BJGP Open: adapting primary care for migrants

Photo by shawn at Morguefile.com

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

“Too big to talk about”: Organisational momentum and its paralytic wake

David Zigmond was a small practice GP in south London 1977-2016. You can
read Obituary for St James Church Surgery here.

Corporatism often enlarges and entrenches itself by increasing demands for compliance. Eventually though, unchecked, this will sicken any organisation. Such is now evidently ailing our NHS. A brief glimpse from a small conference provides a sample.

November 2016, London. A small conference of (mostly junior) doctors. The brief: to better survive the increasing stresses of their work. They are being mentored, guided, enabled and reassured by evidently concerned and sympathetic senior clinicians and cohort managers.

Supportive, ventilatory and distracting strategies are suggested: these may palliate, encourage and help endurance.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are. An older patrician-clinician, Dr O, is able to reassure with statesmanlike knowledge and know-how. Yes, appraisals are an unpleasant, inordinate and major stress for many doctors, Dr O agrees. But he can personally help with this: he knows how the system operates, and who operates it: Dr X, for example. Dr X is very senior in the appraisal hierarchy and wants to be helpful to our many needlessly and haplessly struggling doctors. He can pass on many tricks, feints and shortcuts to neutralise the formidable administrative obstacles and find easier ways to demonstrate the compliance now essential for professional survival. Yes, Dr O continued, these are testing and perilous times but there are those – like Dr X – who will provide sanctuary, ‘a safe house’, help with ersatz documentation. The important thing is that we find ways to tender what we must: to survive.

As I listen to these exchanges I recall heroic stories from World War II: of resistance movements stealthily sheltering, then smuggling to safety, downed allied airmen; of Oscar Schindler duplicitly providing false documentation and work to protect those otherwise doomed. Dr X seemed, to me, like Schindler and Dr O his discrete emissary.

All these efforts, albeit unintentionally, perpetuate a bad and destructive system.

I admired all these caring and protective seniors and the responsibility they showed for the welfare and survival of their juniors. Yet I was doubtful of the larger benefit that would come from these sincere and substantial efforts: to help these tired and craven doctors to pass muster, comply to regulations they experience as draconian, and then survive-by-adaptation with the mandatory documentation. All these efforts, albeit unintentionally, perpetuate a bad and destructive system. Adaptation via obedience can easily turn to collusion.

I attempted, with respectful diplomacy, to say this. I summarised briefly: “I really like the comforting care, support and healing that’s being offered between you. But something much bigger is being ignored: the unsustainable, toxic and oppressive environment we all have to work in. These forces overwhelm and fatally undertow all our attempts to mitigate or repair…”

I had wanted to offer a brief profile of the component-agents of our pathogenic healthcare culture: how the 4Cs – commercialisation, commodification, corporatisation and computerisation – are driving out the human and vocational heart of our work; how our erstwhile (mostly) humanly gratified professional ‘families’ are displaced by managerially driven and depersonalised systems of ‘factories’; how our health services’ administrative devices all drive the larger system that is so ailing and alienating us. The entire Internal Market, Commissioning and Inspection cultures, in their many guises, all contribute: autarkic NHS Trusts, financially-based competitive commissioning; burgeoning performance-related targets with their necessary machinery for monitoring, data, negotiation and penalties; the resulting, ever-increasing need for compliance, surveillance, policing, documentation and (to mop up any surviving outliers) strictly regulated professional appraisal and validation …

But the chairperson arrested the beginning of this flow. She judged it well beyond the scope of this meeting: how may clinicians now best survive?

***

During a short break a veteran manager approaches me. “I know what you want to say. Almost everyone here would agree with you. But there’s nothing we can do about these things: they are far too big for us to influence them”, she says with fraternal commiseration. “In any case, this is not the right forum”, she adds with cautioning advice.

“Well, there never is a ‘right forum’ for discussion of these crucial things now. This recurrent exclusion is not accidental. It is the tip of a systemic iceberg: it tells us much about the size and nature of our problems. Paradoxically, our lack of open discussion indicates why we must talk candidly. And if not now, when?”, I replied.

The manager seems attentive to this but says nothing. She meets my gaze and offers me a brief smile. To me this seemed unjoyfully complex: contrition, appeasement, fear, alliance, apology, irony and respectful pity. I smiled back, wondering what she saw.

She turned to join Dr O. They re-entered the conference room.

—–0—–

Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com

 

Saving the NHS – the struggle to manage increasing anxiety

Peter Aird

Peter Aird

Peter is a GP in Bridgwater, Somerset.
Peter Aird

Photo by hotblack at Morguefile.com

On the eve of the 1997 election, the year I became a GP partner, Tony Blair declared that the nation had ’24 hours to save the NHS.’ Twenty years on, like those who advised the emperor who paraded about town in his nonexistent new clothes, some politicians pretend they cannot see that the NHS is in the altogether perilous state of near collapse. One wonders if they have completed a DNAR form for the NHS without the agreement of those who love it most.

One wonders if they have completed a DNAR form for the NHS without the agreement of those who love it most.

Be that as it may, what is certainly true is that the NHS cannot do all that it is being increasingly asked of with each successive year. This is for at least two reasons. Firstly, as science advances, more things become theoretically possible. But as Isaac Asimov once said ‘The saddest aspect of life right now is that science gathers knowledge faster than society gathers wisdom’. This is still true – not all that can be done should be done. The second reason, I think, is more fundamental. We live in an increasingly anxiety ridden society. Henry Thoreau wrote: “The mass of men lead lives of quiet desperation, and go to the grave with the song still in them.”

