do our job and advocating for our patients is essential part of this. Looking to develop practical services is something that actually any GP can do, effecting change is possible if you take the opportunity and just “have a go”, but it’s vital to plan for the future and engage younger generations with this.
I will try to observe patterns in my patients and look for areas that I can improve options available for reducing inequality and improving long term health outcomes (taking inspiration from Julian Tudor Hart’s longitudinal study of CVD risk factors in his community).
This session also cemented for me the importance of continuity, for patient and doctor satisfaction and for clinical efficacy. The doctor-patient relationship can be therapeutic and this is actually a really important aspect, expecially working in inclusion healthcare. Trust is a vital part of this and cannot always be transferred between doctors, it may be personal to the individual doctor.

Learning points from day 2:

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The Exceptional Potential of GP Conference day 2 (915am – 430pm) This day focussed on what different areas are doing to try to encourage people to work in deep end GP and to give them ideas on how to improve health inequalities.
Northern Dublin training scheme – Austin O Carroll – the most popular GP training scheme in Ireland. GPs tend to stay in the areas that they trained – so we need more trainers in deprived areas.
Yorkshire – the Trailblazer scheme!
Pioneer scheme in Scotland- more structured development time than in the Trailblazer scheme but it’s also longer – 2 years rather than 1 year. Good feedback.
Govan SHIP – excellent multifaceted project with really good outcomes.
Hilltop Surgery in Oldham – Focussed Care workers and the importance of trying to achieve QOF vs making your patients invisible.
Gent, Belgium – the importance of family medicine the community and looking at community assets e.g playgrounds – huge social effect.
The importance of continuity of care, being alongside our patients rather than above them.

Reflection from day 2:

This day focussed on different approaches to realising the exceptional potential of GP rather than the academic background and was inspiring. As a result I’m hoping to become a GP trainer (in a few years) and I have seen the importance of GP networks in pushing for better services, achieving better outcomes and innovative solutions to problems that you just don’t get in posher areas! Coming together and sharing ideas makes a huge difference and seeing how much has been achieved since I last went to a deep end conference a few years ago is incredible. I left the conference inspired and motivated to make changes wherever I can, and to try to help make a West Yorkshire Deep End group this year to share ideas and meet people doing the same kind of thing as us.

Overall it was a very informative conference, the opportunity to hear experts from so many different areas of excellence was incredible and inspiring, and I have taken home with me a renewed enthusiasm and passion for my work – and a recognition that the way many people can achieve such great results is through making the most of connections, networks, peer support and sharing ideas, so that we can inspire each other to keep our passion for the job and make a difference to our patients.

Dr Helen Barclay

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The Exceptional Potential of General Practice Conference- Glasgow- 14-15th February 2019- Dr Mat Fortnam

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The event was highly informative and again had a big influence on my thinking. My previous knowledge of the inverse care law, of the availability of good healthcare being inversely related to the need of the population, was not only enriched but also added to, by the inspirational stories I heard from impassioned every day GP’s who are providing invaluable primary care services to those who most need it. Funding and deprivation is a concept nobody is able to separate with ease and social changes partly secondary to industrial decline, the lack of affordable housing, the rising cost of living and welfare reform are just some of the reasons why socioeconomic deprivation is strongly linked with adverse health outcomes, such as mortality rates. Those brought up in Kensington, a deprived area just east of Liverpool city centre, face a life expectancy of around 15 years less than their Kensington counterparts in West London.

The key message from the conference was that there is action that those working in primary care can achieve. The life of Tudor Hart, a GP who dedicated his life serving a working class mining community in South Wales, demonstrated that the health of the community can be improved by engaging them, allowing them to co-design services, using patient as teachers and educators for the next generation and understanding the concept of holistic wellbeing as paramount for longevity.

Another key to this concept was continuity. One of the major drawbacks of working at scale is a perceived reduction in continuity. As a clinician I feel strongly about my continuing support to a community of individuals, but I understand to provide equitable access, continuity can not always be guaranteed. The patients I meet on a daily basis still yearn for the ‘good old days’ of continuity with the same GP that treated them as a child. I think when dealing with patients of deprived communities this continuity is pivotal, as it allows the clinician to understand them as a whole much more readily as they have built a ready made socioeconomic story for the patient that sits in front of them, so they can view their perception of illness through a different lens. The difficulty with sporadic, single encounter visits is that the patients story and journey gets lost and there may be trends to underplay or overplay the patient’s symptoms which may lead to under or over investigation. I think in my practice I can certainly appreciate the value I have found when working in the more deprived practice in the group to develop a rapport and understanding of the patient’s social circumstances, which of course if paramount in all consultations, but arguably even more important in this context.

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The concept of the Deep End GP, is a notion of the the Gp’s who work in the most deprived practices in a particular region, and is a movement founded in Glasgow by pioneer GP’s who recognised the common struggles and challenges that working in those areas brought and how by working collaboratively, workplace satisfaction improved, improvements via innovation could be achieved and support could be garnered by sharing each other’s experiences. We learnt regarding the Deep End movement had inspired new movements to spring up in Ireland and in Yorkshire and how these movements reflected the similar goal serving a different population with different socioeconomic factors at play.

From a similar project in Manchester I learnt regarding Hope citadel, a community interest health care company that was started as a GP surgery by a medical student prior to qualification. The movement has now spread and they won multiple contracts across the city with a common message to the commissioners that reducing health inequality is part of their MO. One such innovation of working closely with a link worker embedded in the community and employed by the practice has actually seen the reversal of unemployment trends – an incredible feat of the magic of general practice. This was reflected again by the learning from Tower Hamlets of how using data at a large scale can contribute to improving the health of a deprived community, with the highest QOF attaining region in London being the most deprived, due to the ability to capture quality with big data.

Dr Mathew Fortnam

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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

Categories
Trailblazer GP Blogs

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