1. Dr Tom Ratcliffe GP Tutor (Curriculum)
Social accountability, Health Inequity & Community Orientation Autumn School 2017
Dr Tom Ratcliffe
GP Tutor (Curriculum)
Materials – community orientation competencies, get oriented print out for trainees, the arbor notes for GPRs and facilitators, multimorbidity exercise, community orientation competency sheet

2. Programme
Introductions Social accountability and community orientation Coffee Health inequity Lunch Social prescribing and the VCS Using the arts to get closer to our patients and communities Multi-morbidity Coffee Vulnerable groups Reflection and summing up

3. Introductions Who you are A little bit about where you work
What you hope to get from today
WRITE DOWN PEOPLES’ NAMES!

4. Aims
Understand how the concepts of social accountability, community orientation and health equity relate to postgraduate general practice training
Take away practical ideas for helping trainees develop the knowledge, skills and attitudes to address the needs of the communities in which they work, with a particular emphasis on addressing health inequities

5. Objectives - morning Social Accountability and community orientation
Review the concepts of social accountability, inequality and inequity and understand why these are relevant to GP training
Reflect on the changes to society and NHS general practice that make this a relevant subject today
Review the RCGP curriculum statements around community orientation
Health inequity
Know about the variation in health outcomes for different groups, including the epidemiology of multi-morbidity
List the knowledge, skills and attitudes that GPs need to tackle health inequity

6. Objectives - afternoon
Social prescribing and the VCS
Be aware of the findings of the GP at the Deep End movements, the role of inclusion healthcare providers, the resources available in the Voluntary and Charitable Sector and the concept of “social prescribing” within health and social care
Using the arts to get closer to our communities
Consider how we might help trainees learn about the communities in which they practice
discover some practical exercises and arts-based resources to help trainees develop the knowledge, skills and attitudes needed to work in socioeconomically deprived areas / with vulnerable groups
Multi-morbidity
Learn about an educational activity designed to help trainees learn about managing multi-morbidity in the community
Appreciate the role of the GP in ensuring universal healthcare is sustainable: MDT working and sustainable practice
Vulnerable groups
Know about the healthcare needs for specific vulnerable groups

7. Social accountability and community orientation
0945 to 1045
Debate, learn and then coffee!

8. Accountability Who to? Individuals Families Communities Societies
The World!
Decreasing emphasis in professional training and increasing problems with assessment / measurement

9. More unequal...

10. More diverse...

11. Older...

12. Changes in medical workforce
Older
More female
More diverse (increasing proportion of BME doctors)
More international graduates
UK medical students continue to be more likely to be from affluent areas / have parents with occupations classed as “professional”
As is the medical workforce
In other words, there is more likely to be a geographic, economic and cultural separation between patient and doctor
This can be disorientating
Where are we headed...?

13. A changed world...
Fortunate Man... Rural GP in 1960s Forest of Dean... See p 89, 98, 100, 101
The traditional GP was embedded in the community, would live among their patients and spend 30 years + delivering true cradle to grave care, sometimes 24 hours per day, doing most medicine (appendicectomies on the dining room table!)
Society has also changed...
Things have changed... GPs more likely to work part time, commonly do not live in the community they serve and out of hours services are centralised, plus care is so much more complex it is delivered by MDTs spanning primary, secondary and tertiary care
Note... The Fortunate Man committed suicide...
Society is now very different
Can we rely on community orientation to happen naturally?

14. https://www.channel4.com/news/by/jon-snow/blogs/mactaggart-lecture-edinburgh-2017 (0-3.47)
What started me thinking about this issue was a sense that people working in healthcare did not understand or sufficiently empathise with the lives of the people they are looking after... I couldn’t help think about the parallels with Jon Snow’s recent lecture regarding the media... Perhaps things aren’t quite so far gone, but direction travel similar... And perhaps given the changes in society and the way we are working, we need to redouble our efforts to remain orientated... Not to mention the fact that understanding our patients’ social context is essential for doing GP properly...
He is describing the world of the media – could he be describing medicine as well?

