Category Archives: Innovations in Practice

Integration and true collaboration to develop primary care

Cat Roberts is Clinical Lead GP involved in developing and delivering primary care services within an acute trust, including a GP-led frailty service

You can read Cat’s first post: Challenging the norm: GPs as innovators here.

I vividly remember one of my first consultations as a general practice registrar. The patient had a list of complex problems and I did not have the skillset to deal with the multitude of issues or her expectations. The consultation became strained, and as she pressed me for answers and solutions I became more defensive. The defensiveness manifested itself in the use of medical jargon, hiding behind guidelines and explaining resource limitations.  This was a subconscious attempt to assert authority and establish a clear balance of power. It ended rather comically with me leaving the room as I was fearful she never would.  My supervisor emerged from his room, looked over the top of his glasses and inquired:
“Is everything OK?”
“I don’t know how to make her leave my room…”
“Why is she still there?”
“Because I haven’t helped her.”
I perceived she wanted an answer, and whilst trying to find an answer I had stopped listening.  All empathy and rapport had left the room. I returned to the room with some new questions which were able to facilitate meaningful conversation.

These are all symptoms of a floundering relationship and a dynamic that makes sharing management a challenge.

Why did that all go wrong?
Is it possible that this dynamic exists on a larger scale with our colleagues in secondary care, community care and social care? With limited resources and time we may become defensive and confrontational towards one another; too quick to assign blame, judging each other’s skillset and capacity. Do we subconsciously imply a balance of power in the wording of a discharge letter, when referring a patient to a bed manager, or in our tone in a referral form?  Are we creating boundaries, relinquishing responsibility, being fearful of blame? Are we angered by perceived unfair allocation of time and resources? These are all symptoms of a floundering relationship and a dynamic that makes sharing management a challenge.

Tell me about yourself
One of the six principles of our Integrated Frailty Service is Culture and Education. We host joint educational events on topics relevant to frailty and multi-disciplinary team members frequently present. GPs run sessions on managing uncertainty and other strategies that are intrinsic to consultations in primary care. Hospital clinicians present the latest evidence based practice, reawakening our love of clinical medicine and allowing us to cast our net of differential diagnoses wider. These sessions are attended by both clinicians and non-clinicians so we request that anyone attending avoids jargon and tailors content appropriately. Rapport between clinical directorates and across providers is restored, stories are exchanged and challenges are viewed from all perspectives. Myths and misunderstandings surface and are addressed and a true empathy of each other’s skills and constraints develops. This principle, despite being impossible to quantify in data and Key Performance Indicators, has the most tangible benefit and has the biggest impact on patient care.

Both camps are fearful of change, repercussions, impact on patient care and sustainability.

Maybe we both want to achieve the same thing?
Another core principle of our service is Integration. This broad term refers in part to practical challenges such as shared electronic records, imbedding the service within the directorates of the Trust and helping align community services to best respond to patient needs. It also underpins another vital relationship needing bolstering – that of the clinician and the non-clinical manager. Sometimes frustration, exasperation and being overwhelmed by a problem can manifest as apathy, indifference and a reluctance to engage with any system improvement drives. Both camps are fearful of change, repercussions, impact on patient care and sustainability. Perceptions are sometimes tainted by behaviours and the balance of power fluxes between clinicians and managers. The result can be systems which are fragmented, dysfunctional and hinder clinical care and positive patient experiences. The potential gains in true collaboration and understanding result in seamless transitions of care for patients – with experts in clinical care optimising their time and skills, and experts in strategy and operations facilitating this change.

The consultation no longer feels overwhelming or hopeless.  We may have reached a middle ground in terms of mutual understanding and empathy. The complex problems still exist but the management is starting to feel shared.

Read Cat’s last blog: Challenging the norm: GP as innovators

Challenging the norm: GP as innovators

Cat Roberts is Clinical Lead GP involved in developing and delivering primary care services within an acute trust, including a GP-led frailty service

Following a few years of basking in the ‘delicious ambiguity of general practice we returned to the hospital wards to try to fully understand patient care pathways. Any doctor studying for membership exams will describe how the second learning cycle is so much more meaningful when digested with a wealth of clinical experience – the same is true of returning to secondary care having worked in primary care. We were stepping from a land of hypothesis into a land of diagnosis, from a world where uncertainty is used as a tool to a world where much is done to eliminate ambiguity.

