Transforming Primary Healthcare

There is no doubt that responsible GPs are worried about the state of the NHS, primary care, secondary care, the relentless growth in patients with autoimmune and mental health conditions, and, and, and….. And that many of them are fronting or taking part in initiatives, often government backed, to tackle different aspects of these malfunctions. The question is whether the forces that are ranged against them are too powerful for them to succeed in more than a piecemeal and local way.

A number of these GPs came together a few weeks ago under aegis of the Guild of Health Writers in conjunction with College of Medicine Beyond Pills Campaign that aims to replace the over prescription of unnecessary drugs with social activities. But they have massive problems to solve:

• Visits to GPs have increased from 2 per year in 2000 to 10 per year in 2020 yet we are losing an unprecedented number of newly qualified doctors driven away by unacceptable NHS working practices.
• Daily patient lists for working GPs can reach 30 to 40.
• Dispensing in primary care doubled from 10 prescription items per head per year in 1996 to 20 in 2016
• 200-300 million prescribed drugs are wasted each year
• Adverse drug reactions account for 10-20% of hospital in-patient admissions

The speakers on the guild evening included the National Director for Clinical Prescribing, specifically tasked with tackling overprescribing; the first Patient Safety Commissioner, recently appointed to ‘improve the safety of medicines and medical devices by ensuring that patient voices are at the heart of the design and delivery of healthcare in England’  (although at the time of the evening she had a staff of four and as yet neither desk nor office); a ‘social prescriber’  working in Southwark in London and three GPs or practitioners using social prescribing in one form or another in their practices.

And the stand out message that came through from the evening was the need to listen to the patient voice. Shocking though it may seem, there are currently no patient representatives working within NHS England or in the Department of Health and Social Care. Is it surprising that the patient voice so often gets ignored?

Over prescribing – listen to the patients

Professor Tony Avery is both a GP and the National Clinical Director for Prescribing.  While reminding us that drugs do save lives and improve many health conditions he accepted that, especially among the older population, far too many drugs were prescribed without any serious evaluations of whether they were needed or would be useful.

Patient focus groups suggested that:

• Patients were very anxious to be properly informed about the state of their health and to understand any diagnosis or proposed drug regime.
• Patients felt that they should ‘assist’ the GP in looking after them which made them anxious to discuss their case.
• Patients were more proactive when discussing the case of someone else, usually a child or an older person, than when discussing their own health.
• The placebo effect of liking and trusting their doctor or health care provider was significant.

With these findings in mind the three year government programme that Professor Avery is spearheading wants:

• GPs and pharmacists to discuss drug regimes with their patients, to listen to what they have to say and encourage them to ask questions about what they are taking and whether all of their drugs are really necessary.
• A massive expansion of pharmacists in general practice enabling a fuller conversation with patients.
• GPs to always look for alternative options (talking therapies, alternative therapies, social prescribing) before prescribing drugs.
• Regular reviews of drug regimes to ensure that the patient is only taking the drugs that are really necessary. (All too often patients either continue to be prescribed and to take drugs out of habit long after they have stopped delivering any benefit –  or continue to get prescriptions and then just fail to take the drugs.)

Patient Safety – Listen to the patient

Dr Henrietta Hughes was appointed in September 2022 as the first Patient Safety Commissioner, an independent role recommended by the First Do No Harm review. While Dr Hughes brief runs wide her first focus is on the pelvic mesh and Sodium Valproate issues – both cases where patients and their views have been ignored with appalling results.

Pelvic meshes:
The insertion of pelvic meshes to treat urinary stress incontinence although usually successful can result in vaginal scarring, fistula formation, painful sex, and pelvic, back and leg pains – but women were rarely told about these complications, rarely offered any alternative treatment and were ignored when they complained of problems.

Sodium Valproate:
Sodium Valproate is a drug used to control epilepsy and to prevent migraines. But if used during pregnancy it can have serious effects, both mental and physical, on the unborn child. Moreover, these effects can last through the generations.  Even though these effects have been known about for many years, there is a horrifying level of ignorance amongst prescribing doctors – to the point where three babies a month are still being born to mothers who had been prescribed sodium valproate during pregnancy.

