Category Archives: Primary Care

Introduction

 

The  SHA Council agreed to pull together some of the existing policies on prevention and public health, introduce new proposals that have been identified and put them into a policy framework to influence socialist thinking, Labour Party (LP) manifestoes and future policy commitments. The SHA is not funded by the industry, charitable foundations or by governments. We are a socialist society which is affiliated to the Labour Party (LP) and we participate in the LP policy process and promote policies which will help build a healthier and fairer society within the UK and globally. An SHA working group was established to draft papers for the Central Council to consider (Annex 1).

 

The group were asked to provide short statements on the rationale for specific policies (the Why?), reference the evidence base and prioritise specific policies (the What?). Prevention and Public Health are wide areas for cross government policy development so we have tried to selectively choose policies that would build a healthier population with greater equity between social groups especially by social class, ethnicity, gender and geographical localities. We have taken health and wellbeing to be a broad concept with acknowledgement that this must include mental wellbeing, reduce health inequalities as well as being in line with the principles of sustainable health for future generations locally and globally.

 

The sections

 

These documents are divided into five sections to allow focus on specific policy areas as follows:

 

  1. Planetary health, global inequalities and sustainable development
  2. Social and the wider determinants of health
  3. Promoting people’s health and wellbeing
  4. Protecting people’s health
  5. Prevention in health and social care

 

The working group have been succinct and not reiterated what is a given in public health policies and current LP policy. So for example we accept that smoking kills and what we will propose are specific policies that we should advocate to further tackle Big Tobacco globally, prevent the recruitment of children to become new young smokers, protect people from environmental smoke and enable smokers to quit. We look to a tobacco free society in the relatively near future. Whether tobacco, the food and drink industry, car manufacturers or the gambling sector we will emphasise the need to regulate advertising, protecting children and young people especially and make healthy choices easier and cheaper through regulations and taxation policies.

 

Wherever appropriate we take a lifecourse approach looking at planned parenthood, maternity and early years all the way through to ageing well. We recognise the importance of place such as the home environment, schools, communities and workplaces and include occupational health and spatial planning in our deliberations.

 

We discuss the NHS and social care sector and draw out specific priorities for prevention and public health delivery within these services. The vast number and repeated contact that people have with these servces provides opportunities to work with populations across the age groups, deliver specific prevention programmes and use the opportunities for contacts by users as well as carers and friends and relatives to cascade health messages and actions.

 

The priorities and next steps

 

In each section we have identified up to ten priorities in that policy area. In order to provide a holistic selection of the overall top ten priorities we have created  a summary box of ten priorities which identify the goals, the means of achieving them and some success measures.

 

This work takes a broad view of prevention and public health. It starts with considering Planetary Health and the climate emergency, global inequalities and the fact that we and future generations live in One World. A central concern for socialists is building a fairer world and societies with greater equity between different social classes, ethnic groups, gender and locality. We appreciate that the determnants of such inequalities lie principally in social conditions, cultural and economic influences. These so called ‘wider determinants and social influences’ need to be addressed if we are to make progress. The sections on the different domains of public health policy and practice sets out a holistic, ecological and socialist approach to promoting health, preventing disease and injury and providing evidence based quality health and social care services for the population.

 

The work focuses on the Why and What but we recognise the need for further work to support the implementation of these priorities once agreed by the SHA Council. Some will be relatively straightforward but others will be innovative and we need to test them for ease of implementation. A new Public Health Act, as has been established in Wales, but for UK wide policies would make future public health legislation and regulation easier.

 

The SHA now needs to advocate for the strategic approach set out here and the specific priorities identified by us within the LP policy process so they become part of the LP manifesto commitments.

 

Dr Tony Jewell (Convener/Editor)

Central Council

July 2019

The complete policy document is available below for downloading.

Public health and Prevention in Health and Social carefinaljuly2019

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The life long member of the Socialist Health Association, Dr Julian Tudor Hart died on July 1st 2018. The following is the funeral tribute paid to him by Dr Brian Gibbons who worked with Julian in the Upper Afan Valley Group Practice  in south Wales.

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There is no great forest that is made up of a single tree, no great river made from a single tributary or no great mountain range with single peak.

And as we come here to remember and commemorate the life of Julian Tudor Hart—we realise what a multi-faceted individual he was.

He embraced and embodies such a broad range and depth of
subjects, knowledge and skills, accomplishments and life experiences

 

To say that Julian was interested in politics and the life of the community that he served for almost three decades would be like saying that Gareth Bale was known to be able to kick a football.

Julian’s politics were principled, passionate and undiminishing right up to the final months and weeks of his life.

Even then he was involved in the Labour Party, Swansea Labour Left and in the affairs of the Upper Afan Valley — in campaigns to keep the key community facilities open such as Cymer Swimming Pool open.

And he was revived and renewed with Jeremy Corbyn’s victory in the Labour leadership election and the outcome of the last year’s general elections which showed that British elections no longer had to be won from the middle ground of politics.  And that it was possible to offer people, and particularly the young, a radical alternative for change

And, I’m sure, Julian was not only pleased to see a leader from the left at the helm of the Labour Party.
But he would have also been pleased that that leader shared another of Julian’s great passions — gardening.

If Julian had a chance to speak to Jeremy Corbyn he would have talked not only about politics but also runner beans, carrots, radishes and lettuce.

And those discussions would have given a new meaning to the idea of “organising a left wing plot “ !!!!

 

Julian’s politics came from the heart

But it found expression in the head and in the hand.

He investigated and analysed and applied the scientific method to his political beliefs.

And Julian respected all those who did the same even those who took a diametrically different point of view from him.

It was all the more than painful for him, therefore, to see over recent years to see that ignorance, prejudice and bigotry is too often used as evidence in much of the present political debate.

Karl Marx said, and I am sure that to quote him here this morning at a humanist funeral for Julian Hart is in order.
“The philosophers have only interpreted the world, in various ways. The point, however, is to change it.”

And this is what exactly what Julian did.

Yes he used the scientific method to interpret the world but not with some sort of detached view of the ivory tower academic or to provide frothy intellectual fodder for the chattering classes.

But to intervene to make a difference, to make society a fairer and more equal place for us all to live, a place where we can all work together for our own mutual benefit and the common good, where we all live a more enriching and enjoyable life.

Where all would contribute according to their ability and receive according to their need.