Undoubtedly some of our patients are, indeed desperate. Lacking the fulfilment that they desire, but don’t quite know how to realise, they are desperately anxious not to miss out on whatever it is that would give them satisfaction. Idolising absolute health, anxiety rises as their desire for the elimination of every problem, big or small, real or imagined, cannot be met. The constant endeavouring to solve every problem is exhausting and counterproductive, for both those with the problem and those trying to do the solving. As Leonard Cohen sang: ‘There is a lullaby for suffering and a paradox to blame’. Facing our weaknesses and accepting our suffering can be, I believe, paradoxically, comforting.

However this is a difficult philosophy to convey and one that is harder still to convince people of. So anxiety persists, together with its lonely companion, its accomplished accomplice, depression. Anxiety in all its forms is now so pervasive that I think it easily represents the most common problem presented to me at work.

Put these all together and it seems that almost every consultation has an agenda, hidden or otherwise, driven by anxiety.

Firstly there are those patients who present with frank anxiety- by which I do not mean to suggest they have an irrational fear of Frank’s be that Sinatra, Zappa or D. Roosevelt. Rather I mean those patients that present with up front anxiety symptoms – panic attacks and the like. Then there are those patients who present with symptoms that they are anxious represent serious underlying disease. They are often hard to reassure, so twitched are they by the twitches that they experience. And then there are the patients whose symptoms generate anxiety in us – the doctors. We can be left concerned that we are missing something serious and fear what that might mean both for the patient and also for our own reputations – reputations that we cherish, perhaps, more highly than we ought. Put these all together and it seems that almost every consultation has an agenda, hidden or otherwise, driven by anxiety.

I wonder how much of this is tied up with the current postmodern notion of relative truth and its recent spawned offspring ‘alternative facts’. Many have remarked that 2016 was a particularly bad year and perhaps, with all the terrorist outrages, natural disasters and political upheaval the year brought, not to mention all those celebrity deaths, we do all have good reason to be uneasy. But also concerning, perhaps more so, is the fact that the Oxford English Dictionary made ‘post-truth’ its word of the year – a decision that reflects that public policy is being decided based on appeals to personal emotions rather than objective facts. Paul Weller and ‘The Jam’ sang, ‘The public gets what the public wants’ and it seems today the public is at least sometimes promised what it feels it wants, independently of what it needs, because it is politically expedient so to do. I am left wondering if all the anxiety we see, and feel, stems from the fact that, with the throwing out of the still clean, clear bathwater of objective truth, we have thrown out the baby of any sense of assurance.

If nothing is certain, how can our patients be anything but anxious about everything? How can they be reassured that their symptoms are not concerning when the opinion we hold can never be more than what we feel to be true? Our feeling, that their symptoms are not worrying, can never counter their feeling that they are, since their feelings are no less valid than ours. I was surprised once when my assurances, that a lesion on a patient’s scalp was a harmless seborrheic wart, were not accepted by the patient because her hairdresser had felt it was a skin cancer. But then, if truth is relative, an expert’s opinion (and I use the term lightly) has no more authority over that of a non specialist.

Another patient once challenged a consultant cardiologist’s opinion that her ECG was normal as she felt her symptoms were consistent with what she had read of Wolf-Parkinson-White syndrome. The objectively normal ECG, and the expert opinion of the consultant on that ECG, was contrary to the patients feelings. And so a second opinion was requested and, when this was declined, the patient chose to write directly to the consultant expressing her belief that her concerns were being ignored.

This notion extends to the anxieties we experience as doctors. If truth is relative, how can we have any confidence in what we feel to be true, and, if the patient feels differently to us, how can we say that we are right and they are wrong? I am aware, of course, that there are, inevitably, times when a diagnosis is in doubt, when the truth is uncertain, but it sometimes seems we are no longer confident that we know anything for sure. In a society suspicious of intellectualism, the learned are themselves suspicious of their learning. Too concerned that our patients be happy with our opinion, our clinical diagnoses have to be malleable, tempered to acknowledge the validity of the patients’ opinion regardless of how lacking in objectivity that opinion might be.

Is it only me who, knelt at a patients feet and examining their sylph like ankles, has reluctantly murmured; “They are a little swollen I suppose”?

Is it only me who, knelt at a patients feet and examining their sylph like ankles, has reluctantly murmured: “They are a little swollen I suppose”. Of course it is no wonder we sometimes behave like this since we have had it driven into us that we be ‘patient centred’ when all along we really should have been urged to be ‘truth centred’. But it’s arrogant to claim to be right about anything these days – facts prove nothing. In a consumer society, the customer is always right. Is it any wonder then that, as medicine was opened up to market forces, the result would be that the patient is always right too?

And if feelings are what are important, then what others feel about me are every bit as much an indicator of who I am as what I feel about myself. After all, a satisfactory satisfaction survey is sacrosanct – I’m OK, if you’re OK with me. But if everybody’s feelings are different, how can I be OK, since how can I be OK with everyone? How can I make everybody feel positively toward me when they all have different criteria for what it is that would cause them to feel in such a way?

Anxiety is, I think, largely, a fear of unhappiness in the future which leads inevitably to us being unhappy in the here and now. That’s why anxiety and depression are such common bedfellows. With, to a great extent, the loss of religious belief, and with it the hope of a better time and place to come, society no longer is prepared to accept that we must sometimes wait for happiness. In an age when everything is instant, waiting is not an option – we must be happy now. But in a materialistic, consumerist society, which daily advertises to us our discontentment by displaying what it insists we need, but do not have, to be happy, it is no surprise that we are anxious that life is passing us by, that we are missing out on being fulfilled today.

And so the National Health Service has become the National Health Slave.