15. Social accountability: in education
WHO defines the social accountability of medical training as: “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region and/or nation that they have a mandate to serve”

16. Who said this?
“Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution”
These are not new ideas!

17. Community Orientation
Core capability within “Being a GP”
Assessed as part of WBPA (CBD)
Log entries linked by CS / ES
Rated NFD – Excellent in ES Report

18. Community Orientation Understand…
the need to build on community engagement and resilience;
the relationship between family and community-based interventions;
the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare;
the potentials and limitations of the community in which you work;
the community’s character in terms of socio-economic and health features; and
the negative influence of poor socio-economic status on health.

19. Capability: community orientation
GPs may need to take additional steps to understand the issues and barriers affecting their communities
As a GP you have an ethical and moral duty to influence health policy in the community and to work with patients and carers whose needs are not being met
Furthermore, you need to have an awareness of global health issues and to display a responsibility towards global sustainability, both as a citizen and in your professional role

20. Capability: community orientation
GPs may need to take additional steps to understand the issues and barriers affecting their communities
As a GP you have an ethical and moral duty to influence health policy in the community and to work with patients and carers whose needs are not being met
Furthermore, you need to have an awareness of global health issues and to display a responsibility towards global sustainability, both as a citizen and in your professional role

21. Capability: community orientation
GPs may need to take additional steps to understand the issues and barriers affecting their communities
As a GP you have an ethical and moral duty to influence health policy in the community and to work with patients and carers whose needs are not being met
Furthermore, you need to have an awareness of global health issues and to display a responsibility towards global sustainability, both as a citizen and in your professional role

22. Competences
See sheet
Turn to your neighbour – how do you cover this presently?
Can attitudes be taught?!

23. Big picture stuff...
How a community contributes to health and wellbeing and the GP’s role within it:
Proactive... ensuring care reflects need, enabling wellness, building community, finding the sickest
Reactive... understanding need, empathising, dealing with multi-morbidity / fragmented systems, practicing sustainably

24. Accountable care!
Gold plated service for one patient versus universal service... Nub of issue

25. Accountability Who to? Individuals Families Communities Societies
The World!
Decreasing emphasis in professional training and increasing problems with assessment / measurement
Focussing on defragmenting care and needs of individual?

26. Accountability Who to? Individuals Families Communities Societies
The World!
Decreasing emphasis in professional training and increasing problems with assessment / measurement
What about this?

28. Health inequity
1100 to 1200
RCGP curriculum puts this at the centre of community orientation

29. Life expectancy

30. 15y gap in Life expectancy and 20 yr gap in disability-free life expectancy
ONS - age variability in disability prevalence
22% of people in most affluent deciles have disability age 65-69
33.9% of people in least affluent deciles at same age
Or 20y difference in onset age
22% of people in most affluent deciles have disability age 65-69
33.9% of people in least affluent deciles at same age
The nub of the (likely) argument.
If the CCG are funding some primary care locally, one might argue there is an imperative for us to look at how we can ensure resources are targeted at those patients with the greatest need. Flat and inequitable funding can't be the answer given the differentials in need across deprivation deciles.
Any changes need to be mindful of the danger of destabilising other practice funding, this is always an issue in changing funding allocations.
There is a question on whether any funding formula locally (or nationally) derived should weight deprivation, and one of “how” best to do this.
Whether to weight for deprivation
There are two questions for stakeholders to consider.
Do the stakeholders agree that there should be a deprivation weighting given to any formula used to allocate resource.
The implications of weighting for deprivation may be poorer access and satisfaction in those practices that “loose” from any resource shift – is this OK for the population as a whole?
Stakeholders should consider and explicitly articulate the principles unpon which any allocation is made
15y gap in Life expectancy and 20 yr gap in disability-free life expectancy (DFLE) at birth, persons by neighbourhood income level, England,

31. Discussion Why might there be a gradient in health?
What (if anything) can we / should we do about it?
Outcome
Access to services
Exposure to risk
Social determinants
Determinants of determinants
Social processes
Power

32. Health and wellbeing not something that just happens in the GP surgery and wider NHS
It is a product of communities and societies

33. The lifecourse approach...
The review identified four broad themes in which action needs to be taken
The lifecourse – from before birth, through early years and education, employment, family building and at older ages.
In the wider society - social protection, vulnerability, minimum standards of living, gender equity, community engagement and empowerment, sustainable and equitable local environmental policies
The macro-level context - taxes and public spending priorities, , sutainable development plans
Systems to support a strategic approach to equity – local, regional and national partnership working, health care systems and transparent scrutiny of inequities and the strategies to address these.