The aspiration was to create a service for frail older patients. The pilot funding had been secured and we had a year in which to create a service of value. Would there be a role for GPs to work alongside gerontologists to create a Frailty Unit for these patients, focussing on key generalist principles – a holistic Comprehensive Geriatric Assessment, avoidance of over-medicalisation and aligning primary care, community services, social services and voluntary sector to facilitate this pathway?

We needed to learn another language – ‘management’ in order to communicate our understanding and to understand the ideas, concerns and expectations of managers.

The challenges that presented themselves were not clinical, in fact the familiarity of vague symptoms sets and unusual health beliefs in patients provided an anchor in a strange land. The challenges were operational, practical and political. We needed to learn another language – ‘management’ in order to communicate our understanding and to understand the ideas, concerns and expectations of managers.  In working with healthcare managers, we had to develop a new version of a shared management plan and understand each other’s agendas to improve concordance and collaboration. This was a GP consultation on a larger scale, held in an unfamiliar language, with different cultural backgrounds and with intrusive time constraint

In order to design a service for frail older patients you need to ask some fairly controversial and challenging questions of all providers, including familiar questions such as:

  • When is discharge safe?
  • When is it safe to stop a medication?
  • What if I miss something by not investigating?

However, some of the most useful questions include those not routinely asked such as:

  • When is admission safe?
  • When is it safe to start a medication?
  • What am I hoping to achieve in investigating?

Pressures, processes and clinician behaviour often means these questions do not have time to be asked, let alone answered.  And can you ask these questions unless you fully understand the alternatives?  GPs have all trained in secondary care however not all secondary care clinicians have had the opportunity to spend time in primary care – it is challenging to place trust in a system that you don’t fully understand, especially if your perception has been altered by examples of when that system has not worked well for your patients.

GPs will always be scholars – they are puzzle solvers, they delight in ambiguity and they will always seek to liberate themselves from conventions and assumptions.

So, our focus and first step was to start to develop mutual understanding with our secondary care colleagues, because those questions can only be asked and truly shared when they are perceived as a shared challenge. To start to gently challenge systems and behaviours was a fragile and privileged journey that required small tentative steps and open and constructive dialogue.

Over the course of a few blogs we would like to take you on this journey with us, to share our experiences, to explain the organic evolution of our service principles and structure, to reaffirm the notion that clinician-led service design and development can work, to celebrate in our successes and ask for your guidance with our challenges. GPs will always be scholars – they are puzzle solvers, they delight in ambiguity and they will always seek to liberate themselves from conventions and assumptions. These skills are not confined to clinical medicine.

General Practice: The Game of Inches

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

Latest posts by Adam Staten (see all)

Anybody who was a fan of movies, sports, or Al Pacino in 1999 is probably familiar with Pacino’s famous ‘game of inches’ speech. Pacino was playing the part of coach to a struggling American Football team and it was with this speech that he inspired his team before they ran out for a make or break match. Many consider it to be a paradigm for motivational speaking.

In it he describes American football as being a game that is won or lost by inches. The inches are the fine margins found everywhere on the pitch that determine the outcome of the match; the inches by which a crucial kick is made or missed, the inches by which a touch down is scored or stopped, the inches between a ball being caught or fumbled.

The general practice consultation is a game of inches or, more accurately, a game of seconds. In a world of increasingly complex patients and increasing administrative burden every second within the ten minutes counts. Squeezing every second is the difference between running to time or running late, it is the difference between satisfying the patient by dealing with their second problem or getting an unpleasant comment on the friends and family test, it is the difference between having the time to make the right decision or the wrong one.

In between looking at that funny mole and ticking the QOF boxes, it is easy to let the note taking seconds vanish from the consultation. How often is a complex and draining consultation summed up with a couple of rushed and inadequate sentences that hardly do the interaction justice as we hurry on to see the next patient? How often do these rushed entries leave us indefensible in the eyes of the law and the GMC should things turn out badly?

It seems unlikely that our patients are about to become more straightforward and, whilst we might wish it, the administrative burden of our roles is unlikely to diminish any time soon. But there are ways that we can squeeze those vital seconds, ways in which we can make that part of the consultation count.

How many of us ever learn to touch type?

For example, almost every interaction we have with patients results in typing and yet how many of us ever learn to touch type? A proficient touch typist can type as quickly as someone speaks and it is a skill that is relatively straight forward to acquire with a few minutes of practice each day over the course of a few weeks.