But Dr Hughes is not only interested in these areas. She is worried that a culture of listening does not exist in the health sector so that the patient is rarely either consulted or listened to when they express their views or question their treatment. So she also wants:

• Supported decision making – in which the patient is fully informed and able to take an active part in making the decision about their treatemnt.
• Those who have spent 18 months or longer on waiting lists to have their treatment reviewed before it is implemented to see whether their condition might have changed during that period and a different treatment is indicated.
• To reach ‘invisible’ patients – those who temperamentally or for practical reasons are unlikely to reach or talk to their health practioner – in order to involve them in decisions about their care.

Social prescribing – Listen to the patient

Gay Palmer described how, as social prescriber, her first duty is to listen to the patient – and how, as a social prescriber, she is able to spend 45 to 60 minutes on a first consultation so that she can really delve into any issues the patient has. These very often included practical issues like pensions or bill or rent payments which could be seriously stressing that patient and impacting their health.

She saw her job as acting, effectively, as a liason officer with a handle on every service that could be accessed to the benefit of the patient she was working with – connecting people with people.

Connecting – Listen to the Patient

Listening and then connecting was very much the theme of the other presentations.

Dr Laura Marshall Andrews runs a practice in Brighton which for the last ten years has offered a range of alternative therapies and an extensive arts programme to her patients.

She pointed out that loneliness was as big a risk factor for obesity as smoking and can lead to depresssion and lack of self care causing metabolic, neural and cellular changes  – which in turn can underpin illness and the development of autoimmune conditions. Basing her practice on the pioneering Bromley by Bow Centre she has teamed up with a range of therapists and other practioners to offer walking, work with horses, crafts, singing – ‘clearing a space for people to think about themselves’. She noted that this approach also benefited her own medical staff who viewed a good relationship with their patients as being the lynch pin of their practice.

Kevin Feaviour is a community psychologist and social entrepreneur who is developing a network of community health hubs across Cornwall. These initially offer a place where anyone can drop in for a cup of tea or coffee and a piece of cake – the principle being that if you offer people a hot drink and a piece of cake in a friendly space, they will start to chat to each other. Making that initial connection is particularly important in rural communities where isolation, especially among farmers, is a serious problem. (As he noted, up till 20 years ago if he had a problem a farmer could always go and talk to his GP or his bank manager – but in 2023 he is unlikely to know his GP in any group practice – and the local branch of his bank will have closed. There is a move to encourage vets to take up this therapeutic role as being one of the few people that a farmer will see on a regular basis.)

The idea of the Cornish tea and coffee hubs is to bring people together. By offering their tea and coffee drinkers not just tea and cake but activities, arts, therapies, a food bank and other projects including volunteering they hope to engage them and create a sense of community.

They are also trialling the idea of chronic pain cafés where therapists and pharamacists will be trained to be the baristas and where alternative pain management strategies can be developed.

Can it work?

In the Q&A afterwards one audience member voiced all of our doubts when he congratulated the speakers on their sterling efforts but asked whether there was the political will to see any of these initiatives through. And this, of course, is the sixty four thousand dollar question.

Hardly surprisingly, Professor Avery said that there was – but you have to wonder.

• No mention had been made throughout the evening of ‘big pharma’ who can have little genuine interest in reducing anyone’s use of drugs.
• And what of massive drug trial industry? As one speaker pointed out, our medical system is geared to the ‘gold standard’ Randomised Control Trials – but these are designed to test out the efficacy of drugs and are completely useless for any approach which does not use drugs – as alternative therapists have known for many years.
• And then the medical device industry (as in the pelvic meshes). Dr Hughes was concerned, no doubt with good reason, about conflicts of interest in the supply of devices. The numerous ‘scandales’ over the supply of PPE etc during COVID cannot leave anyone with too much faith in the integrity of the system.
• And all these aside, not only is there a massive amount of learning to be done but a serious change of culture is needed throughout the health service. How is that to be brought about?

However, a small tug can move a massive ship and from little acorns mighty oak trees grow so let us welcome and support all of these excellent initiatives – and hope that the benefit that the government of the day may see in pursuing them will outweigh the drag effect of the medical industry whose profits cannot fail to be impacted.