34. Life-course pathway from early life origins to inequality in mortality mediated by smoking
Around half of the inequality in mortality due to smoking is due to early life events – directly or by making you more likely to smoke
Giesinger I, et al. J Epidemiol Community Health 2013

35. Inequality = worse wellbeing
“everyone wins when we pursue equality”

36. Local health outcomes Practice A Practice B CHD admissons * 128 108
Stroke admissions *
132 81
COPD admissions *
154 79
Cancer mortality <75y 95 69
CV mortality <75y
116 57
* Age standardised

37. Local determinants of health
Practice A
Practice B
Long term unemployment
7.1
1.8
Health eating
23.1
35.5
Obesity
25.5
19.7
Binge drinking
15.8
23.4
Alcohol related admissions
121 78

38. “Inequalities that are preventable by reasonable means are unfair”
NHS very good at delivering equality, probably the best in the world according to Commonwealth Fund
No healthcare system good at delivering equity

39. The Inverse Care Law
“The availability of good medical care tends to vary inversely with the need for it in the population served”
 (the difference between what ‘can’ be done and what  ‘could’ be done if care was adequately  resourced, according to need)
Equity v Equality
Ask to define
Mention Julian Tudor Hart
NHS good at equality, no so good at equity (but few systems are)

40. Discussion
What are the features of general practice that enable it to respond to health inequity?
What are the limitations of general practice in tackling health inequity?
Why is it useful for our trainees to understand the concepts of health inequity and the social determinants of health?
Evidence based healthcare

41. Features of general practice?
Unconditional
Personalised
Continuity of care
Provided for all patients
Whatever problems they present

42. Limitations of general practice?
Only one of many determinants
Resources
Limited capacity for changing behaviour
Access, universality and quality already high
Inequitable supply of primary care

43. Maslow’s hierarchy of needs

44. Healthcare IS a key social determinant of health
Healthcare can make a difference

45. BECAUSE THAT’S WHERE THE MONEY IS WILLIE SUTTON
QUESTION
WHY DO YOU ROB BANKS ?
ANSWER
BECAUSE THAT’S WHERE THE MONEY IS
WILLIE SUTTON
SLIDE 29
When asked why he robbed banks, Willie Sutton replied, “Because that’s where the money is”. Why the Deep End? Because that’s where the deprivation is.

46. This is where we should focus
Targetted secondary prevention = greatest area of potential

47. Inverse care law in GP
“The availability of good medical care tends to vary inversely with the need for it in the population served”

48. QOF
There is room for improvement

49. There is hope! Prof Clare Bambra shows the art of the possible..
HI closed after German unification

50. Why know about all of this?
Aids empathy and understanding to help us palliate the effects of social problems
Helps us understand what we can do as GPs and be realistic (appreciate the significant limitations)
Underpins healthcare delivered with humanity: “everyone is worthwhile”
Cold, hard economic considerations...
All very well knowing about this stuff but can we actually do anything? Is there anything we can change?
Removes blame from the individual
Helps us focus our limited resources and prevents us being too self critical – know what we cannot influence
Basic humanity

51. Role of healthcare
If you want to make healthcare sustainable and assume we are not going to abandon universal coverage...

52. Role of healthcare

53. Role of healthcare

54. Trainees want/need to know more...
103 GPSTs (1-3) from across Y&H
Vast majority thought knowing about health inequity, multi-morbidity and care of vulnerable groups is important for GPs
Learning needs they identified
43% did not feel they understood health problems affecting vulnerable groups
51% did not feel competent around communicating effectively with marginalised / vulnerable groups
50% did not understand the inverse care law and its impact on healthcare delivery
69% did not feel aware of local community groups working to tackle health inequalities
45% did not understand the role of GPs in policy-formation / commissioning / public health relating to health inequity (45%)
78% did not understand UK social security and benefits system
% disagreeing / strongly disagreement with competence in these areas

