Introduction by Croakey: To make health and care systems work for those with the greatest needs requires health professionals who are willing and able to subvert inflexible systems – to do whatever is needed for the sake of their patients.
That’s a key lesson from Dr Tim Senior’s visit to Plymouth in England as part of his Churchill Fellowship investigating how to support GPs providing care in socioeconomically disadvantaged communities.
“One of the main lessons from Plymouth is that funding and systems need to be set up to allow flexibility and pragmatism, and to turn a blind eye to the subverting of your systems,” Senior writes.
Croakey notes that patient names and details in the article below have been changed to protect privacy.
Tim Senior writes:
“Oh, Dr Ben, it’s you! I thought I heard your voice!” Tania’s face lit up with a broad smile.
Dr Ben is Dr Ben Jameson, who I am accompanying on his ward round at Derriford hospital in Plymouth, a small city on the southwest coast of England.
Outside the main city are small pretty villages hiding pockets of poverty. Derriford hospital is the main hospital serving the area, and while the distances are far from those in Australia, the experiences of being a long way from central metropolises still show themselves in difficulty recruiting to a health system.
Jameson is the GP on the Health Inclusion Pathway Plymouth (and on X/Twitter as @InclusionGP).
He provides in-reach into the hospital for people admitted who are experiencing homelessness or multiple deprivations and complex health needs.
Tania has been admitted with a fracture needing an operation, which has unfortunately become infected. She looked quite grumpy until we arrived.
“At last,” she says, “I was wondering when I’d see you. I can tell you what’s really happening.” One of the surgeons interrupted at this point, and offered to come back later.
After he’d gone, Tania says: “They’re all tw*ts.”
“He probably heard that,” says Jameson.
“I don’t care. They are tw*ts.”
I’m smiling to myself, as this interaction feels very familiar from my own experience. I regularly hear my patients speak about their interactions in the hospital in similar terms.
From what I can gather, it’s a happy coincidence that the health services in Plymouth have been arranged so that Tania sees someone familiar in the hospital.
Jameson is not only part of the Hospital Inclusion Program in Plymouth (HIPP), but also works regularly in the hospital urgent care centre, and does regular outreach clinics to the local homeless services. This continuity of care hasn’t been designed into the system, but Tania’s reaction tells me that is where the value is. Her story is unique, but not unusual.
What is conventional and visible to the health system is the collaboration. The HIPP team starts with a case conference, with complex care co-ordinators, the community drug health team, and a housing worker, and meets later on with the complex mental health team.
Jameson meets patients on the ward, and talks with the nursing and medical teams, and is able to make suggestions on their care; for example, relating to opiate substitution treatment on the wards.
The relief on the junior doctors’ faces when they realise there is a team to help facilitate discharge in complex social circumstances is also palpable. However, possibly the most significant intervention I saw involved finding clothes for patients who had none.
At the Deep End
Deep End General Practice in Plymouth is centred around a single practice, though the Deep End work is marked by collaboration with third sector organisations outside general practice.
As well as hospital in-reach, Jameson does a clinic with Shekinah mission, for homeless people, again working closely with the drug and mental health teams.
At Shekinah, the visible service arrangements – recognition of the importance of healthcare as part of getting people back on their feet, provision of rooms, rent free, for general practice and drug health – allow room for good Deep End care to happen.
What does good Deep End GP care look like though?
You’ll recognise the terminology, of course. It’s patient-centred, it’s collaborative, it’s multidisciplinary, it’s evidence-based. Of course it is, but what does that actually look like in practice?
I hesitate to answer this question, for fear that health policy makers will read this and pay more attention to the work of their local services. For this work is quietly subversive.
Its foundations are deeply pragmatic, but pragmatic in a system that does not and cannot work for their patients. To get things done – the things that all the medical textbooks and guidelines say need to be done – Deep End professionals are subverting the system, finding ways around policies, bending the rules.
In short, Deep End services are set up implicitly – definitely not explicitly, as that would be to risk being noticed and defunded – to be a set of friendly faces in an unfriendly system, to be the people on the side of those who most need the service, but who are consistently failed by the system.
Ultimately this is an empowering role.
“People are professors of their own lives,” I was told by one of the managers of the HIPP. This extends the idea of a consultation being a “meeting between experts” to a whole team.
This philosophy – that people are the experts on what they need from systems, rather than the other way around – was in action everywhere I looked.
Examples included: the practicalities of ensuring a single pharmacy for dispensing prescriptions to people who were moving around from hostel to hostel; advocating for adequate pain relief in the context of opiate substitution including partial agonists; and ensuring services were set up for someone keen to get out of hospital as soon as possible, no matter what.
It also meant paying serious attention to the concerns of a homeless man who had walked more than 400 kilometres over five days to come back to the city he grew up in.
Purpose and respect
I’m not going to pretend that this subversive, anti-system work is easy.
Everyone I spoke to was driven by a sense of purpose, and a profound respect for the people with whom they worked – patients and professionals. All of the GPs had what we might call portfolio careers – a mixture of clinical work in different settings, teaching and research.
One of the main lessons from Plymouth is that funding and systems need to be set up to allow flexibility and pragmatism, and to turn a blind eye to the subverting of your systems.
Ultimately, whatever else is happening, the only way of getting good outcomes is creating room for generalists to have flourishing therapeutic relationships in your system.
That’s the lesson of Tania’s smile.
Watch this video
Acknowledgements
Thank you to Dr Ben Jameson, Dr Richard Ayres and Dr Richard Byng and all the staff at Shekinah Mission, the Hospital Inclusion Program Plymouth and the Adelaide Street Surgery.
Thanks also to Sarah and Mark Wimlett for accommodation, food and helping me work through my ideas.
Bookmark this link to follow Dr Tim Senior on his #ChurchillDeepEnd investigations
