Month: October 2018

This is Bad Enough

This is bad enough
So please …

Don’t give me
gobbledegook.

Don’t give me
pages and dense pages
and
“this leaflet aims to explain … ”

Don’t give me
really dodgy photocopying
and
“DO NOT REMOVE
FOR REFERENCE ONLY.”

Don’t give me
“drafted in collaboration with
a multi-disciplinary stakeholder partnership
consultation
short-life project working group.”
I mean is this about
you guys
or me?

This is hard enough
So please:

Don’t leave me
oddly none the wiser or
listening till my eyes are
glazing over.

Don’t leave me
wondering what on earth that was about,
feeling like it’s rude to ask
or consenting to goodness knows what.

Don’t leave me
lost in another language
adrift in bad translation.

Don’t leave me
chucking it in the bin.

Don’t leave me
leaving in the state I’m in.

Don’t leave me
feeling even more clueless
than I did before any of this
happened.

This is tough enough
So please:

Make it relevant,
understandable –
or reasonably
readable
at least.

Why not put in
pictures
or sketches,
or something to
guide me through?

I mean how hard can it be
for the people
who are steeped in this stuff
to keep it up-to-date?

And you know what I’d appreciate?
A little time to take it in
a little time to show them at home
a little time to ask “What’s that?”
a little time to talk on the phone.

So give us
the clarity, right from the start
the contacts, there at the end.

Give us the info
you know we need to know.
Show us the facts,
some figures
And don’t forget our feelings.

Because this is bad
and hard
and tough enough
so please speak
like a human
make it better
not worse.

by Elspeth Murray

Link workers and Realistic Medicine

My last post was a poem that really struck me. I’ve been wondering why, and I think it was because it articulates the need for help to be practical, to be real, and to have relevance and credibility for the person accessing that help. Just wanting to help, wanting to be useful, is not the full story.

What attributes would an effective link worker have? They’d have to be comfortable around people, good at connecting with professionals, community groups, officialdom and patients. They’d be able to gain trust, and then walk alongside people who may be disempowered in the face of the clinical professions, enabling communication. They’d need to be enquiring, able to find out and keep in contact with key people within organisations, to understand how to get the best from them. They would be able to understand the needs of each person that they support, and advocate for those needs to be met.

What evidence do we have that individuals need this kind of support?

% who can ask

We know there is a gap, data tells us that even though patients tell us they could raise questions in a consultation, in reality, this doesn’t always happen. For 10% of patients, they know they won’t ask if they don’t understand. For a further third, they think they could ask, but in reality they don’t. It is those with the least health literacy that need this support the most, otherwise realistic medicine is going to be beyond their grasp.

The new GP contract includes an aspiration for employing link workers so that every General Practice has access to a link worker, and that link worker can work with patients without need for a separate referral. It remains to be seen whether the people that need this support the most get the most access.

So, it seems to me that our link workers could be powerful allies for patients, decoding the language that is already building up around the concepts of Realistic Medicine, and keeping it basic, keeping it real, and keeping the patient at the heart of our consultations.

We don’t have a link worker identified in our area yet, but she or he will be on the project team.

Liason Coordinator

With thanks to Dr Duffy, who shared this with me and with whom I have done a practice exchange – I worked for her last week in the Peat Road Medical Practice, which was a great experience. I’ll blog more about this later.

By Tom Leonard, from Ghostie Men

efturryd geenuz iz speel
iboot whut wuz right
nwhut wuz rang
boot this nthat
nthi nix thing

a sayzti thi bloke
nwhut izzit yi caw
yir joab jimmy

am a liason co-ordinator
hi says oh good ah sayz
a liason co-ordinator

Just what this erria needs
whut way aw thi unimploymint 
inaw thi bevvyin
nthi boayz runnin amock
nthi hoossyz fawnty bits
nthi wummin n tranquilisers
it last thiv sent uz
a liason co-ordinator

sumdy wia digree
in fuck knows whut
getn peyd fur no known 
whut thi fuck ti day way it

I must add – the social interventions from this practice were nothing like this. It was joined up, aimed at getting the best from available resources, ensuring people got the best help from the right people.

I’m already thinking of going back…

Poetry as a way of seeing another perspective, in carefully chosen words.

Precious 10 minutes

The GP stands at the door of his room,
shakes my hand, asks me how I am.
I always smile and say fine, except for…
this niggling problem
or I’m just here for a checkup
or a repeat prescription
or something.
He listens.
He’s a cautious man,
gets me tested
just in case: ‘Let’s be sure.’
He sounds me out about an ongoing condition:
if I can live with it
he can live with it.
‘As long as you can do the things
you want to do.’
He knows I’m a worrier.
I don’t feel rushed.
It’s a conversation.
It all seems as it should be.
Hamish Whyte



	


	
	






	
	

		
Health inequalities in Rural Scotland
	


	

		

I wrote this essay after attending a discussion about health inequalities in Scotland. It isn’t directly about Realistic Medicine, but it sets the background.