 

Julian was a man of action.
From campaigning side by side with the people who lived in Glyncorrwg and the Upper Afan Valley, through writing papers, pamphlets and books, giving interviews and partaking in debate, peaking and organising meetings,

He was an active, conscientious and creative member of many organisations as diverse as the Socialist Health Association of which he was the first honorary president and the Royal College of General Practitioners of which he was a council member for many years – where he constantly took the view that high professional and clinical standards, particularly for those with the greatest health care needs, were the natural ally of a thriving NHS.
He advised national political parties and governments in various parts of the world.
And he had a particularly important role in the development of health policies in the run up to and in the early years of Welsh devolution.

In short he walked the streets with the people of Glyncorrwg in their campaigns and he also walked on an international stage.

And in mentioning all of this, we do need to remember the support he received from his wife Mary and his children whose home was often a cross between a Heathrow terminal and Piccadilly Circus as people dropped in from far and near from the Afan Valley to the Appalachian Mountains and even further afield.

He also brought his activism and creative thinking to many local campaigns.And we can see the physical legacy of that in the Upper Afan Valley – the South Wales Miners Museum, Glyncorrwg Ponds and Glyncorrwg Mountain Biking Centre.

Of course Julian would agree that none of this would have been achieved without the co-operation in local community efforts and a massive amount of hard work and effort by many local people.
But equally I am sure that there are few who would disagree that none of these projects would have achieved what they did without Julian Hart.

 

Julian Hart was an unrepentant socialist …but he was most particularly committed to promoting and protecting the NHS.

He saw the NHS as being the embodiment of the values of a socialist society, where people contribute, through their taxes, according to their ability to pay – unless you are Google or Amazon, of course — and you receive according to your need.

Nye Bevan was, apparently, once asked how long he thought the National Health Service would last and he is reported as saying “ The NHS will last as long as there’s folk with faith left to fight for it.”

But one of our most resolute fighters for the NHS has left us.

Already many people have started to consider what sort of monument or memorial would be fitting to commemorate Julian Hart’s life work.

But I am sure that Julian would be first to say – the greatest of all memorials would be the continuing campaign to protect the NHS and the work to allow it to innovate and expand, to develop and to flourish as an even greater public service than it is now.

One of Julian’s favourite singers was Paul Robson, who was once one of his patients, and one of Paul Robson’s most popular songs was Joe Hill which you will hear later.

Joe Hill was a Swedish immigrant and trade union organiser in the USA who was framed for murder and executed in Salt Lake City.

The song reminds us that even though Joe Hill did die, his spirit lived on wherever there was a the struggle for trade union rights and a campaign for social justice

And Julian’s spirit will live on to be a similar source of
inspiration though he is no longer with us.

Joe Hill said is his last letter – “Don’t mourn, organise!”

Julian would have repeated that message

Organise to protect and build the NHS.
Organise to build a better, more caring and equal society.

That must the first and enduring monument and then we can get on with the rest.

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The Welsh Government has announced its intention to increase Welsh GP training positions by  a further 18%. This follows a significant increase in the fill rate for training posts, which this year has already seen 155 places already filled against the target of 136.g

The Health Minister, Vaughan Gething, has now asked Health Education and Improvement Wales (HEIW) to review the number of places in Wales to ensure a skilled workforce is in place to meet the aims of A Healthier Wales to provide care closer to home and reduce pressure on hospitals.

The target fill rate for GP training places is set to increase from 136 to 160, starting this autumn. This figure will be kept under review with a view to increasing it further in the coming years.

Mr Gething said:

We have made excellent progress since launching our Train, Work, Live campaign in 2016 to attract GP trainees to Wales. In 2 of the last 3 years we have over-filled our target number of training places so now is good time to look at increasing the target.

I have asked HEIW to review our GP training places to ensure we have the skilled workforce we need to meet our long term ambitions for the NHS, set out in A Healthier Wales. I want to increase the number of places to 160 in time for the next round of recruitment in 2019 and I hope we can move towards an even higher target in the near future. I have also agreed where there are further opportunities to take on more GP trainees than the 160, HEIW can proceed if there is capacity to do so.

The Train, Work, Live GP trainee campaign includes 2 financial incentives schemes: a targeted scheme offering a £20,000 incentive to GP trainees taking up posts in specified areas with a trend of low fill rates, and a universal scheme offering a one off payment for all GP trainees to cover the cost of one sitting of their final examinations.

HEIW Medical Director Professor Push Mangat, said:

We are absolutely delighted the Welsh Government have agreed to fund our plan to increase GP training numbers in Wales. This will have a positive impact on local healthcare services and the health and wellbeing of residents. Wales has a lot to offer and we look forward to welcoming more doctors to train as GPs in Wales.

 

SHA Cymru has also welcomed the increase in line with its vision to see a significant increase in front line primary health care staff as outlined in its recent submission the Welsh Labour Policy Forum.

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Further investment in Welsh general practice  has been promised  following negotiations for the 2019-20 General Medical Services (GMS) contract – which is worth over £536.6m. Additional funding will also be made available this year to cover the rising costs of pensions, following changes made by the UK government according to the press released from the Welsh Government.

The funding will mean an increase per patient in Wales from the current contract, from £86.75 to £90. The new value per patient is also more than offered in England.

The contract reforms the way in which services operate with a much stronger emphasis placed on clusters working together to plan and deliver services locally to enable patients to access care at or close to home – one of the key aims of A Healthier Wales.

As part of the additional £25m the GMS contract for 2019-20 will deliver:

An uplift of 3% to the general expenses element of the contract for general expenses.

Investment of £9.2 million for the implementation of the Access to In-hours GP Services Standards published on 20 March 2019.

A further £3.765 million going into Global Sum this year, to fund the infrastructure needs of practices in working towards achievement of the in hours access standards.

An investment of up to £5 million will be made available to incentivise partnership working as the preferred model for GMS and to encourage new GPs to take up partner roles though the introduction of a new Partnership Premium available to all GP partners regardless of length of service.
Health Minister Vaughan Gething, said:

Over the last 18 months we have continued with our ambitious programme of reform to the GMS contract. I acknowledge that negotiations have taken longer than preferred, but this reinforces our commitment to fully engage with the Health Service and General Practitioners Committee on contract reform – with Wales being the only nation in the UK to fully engage the Health Service in this way.

This agreement provides an additional boost to GMS services and once again represents a better deal than that being offered in England. The new contract delivers the much needed investment into services to improve sustainability and to meet the aims set out in a Healthier Wales, including an increased focus on cluster working and seamless provision of services.”

