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Trailblazer GP Blogs

Project 6 Visit Sheffield

Session ran by Jan Mayor, Waypoint 

Blog write up by Dr Saira Khan

13th September 2019

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

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

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

  • AA originated in America. 
  • SMART stands for Self Management and Recovery Training 
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SMART uses a ‘four-point programme’. These four points include:

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

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

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

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

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

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

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

“I’m not fixed and you’re not broken”

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

Freedom programme

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

Weekly timetable for alcohol recovery community (right) 

Patient Experiences

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

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

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

He stated:- “Define what normal is.”

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

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

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

Five ways to well-being

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Trailblazer GP Blogs

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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New Wortley Community Centre and Practice visit

Learning points: The day encompassed a practice visit to New Wortley, a deprived region in South East Leeds, which bordered Armley to the West, and Holbeck to the East. The work of the former GP partner, Dr Andy Sixsmith had focused on the importance of the GP practice in the community, as a safe place to go to obtain advice, help and treatment. With funding obtained, a new community centre was built next to the medical practice with the idea that residents of the community could benefit from the symbiotic relationship between the GP practice and the community centre, with the sense that if the overall wellbeing of the community could be improved, this would have a positive impact on the health of the community as a whole and thus even reduce GP attendance and workload. The notion of the popularity of social prescribing is a newer construct, but in reality, attempts like these to connect health to the heartbeat of the community have been commonplace in pockets of the country for a number of years. We first met the community link worker and social worker, who helped staff the community centre, and John Battle, a retired MP for Armley who ran the men’s walking club, a permanent Friday fixture for men suffering mental health problems or isolation. This then led to meeting the practice community link worker and the PEP worker (Patient empowerment Project) who worked for the local practice federation as a type of social prescriber. These highlighted the large scope of her work for those requiring extra support with finance, housing or mental wellbeing, with 90 minute appointments and two follow up appointments being offered. We also met two members off the executive board from Community Links, a mental health charity commission by the CCG with a brief of providing support via social prescribing, who are now opening wellbeing cafés as a drop in service for people experiencing mental health problems to talk about their problems. The day as a whole was a really rewarding experience, and demonstrated the power and importance of community activation within a patient population to help improve long term health outcomes.

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Reflection The impact of the day shaped my thinking of how in the future I would like to be involved in shaping services to reflect meaningful wellbeing provision to the local community. It built on my previous meetings with social prescribing hubs to realise the importance of not just working with supplementary services, but utilising them within teams. At future practice meetings and pending involvement at partnership level, my vision would be one of utilising link workers directly employed by a practice group or federation to cover a patient population, rather than as a separate organisation. The day also invigorated my sense of serving a local population as a community practitioner and allowed me to think of ways I could do something on a local level – for instance, setting up walking groups. Following the day, I have signposted more patients to social prescribing groups and projects than I previously had done in the past so I think the day has impacted my practice and will continue to do so.

Date of visit- 5th April 2019

Dr Mathew Fortnam

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Social Prescribing Visit- Connect Well

Learning points As part of my trailblazer role, I met with the local operations manager of the local social prescribing service, Connect Well. The purpose of the meeting was to forge a good working relationship which may benefit us mutually in the future. This would hopefully improve my understanding and knowledge of the service and also to help inform the service of potential areas for service improvement regarding increasing their visibility in primary care and maximising utility. I learnt primarily about the scope of the service locally which enabled me to consider how I may be able to incorporate their service into my management. I commonly encounter patients where medical problems exist, but their overriding difficulties may well be based within a social problem or context.

From experience trying to separate interpersonal and social problems from a patient’s presentation is rarely productive and I increasingly viewing patients through a different lens of establishing their presentation on a continuum of wellbeing  and fulfilment and explaining their routes to recovery, rather than focusing on curative outcomes. I learnt specifically that the service not only exists to help patients with difficulties with housing, finances, benefits and support but provides a holistic service to help patients with specific interests and to engage them back into social interaction to improve their mental wellbeing. Specific examples included tailored groups which were available in the Hull area, such as Andy’s Man Club, a group for men with mental health problems to meet once a week and share stories to gain collective strength, or Men in Sheds, a group for isolated males who want to reconnect and learn new skills, walking groups, park runs, new mum groups, breastfeeding support, community centres, voluntary groups to help people back into work, groups tailored to particular ethnic minorities to find friends and support and lots more.