INTRODUCTION:





17% of Scotland’s people live in remote and rural areas, nearly a million people, double the population of Edinburgh. (1, 2). They live in one of the most beautiful places on the planet, with one of the lowest population densities in Europe. All of them have a right to be registered with a GP and have access to healthcare that is safe, effective, person-centred, equitable, timely and efficient, as outlined in the Chief Medical Officer’s annual reports. (3)





However, the current challenges facing remote and rural health care teams are barriers to meeting these aspirations. Existing good practice seems to be undervalued, and the principles of the new Scottish GP contract do not seem appropriate for very small and remote clinical teams.





CONTEXT AND BACKGROUND:





We have a shortage of GPs in Scotland, with many areas reporting longstanding and significant levels of vacancies. With shrinking clinical teams, it becomes harder to deliver the additional extras, the enhanced services that were a feature of the previous GP contract; enhanced service contracts became the mechanism for encouraging GP practices to take on additional work for additional income. Increasingly, GPs across the UK have been concerned about secondary care work being shifted out into primary care without adequate funding or support.





In response, the new Scottish GP contract has pared back the requirement for GPs to undertake non-core services, so that they can focus on the core work of providing primary medical services. At the same time, some of the clinical work currently done by GPs could be done by others, such as physiotherapists, pharmacists, psychiatric nurses and others, and the new contract asks health boards to change to this model.





In our rural practices, with small numbers of patients scattered over wide areas, GP practices have been the only realistic option for providing health care services without travelling huge distances. Small teams based round one or two GPs have provided a very wide range of services, taking on additional roles to provide a holistic service. Recruitment, retention, and support appropriate to the area would sustain services.





The rural GPs that I know are proud of the excellent services they can provide to their communities. Being a member of such a community means that rural GPs identify very highly with their patients, their difficulties and aspirations. They are advocates for local health services, with a deep knowledge and understanding of the local population. There is a strong culture of stewardship, of using the resources of the NHS wisely and appropriately for the best outcomes. Rural General Practice has been delivering Realistic Medicine for many years before it was branded and marketed by the Chief Medical Officer for Scotland.





Published data shows that Scotland’s rural areas have a static and unacceptably high level of fuel poverty, (4) with nearly two fifths of residents needing to spend more than 10% of their income to heat one room of their homes to safe levels. Fuel poverty is associated with worse health outcomes.





Populations are older too. In the Western Isles, for example, a quarter of the population is over 65, retired, less economically active, and this number is set to rise to over a third in the next fifteen to twenty years. Older populations have higher rates of multi-morbidity, cancer, falls and frailty, with complex health and social care needs.





Within the last year, the new contract for primary care in Scotland has been voted on and implemented. It has been a radical revision of the way that medical services are provide out with hospitals, aiming to address the shortfall of GPs by increasing access to other healthcare professionals in the context of multidisciplinary teams.





It has come with a new allocation formula, claiming to improve funding for teams providing care for older patients, and improving funding to practices where GP income is low.





THE NEW CONTRACT – DOES IT ADDRESS HEALTH INEQUALITY AND GP RETENTION AND RECRUITMENT?





The new contract has left many rural GPs feeling devalued and disheartened. Their professional raison d’etre has been to provide a holistic service, going the extra distance to ensure that care can be delivered by clinicians who know their patients well, delivered by teams that are stable and supportive.





By breaking these teams up, telling GPs that their enhanced services are no longer required, whilst parachuting in a number of peripatetic staff each working one session a week in each of multiple practices, this all feels like a betrayal. The contract does not value the extended services that make rural practice so effective in delivering rural Realistic Medicine.





While no practice in Scotland will receive less money initially, the Scottish Allocation Formula makes it clear that some practices are more deserving than others. In rural practices and in ‘deep end’ practices, there is little in the way of hope of an uplift. The formula does not  recognise adequately the additional costs of running a rural service, the cost of addressing the health needs of rural poverty, of fuel poverty, the personal health and financial cost of travel to care, or the additional costs of professional training and networking.





The striking map below illustrates where practices are getting an uplift in funding in green dots. It was put together by Dr G Wheeler, North Uist Medical Practice, from data from the Scottish Government. (5)





the right map





At the same time, the impact of other policies is still being felt. Scotland’s broadband and mobile phone networks were designed to reach the majority, rather than the populations that needed them most. Even though broadband roll-out has been trumpeted widely, on the ground in rural areas, the infrastructure is incomplete. Rural practices still don’t have access to new data-collection systems, and wifi is still limiting participation from remote areas.