Dr Charlotte Jones, chair of the BMA’s Welsh GPs committee said:

I am pleased that GPC Wales and the Welsh Government have been able to reach an agreement for hardworking GPs across Wales.

The introduction of the partnership premium, an increase in the Global Sum and the additional funding to address the rising costs of employer pension contributions, are a clear commitment by the Welsh Government that they intend to secure the independent contractor model for GPs into the future.

The move to addressing last person standing issues will also ensure that those who have dedicated their careers to improving the health and wellbeing of the communities of Wales do not face the risk of bankruptcy.

This contract will provide reassurance for GPs and ensure that patients continue to receive services in the community and as close to home as possible.

Judith Paget, Chief Executive of Aneurin Bevan University Health Board, said:

I welcome this agreement which has been reached between the General Practice Committee, Welsh Government and the Health Boards in Wales.

The changes to the GP contract and the additional investment will underpin the sustainability of local GP services, which we know patients value so much. We look forward to supporting the local implementation of this agreement so that patients, GPs and the wider community will benefit from the improvement in both the quality of services and the access to services that this agreement supports.

Alongside the financial changes, a number of other commitments have been agreed as part of the reformed contract. Including:

A stronger emphasis on cluster working to plan and deliver local services with improved cluster planning, engagement and activity indicators and a shift of some activity to delivery at cluster level

A streamlined Quality Assurance and Improvement Framework (QAIF) with a focus on Quality Improvement activity.

An agreed scope of the approach LHBs will take in providing support to our most vulnerable GPs who find themselves at risk due to Last Person Standing issues.

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It is over 40 years since the Alma-Ata Declaration asserted the crucial role of primary care in the promotion of the health of people world wide. Since then global health policy has attempted to give effect to the Declaration with varying levels of success. The situation has been no different in Wales.

The Wanless Review in 2003 re-emphasised this message. It stated “ …(t)he current configuration of health services places an insupportable burden on the acute sector and its workforce. This is the most expensive part of the system … (t)he primary care sector in turn is not sufficiently resourced or incentivised to keep patients out of hospital though it is hoped that the new General Medical Services Contract (under discussion at the time of this report) will create such incentives.”

The publication of the final report by the Welsh Parliamentary Review on health and social care ( January 2018) shows that this still remains the main challenge. In response the Welsh Government has published A Healthier Wales and a Strategic Programme for Primary Care. Both these policy statements will have to be matched by a determined political will if they are to prove successful.

In 2018 the Wales Audit office stated that “ (b)etween 2010-11 and 2016-17, total health board spending in Wales …. increased from £5.39 billion to £6.32 billion. However, over the same period, recorded spending on primary care as a percentage of total health board spending in Wales ….. reduced from 25% to 22%.This would suggest that the shift in resources towards primary care that has been at the centre of much of the NHS policy in recent years is not being achieved.” No amount of smart or new types of working will be able to make up for this basic deficit. If primary care is to thrive it needs resources and investment.

This has been highlighted in the number of GPs working in Wales. Between 2004-05 to 2010-11 the number of GPs rose from 1,800 to 2,000. However since then things have been more or less been static until there was a 4% decline between 2016 and 2017. By way of contrast the numbers of hospital consultants has increased by 40% between 2009 and 2017.

However these headline figures do not tell the full picture. While there are now just under 2,000 GPs listed in Wales. Approximately 1,500 of the listed GPs were contractors with the remaining 400+ being salaried. However there is a concern that the official statistics do not present a fully accurate picture particularly in relation to the number of salaried doctors. And there are, in addition, a further 750 doctors working in system who are classified as locums or sessional GPs . This represents a 10% increase since 2016 when figures were first collected.

Vocational training is central to securing a future workforce. The RCGP estimates that Wales needs to have 184 positions to be on a par with the rest of the UK. There has been an increase of 15% in posts over recent years with to 90% being filled but the overall numbers have still to reach UK levels.

The Welsh Government therefore faces a major challenge to increase capacity in its primary care and general practice service. There is abundant evidence that GP workload is increasing both quantitatively and in its complexity. In response there must be an a substantial increase in the workforce as the Welsh Government itself acknowledges the service is not sustainable if it can only survive by the “heroic” efforts of its staff.

Non-medical practice staffing levels has increased by over 7% in the last half decade with approximately 2,500 clinical and 5,000 administrative staff now being employed. Despite these increases the RCGP reports that there are still 20% of GPs do not have access to a practice nurse, 35% to a practice pharmacist and 50% to a physiotherapist. This is clearly not good enough.

The challenge in recruiting and retaining GPs also looms large. Both the GPC and RCGP in Wales still insist that “.. (i)t is a fact that the independent contractor model is best for the patients of Wales and is the most cost-effective option for those who hold the purse strings in both Welsh Government and Health Boards. “ But with 20% of GPs already salaried and with almost twice as many more working as locums and sessional doctors there must an urgent need to review the way they work for and with the NHS.

The Welsh Government acknowledges that the contractor partnerships will continue to be the cornerstone of general practice in Wales. But it also accepts that this model it is no longer a preferred option for many new doctors. They are not attracted to the business ethos, financial risks, administrative demands, inflexibility and investment costs which go with being an independent contractor. So while the concerns of independent contractors must be addressed there is also a need for a more diverse range of career options for future general practitioners.

There are some interesting innovations taking place seeks to address this need. The Primary Care Support Unit in the Cwm Taf Health Board has been in existence since 2002. Social enterprise models for care delivery have been adopted in Bridgend and south Powys. But overall they are still too few to achieve the critical mass that is needed to achieve transformational change.

Somewhat strangely the “GP establishment” seems to fear that health boards and the Welsh Government are rubbing their hands in glee at the prospect of becoming direct providers of primary care services. The reality is almost totally the opposite. There are now over 30 directly managed GP practices in Wales but in virtually every case local health boards have found themselves reluctantly obliged to get involved. This lack of enthusiasm for a public service general practice option must be urgently addressed.

The Strategic Programme for Primary Care confirms the Welsh Government’s commitment to delivering primary care services through 64 primary care or clinical networks based on populations of 50-100,000. These networks are tasked with bringing primary and social care services together along with the third sector to cater for the needs of their populations. There is a widespread support for this model both politically and across the professions. The Welsh Government has channelled much of its recent primary care investment through the networks to stimulate local innovation and service improvement. Their success to date is a bit mixed and in some cases they have an uneasy relationship with their local health boards.