We then talked about how me may be able to help improve the utilisation of the service with the consideration of how to increase referral rates when GP time is pressed.

I agreed that i would help organise educational meetings at the practice to widen the knowledge base and understanding of the service, whilst I have also help organise the team to perform sessions for the local VTS scheme to increase understanding of the registrars of the services the social prescribing team offer and how to access their services.

Reflection The meeting has not only reinforced my knowledge and understanding of the positive benefits of social prescribing but has allowed me to think about patient care in a different way and I have since been more open in talking about the possible options for patients which don’t necessarily involve medical investigation or treatment. Recently I have been able to signpost myself to some of the above services and groups but I also was able to refer a patient to the service who was increasingly lonely and nervous about getting out of the house unaccompanied. We were able to sort a visiting service which meant he could go for a walk with a regular visitor and have a friendly chat over a coffee which really improved his symptoms of anxiety.

Date of visit: 22 March 2019
Dr Mathew Fortnam

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Social Prescribing Visit

Bassetlaw Community and Voluntary Services

I met with Allison Palmer, the partnership officer and one of the community advisors at Bassetlaw Community and Voluntary Services (BCVS). She told me about the service that had been running for the last 45 years and was seen as a “hub” for voluntary services in the local area. In the last 3-4 years they have developed the social prescribing and community advisor roles with funding from the Bassetlaw CCG.

The social prescribing role is for those aged 65 years and over that are felt to need  more social input, most commonly due to loneliness and lack of community involvement. They are required to be referred by healthcare professionals and start with an initial 2 hour visit at home where their needs are assessed. Following this they are supported for 12 weeks in accessing the services they have been signposted to, they are given transport costs and chaperoned for their first 1-2 visits to help build confidence. They are then followed up 12 weeks after the input has ended and assessed in terms of ongoing engagement but also impact on GP/A&E attendances. On evaluation 2/3rds of those who have gone through the program have remained engaged with the services they were encouraged to attend.

In contrast the community advisor role is for anyone under the age of 65 years and can accept self-referrals. They can do assessments on the phone or meet for a face to face appointment and run a morning drop in session at a number of our surgeries. They are mostly involved in signposting to groups but can help make the initial email / phone call to encourage engagement. The level of support isn’t as great as the social prescribing group but they feel the age cut off will drop due to the governments new 10 year plan.

BCVS also runs Bassetlaw health, a website with information on 75 voluntary sector groups in the local area. They monitor which subjects are searched for to tailor the service to the community’s needs.

A few weeks after my initial trip to BCVS I attended 2 visits with Sarah, one of the social prescribers, to see how they performed their initial assessments. She enquired about subjects such as mental and physical health, finances, social support and engagement and safety in the home. During the two visits she was able to offer a wide range of different support recommendations including bereavement counselling, a car service, support with benefits, gym membership, silver line (a telephone service for older people) and a support group for those with reduced vision. It was really helpful to accompany a visit and see the broad range of services that could be offered. 

I found it really useful going to speak to Allison and her team about what BCVS do. I have often given out the leaflet for using the community advisor service for patients but often wondered whether they would actually engage with the service. Now I know more about it I feel I could “sell” the service better to patients. I wasn’t aware of the social prescribing or Bassetlaw health website which are two really useful resources I will definitely use within practice. It was also interesting comparing what services we have here to those in other areas e.g. the Hope Citadel Focussed care workers. Alison discussed her vision of integrating a well-being centre into the hospital to try and engage those requiring help at secondary care level also which I thought was a brilliant idea.

I presented this information to the Trailblazers at a later session where we discussed and compared the different ranges of social prescribing that was available in out different areas. It was interesting comparing what was available and there was significant variation in who was able to access what depending on where you lived. We discussed the importance of linking the voluntary sector with the health sector as it is often the communication channels that are lacking, and how the new primary care networks may be able to help with this in the future.

Date of visit: 15th March 2019

Dr Katie Burgass

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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