The new contract does not address rural health inequality and may be contributing to reduced retention. The allocation formula does not address the additional costs of providing health care in rural areas, the need to provide care to small and isolated populations all day every day, the need to provide realistic care in the case of widespread multimorbidity. If a multidisciplinary team is led by a GP now, expanding the team by adding fractions of WTE staff to many practices, makes co-ordinating that team more complex, without solving the recruitment needs.





The new contract in rural areas might mean many more clinical staff each offering only a tenth of a whole time equivalent each, never meeting to form a team. Accommodation for small rural teams doesn’t include space for expanded teams, and there seems to be no plan to address this.





The new contract does not seem to address deep-end health inequality either; their patients suffer from multimorbidity at an earlier age, before funding catches up. Their barriers to engagement and access may be societal rather than geographical, but poverty in both settings makes it harder to overcome those barriers.





The new contract cannot be accommodated easily in rural practice, and many practices feel they stand to lose much of the work that they held in highest value, the ability to go further to address clinical need and provide patient centred care in patients’ own homes and communities.





CONCLUSION





Addressing health inequalities in Remote and Rural, and in Deep-end practices should not be an afterthought. Bolting on solutions after the fact doesn’t seem secure. Is Rural Health Care really an additional extra?





Health policy should address the needs of the most vulnerable people in our country. Addressing the challenges first means that provision is fit for all, not just for the central belt. This ‘Rural First, Deep-end first’ approach is appropriate in many ways, from consultation, to creating policy and developing infrastructure.





Consultation for hard-to-reach areas needs to be more enquiring, more inclusive, more investigative. Relying on representatives means that only the views of a politically minded few are heard. Most GPs are in the service to provide health care, and as our ranks are depleted, fewer and fewer find time to get engaged in political lobbying and research.





Scotland sets itself out as a country where the Government listens to GPs, a country where it is the best place in Britain to be a GP. For those GPs who are working in the poorest, most deprived, most rural, most remote areas, these aspirations are not yet being met. Whatever we set out for the people of Scotland, it should work as well for the people of Barra, as for Barrhead and Bearsden.





REFERENCES:





  1. http://www.gov.scot/Publications/2018/03/6040/5 (accessed 06.06.2018)
  2. http://www.gov.scot/Publications/2011/09/29133747/2 (accessed 06.06.2018)
  3. http://www.gov.scot/Publications/2018/04/4249/0 (accessed 06.06.2018)
  4. https://www.eas.org.uk/en/fuel-poverty-overview_50439/ (accessed 14.10.2018)
  5. http://ruralgp.com/2017/12/mapping-out-the-proposed-scottish-gpcontract-allocation-formula/ (Accessed 15/10/2018)

	


	
	






	
	

		
Another list
	


	

		
I do like a list. I’m also partial to spreadsheets. This is a list of things to blog about, in no particular order. .


    

  • 

      

    • Why Realistic Medicine is so important to me
      • 

    • Realistic Medicine – why call it that
      • 

    • My project Charter
      • 

    • Who should I have on my project team?
      • 

    • Scottish Health Council
      • 

    • Twitter
      • 

    • My practice exchange
      • 

    • Continuity of care
      • 

    • A driver diagram
      • 

    • ‘It is the patient stories that I remember, that are my most powerful inspiration.’
      • 

    • The House of Care
      • 

    • Finding Patient Leaders
      • 

    • A review of the PBSGL module
      • 

    

    • 



 

	


	
	






	
	

		
Patients and quality in health care – co-production at scale.
	


	

		
If you type patients, quality and care into google, the results suggest that this is something that we do for and to patients. Discussions about change agents take me to pages about how to engage clinicians within the healthcare system, but nothing directly about patients as systematic change agents.


I want to flip this on it’s head, and inspire patients to shape the health service, seeking provision that meets what matters to them. A 180 degree revolution. Clearly, there needs to be some strategy, some oversight from health care providers, so that those with greatest need don’t lose out to those with the strongest lobby. Both parties are required to create the service.


The current term for this process is co-production. On a personal level, working as a GP, this is our bread-and-butter. An effective consultation supports the patient with diagnosis, providing information, management choices, and opportunities to meet again to discuss progress.


While I was looking for articles about patients as change agents, I came across the concept of the Patient Activation Measure, a tool to assess how ready patients were to engage in these discussions. The tool is used on an individual, case-by-case level, where the doctor-patient relationship and the problem to be managed is the scope of the co-production. How could we lift this to a more strategic level? Could we use the Patient Activation Measure to see how successful systemic change is in increasing the number of patients able to use the tools of realistic medicine, able to develop that agenda with the clinicians they meet?