Of all the technology in our rooms, the keyboard is amongst the most simple and yet most of us use it badly. Data from NHS England suggests that the mean number of words typed in a GP consultation is 29.¹ This seems very little given the often complex nature of the consultations and probably reflects the time pressures involved. This data was from an audit of 200 consultations and data acquired from the same audit suggested that a GP who touch types rather than using the ‘hunt and peck’ method of typing could save 17 minutes each day, or nearly two consultations worth of time, based on 40 consultations per day.

Perhaps better yet is to stop typing altogether. Voice recognition technology is not new but it has taken some time for it to become capable of handling medical dictation. At my practice, most of the GPs now dictate directly into the patient notes, both for consultation notes and for letters, obviating the need to type at all. We use Dragon Medical which can transcribe at a rate of 160 words per minute, but there are numerous other medical transcription software packages that are capable of the same.

The ten minute consultation is bursting at the seams as is, arguably, the whole of general practice. If a seismic shift in the way we work is not soon forthcoming then, for now, we need to work in the inches. We need to find ways to make every precious second count and there are relatively simple technologies available already that can help us do that.



Self discovery with an ankle fracture

Kate Dawson is a full-time remote and rural ​GP on the Isle of Benbecula in the Outer Hebrides.

At our staff night out, I slipped on a wet dance-floor, and in a moment, fell and became a patient. I couldn’t put any weight on my foot, and my ankle swelled dramatically. As a consequence, I have learned a lot about myself, our systems, my colleagues, and about being a patient.

Our practice manager showed the most clinical acumen, and provided paracetamol and an icepack. The party continued as I watched from the side-lines,

I was on duty in A&E in our community hospital two days later and arranged for my ankle to be x-rayed. I knew there was something up when the radiologist asked me how much my ankle hurt; I had walked into the department, having done a full surgery. She confirmed that I had a comminuted fracture of my right ankle, in the run-up to Christmas, a time of year when medical locums are hard to find. I had an air-cast boot and crutches provided by the A&E nurse, and continued to the ward-round.

Three weeks later, the swelling was down but the orthopaedic surgeon was not happy, and I was admitted for open reduction and fixation in the Western Isles Hospital, adding another few weeks onto my recovery.

Firstly, I had no idea how much hard work it was using crutches. I had no problems with the co-ordination, but the strength required to walk more than ten yards is significant. My hands hurt, my shoulders were cramping up and my gluteal muscles had to learn how to balance me on my good leg. It took me quite a while to get to grips with this.

Secondly, my sisters both broke their wrists, and we have been able to compare notes about progress, the advice we were given and the progress we have made. It led me to examine the information and support we give to patients with common wrist and ankle fractures. The information that we have is quite brief, and focuses only on plaster care. Between the three of us, we have written four patient information leaflets, which are now being reviewed by a patient panel, plaster technicians, orthopaedic surgeons and physiotherapists. The aim is to adopt this board-wide.

The physios are very keen to be able to provide support with walking aids, exercises and treatment plans much earlier. We are meeting to discuss how we improve the pathway for patients with musculoskeletal injuries.

I am prone to doing everything myself, and I had to learn to ask for help.

Thirdly, the kindness that I experienced first-hand from colleagues and patients alike was wonderful. I am prone to doing everything myself, and I had to learn to ask for help. There is an art to this, making sure that your wishes are clearly expressed and the need for action described. Our wonderful practice manager rearranged the rota to cover my two weeks ‘resting’ with my leg up post-op, colleagues and locums all stepped up to fill the gaps.

Fourthly, I have learned that slowing down doesn’t mean that I do less. Instead of rushing around, sorting out everything in a whirl, I must plan my route through the day to take into account lifts, locations and tasks to be done. I have successfully ‘reabled’ myself by buying aids online, unbelievably cheaply, and remained independent where possible.

Lastly, this experience of being a patient has also illustrated very clearly how my agenda as a patient can be reframed by a few wise and confident words from a fellow professional. The orthopaedic surgeons and physiotherapists knew exactly how to motivate me into doing the right things, with good direct communication.

In exchange for a broken ankle, I have found my practice team to be kind and resilient, and I have developed the arts of patience, planning and delegation. I have started the improvement of the care that we offer patients with MKS limb injuries, anticipating better outcomes in the future.  My focus on good consulting skills is going through another cycle of improvement, and the cat is pleased too; I am sitting down more, and my lap is available more often.