55. HEE doing their bit regionally...

56. The Deep End

57. GP at the Deep End Blog: www.yorkshiredeependgp.org
Paper: January 2017, BJGP…

58. Curriculum

60. Objectives - afternoon
Social prescribing and the VCS
Be aware of the findings of the GP at the Deep End movements, the role of inclusion healthcare providers, the resources available in the Voluntary and Charitable Sector and the concept of “social prescribing” within health and social care
Using the arts to get closer to our communities
Consider how we might help trainees learn about the communities in which they practice
discover some practical exercises and arts-based resources to help trainees develop the knowledge, skills and attitudes needed to work in socioeconomically deprived areas / with vulnerable groups
Multi-morbidity
Learn about an educational activity designed to help trainees learn about managing multi-morbidity in the community
Appreciate the role of the GP in ensuring universal healthcare is sustainable: MDT working and sustainable practice
Vulnerable groups
Know about the healthcare needs for specific vulnerable groups

61. Social prescribing and the VCS

62. Community orientation: your ideas?
Where could you send your GP trainees to learn more about the community?
When and how?
What other resources are there?

63. Getting out and about Job Centre / Magistrates Court / Social Services
Local newspapers / public transport timetables
Children’s centres – could you help with sessions?
Citizens Advice Bureau / Carers Resource
Food banks – where, how to refer, could you go along and meet some users?
Other VCS – more later...
Placement with services for vulnerable groups:
(list of learning objectives)
Get orientated handout

64. Social prescribing
What is it?

65. GPs and the VCS
4% of GP appointments might be dealt with through social prescribing / navigation
Making Time in Primary Care, NHSE 2015
Vital need to form stronger partnerships with charitable and voluntary sector organisations
VCS organisations have an impact well beyond what statutory services alone can provide
Better able to reach underserved groups
Source of advice for commissioners
5 Year Forward View, NHSE 2014
140 GP appts per week for GP in Keighley... One FTE GP

66. Building community
Loneliness (almost) as dangerous as smoking…

67. What is social prescribing?
A mechanism for linking patients with non-medical sources of support within the community
Provides healthcare professionals with a referral option that can operate alongside existing treatments to improve health and wellbeing
It is a type of social action

68. Levels of intervention
Signposting from GP surgery
Level 2
Referral from GP to VCS
Level 3
Referral involving social prescribing liaison service

69. Does it work? Scheme NHS utilisation Wellbeing scores Economic
Rotherham
20% reduction inpatient, A&E and outpatient use. Not statistically significant.
Yes % progress overall % with low scores at outset.
£1.41 to £3.38 return for each £1 invested after 5y (NHS costs)
Doncaster
GP visits reduced from 3.4 to 1.5 over 3m for cohort
Yes % agreement with outcome measures.
Not known
WellSpring (Bristol)
60% of cohort reduction in GP visits, 14% increase.
Yes. PHQ9, GAD7, Friendship scale for isolation, ONS wellbeing, perceived economic wellbeing, IPAQ
£2.90 per £1 invested (social return)
Rotherham wellbeing – feeling positive, lifestyle

70. Examples Focussed Care Greater Manchester Govan SHIP project
Embedded Focussed Care Workers
GSF type meetings across whole team
Caseload 20/practice
Govan SHIP project
Social worker and Link worker
Funding for increased GP consultation length
Leadership / development time for GPs
MDT meetings

71. CARE Plus prevents decline in QOL
SLIDE 40
After 6 months and a year, Quality of Life was higher in the intervention group, on the left, not so much because it improved in this group, but because it got worse in those not getting the intervention, on the right. The intervention slowed decline. That’s a crucial observation.
Mercer, S. W. et al. (2016) The Care Plus study – a whole system intervention to improve quality of life of primary care patents with multimorbidity in areas of high socio-economic deprivation :exploratory cluster randomised controlled trial and cost utility analysis. BMC Medicine, 14, 88. (doi: /s

72. THE COLLABORATION LADDER
Involving joint working between two potential partners
0 Never heard of each other
Have heard but have had no contact
Contact but no relationship
Relationship between named individuals
Joint review and planning
SLIDE 23
Two professionals might work in the same community. On the Collaboration Ladder, zero means they have never heard of each other; 1 they have heard of each other but have never met; 2, they’ve met but that’s it; 3, they work together haphazardly; 4, they sit round a table to review and plan joint work.