As a GP partner in Scotland, I am responsible for ensuring that our practice systematically provides safe appropriate patient-centred care. We provide opportunities for patients to feed back to us about their experience of healthcare, and give us suggestions about improvements. These tend to be about small things – how comfortable our seating is, whether we should have Radio 2 or another station in the waiting area.


Nationally, Care Opinion collects patient feedback, enables organisations to respond and reply, as well as being searchable. But this doesn’t of itself, change the relationship between clinicians and the public. Much of the positive feedback includes stories about care where the principles of Realistic Medicine has been at the heart of care. Within this movement, I feel I am getting closer to system-wide patient-led quality improvement.


The place where I feel this project really sits is as part of the House of Care. I seem to be trying to create an environment in which the left-hand wall is nurtured. Imagine a house which has, at it’s centre, conversations about care, support, realistic medicine. The foundation and floor is the social context, all of the sources of support in a community. The roof, sheltering this all, is the system and processes that bring the patient and clinician together. The conversation has on one side, individuals ready to engage in a therapeutic dialogue, and on the other, clinicians who are committed to partnership working with patients.


House of care


So far, most of the Realistic Medicine discussions that I have been involved in have focused on the clinicians, the ‘right-hand wall’, and on the roof. However, we could possibly be talking only to each other, unless we have individuals and carers that are speaking the same language, individuals and carers who can start these conversations spontaneously.


This model allows for work at local, regional and national scale. The British Heart Foundation has just published a report on a three-year project that used the House of Care Model in five health communities. The report describes how patients were involved in championing this approach, how important an enabling infrastructure is, how to flex the model to fit local need, and the importance of culture before paperwork.


I’m feeling inspired.


References (accessed on 11/10/2018):



 

	


	
	






	
	

		
Hebridean glitches
	


	

		
Today I was going to meet up with Carmen Morrison from the Western Isles branch of the Scottish Health Council. She was also planning to get to Barra for a meeting, and because of the Autumnal Gales, the meeting didn’t happen – the Sound of Barra is not very nice in a storm.


Carmen was involved in drafting the SHC’s report on Realistic Medicine and has a lot of experience when it comes to involving the public. I shall have to pick a day when it is not stormy for our next planned meeting.

	


	
	






	
	

		
Who was Warner Slack?
	


	

		
Subtitle: Why communication technology matters.


I read last week’s BMJ obituaries, as I often do. (read the article HERE) The main tribute reflected on the work of Dr Warner Slack, who believed that ‘the patient is the largest and least utilised resource in healthcare’.


As I read further, I was astonished at the foresight of his vision. In the 1970s, with others, he set up the Center for Clinical Computing at Harvard, and created one of the earliest hospital information systems. He wrote much about clinicians and information technology, but the area I wish to focus on today is his vision of patient-clinician partnership, enabled by Information Technology.


Dr Slack trusted the agency of patients to use automation for their benefit decades ahead of his time. His underlying inspiration was that computing and information technology would empower clinicians and patients. He wrote about online patient communities, now a reality, with websites such as Patients like me and Smart Patients empowering patients to find out from others about the experience of their conditions, and the reality of treatment choices.


He also believed that patients should have access to their digital records, and now we have the OPEN NOTES movement.


I believe that patients need time to understand what we have told them, have the right to consider what we have recorded in their notes, and to consider the implications of their condition and the treatments that they are choosing between. This access, alongside health literacy, means that patients are on the therapeutic team for their own care.


I’ve had a look at the Primary Care Digital Services analysis of what we are working towards, and patient access to their clinical notes has been classified as High Input, Low Impact, meaning that it will be low down on the list of projects being progressed. I know that this is already part of the English GP contract, so it can be done.  This week’s mission: to find out whether this access is coming across Scotland, across the Western Isles, and on Benbecula.


Also, to link the blog to the practice website and the practice patient participation facebook page. (Done)


I’m inspired by Dr Slack, whose ideas are so relevant to Realising Realistic Medicine.

	


	
	






	
	

		
An ode from Horace
	


	

		
Ode I. 11


HORACE

TRANSLATED BY BURTON RAFFEL


Leucon, no one’s allowed to know his fate,


Not you, not me: don’t ask, don’t hunt for answers


In tea leaves or palms. Be patient with whatever comes.


This could be our last winter, it could be many


More, pounding the Tuscan Sea on these rocks:


Do what you must, be wise, cut your vines


And forget about hope. Time goes running, even


As we talk. Take the present, the future’s no one’s affair.