BJGP Open: adapting primary care for migrants

Photo by shawn at

The aim of this paper was to provide some insight into how primary care is managing to offer care to migrants. In particular they were interested in looking at the challenges and the ways in which practices and practitioners were adapting to meet this need.

The first phase was an online survey. During this they surveyed 70 primary care practitioners. They then used responses to select eight case studies for a further qualitative phase. They had a mix of mainstream GP practices as well as specialist services that offered tailored services to refugees, asylum seekers and other migrants. There was one group interview (with three GPs from the same city) and seven further in-depth interviews. The descriptive analysis was structured around the principles of equitable care that drew on the framework from Browne et al.

They found that practitioners tended to focus on working with community and external agencies and adapted their own processes in order to avoid care. This was particularly evident in areas such as screening, vaccination, and health checks. The biggest barrier was the lack of funding and this was cited in 73% of cases. The organisation and partnerships were regarded as particularly important to ensure there is an awareness of wider social determinants, the impacts of trauma and violence, and all this had to be wrapped up into culturally-competent care.

Opinion: There is a small section in this paper that caught my eye in relation to burnout. Just over one-third (34%) cited personal fatigue/burnout/capacity as a barrier to developing services. The additional workload ramped up the stress for some healthcare professionals and in one of the services they had introduced life coaching. In another they had adopted debriefings that are similar to those used in conflict areas.

“I think in terms of values, everyone sees the work that we do in serving vulnerable groups as a privilege.”

I’d put a positive spin on the burnout angle – it can be enormously re-invigorating to get involved with marginalised groups. As one ‘mainstream’ GP stated: “I think in terms of values, everyone sees the work that we do in serving vulnerable groups as a privilege.”

There are some fine examples in this paper on how primary care can be developed to give a more “equity-oriented service”. It showcases how, despite all the appalling strain on the system, there are still ways for primary care to innovate to reduce health inequalities. More than anything we should be driven by the principle that we need to reduce health inequalities to improve our societies. And sometimes we need to hunt these people down. Whether it is people with learning disabilities, or the mentally ill, or people who inject drugs, the homeless or as in this case migrants and refugees – these are the groups of people that need our attention.

ResearchBlogging.orgSuch, E., Walton, E., Delaney, B., Harris, J., & Salway, S. (2017). Adapting primary care for new migrants: a formative assessment BJGP Open DOI: 10.3399/bjgpopen17X100701

Arclight: a new ophthalmoscope and otoscope

John PorterJohn Porter recently completed his GP training and is enjoying living in Bath and working as a salaried GP in Bristol.

There are items of equipment without which a GP in clinic cannot function. Top of this list comes a stethoscope. Closely followed by an ophthalmoscope or otoscope.

As I neared the end of GP specialist training the time was nearing to hand back the practice supplied equipment and to put a hand in my pocket and buy an ophthalmoscope/otoscope of my own. A few hundred pounds, this tends to be the most expensive item needed to get started after training.

With my credit card about to take the hit I got talking to a friend who had returned from working as a doctor in Uganda and was continuing to use a novel ophthalmoscope/otoscope designed for use in developing world environments in his work as a NHS hospital doctor.

After giving it a once over my initial impression was that the Arclight device worked well. ( I could see the benefits the novel lightweight device would have when used in areas of the world where its inexpensive price and the lack of need for batteries is an advantage, and wondered if it also had a place in the bags of GPs in the UK.

Out of personal interest in low cost and innovative technology I acquired and distributed 36 devices to both qualified GPs and final year trainees to find out more (mean clinical experience was 11 years).

I started with questionnaires to gain insight into what GPs thought of their current kit. What I found was that the vast majority of GPs who took part used their ophthalmoscope between 5 to 10 times per week. Their confidence in ophthalmoscopy using their regular devices was 6.4/10 (mean), with a range of 4/10 to 9/10 (1 being no confidence and 10 being very confident). In otoscopy confidence was 7.8/10 (mean) and ranged from 6/10 to 10/10. Problems with batteries and bulbs, being cumbersome to take on visits and expense were widely shared complaints.

Arclight devices were trialled in clinics for 6 weeks. End questionnaires found confidence in ophthalmoscopy using Arclight scopes was 6.9/10 (mean), a range from 3/10 to 9/10. Confidence in using the Arclight scope for otoscopy was 8.1/10 (mean) and ranged from 6/10 to 10/10.