Innovation in primary care is also being actively promoted though the £4m Pacesetter / Pathfinder programme which began in 2015 with 24 distinct projects. The objective was to either develop new ways of working or to promote the wider dissemination of new ways of working. The programme received support from Public Health Wales and it is hoped that health boards would mainstream the practice of the successful projects. As these projects come towards the end of their initial phase this is recognised as being critically important. But it has also been appreciated that those areas where services are under the greatest stress are least likely to engage with the exercise.

The Welsh Government has prioritised tacking health inequalities and asserts “..the fundamental Bevan principle that it is clinical need which matters when it comes to deciding treatment by NHS Wales.” In his annual report 2015-16 the Welsh Chief Medical Officer, Dr Frank Atherton, recognised this in stating “ … we make the case that one-size-fits-all health and care services in the traditional sense may not always be the best approach, as they can maintain, and sometimes increase, health inequalities. Instead we argue for an approach which is proportionate to the level of disadvantage which is often referred to as proportionate universalism.” But Welsh Government policy  is at its weakest it comes to outlining how this is to be achieved.

Public Health Wales (PHW) has done a lot of work in identifying health inequalities across Wales and profiling populations to clinical network level. It shows that the difference in prevalence of good health between people living in the least and most deprived areas is already apparent at age 0-15. This gap then grows as age increases, peaking in males at age 65-74 (79% in least deprived vs 52% in most deprived) and in females at age 55-64 (84% vs 56%). And it is in these disadvantaged areas where we also find the greatest prevalence of patients with complex multi-morbidity.

This work by PHW provides an excellent stepping stone for planning the promotion of health and well-being and the delivery of primary care services. But there is little evidence that this is happening on any scale. The Strategic Programme for Primary Care provides a lot of important one-size-fits-all advice for primary care but it only makes the most cursory of references as to how the new, transformed Welsh NHS will address health inequalities on the front line where 90% of health service contacts take place. This is its fundamental weakness.

Welsh health and social care policy strongly argues for a new approach that will put a focus on prevention, which promotes a social model of health and well-being, seeks to address the social determinants of poor health and which will tackle the stubborn continuation of health inequalities. In many policy areas concrete proposals have been put forward to address this agenda. But there in health and social care the details still need to be outlined and put in place.

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DELIVERED AT JULIAN HART’S FUNERAL — JUNE 16th 2018

 

Julian and I were chatting once about heaven and hell, as you do. He didn’t believe in either, but supposing he was wrong, he thought he might be allowed into heaven, not as a believer, you understand, but for good behaviour.

Julian always wanted to be a doctor in a mining village, partly because his father had been a colliery doctor in Llanelli; partly it was the romance of mining practice as popularised in AJ Cronin ‘s novel The Citadel; but mainly it was the sort of community to which he wanted to belong.

And belong he did. As Gerald Davies, one of his patients, said in a BBC documentary , Julian wasn’t aloof like the other doctors, the headmaster and the colliery manager. He lived in the village and shared the common experience.

He wrote about it for medical students, “No one is a stranger; they are not only patients but fellow citizens. From many direct and indirect contacts, in schools, shops and gossip, I have come to understand how ignorant I would be if I knew them only as a doctor seeing them when they were ill.”

Julian loved his patients – not romantically, of course. The opposite of love in this context is indifference and Julian was never indifferent. He hated when bad things happened to his patients, especially when they could have been prevented. In his last 28 years at Glyncorrwg, there wasn’t a single death in women from cervical cancer.

In his book A New Kind of Doctor, he described a man, invalided out of the steel industry after a leg fracture, aged 42. With no further use for his big muscular body, he had become obese, had high blood pressure and cholesterol, got gout and was drinking too much. 25 years later, Julian described how, after 310 consultations and 41 hours of work, initially face to face, eventually side by side, the most satisfying and exciting things had been the events that had not happened: no strokes, no heart attacks, no complications of diabetes. He described this as the real stuff of primary medical care.

At a seminar in Glasgow, we asked Julian what happened next. The man had died, of something else, a late-onset cancer I think, but when Julian told us this, there was a tear in his eye. His patient had become his friend.

This was Dr ‘art, without an “H”, as known to his Glyncorrwg patients. None of this explains why Dr Julian Tudor Hart became the most famous general practitioner in the history of the NHS.

In 1961 with large numbers of very sick people, huge visiting lists and a nearby colliery that was still working, the Glyncorrwg practice was extremely busy. His initial base was a wooden hut. It took five years to reach a stable position.

He was the first doctor in the world to measure the blood pressures of all his patients. Famously, Charlie Dixon was the last man to take part, had the highest blood pressure in the village but was still alive 25 years later. Julian became an international authority on blood pressure control in general practice and wrote a book about it which went to three editions and was translated into several languages, with a companion book for patients.

What he did for patients with high blood pressure, he did for other patients, delivering unconditional, personalised continuity of care. After 25 years he showed that premature mortality was almost 30% lower than in a neighbouring village – the only evidence we have of what a general practitioner could achieve in a lifetime of practice.

It’s said that behind every great man there is an astonished woman. Behind Julian, was a great woman. When Deborah Perkin was planning her BBC documentary, the Good Doctor, (which we keep showing to medical students and young doctors), I said to her, there is something you have to understand. There’s two of them. Mary was his partner and anchor every step of the way.

Glyncorrwg was the first general practice in the UK to receive research funding from the Medical Research Council. Mary and Julian had both worked with Archie Cochrane and his team at the MRC Epidemiology Unit in Cardiff where they learned a democratic type of research in which everyone’s contribution was important and the study wasn’t complete until everyone had taken part. And so, in Glyncorrwg, there was the Shit Study, the Pee Study, the Salt Studies and the Rat Poison Study, all with astonishing high response rates.

Julian counted as a scientist anyone who measured or audited what they did and was honest with the results. Brecht’s The Life of Galileo was his favourite play and he often quoted Brecht’s line, “The figures compel us.” Julian didn’t pursue scientific knowledge for its own sake. His research always had the direct purpose of helping to improve people’s lives.

He had a talent for the telling phrase. His Inverse Care Law stated that the availability of good medical care tends to vary inversely with the need for it in the population served, or more simply, People without shoes are clearly the ones who need shoes the most.

When Sir Keith Joseph, a Conservative Secretary for Social Services, announced that
“Increased dental charges would give a financial incentive to patients to look after their teeth,” Julian commented, “The government has not yet raised the tax on coffins to reduce mortality, but Sir Keith is assured of a place in the history of preventive medicine.”