And of course it’s not just material goods that our society consumes. We consume health – it is the ‘must have’ we assume and insist upon. No suffering, however small, ought to be tolerated. We must have health and we must have it now – not next month, nor next week, not even tomorrow. The doctor will see me now – be it Tuesday morning or Sunday afternoon. And so the National Health Service has become the National Health Slave even as the NHS itself, colluding with society that it can meet its greatest needs if it would just do as it was told, slavishly insists patients behave in ways current medical opinion deems appropriate. Don’t smoke, don’t drink, don’t fail to exercise, don’t eat just four of your five a day, and whatever you do, don’t forget your Vitamin D. Don’t, don’t, don’t, don’t, don’t – and you might just live forever.

And so it seems to me that what this all ultimately boils down to the existential question of death. It is the one thing certain about life but we, increasingly perhaps, try to pretend that this too is uncertain as we pursue, and push, eternal life through medicine, lifestyle adaptations and sentimental and fanciful notions of how those who undeniably have died, somehow live on. In a world where nothing is certain, the certainty of death is above all to be doubted.

But we need to face facts, and so must our patients. Despite how much money is pumped into the  NHS to fund all that medicine increasingly can do, despite how long GP surgeries are open or how short waiting times in A&E departments become, and despite how much we heed medical advice and adjust our lifestyles accordingly, we, and our patients, will all one day die. Regardless of what we may or may not believe about life after death, if we are to find any happiness in this life, we need to stop pretending otherwise. We must stop believing that our interventions could ever prevent the inevitable. Rather than doing more for longer, if we want a population that is healthy in the fullest sense of the word, we need to do less. Yes the NHS must be funded adequately but it must be funded adequately to do what a long hard look determines is objectively thought to be important rather than subjectively felt to be urgent.

We must stop pandering to those who are intolerant to even the slightest inconvenience or hardship.

We must stop pandering to those who are intolerant to even the slightest inconvenience or hardship and we must stop suggesting to our patients that life is all about attending to our cholesterol, BP and vitamin D levels so that future suffering is prevented. Why? Because a good life is not solely determined by the absence of suffering – now or in the future. Unrealistic attempts to deny the inevitability of death all too often serves only as an expensive and time consuming distraction that compels us to look down at the temporary and trivial and leaves us neglecting to look up at the significant and satisfying.

We and our patients need to learn to ignore the mundane and consider instead the transcendent. Only then will we, and they, instead of enduring an existence weighed down with anxiety and depression, enjoy a life buoyed by contentment and joy.

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. (www.arclightscope.com). 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.

Outcome

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!

GP partnerships – sinking into obscurity or sailing into the future?

Johanna Spiers

Johanna Spiers

Johanna Spiers is a qualitative health researcher working at the University of Bristol. She uses a range of methods to investigate different health psychology topics. Her current work explores the experiences of GPs who are in need of support.
Johanna Spiers

vmrmyolqzwo-andreas-ronningenThis post was co-authored with Ruth Riley. Ruth is a medical sociologist and qualitative health researcher with an interest in the mental health and wellbeing of NHS healthcare professionals. She is Principal Investigator of a NIHR SPCR funded study: Exploring the barriers and facilitators to help-seeking amongst GPs: Improving Access to Support.

In the past, the huge majority of GPs were partners, with partnership seen as the obvious career pathway. Partnerships consist of groups of general practitioners who own and run their practices, meaning they are in some regards their own bosses. However, the numbers of salaried GPs (employed by the partners) and locum doctors have been soaring in recent years. Many younger doctors and GP students are now deterred from seeking partnerships, seeing them as unattractive or even risky.

As a researcher looking into the mental wellbeing of GPs, I have found myself inclined to agree. I have spent the past 12 months of my working life interviewing distressed and anxious GPs who are working in a context of increasing workloads and financial pressures, and analysing those interviews. So many of those GPs have spoken to me and the project’s PI Ruth Riley about the difficulties of partnerships that it’s been hard to see what the advantages might be.

When more and more partners resign, it can become a sickening game of tag to find out who is the last doc standing.

It won’t be news to any readers of this blog that there is a recruitment crisis in general practice. GPs are retiring, resigning and relocating in droves, meaning those remaining are hideously, heart-breakingly overworked. And they don’t have the option to leave at the end of their shift and sign the work over to the next doctor; a GP partner’s shift starts and ends with her or him.

Being small business owners, GP partners are financially responsible for their practices, meaning that when more and more partners resign, it can become a sickening game of tag to find out who is the last doc standing – and who is therefore personally responsible for the masses of debt a forsaken GP practice will have built up.

GP partners are also expected to act as managers, running the books, organising human resources for staff members and disciplining wayward employees. Medical school doesn’t currently offer much in the way of management training (although there is a move towards introducing this), meaning these roles can be extremely stressful for GPs and are sometimes very badly handled, resulting in stress for the whole practice.

Add to this a total absence of formal occupational health protection during periods of ill health, no guaranteed maternity leave and having to juggle the potentially fragile and fraying egos of your colleagues every week in a partnership meeting, and it becomes resoundingly clear why partnership feels like a poisoned chalice to so many.

To counter this gloomy picture, I have heard some arguments in favour of the partnership model. Some of the doctors I interviewed spoke glowingly of the team work, trust and mutual support within their partnerships. One participant in particular worked at a surgery which is a shining example of good practice, with all members chipping in to fund a therapist to come in twice a month and provide supervision. If more partnerships were able to run this way, how much better could things be?

A recent debate (2016) in the BMJ argued that maintaining semi-autonomous employment will save GPs from a similar stand off to the one in which the junior doctors continue to find themselves. However, I wonder if this is true? The department of health and the NHS seem entirely capable of imposing changes and demands on GPs within the current model, so I find this doubtful.