Users found that the Arclight scope’s light weight and small size was beneficial to them in general practice, as were the bright LED lights which were found to stay consistency bright. Suggestions for improvements in the device included making USB charging less fiddly and improving the stability of the otoscope ear pieces when fitted. 75% of users said they would continue using this device after this trial and 92% would recommend the device to a friend.


It would appear that the Arclight ophthalmoscope and otoscope device would be very welcome in GP bags (and I would anticipate around the necks of hospital doctors and medical students).

Interestingly I found user confidence with the Arclight scope better than that reported from the traditionally used more expensive and cumbersome devices without their frequently encountered battery and bulb problems.

Dr John W Porter, GP, Kingswood Health Centre, Bristol & Dr Keir EJ Philip, Core Medical Trainee, Barts Health NHS Trust.

Of note neither I nor my friend Keir Philip have interest invested financially or otherwise in Arclight ophthalmoscope/otoscope devices, we’re just intrigued by this sort of thing!

Tasked based medicine and the generalist

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

Latest posts by Adam Staten (see all)

photo-1463171379579-3fdfb86d6285Perhaps I have had a run of bad experiences but I sometimes feel that our secondary care colleagues are beginning to act as technicians and not physicians, directing themselves to a particular task to rule in or rule out a particular diagnosis, and ignoring the fact that the patient is suffering from symptoms, not from a diagnosis. For instance, you may refer a patient complaining of acute onset shortness of breath to the medical team, querying a PE, to have them sent back to you with ‘no exertional desaturation, d-dimer negative, no evidence of PE’. So now you find yourself with a breathless patient who mere hours before was tantalisingly close to investigative possibilities that would have given you an explanation for their breathlessness, but who is now back in the community, still breathless, and as distant from those investigations as they were when they first came to you.

I don’t hold this against those working in secondary care, they are usually as swamped as we are, and they get given a task, get on with it, and then move on to deal with the mountain of other tasks awaiting them. But this task based approach to medicine makes for some very clunky and uncoordinated care for patients with complex or difficult to diagnose conditions. These patients can end up batting back and forth to the hospital being seen by different specialists in different specialties to get the investigations that they need.

It may just be the local guidelines and protocols where I work but I often feel that I make referrals simply to get a particular investigation done. Colonoscopy for example. There are certain patients who clearly need a colonoscopy, such as those with suspected inflammatory bowel disease. I can take the history, take the bloods, check the faecal calprotectin but then, at the final diagnostic hurdle, I have to refer, and so my patient will wait weeks to see either an SHO or a registrar in clinic who will take the history again, probably repeat the bloods, and then agree that they need a colonoscopy.

Part of the problem has been the inverted investment strategy of the last decade that has seen the number of hospital consultants increase at double the rate of GPs. This burgeoning cohort of consultants are sustained in purpose by the artificial rationing of investigations and the production of guidelines where every step is caveated with the advice to consider referring to a specialist.

Clearly resources are finite and we will always need appropriate stewardship of diagnostics but is this not best done at arms-length by specialists, rather than with face-to-face consultations?

In this month’s BJGP Sampson, Barbour and Wilson explore the use of email communication between primary and secondary care and their findings suggest that its use is patchy and limited.1 But should this not be the default means of accessing secondary care investigations for the majority of our patients? A brief email exchange between GP and specialist to guide and rationalise investigations is surely a far more effective use of everyone’s time and money than sending patients to have an outpatient appointment to have investigations arranged that could have been arranged weeks before?

This would enable GPs to do what they are supposed to do: provide holistic and co-ordinated care for their patients. It would also allow consultants to do what they are supposed to do: be consulted. There is some evidence that working in this way can cut the need for outpatient appointments by up to 50% in some specialties which would certainly ease the pressure on the whole system.2

As outlined in the same paper, there are some potential problems with email communication, particularly around the issue of confidentiality, but there are already systems in use around the country that have overcome these issues. Surely the use of these should be much more widespread.

NHS England’s Five Year Forward View has lofty ambitions of moving care back into the community. Allowing GPs much freer access to the full range of diagnostics will hugely facilitate this aim.