Julian’s friend and fellow GP, John Coope from Bollington in Lancashire, admired Julian’s nose for what mattered in the published literature. In his book The Political Economy of Health, that magpie tendency was on display, the footnotes comprising one third of the book and worth reading on their own. A Google search could never assemble such a mix. Goodness knows what readers made of it in the Chinese translation.

He lectured all over the world – in the US, Australia, Kazakhstan, Italy and Spain in particular. Julian could deliver formal lectures but for brilliance and exhilarating an audience he was at his best in impromptu, unscripted exchange.

When principles were at stake, Julian could argue until the cows came home. In his younger years he took no prisoners. A famous medical professor reflected that he had been called many things, but never a snail.

Dr Miriam Stoppard arrived in the village to interview Julian for her TV programme, determined to cast him in the role of a doctor who made life or death decisions concerning his patient’s access to renal dialysis and transplant. They battled for a whole afternoon, Stoppard trying to get Julian to say things on camera that fitted her script. He defied her, ending every sentence by mentioning how much dialysis and transplant surgery the cost of a single Trident missile could buy. She went away defeated and empty-handed.

I was surprised once at Paddington station to see him with a copy of the London Times. He was no fan of the Murdoch press. On boarding the 125 for South Wales, he laid out the newspaper as a tablecloth and over it spread a messy, aromatic Indian carry-out meal. If businessmen in their smart suits wanted to sit next to us, they were very welcome.

Standing for election to the Council of the Royal College of General Practitioners, Julian topped the poll. What he offered GPs was a credible image of themselves as important members of the medical profession – alongside specialists, not beneath them.

Julian was humble in himself but ambitious for his ideas. He accepted with ambivalence the honours and sentimental treatment that came with age but he never lost his edge, and if we are to celebrate his life it should be by holding to the principles he held dear.

The work of a general practitioner is immeasurably enhanced by working in, with and for a local community, for long enough to make a difference.

Everyone is important, the last person as important as the first, and the work isn’t done until everyone is on board.

Julian was the “worried doctor”, anticipating patients’ problems, not waiting for them to happen, and then avoiding them by joint endeavour.

Drawing on his reading of Marx, he saw health care as a form of production, producing not profits but social value, shared knowledge, confidence, the ability to live better with conditions, achieved not by the doctor alone but by doctors and patients working together. Patients were partners, not customers or consumers.

The NHS should never be a business to make money but a social institution based on mutuality and trust – the ultimate gift economy, getting what you need, giving what you can, a model for how society might run as a whole. In re-building society, co-operation would trump competition, not marginally, but as steam once surpassed horsepower. The Glyncorrwg research studies showed glimpses of that social power.

My daughter Nuala met Julian many times. Losing him as a person, she said, was like the Mackintosh Building at Glasgow School of Art, burning down. We lost someone dear, a big part of our lives, an institution, a one man “School of ‘Art”, full of life, light and creativity.

Julian’s gift to us today is not the example he worked out in the microcosm of a Welsh mining village over 25 years ago; it is the present challenge of how we follow and give practical expression to his values in local communities in the future. In honouring his memory, there is work for all of us do.

 

Professor Graham Watt
MD FRCGP FRSE FMedSci CBE
Emeritus Professor
General Practice and Primary Care
University of Glasgow

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Last year I told you about a group of 7,000 health professionals who had spent 7 years fighting for their trade union to be recognised by their employer. That campaign has now lasted 8 years. See: https://www.sochealth.co.uk/2018/05/05/solidarity-with-community-pharmacists/

The Boots pharmacists were the first workers in any sector to challenge an employer through the ballot process described in that earlier article (above).  The law requires not just a majority, but that 40% of those eligible to vote, known as the “bargaining unit”, must vote “Yes” to make a difference.  The result was 87% of those who voted (2,826 pharmacists) voted Yes and that constituted 41% of the bargaining unit in favour.  This passed all the legal tests and the blocking agreement with the “sweetheart” union that the company was using to keep independent trade unions out, was ended by order of the Central Arbitration Committee.

To emphasise what an achievement that is, if you measure the BREXIT referendum in similar percentages, of those eligible to vote it was just 37% vs 35%, so getting over 40% of eligible voters to support anything is no small achievement. Despite the clear result, the employer has continued to resist pharmacists’ efforts to secure an independent voice at work in the largest community pharmacy multiple chain.  However, in February 2019 the 7,000 pharmacists can vote again in a further postal ballot and this time it will force the employer to recognise the PDA Union

One of the big issues for pharmacists is the company’s approach to performance management and the union have been hearing from pharmacists about what it means to them.  These quotes from pharmacists illustrate what the PDA Union are trying to fix so that these health professionals can get on with caring for patients.

“In regards to its pay structure and market based pay it should be ashamed. It should be ashamed for its performance review where no person I have spoken to has any idea what it means to be above performing and where the pharmacy advisors, the people on the front lines get no bonus at all unless they are above performing.

Nobody knows what exactly they need to do to be “above performing”. Even if you hit all your targets and are green on the scorecard despite those targets being an increase you are performing.”

 

“I worked under this regime and it is a terrible way to work. The constant threat of a ‘non-performing’ rating is so demotivating and demoralising and it sometimes felt like a personality contest. I challenged it many times (probably another reason I would never win a corporate personality contest) and was told that even if all targets were met/exceeded you could still be classed as non performing so what’s the point!”

Ballot papers will be mailed to pharmacists on Monday 18 February and completed ballots must be returned by noon on Monday 11 March in order to be counted.

Boots directly employs well over 10% of all pharmacists in the country and has many more working occasionally as locums, so this is a significant story for pharmacy, but sadly under reported by the media.  Anyone interested in supporting the PDA Union and their members can help by spreading the word about this historic trade union campaign.

The PDA Union was established in 2008, it is the only independent trade union in the UK which is exclusively for pharmacists.  It received a certificate of independence in 2010.  PDA Union is a member of Unions 21 and affiliated to the Employed Community Pharmacists in Europe (EPhEU) organisation and a member of Health Campaigns Together.  You can follow the PDA on Twitter, Facebook, Instagram and LinkedIN

Written by Paul Day, National Officer at PDA Union.