The partnership model works well for some; merged super-practices with all salaried GPs may be best for others.

There is no one model which will suit all doctors; and there is no one way of working which will suit every team of doctors. Some partnerships are small and supportive, some are large and lonely. And the reverse can also be true. The dynamics of each group will depend on so many factors: the personalities of the doctors involved, their experience, the socio-economic status of the area and much more besides. The partnership model works well for some; merged super-practices with all salaried GPs may be best for others. This is a complex debate and there is no easy answer.

However, there is one thing which would help towards solving these problems, and that’s a genuine increase in funding to general practice from the government. More money could mean more doctors, more capable managers, more training and more occupational health support, all of which could make the partnership model more sustainable, or allow thinking space for a viable alternative. The GP Forward View promises this cash, but will it arrive in time? Critics have said the promised money isn’t in addition to existing funds, but is just rebranded existing funds. Without that extra money, the future of GP partnerships seems in danger of sinking.

References

Majeed, A. & Buckman, L. (2016). Should all GPs become NHS employees? BMJ. 355:i5064

 

 

 

Long Read: The changing face of general practice in the 20th century

Dr Stanley Jeffs

Dr Stanley Jeffs

Dr Stanley Jeffs is a retired GP who has made regular contributions to the College Journal. He is now 90 years old. His first article, An Epidemic of Lumbago, was published in 1961. You can download and read it from our archives here. He has suggested this contribution will be his last offering to the BJGP. It gives a fascinating glimpse into the history of general practice as well as much for us to consider for the future.

 THE CHANGING FACE OF GENERAL PRACTICE IN THE 20th CENTURY

By Dr S. G. Jeffs (a personal opinion based on doctors I knew)

Dr Joseph Porter

By my calculations Dr Porter must have been born about 1890. Certainly he was a medical officer in the First World War when his personal transport was a horse. Tall and with a slightly mischievous look on his face even in his old age, I first knew him in the late 1950s in Levenshulme, a district of South Manchester, where, at that time, there were eight doctors in practice, all within a thumbprint on the map. There were two partnerships of two and four single handed doctors. Three of the single-handed doctors lived above the surgery premises. The NHS had been going for a decade.

Dr Porter and I, both single handed, stood in for each other occasionally for emergency on-call, which, in truth, was not very often, quite rare in fact. The law at that time, required each doctor to be responsible for his patients’ care at all times all year round. Our trade union, the BMA, struck a really bad deal for general practitioners, and for junior house doctors too. So, if I wanted to go to the cinema for instance, I would arrange with the manager of the cinema to give his telephone number as my emergency contact number and he would provide an end seat for me in the auditorium. In that way, should an emergency arise, the usherette could find me easily without disturbing anyone else.

It was only a few years after I came to Levenshulme, about 1957, that Dr Porter took ill and he sent for me. I was not his physician and I regarded it as a privilege that another doctor wanted my opinion, an inexperienced youngster in his late twenties. At that time Dr Porter must have been nearing 70 so I was less than half his age. The diagnosis was easy. He was in congestive cardiac failure.
“I will have to admit you,” I said. “wherever I can find a bed. Would you like me to try Manchester Royal Infirmary first or Withington Hospital?”
Withington Hospital had been built originally as a workhouse and to many patients it still bore the stigma.
“It doesn’t matter to me,” he replied. Then taking my hand in his he said, “Will you look after my patients for me?”
“Of course I will,” I said.

There was a sort of unspoken brotherhood, an ethic that, regrettably, was dying with Dr Porter’s generation.

There was no question of money or how much extra work I would have to do. There was still at that time, a feeling among many doctors, but not all, of a sort of unspoken brotherhood, an ethic that, regrettably, was dying with Dr Porter’s generation. But I had had ethics rammed down my throat in medical school from the dissecting room to finals in medicine and considered it the right and decent thing to do to look after another doctor’s patients when he was sick.

Dr Porter was in hospital for three weeks and even when he was discharged he was too ill to continue in single-handed practice. It seemed natural at the time though I can’t remember now precisely how it came about, but we joined in partnership which, sadly, was to last only a few years. I can picture now, when Dr Porter died, one of his patients standing in the entrance hall of the practice, a man of about 50, his hat in his hand, a look of total dejection on his face, a man lost and alone in the world as if he had been one of the Children of Israel in the Sinai desert when Moses died, saying to me, and these are his exact words which I shall remember for ever: “The doctor’s dead. What shall I do?”

I don’t know how Dr Porter saw himself as a doctor but if I can put words into his mouth, perhaps he saw himself as a shepherd tending his flock. I shall never really know, but, together with his patients, I saw him as a deeply caring, godly man. He did his best to keep up with modem advances in medicine, and mostly succeeded, but the driving force within him was his devotion to his fellow man and his ability to help others through his medical training. Before the NHS, when all practice was private, his patients told me that, when they couldn’t afford to pay him, Dr Porter would smile, put his fingers in his waistcoat pocket, extract a two shilling piece or a half crown coin, and, giving it to the patient would say “I think you need this more than I do”.

Dr Porter did with words what I tried to do with Valium and he was far more successful than I was.

Many of his patients told me that, if one member of a family had a serious illness, like pneumonia, Dr Porter would summon the family together and, by the bedside, they would all go down on their knees and pray – pray that on the fifth day of the illness, when there would be a crisis, the good Lord would see fit to deliver him back to the fold of his family. And if the patient did die, Dr Porter would be there at the funeral to help and console the family. Dr Porter did with words what I tried to do with Valium and he was far more successful than I was. He gave his patients the will to strive to get better, not to sit back and complain and demand attention and blame others It was this very personal approach to each patients inner strength that made Dr Porter so loved.