1. Sampson, Barbour, and Wilson. Email communication at the medical primary–secondary care interface: a qualitative exploration. Br J Gen Pract 2016 Jul; 66 (648)

2. Roland M, Everington J. Choose and Consult over Choose and Book. Health Serv J 21 Jan 2016

Shared medical appointments: better by the dozen

Jonny Coates

Jonny Coates

Jonny Coates is one of the First5 GPs that’s not in Australia.He works in Newcastle upon Tyne.
Jonny Coates

file0001900347815A great deal of medicine is education.  The title ‘doctor’ is derived from the Latin word for teacher.

Before getting that title, I spent three years working as a TEFL (Teaching English as a Foreign Language) teacher: first in Spain, and then with VSO in Eritrea. I’m no expert educationalist; but I learnt enough to see that a 1:1 interaction is often not the best way to impart complex information.

In general practice, I see patients exclusively on a 1:1 basis, in short 10 minute bursts. I have to explain and discuss difficult concepts, and am often left frustrated that I can’t do this justice in a rushed 10 minute consultation. Many of my patients share this frustration.

It’s all the more frustrating, because I often have almost-identical conversations (let’s say lifestyle change in diabetes) numerous times each week, with different patients. I’ve often wished I could have all those patients sat together, and instead of delivering six sub-optimal 10 minute explanations, I could spend an hour doing it really properly, and have more in-depth discussion.

But the increased time we’d have wouldn’t be the only advantage. What I learnt from teaching – whether it was classes of 8 businessmen in Barcelona, or 80 school students in Eritrea – is that learning in groups provides the opportunity to learn from each other; for ‘horizontal’ as well as ‘vertical’ (top-down) learning. It is active learning: the concepts are brought alive through being discussed.

So when I read about ‘shared medical appointments’ on the RCGP Bright Ideas website it rang a whole heap of bells. Here was a way of consulting that sits between the 1:1 appointment and a group education session (where a teacher addresses the group, but only as a group, not individually).

And so, I wrote to Rob Lawson, the article’s author, who set up a group of like-minded clinicians.  Now, a few months down the line, we’ve tried them in our practice.

We invited patients to have their COPD reviews in a group.  Patients were seen in the waiting room, on a Saturday morning. They were given refreshments on arrival, and signed a confidentiality agreement. The practice nurse and pharmacist collected key data: FEV1, their MRC dyspnoea score, smoking status and sats, and put all this information on a white board.  Then I came in, and proceeded to consult with each patient in turn.

The nurse facilitated these conversations, directing me and other patients as appropriate. When an issue came up that had relevance for numerous patients (as it invariably did – smoking, spacers, nebulisers, inhaler technique, pulmonary rehab, rescue packs) I spent longer discussing it, often using the whiteboard for explanations. Other patients with relevant experience chipped in.

Patients really liked it, evidenced by their evaluations (see below), but more importantly, by the practice grapevine – conversations with receptionsts, overheard things in the waiting room. A common refrain was how much they’d learnt, and how good it was to know that other people were in the same boat. The appointments themselves felt warm and supportive, and there were lots of laughs; a breath of fresh air for us clinicians.



Some great things happened, during and after the appointments:

We had an unprecedented uptake in pulmonary rehab classes. Like many practices in deprived areas, we’ve previously had very low uptake in these classes (and the same is true for DESMOND for diabetes). There was some great peer-peer learning and motivation: a patient saying how good they feel for stopping smoking/doing exercise/using a spacer is much more powerful than me as a doctor saying it. Connections formed between patients – e.g. two patients who previously didn’t know each other, but walked home from the appointment together, and agreed to give pulmonary rehab a try together.

Patients got answers to questions they didn’t want to ask themselves. For example, a patient raised panic attacks in the context of COPD: we know these are a big issue for patients with respiratory disease but it’s often not raised by either patients or doctors. We were able to go into this in detail, and it was clear that this resonated with many other people in the group. This was extremely powerful in normalising what they were going through, and how to seek help. There were challenges of course, mainly logistical: space (we can’t use the waiting room during the week), staff time, recall systems. These are surmountable, but need thought if we are to extend the use of these consultations. In terms of resource, we expect that these should be at least cost neutral (compared to current ways of working) once we get teething problems out of the way.

Our biggest concern as clinicians before doing these, was confidentiality. However, in common with the experience of other countries, patients didn’t raise any concerns about this. We only discussed things that patients themselves volunteered, so the patients were in control of what was disclosed. In fact patients were surprisingly candid.