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The following article was first published in the Camden New Journal on 06 December, 2018

A private company being promoted
by government to recruit patients to its doctor service spells ruin for the whole-person integrated care we need from the NHS, argue
Susanna Mitchell and Roy Trevelion

The sneaking privatisation of our National Health Service now aggressively threatens our GPs. In Camden and across London, we all need to be aware of the long-term harms this development will cause GPs and primary care NHS services.

Last year, a global multinational corporation called Babylon Healthcare – owned by a former Goldman Sachs investment banker and Circle Health CEO – established a “digital- first” business called “GP at Hand”.

Disastrously for the NHS, Babylon Healthcare Services Ltd can be traced back to a holding company in Jersey, the offshore tax haven.

GP at Hand is contactable through a mobile app which uses standard calculations as a symptom checker. Unfortunately NHS England have not provided our existing practices with this software.

Instead any patient registering with this commercial enterprise will be deregistered from their normal GPs. And, although the GPs employed by the company can also be accessed by video or phone, this process delivers no continuity of care or whole-patient assessment.

Continuity of care is a cornerstone of general practices. However, Matt Hancock, the health secretary says, “If we need to change the rules to work with the new technology then change the rules we must.”

In addition GP at Hand’s own promotion material actively discourages older people from registering. Explicitly these are those who are frail or living with dementia, or in need of end-of-life care. Pregnant women and those it describes as having complex social physical and psychological needs are also discouraged from signing up.

In other words it is “cherry-picking” young and healthy patients who will be more profitable to its shareholders. Its use of standard practice via information technology, and the easy access it offers, is particularly attractive to the young.

Of the 31,519 new patients who have signed up with GP at Hand over the past 12 months, 87 per cent are aged between 20 and 39 years, while patients over 65 now make up just 1 per cent of the population registered with the service.

All this poses serious problems both for patients and general practices. In the first place, our present primary care system consists of GP practices committed to whole-person and integrated care for everyone in their local communities. Healthcare services are organised around geographic areas to enable better co-ordination with hospitals and social services.

In contrast to this, GP at Hand fractures this fair and impartial community-based model, registering patients who live or work anywhere within 35 to 40 minutes of one of the clinics. In addition, should any of their patients require more complex care, they will no longer have their own GP to turn to.

Secondly, by picking the most profitable patients, GP at Hand drains money away from ordinary GP surgeries. Normal GPs are funded according to the number of people on their patient list and this funding is combined into a single budget to provide the services they offer. This means that funding from the roughly 80 per cent of patients who remain reasonably well helps to pay for the 20 per cent who are elderly, who are chronically sick, or have multiple illnesses.

But if the “capitation fee” of the young and healthy is scooped up by a for-profit company like GP at Hand, it will critically undermine the funding available to surgeries. This will leave practices to deal with the sick, the frail and the old on a much reduced budget.

Shockingly this commercial entity is funded by NHS England. It can be commissioned through our clinical commissioning groups (CCGs).

It’s expanding fast, and already has over 35,000 patients. Currently the corporation operates out of five clinical locations in London including one in King’s Cross. Plans for rolling it out nationwide are under discussion. It is also advertised widely, with the health secretary Matt Hancock recently announcing that he has registered with the company.

Future developments in information technology and artificial intelligence that can be useful to our public health systems should be funded directly towards our existing GP surgeries.

It should not be used as a vehicle for profit-making by private corporations at the expense of our NHS.
We need to make the dangers of adopting this business model clear to the widest possible public. We must encourage those who care about our publicly-funded NHS to boycott Babylon’s GP at Hand.

We need to bring public pressure to bear and end this attack on a valued and trusted institution that serves us all.

The NHS has always been for the benefit of everybody. It must be kept that way.

• Susanna Mitchell and Roy Trevelion are members of the Holborn & St Pancras Labour Party and of the Socialist Health Association.

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Nick Bostock reports at GPonline that:

Under-pressure GPs are delivering ‘remarkable outcomes’ on cancer

You can read the complete article here. Nick reports:

GPs ‘can take a lot of credit’ for marked improvements in early cancer diagnosis and reductions in the proportion of cases detected as an emergency, according to a cancer expert.

In the year to March 2018, the proportion of cancer patients who first presented at hospital as an emergency fell to 18.8% – down from 21% in the year to December 2012.

Over roughly the same period, cancers detected at an early stage increased significantly – rising from 46% in 2013 to 52% by mid-2017, according to figures from the National Cancer Intelligence Network (NCIN).

However: GPonline reported earlier this year on research showing that GPs were as good as consultants at making appropriate use of cancer diagnostic tests – and yet pledges to give GPs direct access to four key diagnostic tests – blood tests, chest X-ray, ultrasound and endoscopy – have not been delivered in many areas.

Isn’t it about time that GPs were also given access to the new technology for GP consultations via mobile and Skype? This is currently being ‘rolled out’ by GP at Hand. Here’s a transcript of the R4 Today programme 13 September at 6 mins to 9:00 am (I made this transcript and I believe it’s a fairly accurate job – but any mistakes are mine):

(Int) Interviewer

AP (Ali Parsa, CEO Babylon – parent company that runs GP at Hand)

RV (Dr Richard Vautrey, Chair GP Committee, British Medical Association)

SoS = Secretary of State

 

(Int): So Ali Parsa just explain to us how your App works.

(AP): So, we have a very simple service. So, what it does is allow patients to check their symptoms whenever they want. To make an appointment with a doctor within seconds, to be able to see a doctor within minutes. In fact, I was just checking my App and it says that if I want to see a doctor I can see one at 9 o’clock today, in the next few minutes.

(Int): You mean ‘see’ over the phone?

(AP): Over the phone. And if you want to see somebody physically then, you can go see them that very same day. It is open 24hrs a day, 365 days of the year. And it is available for the same price the National Health Service pays any other GP. What we have done is to solve the problem of accessibility and the continuity of healthcare – using technology and what the SoS and the NHS is doing today is celebrating that and promising it for the whole country.

(Int): And Richard Vautrey, this is something which patients complain about again and again, isn’t it, access to their GP, so is this kind of App the solution?

(RV): We have real concerns, as well as patients do, about the inability of many practices to be able to offer enough appointments and that’s simply because we haven’t had the funding over the last decade to support the expansion of the health service to be able to meet the growing needs of our patients. What General Practices are doing right now is seeing thousands and thousands – if not a million – patients today offering, you know, face-to-face consultations and seeing them in their surgeries, so that’s when patients approach them today. So that’s happening right now. What we haven’t got is the resources to be able to offer some of the IT technologies in every single practice. And the SoS’s commitment to IT is welcome, but we need to see that commitment translated into resources provided to enable every practice to offer this type of consultation.