Dr Alan Guthrie

I joined Dr Guthrie in 1973 in Chester. I was the third doctor in that practice that century. The first doctor practiced from about 1900 to the 1930s. Then Dr Guthrie till the 1970s. Then me. I stayed with him for three years while he prepared for retirement. As a GP, Dr Guthrie was quite different from Dr Porter – and from myself. I gained the impression that Dr Guthrie saw himself as a medical sorting house. His job was to look after a section of the community, 4,500 patients at one period but just over 2,500 when I joined him. Roughly, I would say, for practical purposes, in his mind he divided his patients into 2 groups – those who had serious illnesses or long term conditions that could become serious if unattended -and all the rest. The first group comprised all patients with cancer, suspicious lumps, serious disease of any organ, hypertension, diabetes, and so on. All these patients were sent to hospital for diagnosis and long term treatment.

Dr Guthrie never worked with any other professional. He left messages for the nurse but did now know her.

Dr Guthrie did not do any laboratory or X-ray investigations of his own, not even follow up. That was hospital work. All the rest of the patients, the second group so to speak, comprised every day illnesses and complaints. He was not as personal a doctor as Dr Porter who came before him, or as advanced in diagnosis and treatment as I had been taught to be, but nevertheless, I never found a carcinoma he had missed, nor any serious condition undiagnosed and untreated. He never worked with any other professional. He left messages for the nurse but didn’t know her. He did know the midwife but never worked with her. He refused to accept the need for a health visitor. “I am the health visitor,” he said when I queried him.

He knew all his patients he said, and he knew what was happening to them all the time. If he got a house call to a patient in St Ann Street, while he was there, he would knock on the door of every one of his patients in that street to know how they were getting on -even shout through the letter box. “It’s the doctor, are you alright?”. If the answer was “Yes thank you,” as it usually was, he’d go on to the next house, and so on. But, if the answer was “I’m not very well today, doctor,” or some similar reply, he’d stay and attend to that patients’ needs. In this way he’d do 40 “visits” a day. As I say, he kept an eye on his “flock” in a totally different way from Dr Porter. Dr Guthrie was not a personal doctor. He saw it as his job to look after the medical requirements of a section of the community, and by his standards he did it very well indeed.

Myself

I was a medical student from 1944 to 1950. It was a singular time in the history of medical education for three main reasons which shaped the outlook of those students who would become the future practitioners. Firstly, the profession was changing from being predominately an art form to becoming a blend of art and science. Secondly, the discovery of new drugs, particularly the antibiotics penicillin, sulphonamides, streptomycin, chloromycetin, revolutionised the treatment of bacterial illnesses. And thirdly, and possibly most importantly, the revulsion and abhorrence of the German and Japanese wartime crimes, produced a national, in fact an international, attitude of moral questioning – how could it have happened, what kind of animal was homo sapiens, what kind of world did we now want to build? This moral questioning went through the whole of society – including the undergraduate medical education.

Ethics was rammed down our throats from the dissecting room to finals in medicine. The cadavers we dissected, we were reminded, were once living human beings who loved and laughed and prayed to God and we should respect them. One student was failed in finals for not showing due care and consideration to his patient, even though his diagnoses and treatments in major and minor cases were correct. Not surprisingly the doctors who graduated at that time were to become creators of new, different and hopefully better things, pioneers in their field.

It was our generation which fought to create a College of General Practitioners with their own academic journal full of original contributions.

But the GPs of my generation were inheritors of a lowly position in the medical hierarchy. We were the dregs of the profession! Lord Moran PRCP called GPs – doctors who had fallen off the consultant ladder, not thinking that many of us, even the cleverest in my year, never wanted to be consultants in the first place. To be a consultant you had to have post-graduate training and pass further exams whereas GPs just went straight into practice and, theoretically, need never open another textbook or journal. Not surprisingly then it was our generation which fought to create a College of General Practitioners, to establish University departments of General Practice with their own lecturers and professors, their own academic journal full of original contributions in academic, community and social aspects of general practice.

I can only speak with direct knowledge for Manchester University but I have no reason to doubt that my experiences reflected national feelings and aspirations, and not only in Britain but also throughout Europe and beyond. The aim of our medical school at the time I was a student, through its pyramidal system of education (which in my opinion has never been bettered), was to produce a complete and highly competent, highly ethical doctor, with an enviable ability of bedside diagnosis and capable upon graduation, of looking after a section of the community in all its requirements including midwifery.

And so, as an illustration, in my first job, which was advertised simply as House Physician. I was expected to run a casualty department, to suture wounds down to the deep fascia, to take and interpret my own X-rays and plaster fractured upper limbs, and generally do everything a Casualty Officer needed to do short of specialised therapies. On other nights, I was expected to stand in as the doctor in charge of medical admissions in which role, in the hospital laboratory, I had to measure patient’s blood sugars and ureas, set up my own drips, and initiate whatever treatment was necessary. I was also asked once to anaesthetise for the gynae list when an anaesthetist failed to turn up. I was competent with gas, oxygen and ether – and happily all the patients lived and none got pneumonia!

Other doctors, who, on graduation, did not want to work in hospitals, were able to go straight into the community, deliver their patients babies and perform minor surgery in the local cottage hospitals. All this was possible because our teachers had aimed at producing graduates of wide ranging abilities with a strong ethical background. It was an exciting time. It was also the time of the birth of the NHS.

The science of medicine is what you do for the patient. The art is how you do it.