Where next? We plan to continue piloting these, and diversify into other disease areas. Diabetes and childhood asthma/eczema are the next areas we’re trying, and I’d like to try them in chronic pain in the future. Elsewhere, they have been used for a huge variety of conditions (acute and chronic), with great success.

If you are a clinician interested in finding out more, or trying these for yourself, the UK SMAC group now has 40 members from primary and secondary care. We are holding a meeting in Sheffield in October, and new members are welcome. If you are interested, please get in touch by leaving a comment, or by emailing Rob Lawson, the secretary of the UKSMAC group:

Genuine patient participation: implementing change in Islington

Philip WrigleyPhil Wrigley is a Commissioning Manager in Islington where he has worked for over 12 years; he currently leads on LTCs and Self Care – prior to 2004 he was a professional actor for 25 years.

There is a scenario frequently used by visual comedians which opens with an elderly, infirm lady standing at a busy crossroads looking a little glum as she watches the traffic whizz past. Our hero, (Benny Hill, Norman Wisdom, et al), assuming that she is trying unsuccessfully to negotiate her way to the other side, takes her by the arm and merrily frogmarches her to the other side. Setting her gently down and beaming at her, he stands back expecting grateful thanks. Instead he is met with a barrage of abuse and repeated thwacks from her handbag and walking stick. The woman of course had had other intentions: she wanted to go across the other road or in the opposite direction or she was standing waiting for her friend, etc. Whatever the reason for her irritation, the point is – the last place she wanted to be was where she ended up.

The story highlights the problems of well-meaning people (in our case care professionals) who fail to take into account the real needs and goals of the people whom they are trying to help. It’s extraordinary in this day and age that we still consider actually taking note of the views of patients/service users/people to be such an innovation.

In Islington for the last few years, we have been trying to change the way that our whole workforce delivers care, by ensuring that we commission services which support and promote a more personalised and collaborative interaction with our residents who are using the health and social care system.

The change is not an easy one and involves that heart sink phrase: “culture change”. As commissioners we tend to over use the phrase and it loses some of its weight. It is important constantly to remind ourselves that changing the way people work and interact with others is extremely difficult and can be the cause of a great deal of anxiety on both sides of the interaction.

In Islington we believe that it is not unreasonable to expect residents to take on some of the responsibility themselves and to work with their care professionals to take control of their own wellbeing. In order to take that opportunity, they must be provided with the education, support and the tools to take on the shared responsibility. We acknowledge that this concept is new for both professionals and the population itself, so expecting a whole workforce to move away from the paternalistic approach to healthcare and treat patients as experts in their own care can be unnerving to say the very least.

If this change is to happen the whole system needs to be committed to the approach and the people who will drive the change are the commissioners. No single method is correct but it must also be recognised that no single method will ever be enough. At Islington CCG, we like to refer to ourselves as a “patient centred care organisation”. This may be wishful thinking but I believe we are a little further down the road towards this goal than many other organisations.

The most important thing for us has been a commitment from the top in the CCG and the Council and we are lucky enough to have some extremely charismatic and committed leaders, both at a clinical and commissioning level. Make no mistake this is crucial to any shift in attitude and needs to be in place before you can start to drive the change from the bottom up. Professionals need to be secure in the knowledge that they have the approval from above in order to start changing the culture on the ground and to be confident that this is a strategic approach.

Once the commitment is in place from people who are passionate about care and support planning you have won the first battle, though the way ahead will undoubtedly present further skirmishes. Our commissioning approach to embedding person centred care in Islington is basically not to concentrate it on a single area but to try and make it business as usual across the whole health and social care setting. We have a range of initiatives which we are using to influence professionals across the whole system. As long as the people who implement the changes at the coal face can witness the improvements to patient care, patient well-being and their own job satisfaction, it doesn’t matter that there is no single implementation process. In fact if change is coming from all angles then that is a signal that you are getting it right and that the message is being broadcast and received across the whole landscape.

There are naysayers who will complain that there isn’t sufficient evidence to show that it works, but honestly, there is actually a lot of evidence out there and even in situations where it is thin, there has to be a point when you turn and say, “It’s just common sense to treat people as grown-ups and as experts of their own health conditions”. We just need to learn to step back from our compulsion to do things for people and start to work with them instead.

Bridging the gaps in care: are charities the way forward?