73. INVENTING THE WHEEL INTEGRATED CARE DEPENDS ON MULTIPLE RELATIONSHIPS
HUB
Contact
Coverage
Continuity
Comprehensive
Coordinated
Flexibility
Relationships
Trust
Leadership
SPOKES + RIMS
Keep Well
Child Health
Elderly
Mental Health
Addictions
Community Care
Secondary Care
Voluntary sector
Local Communities
SLIDE 22
The intrinsic features of general practice – patient contact, population coverage, continuity, flexibility, long term relationships and trust – are essential, they make general practice the natural hub of local health systems, but they are not sufficient. Links are needed to a host of other resources and services.
INTEGRATED CARE DEPENDS ON MULTIPLE RELATIONSHIPS

74. Access bus service
Active Wharfedale Walking Football
Age UK
Alzheimers Society
BIASAN
BMDC Blue Badge scheme
BMDC Housing Options
Bradford Bereavement Support
Bradford Resource Centre
British Heart Foundation
CAB
Carelinks Befriending
Carers’ resource
Champions Show the Way
Creative support
Cruse
DV & SV services Keighley/Bradford
Equality Together
Food poverty network
IAPT
Keighley community transport
Keighley furniture project
Keighley Leisure Centre
KHL
KIVCA/Central Hall events
KVC Handyman service
KVC Learning disabilities support
KVC volunteer opportunities
Luv2cu Bradford
MacMillan Cancer Support
Memory Tree
Mind
People First Keighley
Rally Round
Relate
Remploy
Roshni Ghar
Safe and Sound
Sight Airedale
Silverlinks Day care
Social Services
Specialist Autism Services
Stroke Group
The Silverline
U3A
Welcome Project
Wellbeing cafes
West Yorkshire Fire Service home safety team
Yorkshire Cat Rescue volunteer programme

75. What should your GPST know about local services?
Problem
Sources of support
Finance, debt and benefits
CAB, debt counselling charities
Substance misuse
SMS
Food shortage
Food banks, local places of worship
Isolation
“Befriending”, social groups, meal groups
Mental health & relationship problems
mywellbeingcollege, local charities, Relate
Pornography addiction
Online support
Homelessness
Emergency accommodation, housing associations, outreach services
Domestic violence
Refuge, support groups
Parenting skills
Children’s Centres

76. Inclusion health
Providers commissioned to serve specific groups at high risk of social exclusion: refugees and asylum seekers, homeless people, sex workers etc
Examples: Bevan House in Bradford, York Street in Leeds
An excellent source of support for you and your trainees

77. Using the arts to get closer to our patients and communities
Song, TV, film, books and your ideas?

78. Vulnerability The Arbor (2.51 to 4.51) *
An Inspector Calls (52 or 1.06)*
People of Nowhere*
Renee – case study
What is it that makes these people vulnerable?
What effect might this vulnerability have on their health and wellbeing?

79. TV / Film / Audio The Arbor The Death of Mr Lazarescu
An Inspector Calls
The Divide
Amnesty International
People of Nowhere
When you don’t exist
The Selfish Giant
Fish Tank
Ken Loach films…
I, Daniel Blake
Cathy Come Home

80. “You will never understand How it feels to live your life With no meaning or control And with nowhere left to go. You are amazed that they exist And they burn so bright, Whilst you can only wonder why.” Jarvis Cocker, Common People, 1995

81. The Arbor Introduction Watch whole film Post-it note exercise
Structured discussion in small groups

82. Don Berwick

83. Books The Health Gap (Michael Marmot)
The Road to Wigan Pier (George Orwell)
Working with vulnerable groups: a handbook for GPs (RCGP)
A Fortunate Man (John Berger)
The Citadel (AJ Cronin)
The Lady in the Van
The Selfish Giant

84. George Orwell
“Would it not be better if they spent more money on wholesome things like oranges and wholemeal bread or if they even, like the writer of the letter to the New Statesman, saved on fuel and ate their carrots raw? Yes, it would, but the point is that no ordinary human being is ever going to do such a thing. The ordinary human being would sooner starve than live on brown bread and raw carrots. And the peculiar evil is this, that the less money you have, the less inclined you feel to spend it on wholesome food. A millionaire may enjoy breakfasting off orange juice and Ryvita biscuits; an unemployed man doesn't. Here the tendency of which I spoke at the end of the last chapter comes into play. When you are unemployed, which is to say when you are underfed, harassed, bored, and miserable, you don't want to eat dull wholesome food. You want something a little bit 'tasty'. There is always some cheaply pleasant thing to tempt you.”
The Road to Wigan Pier, 1937