So when I joined Dr Guthrie in 1973 to look after 2,500 patients, not surprisingly, he was horrified at the changes I made. From there being just him and no-one else, suddenly there were two doctors plus a trainee (post-graduate student), a practice manager, a receptionist, a filing clerk, a nurse and her bath lady, a health visitor, and a midwife with her pupils, plus visiting other professionals from the community. At that time I saw myself as primarily a family doctor who practiced medicine half as an art and half a science. The science of medicine is what you do for the patient. The art is how you do it. The bedside manner of old is, for example, part of the “art.” I also saw myself and my contemporaries as the new general physicians who would, in time, replace hospital general physicians. Comprehensive specialties were breaking down into smaller more highly specialised units. No matter how much I pleaded with him, Dr Guthrie refused to allow my post-graduate students to sit in with him. He dido’t want any young whipper-snappers criticising him. I was sorry about that. They would have learnt so much from him. My generation then, were ethical revolutionaries with their feet finnly placed in the past but with their sights on a new future.

The Modern Graduate

We must be careful not to sacrifice the bedside for the laboratory, for then we will lose more than we will gain.

By the end of the 20th century the medical graduate has become primarily a scientist. To enter medical school (s)he must have the highest grades in physics, chemistry and biology, and graduate with, among some traditional learning, an enviable knowledge of human biochemistry.  So how will future generations think of the modern doctor? I used to teach my trainees that, in every age, there were some good things and some bad ones, and that they should try to keep the good which our predecessors established, like the trust and deep caring of Dr Porter’s time, and add to it the best of modern medicine. But, we must be careful not to sacrifice the bedside for the laboratory, for then we will lose more than we will gain.

Conclusion

Every doctor must be judged against the background of the times in which he lived. Did he, as a representative of the profession, serve his patients, and society, well? By creating an academic College and teaching programmes to help our juniors into their professional careers, I think we made a worthwhile contribution to society. From the point of view of the individual doctor and his professional relationship with his patient, Dr Porter’s generation produced outstanding physicians. Indeed, if I was ill, I would like to be cared for by someone like Dr Joseph Porter.

Book Review: The State of Medicine by Margaret McCartney

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

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thestateofmedicine300The State of Medicine is an eloquent, passionate, comprehensive, and, in many ways, dispiriting overview of the repeated damage inflicted on the NHS at the whim of successive governments. The frustration of the author, a GP from Glasgow, pours from every page, every paragraph and every sentence, as she contrasts the efforts of doctors to practice evidence based, safe, humane and cost-effective medicine, in a system that is routinely upended and overhauled according to manifesto sound bite, political opinion and, occasionally, outright self-interest.

Whilst the general themes of this book will surprise few who work in the NHS, the actual facts and figures, such as the vast sums wasted on management consultancy firms, may make the eyes of even the most hardened cynic water.

Each chapter begins with an interview with someone who is able to give a different perspective on our collective woes. Amongst these are some real gems that offer unexpected insights into different niches of the NHS world. The words of an A&E consultant who was working at Mid Staffs during the scandal may send a there-but-for-the-grace-of God shiver down your spine, and the thoughts of a Nobel prize winning economist will have you bewildered that there are still so many advocates of insurance based health care systems.

Dr McCartney offers a clear account of the follies of the last few decades and a personal view of where and how the NHS should proceed from here with ideas such as buffering the NHS from policy makers, funding it properly, treating health professionals with respect, and actually basing policy on evidence.

The message of this book is important. We must hope that it reaches a general readership, or, hoping even more bravely, that it reaches an audience amongst the political classes.

Just how successful are STPs likely to be?

Jonathan Leach

Jonathan Leach

Jonathan Leach is a GP in Bromsgrove and Chair of the Midlands Faculty of RCGP. Jonathan initially pursued a military career for 25 years as a doctor before returning to the NHS. He is especially interested in supporting general practice at a time when it is under significant pressure.
Jonathan Leach

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PlansThe NHS in England is going through a process called Sustainability and Transformation Plans (STPs). As the NHS England website describes “each system will produce a multi-year Sustainability and Transformation Plan showing how local services will evolve and become sustainable over the next five years – ultimately delivering the Five Year Forward View vision of better health, better patient care and improved NHS efficiency”.1

All 44 STP areas have now published their plans and it appears that there are a number of common themes. Firstly that there is a recognition that there are efficiencies and cost reductions to be gained by reducing back off costs, by improving procurement (mainly from single and at scale purchasing) and by co-locating health and social care staff and thus being able to reduce the buildings estate and improve integration. Secondly by reducing (or at least not having any more) acute and hospital beds often by centralising services in a given area. Thirdly that a considerable amount of work currently undertaken in a hospital sector can be encompassed within primary care and that primary care (including general practice) will have the capacity to undertake additional work transferred from secondary care by improved prevention, better integration and the greater use of (predominantly) nursing and allied staff supported by better social care and that fourthly that themes 1 to 3 will lead to better care and at lower costs. Do current STP plans stand up to scrutiny and have they used the lessons of history in building their plans?

It may surprise some to realise that a British health service successfully did a very similar task over 20 years ago. Following the fall of the Berlin Wall there remained a British population attached to HM Forces in North West Europe and spread from Berlin through Northern Germany and into the Low Countries. It was served by British GP and community practices (often with integrated community hospital type beds) with British hospital services located at four locations across the wide geographical area. There was widespread recognition that whilst primary care (including general practice) services were good, access to secondary care was difficult due to the large distances patients had to travel and that the overall system was inefficient and expensive even if other standards were high. Following considerable work, the eventual model implemented a system whereby it increased the focus on community services; on prevention; on only referring patients to hospital when the experience, expertise and technology that a hospital setting could provide and it integrated staff under one management structure. Within this all health staff (including community based consultants) used the same GP based computer system2 and within the structure there was the ability to ‘flex” staff in a geographical region according to patient demand.