(Int): But could this kind of technological approach actually help some of the pressure on GPs because people would consult a doctor over the phone rather than going to the surgery.

(AP): Well many practices, if not most practices, already offer telephone consultations. What they haven’t got is the IT kit to be able to offer smart phone consultations, or Skype-phone computer consultations, any many would like to be able to do that, if the technology was provided to them. But the other big difference is that every Practice that is open today will see any and every patient who lives within their area, and we have concerns about the model of which GP Hand has been built, which is primarily about looking at some of the relatively mobile healthy patients and not accepting every single patient who lives within their area.

(AP): I’m afraid Richard that is simply factually not true. We will ask when patients started the service, to ask patients to seek advice if they want to change their GP Practice to our Practice, if they have any clinical issues. Most patients seek advice and join us – we look after them, young, old, sick, healthy, our patients are across the border, and we don’t do that just in Britain, remember we look after one third of the population in Rwanda, and we do so in the United States, we do this in Canada. . .

(Int): But specifically, on this idea of whether you cherry pick patients, it’s likely that patients who don’t have very serious health problems, and maybe younger, are more likely to want to use an App on their mobile.

(AP) . . . but, why is that? If the patient is not very mobile, if the patient is very old, if the patient can’t wait a few weeks to see their GP, they’re significantly more likely to use a service that is continuously available. Many of our patients have mental health issues – they can’t wait for a few days or a few weeks to see their GP. That’s why they switch to us. A thousand patients today will choose to apply to GP at Hand, and then switch their GP Practice – one every three minutes.

(Int): Richard Vautrey, some GP Practices are worried about the fact that if their patients sign up to GP at Hand they then lose that funding, don’t they?

(RV): That’s exactly right. And the way that General Practice is funded at the moment is a balanced mechanism, so those patients who use the service less, and there are many patients that use the service more, and that overall, that compensates one for another. What we have concerns about is that this would effectively replace a personal service with an anonymous call centre and patients don’t want that.

(Int): And finally, Ali Parsa, this was something that commissioning groups in Birmingham were worried about and that was clinical safety – isn’t it better to see a doctor the next day.

(AP): No, it wasn’t clinical safety, you do see a doctor, not a call centre, face-to-face on your mobile and then see one in one of our surgeries. We will open up across the country physical surgeries, their issue was not that. It was an IT hitch that doesn’t allow its screening to be done with your local hospital and that IT hitch has been fixed. This is the future, and I encourage more and more patients to join it.

(Int): Okay thank you both, we’ll leave it there, let us know what your think via twitter.

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  1. Pressure to not admit  people –  fair enough – but can be overdone and mean people are not admitted who should be
  2. Bad experience  esp for elderly frail in hospital, especially A&E,  so they wont go back even if that seems the best  course for them
  3. Lack of capacity in emergency social care – so people  have to be admitted as there is no where else for them to go
  4. Lack of community social care so people end up stuck in (sometimes dying in) hospital when they  would rather be out
  5. Slow response of  social care from council  so that  realistically most of our referrals for social care  are emergency ones
  6. Ambulance service overwhelm so that sometimes people  wait for  hours on the floor  or even with chest pain and  we get called to cover 999 calls they can’t get to
  7. Housing crisis- I  dictate  1-2  letters a  day re people’s  problems
  8. Stress and anxiety caused by benefits  reviews and assessments. We don’t have a great deal of input strangely now into the original benefit application  forms so we tend to only see the fall out eg the distress in anticipation or  after the assessment
  9. The common finding that at review benefits assessments are reviewed in favour of the claimant but financial issues common whilst in the process of assessment
  10. Consequent low morale in the medical ( and other associated professions ) associated with the sense of failure to deliver adequate care  when resources  do not permit ,but where provision of adequate care is seen as a personal / practice responsibility
  11. Increasing complexity ( age new treatments etc ) and increasing cohorts  with multiple morbidity /  age  – but no increasing resource to adequately serve that need
  12. Short sighted  cost cutting choices – eg  health visitor numbers  district nurse numbers  GP numbers – all below full complements –tendency for the loudest voices to be heard and consequent further entrenchment of the “ inverse care law”
  13. Removal / scarce resources for independent  housing/benefits  advice – bht are  good. CAB now very hard to get appointments  – but my experience is  successful benefits  appeals  need you to be very switched on or have  support from  an organisation with experience of what “ boxes to tick”

First published by the War on Welfare blog

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Only a tiny fraction of the ocean of human physical and mental suffering reaches the shores of general practice, from where barely ten per cent of patients are referred for specialist attention. GPs have been trusted to refer judiciously, according to their clinical judgement, saving time and costs of specialist interventions. This gatekeeper role is widely acknowledged to be a key feature of the NHS, which keeps it at the forefront of cost effectiveness internationally.

In recent years, however, the rate of referrals began to rise – the opposite of NHS England’s strategic aim of shifting care away from hospitals. Some commissioners have been offering financial rewards for reducing the rate, a measure which many GP feel is unsafe. The reason for this situation lies in a basic policy conflict.

Since the Conservatives took power in 2010, NHS funding has been practically at a standstill, while costs have risen at a steady 6-7% per year, leading to the present catastrophic deficits with correspondingly desperate cost-cutting interventions. At the same time there has been an unprecedented focus on patient safety, resulting ironically, and tragically, in a culture of fear – reaching its zenith in the recent case of Dr Bawa Garba, a paediatrician who was struck off after a child died while she was working under in an understaffed department without senior cover. A culture of fear is overwhelming attempts to cut costs by doing less. Fearful of missing a rare diagnosis, GPs are investigating more than ever; fearful of a delayed diagnosis of cancer, GPs are referring more than ever; fearful of patient complaints, GPs are prescribing more than ever – with very few exceptions.

At a political level there is a refusal to acknowledge that the problems of high rates of investigations, referrals and prescribing are a consequence of fear, stress and overwork. It is impossible to do less if you do not have time to think more. The quadruple aim of improving patient and professional experience and the health of the population while decreasing costs has been in practice a single aim of reducing costs. By almost every measure, the other three aims (shown by the British Social Attitudes Survey and recent reports into the health of children) have worsened significantly. The only thing the government has succeeded in doing is screwing up (or down, depending on your perspective) the costs.

