Tag Archives: GP scholarship

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.

My story of everyday scholarship in general practice

Faraz Mughal is a GP in Birmingham and the RCGP Clinical Fellow in Children and Young People’s Mental Health. He is on Twitter: @farazhmughal

Making scholarship part of my daily practice contributes to the intellectual challenge and enjoyment of my work in general practice.

Self-harm affects 1 in 12 child or young people (CYP).1 Nearly 10% of 5-16 year-olds have a mental health illness which means in an average school class of 30 schoolchildren, three will suffer from a diagnosable mental health disorder. With increasing pressures facing young people in all aspects of their lives, the rates of mental illness are likely to rise. CYP mental health is thus a challenge for GPs everywhere.

At the frontline, we as GPs detect mental health illness; whether it presents as a physical health symptom, through parental/family concern, or simply an instinct you have when seeing a CYP in surgery. It is known that CYP with mental illness are twice as likely to attend to see their GP.1 Mental health is something we should be all thinking in every CYP we see.

But it can be an area of practice that we all find difficult, we can feel uncomfortable tackling this clinical area. Locally GPs have described, both personal issues (a lack of training) and service problems (difficulties accessing specialist services) as reasons for this.

In my own practice, I realised that there were limited resources available in this area and that accessing support from specialist services was difficult. I explored this further and realised others were experiencing similar problems. So, I began to think about how I could help address this, how I could improve my own practice while also helping the wider primary care community?

When RCGP advertised an opportunity to become the RCGP Clinical Fellow for CYP Mental Health I grabbed the chance to apply (these are regularly advertised through the RCGP so do keep an eye out!). Through this role, I have been part of an enthusiastic team developing quick-access resources for GPs and primary care staff to use in consultations with patients (accessed through the RCGP Mental Health Toolkit: http://www.rcgp.org.uk/clinical-and-research/toolkits/mental-health-toolkit.aspx). I also have the chance to influence policy through pushing for improvements in national and local services for CYP mental health. In addition, we have developed ‘TopTips’ articles for GPs on self-harm and eating disorders in CYP with more in the pipeline.

We are always thinking of how we can support GPs and if you would like to get involved with the college on working in this area, please do get in touch, we would be really pleased to hear from GPs and primary care professionals who want to work with us.

Reference:

1.     Department of Health. Future in mind: promoting, protecting, and improving our children and young people’s mental health and wellbeing. 2015. Available at: https://www.gov.uk/government/publications/improving-mental-health-services-for-young-people

You can read Revitalising general practice: unleashing our inner scholar by Joanne Reeve and Adam Firth at the BJGP here.