A key element of the changes was the closure of the British Military Hospitals and a change to accessing local German hospital services for episodes of care under contract. Within this was an aim to save over £4M or 10% of the then budget (based at 1994 prices).3 As part of the process there was a ‘bottom up’ mathematically derived approach on the numbers and types of community staff required to meet both accessibility needs and quality standards and especially in the changed system whereby many services which had previously been supplied in a hospital setting moved into the community.With the changes predicted to hospital services, there was a significant increase in community resources and staff which included general practitioners, midwives, health visitors and others.

There are clear parallels from the above experience in British Forces Germany (BFG) to the challenges that currently confront STPs; what can be learnt from this experience? Firstly that there needs to be a single and coherent vision based upon a needs assessment of the population; in BFG there was a large evidence based exercise in involving patients by means of questionnaires, public meetings and focus groups and it was clear that most patients wanted improved access and that travelling the large distances for British secondary care was unacceptable. Secondly there needs to be “cross system” professional engagement and broad agreement on the direction of travel; within this is an ability to address the many difficult issues and questions that any major system change will raise. Thirdly that there needs to be a full understanding that as hospital systems change, that there is detailed plan (including mathematical modelling) of how, where and when community services would be able to cope with the increase in patient volumes and potential complexity. The BFG experience is that practice workload increased by approximately 10%, so this area is not to be underestimated and as described above was expected and met with a large increase in staffing of all groups. Fourthly that whilst integration is helpful (predominantly to the quality of care), improvements in productivity are likely to be marginal. Other studies have reached similar conclusions.5

The challenges confronting STP leaders are significant.  In many cases engagement with the public, the professions and politicians has only just started – this is to be regretted as consistent evidence on system change is that early engagement, considering and overcoming barriers is required. Secondly there needs to be urgent analysis of the implication of proposed changes to hospital services on the community services including general practice This is much wider than increasing the number of nursing and allied staff but must include where and how medical care is provided including prescribing, taking a broad holistic approach to patients many of whom have polymorbidity, managing risk and where responsibility for decisions lies. An analysis of published STP proposals reveals that this area of detail is lacking in all. Finally there needs to be an overview on whether current STP plans can be delivered in planned timescales given the significant number of barriers they are likely to encounter and very importantly whether in reality they are likely to deliver the required improvements in productivity and cost reduction without significantly affecting patient safety and experience.

References

1. https://www.england.nhs.uk/ourwork/futurenhs/deliver-forward-view/stp/ accessed 18 Dec 16
2. Everington P and Leach AJ. Integrated Primary Led Care – A view of the future? In Richards J (Ed). Conference Proceedings – Current Perspectives In Healthcare Computing. 1996.
3. Hansard http://hansard.millbanksystems.com/written_answers/1996/jun/04/market-testing accessed 18 Dec 16
4. Leach AJ, Whitmore MK, Schofield J, Morris G. Health Service Market Testing – the Experience of the Community Services Review Team in British Forces Germany. J R Army Med Corps. 1996. 142. 67-70.
5. McWilliams JM. Cost Containment and the Tale of Care Coordination.  N Eng J Med 2016: 375: 2218-2220

Top 10 most read BJGP research articles published in 2016

16Jan_Top10_research_2015_BJGP_smThese are the top 10 most read research articles based on full text downloads from bjgp.org in 2016.

1. Overdiagnosis of asthma in children in primary care: a retrospective analysis. 
http://bjgp.org/content/66/644/e152

Overdiagnosis of childhood asthma is common in primary care, leading to unnecessary treatment, disease burden, and impact on quality of life. However, only in a small percentage of children is a diagnosis of asthma confirmed by lung function tests.

2. Telephone triage systems in UK general practice: analysis of consultation duration during the index day in a pragmatic randomised controlled trial. 
http://bjgp.org/content/66/644/e214

Telephone triage is not associated with a reduction in overall clinician contact time during the index day. Nurse-led triage is associated with a reduction in GP contact time but with an overall increase in clinician contact time. Individual practices may wish to interpret the findings in the context of the available skill mix of clinicians.

3. Primary care clinician antibiotic prescribing decisions in consultations for children with RTIs: a qualitative interview study.
http://bjgp.org/content/66/644/e207

Prognostic uncertainty remains an important driver of health care professionals’ antibiotic prescribing. Experience and training in recognising severe respiratory tract infections (RTIs), together with more evidence to help professionals identify the children at risk of future illness deterioration, may support identification of the children most and least likely to benefit from antibiotics.

4. Continuity of care in primary care and association with survival in older people: a 17-year prospective cohort study.
http://bjgp.org/content/66/649/e531

This study demonstrates that low continuity of care in general practice is associated with a higher risk of mortality, strengthening the case for encouragement of continuity of care.

5. Nursery sickness policies and their influence on prescribing for conjunctivitis: audit and questionnaire survey.
http://bjgp.org/content/66/650/e674

Most of the childcare providers’ sickness policies contain requirements that are inconsistent with Public Health England guidance. The requirements of childcare sickness policies are likely to be resulting in unnecessary primary care consultations and thousands of prescriptions for antibiotics with little demonstrable clinical or public health benefit.

6. Unrecognised bipolar disorder among UK primary care patients prescribed antidepressants: an observational study.
http://bjgp.org/content/66/643/e71

Among people aged 16–40 years prescribed antidepressants in primary care for depression or anxiety, there is a substantial proportion with unrecognised bipolar disorder. When seeing patients with depression or anxiety disorder, particularly when they are young or not doing well, clinicians should review the life history for evidence of unrecognised bipolar disorder. Some clinicians might find the Mood Disorder Questionnaire to be a useful supplement to non-standardised questioning.