Ashika Sequeira (top right), Vanessa Oo (lower right) and Alexandra Grove (left)

Ashika Sequeira (top right), Vanessa Oo (lower right) and Alexandra Grove (left)

Ashika Sequeira trained on the Bromley GP Scheme and is a Locum General Practitioner. Alexandra Grove is an ST2 trainee in General Practice in the Tower Hamlets training scheme, East London. Vanessa Oo is a GPST2 in the UCLH GP training scheme.

Work can sometimes feel like a battle: a daily struggle to engage with our ever increasing list of patients and their complex co-morbidities. One of the challenges we face is a society which promotes unhealthy practices. Despite a growing awareness of the negative impact of poor diet and sedentary lifestyles on health, effective preventative care is increasingly difficult to deliver in our time-pressured consultations. Empowering our patients to proactively manage their health has never been more important in the role of a GP.

Our recent experience working with a homeless charity has opened our eyes to ways we as GPs can tackle preventative care through collaboration with community groups. Through Team Up, (an initiative bringing charities and trainee health professionals together to improve health), we worked with Single Homeless Project (SHP), a charity organisation based in North London.

Our aim was to provide the charity’s homeless clients with a simple, sustainable intervention to improve their health.

There were several challenges: the clients were difficult to engage in regular healthcare promotion and re-attendance was low. The homeless population in general has a higher incidence of medical and psychological morbidity, exacerbated by factors such as smoking, alcohol and drug abuse.1,2,3 Barriers to accessing healthcare in this population often leads to multiple presentations to A&E, a difficult and inappropriate environment for preventative care.

An extensive survey by the charity identified 70% of their clients were interested in taking part in some sort of exercise and 60% were interested in exploring their community.4

This led to the idea of a regular walking group for clients within SHP’s existing geographical sites. We decided to deliver health promotion through SHP’s existing staff to take advantage of their personal relationship with clients and to ensure the project would be sustainable. We designed an interactive session based on the theme of exercise to be delivered to SHP’s staff.

Feedback from both staff and managers was that the presentation was accessible and served to highlight the usefulness of health statistics in relating the impact of walking to a healthier lifestyle. 65% of staff felt they would not be able to discuss exercise confidently with their clients and over 87% did not know the current Department of Health recommended exercise guidelines. Following our intervention, this increased to 100% in both domains. ‘It’s easy to forget about exercise when dealing with clients who may be living in chaos, I hadn’t thought about what they might already be doing as a way of highlighting other strengths’ commented one staff member.

The momentum has continued to build. SHP walking groups have now been set up at least monthly in four London boroughs. Part of their success has been SHP enthusiastically taking over the original idea, developing their own versions, including mushroom collecting and photography walks to suit their smaller groups.  One of SHPs most encouraging comments has been that it has put exercise on the agenda for their charity.

These successes have demonstrated the power we have as health professionals to involve health as part of the conversation with charities. Charities have a wealth of experience with patients we may otherwise find difficult to engage. They provide a unique understanding of the community, can provide local links to resources and have often built up years of trusting relationships with clients.

GPs working in partnership with such community groups could provide effective prevention and health education to a much larger population than within the confines of a consulting room. Furthermore, working with a charity can be an invigorating way to flex a different part of your brain and develop a unique skill set.  It was really enriching to take on an organisational role and work with specialists from another discipline.

Of course, with primary care already at breaking point and resources thin on the ground, we are certainly not suggesting this should further overburden GPs at the expense of regular patient care. CCGs should encourage building networks between GPs and community groups and provide funding for GPs to support these groups. We would argue, in the long term, this represents a more efficient model for health promotion and providing preventative care, particularly in populations with significant barriers to access. In resource-pressured times, we need to think outside the box.  It’s time to come together with charities – for our patients, for our NHS, and even for us.


1. Schanzer B, Dominguez B, Shrout PE, Caton CLM. Homelessness, health status, and health care use. Am J Public Health. 2007;97:464–469
2. Chau S, Chin M, Chang J, et al. Cancer risk behaviors and screening rates among homeless adults in Los Angeles County. Cancer Epidemiol Biomarkers Prev. 2002;11:431–438.
3. Fischer PJ, Breakey WR. The epidemiology of alcohol, drugs, and mental disorders among homeless persons. Am Psychol. 1991;46:1115–1128.
4. Single Homeless Project, London. Available at