85. “Vulnerability may have its own private causes, but it often reveals what is wounding and damaging on a much larger scale.”
Berger and Mohr, A Fortunate Man 1967

86. E-learning / internet
Bridging the Gap (NHS Scotland health inequalities e-learning module)
GPs at the Deep End Scotland
Health Talk website
TEDx talks
Institute of Health Equity – videos and massive online courses
Joseph Rowntree Foundation

87. Your ideas? Please turn to a neighbour: Out and about Film / audio
Books
E-learning / internet
Other?

88. Overview of learning exercises around these areas 1415-1500
Multi-morbidity
Overview of learning exercises around these areas

89. Multimorbidity
Aged % have >1 morbidity in most affluent. 36.8% in most deprived
10-15y difference in age at onset of MM
Lancet 2012; 380: 37–43

90. Multi-morbidity exercise
Education primary care – description of workshop in rural GP training setting (
Brief 40 min HDR / tutorial session that covers multi-morbidity in the community
Challenges for patient / doctor
“Rules” to pass on to colleagues
Social context and community support

91. Case study What are the main issues (bio/psycho/social)?
What is your management plan for this consultation? And any subsequent consultations?
How can you ensure you and your practice meet Carolyn’s needs and those of patients with similar problems?

92. Case study
Challenges for the patient
Challenges for the doctor ?

93. Case study
Solutions?
5 or more pointers to help you deal with these sort of consultations…

94. Case study
From multimorbidity workshop (Education for Primary Care, 2015)
GPST ideas:

96. Overview adapted from RCGP Working with Vulnerable Groups Handbook
Overview adapted from RCGP Working with Vulnerable Groups Handbook

97. Homeless people

98. Homelessness Life expectancy... 47y...
Most deaths from primary care sensitive conditons
Situational awareness – key

99. Diagnosis What is homelessness (ETHOS categories)? Risk factors
Roofless
Houseless
Insecure
Inadequate
Risk factors
Structural
Institutional
Relationship
Personal
See p44 handbook; recent Shelter report… 1 in 3 families one month’s pay away from losing house… LE 47 years

100. Response Prevention Emergency action Support See p 45 handbook
Prevention = DV mediation, debt counselling, CAB, housing and finance support, statutory and VCS mental health services
Emergency action = shelters, temporary emergency accommodation
Support = outreach services, day shelters, soup kitchens, education/training support services

101. Health needs
Physical – VTE, TB, infestation, foot problems, dental issues, usual chronic diseases
Psychological
Most homeless people die early from ambulatory care sensitive conditions

102. Prescribing and referrals
Issues with registration
Prescribing – diversion of medication, storage of drugs, policies for prescribing, nutritional supplements
Referrals – podiatry and dentistry, receipt of appointments

103. Refugees and asylum seekers

104. Definitions: refugees & asylum seekers
270,000 of the world’s 11.4 million refugees live in the UK (3%)
As Asylum seeker is someone seeking recognition as a Refugee
A Refugee is permitted to stay in the UK for 5 years, with permanent status following this if still at risk
2011… >100,000 “failed asylum seekers” in UK (est)… theoretically no longer entitled to free non emergency NHS care
Refugee… 1951 UN Refugee Convention (Geneva Convention)
Asylum seekers… cannot work for 12 months, may be detained without recourse to judicial review in detention centres or prisons

105. “Triple Trauma” In country of origin During flight and migration
In host country

106. Country of origin

107. During flight and migration

108. In host country

109. Two short films… People of Nowhere When you don’t exist
Two films to bring home triple trauma effect

110. Healthcare needs of refugees
Mental health problems common
Cultural factors… stigmatisation?
“Home Office Syndrome”
Lack of social support a better predictor of distress than trauma
PTSD