7. Identifying depression among adolescents using three key questions: a validation study in primary care.
http://bjgp.org/content/66/643/e65

Depression in teenagers can have serious consequences and the incidence seems to be increasing. Three short questions, suitable for use in general practice, are useful for identifying depression in adolescents in primary health care.

8. Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review.
http://bjgp.org/content/66/643/e114

Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than ‘one size fits all’ approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians’ skills and emotions around treatment intensification and facilitation of patient behaviour change.

9. Comparison of brief interventions in primary care on smoking and excessive alcohol consumption: a population survey in England.
http://bjgp.org/content/66/642/e1

Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, less than 10% of those who drink excessively report having received advice on their alcohol consumption.

10. Molluscum contagiosum and associations with atopic eczema in children: a retrospective longitudinal study in primary care.
http://bjgp.org/content/66/642/e53

Consultations for molluscum contagiosum in primary care are common, especially in 1–9-year-olds, but they declined significantly during the decade under study. A primary care diagnosis of atopic eczema is associated with an increased risk of a subsequent primary care diagnosis of molluscum contagiosum.

 

BJGP Blog Christmas charity: Help Malawi medics this Christmas

christmas_pound-1Perhaps you are thinking of giving of some money to charity rather than sending Christmas cards or maybe you want to give a different type of gift package. Or maybe you’d  just like to support a worthy cause. UK registered charity Medic to Medic supports disadvantaged students training at the College of Medicine in Malawi by providing student scholarships. Here’s an update on the work they do and the problems faced by medical students in Malawi.

“On the opening day of school, a few students litter the registry whilst a multitude are packed at the assistant registrar’s office pleading for waivers in order to get registered. Many have come as far as Karonga, the district bordering Tanzania and Zambia on the far north. The queue is slowly winding the pillars, meandering back and forth outside the assistant registrar’s office. At the dean of students’ office, there is an uncomfortable sight of premedical students wrestling the queue, pushing and dragging one another to the back on a hot summer day longing to meet the dean of students. Both students standing at the Assistant Registrar’s office and the Dean’s office have one problem akin to them; the insufficient tuition fee.

Following the overwhelming tuition fee hike of 600% at the College of Medicine, the students at the only medical school in Malawi are in dire situation and are languishing due to the inhumane hike. About 60% of the students have failed to register for the 2016/17 academic year and others have opted to withdraw temporarily on financial grounds.

The fee hike has rendered many students destitute as it comes at a time when Malawi’s economy has nosedived into oblivion. On the household level, most of the people in Malawi about 80% are in the rural areas and many of the students are from the rural areas where poverty has sky rocketed. In the villages, the parents can hardly afford three meals a day and most of them are going to bed on empty stomachs. If the parents can’t afford a descent daily meal, where will they get the huge money demanded of them to educate their children with the fees at 350,000 Malawi Kwacha (£400) per annum?  The only resort for the impoverished students is to ask for temporary withdrawal since they cannot get admitted in the college.

Malawi ranked the world’s poorest nation has been marred with intermittent blackouts, inconsistent water supply and insufficient harvest as the result of climate change. It is unbearable for medical students to be attending lectures as well as clinical sessions at the hospital on an empty stomach. Following the non-residential policy put in place about half a decade ago, more than half of the students at the college live outside the campus where their security is very unreliable, poor studying environment, pitiable sanitation and very high rentals.

Currently, the future of Malawi’s competent health practitioners hangs in the balance as mass withdrawal of the students on financial grounds has already commenced and it ought to deteriorate in the second semester if the current situation persists. The battle to reduce the fees had taken the students to the state president of the republic of Malawi who also doubles as the university of Malawi chancellor but it yielded almost nothing as the fees were only slashed by about fifty-five pounds from about four hundred and fifty pounds. The present situation for the medical students at College of Medicine is worrying.”  Fatsani Gundah, MBBS year 5 student.

UK registered charity Medic to Medic supports disadvantaged students training at the College of Medicine in Malawi by providing student scholarships. Scholarships cover the cost of tuition fees, provide a twice yearly stationery allowance, medical books, medical equipment and if funds allow, a laptop. This enables each student to study optimally so that they can fully concentrate on their studies and successfully qualify as health workers in Malawi, a country that has just 2 doctors for every 100,000 people.

Malawi desperately needs more health workers. It has some of the worst infant and maternal mortality ratios in the world. For many of the students training at the College of Medicine, the tuition fee increases are unattainable and there are more students struggling than ever before. Many students will be forced to drop out of their training, go back to their villages where the cycle of poverty will continue. Normally Medic to Medic have been able to take on 15 new students each year, but because of the 600% tuition fee increase, they have not been able to take on any new students.

This Christmas you can support Medic to Medic by buying a gift package for a loved one from their website. There are pre-set amounts starting from £10, through to £1,000. Each package goes towards a different aspect of a students training, ranging from paying for a stationery allowance, through to providing a laptop, medical pack and covering tuition fees. For each gift the recipient will receive a certificate, student profile, their latest student update and a selection of Medic to Medic gifts. Gifts can be sent direct to the recipient or back to the buyer. Packages can be sent internationally, although there is a minimum donation for these packages. It’s also possible for overseas friends to purchase gifts online in their own currency.

In an era when not knowing what to get someone for Christmas is such a first world problem, Medic to Medic offers a solution: an ethical gift of giving this Christmas.

For more information please visit:
www.medictomedic.org.uk
Email: info@medictomedic.org.uk
Call 0208 869 3603