A few years ago I audited referrals of patients with headaches to our local neurology clinic. I read the referral letters to see if the reasons for referral were clearly stated and if there was sufficient detail about the clinical features, the treatment history, the social context and the patient’s concerns. Many letters had inadequate information and others were comprehensive but were about problems that a competent GP ought to be able to manage. Unsurprisingly all these ‘unnecessary’ referrals came from a handful of practices. We invited representatives to an ’education session’. The session was run by a neurologist to present the expert view while I was there to help think about some of the psychological reasons behind referrals. I told the group how, as a junior doctor working in A&E several years before, I had sent home a young man with a headache who was readmitted after my shift, unconscious and fitting. He had suffered a subarachnoid haemorrhage – a bleed from a vessel in his brain. I nearly gave up medicine then, right at the start of my career, and was very anxious about managing patients with headaches for years afterwards.

About a year before the education session I had met another patient who had suffered subarachnoid haemorrhages and together we spent several sessions teaching medical students about headaches. This way I got over my fear and became our practice lead for headaches. By sharing this at the session I helped the other doctors in the room to think about their own lack of confidence. A year later, referrals from the doctors that came from the practices represented at the session had reduced by between 50 and 100%.

The use of financial incentives to reduce GP referrals reveals a failure to recognise the complex reasons behind a referral. If I am anxious, stressed, rushed and lack time to think carefully and critically, it is much easier to refer patients so that they become somebody else’s problem. Working in the NHS in a time of austerity and digital technology I find myself with less time than ever to reflect or discuss cases with colleagues, while it is easier than ever before to order a wider range of tests. We need to shift our focus of attention onto the experiences of patients and health professionals and the quality of referrals and the outcomes, and then see what that does to cost effectiveness, not the other way around.

First published by the Centre for Health and the Public Interest

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1) Holistic care:

Mental health and social prescribing services are doing their best in our practice area but are massively under resourced. Don’t forget the critical importance of valuing continuity and teamwork in the primary care team – really important for safeguarding, morale and retention of staff. See Watton in BMJ, especially around Health Visitors and District Nurses within practice teams. Same points apply re social prescribing / CSW / Health Trainers

Due to the clear correlations between deprivation, psychosocial problems and physical health, it is a false economy not to invest in mental health and social prescribing as ultimately patients fall back on more expensive NHS services. Many of our patients are illiterate or have poor health literacy and so patients often fall through the gaps of traditional appointment systems with letters and phoning back to make appointments even if they are in the correct age range (which many are not as they are too young or housebound). Many of our patients are struggling due to being victims of emotional, physical or sexual violence: their anxiety can be displayed as anger or addiction.

Improving Access to Psychological Therapies

It is fantastic to have IAPT counsellors in the building (as you know many patients do not attend other sites) but due to the constraints they are working under often our patients living in the most deprived area of Sheffield do not fit the criteria as they can be chaotic or ‘not ready’ for the emotional challenge of counselling.  I wonder if a more flexible type of approach could be taken, many of our patients need to build up trust with professionals over serial encounters before being able to engage – the IAPT triage service doesn’t allow for this, sadly. 

Groups or lectures are on offer around the city but our patients struggle on many levels to attend these due to poor self esteem, confidence and practical issues such as buses, school pick up and travel costs.

I also wonder if a ‘trauma therapy’ approach may be more useful for our patients as I heard about this from another Deep End GP in Glasgow.

In summary there are great counsellors and charities working in our area doing outstanding work beyond their resources but it is insufficient due to the massive need on the our, patients fall through the cracks and this perpetuates poor health and greater pressures on NHS services. Investing more to support mental health services and social prescribing feels right on a moral and financial level to reduce inequalities.

 2) Families and Children:

The links between early childhood experience and brain development has long been known and the field of epigenetics is emerging.

The local family planning clinic has been closed. We predict that unwanted pregnancies will go up in our area. We think investing in sexual health and contraception services, educating girls and women would help inequalities. Early years are crucial yet we have had the team dismantled – the overstretched health visitors are no longer in our practice. When I was a trainee in 2002 the health visitors knew all the families and who to worry about, came to all the practice meetings and we also debriefed over the kettle (a very underestimated source of support and sharing ideas and information!).  Not having the health visitors in our practice feels like a serious threat to safeguarding.

My suggestion would be to get the health visitors and district nurses back in the practices and integrated in the teams – we need more of them too! We need more support to provide contraception, sexual health services and parenting sessions.

3) Multimorbidity & Complexity: 

Again the links between deprivation and complex medical problems and multi morbidity at a young age have been proved and we need help to support our patients with these.

There has been a fantastic collaboration at The Whitehouse for many years between Prof Heller the diabetologist and the primary care team; once a quarter Prof Heller and his specialist nurses come for lunch and a cuppa at the practice and the Multidisciplinary team present our patients with Diabetes for a case discussion. These are complex patients who often won’t attend hospital outpatients. This opportunity of case discussion is so valuable on many levels. It builds personal relationships between primary and secondary care which allow a 2 way flow of information, education and morale essential to providing high quality care to patients. Our patients are not only suffering serious physical problems but the case discussion also allows us to acknowledge their complex lives and histories.

We have also been lucky enough to be part of a pilot with joint clinics between a Paediatric Registrar and GP trainee: this has been shown to reduce out-patient appointments and again develops supportive educational relationships.

We particularly need help with patients who have persistent pain and addiction to prescription drugs – experienced physiotherapists who are aware of issues surrounding deprivation would be a real asset to decreasing inequalities, as this could improve people’s chances of getting back into work and improve quality of life.

More educational cased based discussions between primary and secondary care specialists are fantastic educational opportunities and are invaluable to give the best patient care: Could we have more specialists coming to the practice like Prof Heller? It must be cheaper than running an out patient clinic and studies show that it does reduce referral rates and improve the quality of referrals.

4) Lifestyle: Smoking and getting more active.

We would like our stop smoking service back in the practice! Patients are reluctant to go to the ‘pharmacy’ for this, even though it is relatively close by.

We have recently been in discussion with SIV to see if our patients can have more support in our practice building to get more active and build confidence to going to other venues with someone they trust. The barriers to exercise are complex: one of my patients has flash backs to being raped by her brother and father when her heart rate goes up; another after being raped wanted to make herself obese so no-one would ever fancy her again.  Our patients need kind, broad shouldered, flexible and good humoured health trainers to overcome these barriers.

Health trainers working in house with physios would be really helpful to reduce inequalities.

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