111. Healthcare needs of refugees
Undiagnosed or unmanaged common chronic disease
Also consider: HIV, viral hepatitis, TB, scabies, tropical infection, vitamin deficiency
Physical injury: torture, brain injury
Women’s health issues: non disclosed rape, FGM

112. Services for refugees Freedom From Torture charity…
Mainstream mental health services
Advocacy and support
Specialist inclusion health providers
The NHS… expectations of primary and secondary care

113. Travelling community

114. “Travellers” and “Gypsies”
Not a homogenous group
Romany Gypsies
Irish Travellers
Scottish Gypsy Travellers
Kale
Boat dwellers
Estimated population 300,000 in UK
Centuries old history of discrimination and marginalisation

115. Social problems Housing Education Access to healthcare
50% live in “bricks and mortar” accommodation
Travellers sites often located in unhealthy sites (i.e. by motorways, sewerage works)
Education
Access to healthcare
Itinerancy makes this more difficult
Lower rates of immunisation
Lower rates of dental registration
Inadequate provision of travellers sites… many people have to live in bricks and mortar accomodation… separated from community… often at a time when needed most due to illness / poverty / eviction

116. Health problems Lower life expectancy (12 y in women & 10y in men)
Self report higher rates of
Respiratory illness
Chest pain
Anxiety and depression
Arthritis

117. Cultural factors Travel synonymous with health Close family networks
Moving to permanent accommodation often associated with poorer physical and mental health
Fatalism
Accepting of poorer health and function
Less uptake of preventative services
Avoidance when faced with potentially serious illness
Sometimes tied in with belief in God’s predetermination

118. Rural communities

119. Rurality
Tools such as the Index of Multiple Deprivation underestimate deprivation in rural areas, where “Pocket Deprivation” is a real issue and can be severe
Mortality from road traffic collisions, asthma and cancer worse in rural areas
Life expectancy is lower in very rural areas when compared with areas with similar population demographics

120. Social determinants in rural areas

121. Healthcare in rural areas
Acute response times are greater (ambulances, thrombolysis / PCI for MI & Stroke etc)
Chronic care must be delivered without access to specialist outreach services and less involvement of consultants through OPCs
Centralisation of primary care has a disproportionate impact on access in rural areas

122. Pocket deprivation
The absence of services to assist vulnerable groups such as the homeless, drug users, people with learning disability and refugees can lead to people experiencing severe poverty (compared with urban areas)

123. Putting it all together

124. Trainees: what to expect?
Basic – primarily reactive care, think about individual patients’ needs, focus on individual disease, look mainly at the physical
Intermediate – reactive care with management of acute and chronic needs simultaneously, see the patient in their social context, think about wider impact of decisions in the consultation, think about biopsychosocial needs at the individual level
Advanced – reactive care combined with proactively seeking the sickest patients (the unworried unwell), see the patient as a whole person who is an interconnected product / part of their community, see how health, social care and the VCS can work together to meet needs, think about wellness and how patients and communities can co-create health
Refer back to community orientation curriculum sheet
If you do this you will make education social accountable

125. Citadel Healthcare
Build community Seek out the sickest Give them the best care
Angry compassion, get out of the light and into the dark, find the patients in the health inequalities bubble
But don’t be naive

126. Heather’s thoughts
Be passionate Be kind Be human

127. There is hope! Prof Clare Bambra shows the art of the possible..
HI closed after German unification
It can be sorted

128. Being a sustainable GP Upstream (helping the well)
Downstream (helping the unwell)
Map / target areas of risk (need)
Address determinants...
Antenatal care
Children, young people and families
Building community
Advocacy
Improve health literacy
Primary prevention...
Vaccination
Modifiable risk factor management: behavioural change, pharmaceutical intervention
Case finding (unworried unwell)
Secondary prevention
Defragmenting care for complex patients
Cost effective prescribing and referrals
Use / development of local care pathways
Social prescribing
Ensure universal care is feasible – meeting the needs of the patient in front of + those in the waiting room

129. Being a sustainable GP But also...
Keeping a strained universal system on its feet whilst making it more equitable
Changing the system so that it truly responds to need
Maximising your potential as an advocate

130. Being a sustainable GP This is not an add on the day job
This is the only way of saving the day job!
(But try and avoid being a “busy fool”)

131. Last word!
One small piece at a time