Earlier this month I had the privilege of seeing raw general practice at its best; visiting the sort of practice 'The System' wants to iron out as an anomaly, but GPs and patients need to fight for more of.
I joined The Doctor Hickey Surgery, workplace of Dr Paul O'Reilly, one of our LMC Chairs, for its regular Patient Participation Group (PPG) meeting and an evening 'Walking Round' of Westminster's rough sleepers. This practice exclusively treats homeless or previously homeless patients. The PPG is impressive, being chaired by a patient who was previously homeless and supported back into society by the practice.
For background, the Mayor of London's statistics for 2014/15 say there are 7,500 rough sleepers in the Capital, up 1,000 on the previous year. 2,500 of these are concentrated in Westminster. Doctor Hickey's staff and others who work with homeless people view these figures as a conservative estimate on the actual numbers.
At the PPG I heard from its once rough sleeping chair - an electrician by trade - about the value patients place on the practice team members for their compassion, their tough love on occasion, and above all the relationships, support and care they provide to those with chaotic lives. Doctor Hickey is a small practice of 1,700 registered patients, plus any number of Westminster's homeless who walk through the door, or who they find on the streets. They show that two doctors and a nurse, properly supported in a multidisciplinary primary health care team culture of working (remember that?) with counselling, housing and benefits advice, and other community based services is indeed a perfectly appropriate, safe and sustainable model for general practice delivery. (Question to self - so why doesn't government want to buy it? - echoes of 'unprofitable pits' and 'devastated communities' come to mind for those who know their recent history).
The PPG members use terms like 'holistic', 'teamwork', 'relationships', 'coordination' and 'continuity' as descriptors. This is patient empowerment, self-care and engagement at its very best. It also reaffirms to me the benefits to people's mental and physical health that are gained from tackling the social and societal (wider) determinants, the absolute need for care navigation and co-ordination (not integration) across primary, community, social and mental health services around practice populations, and the better outcomes that are achieved if the right ones are measured. These may seem intangible in comparison to the world of targets and politicians' grand desires, but the better health and wellbeing delivered by motivated health and social care workers who feel supported (to get on with the care rather than feeling frustrated and corralled into unwieldy structures) is wholly palpable.
THIS is general practice values being delivered by motivated individuals working within patient-centred teams. Amazing. The 'Walking Round' gave us the visible facts on the ground. From 7pm - 11pm, 10 miles of trudging the wet and windy streets of our complex city brought it all home. Hostels of 200 beds shut down and left unoccupied contributing to the desperation, people sheltering under the noise of Chelsea Bridge, in the hope of catching a few winks of sleep, huddling together for warmth and protection.
One poignant message I learned - three broken key relationships is all it takes to become homeless.
Around these people walked a doctor and his practice manager, seeking them out to tell them how to access care, knowing that it may take four or five weeks of repeated attempts to get them to come along for a cuppa and a health check, but measuredly confident from experience that most will. And then the treatment and prevention will start.
These are facts on the ground. Not grand schemes or integrated organisations full of their own self-propelling managerial and box-ticking agendas (sorry managerial friends, but I know these are things you also often feel powerless to challenge - perhaps the advantage of the independent nature of general practice).
Dr Hickey faces unique challenges, but the way it meets these has some universal truths for all practices: if we treat the whole person they can overcome the factors that drive them back into ill health - lack of stability in life, broken relationships, underlying mental health problems. To do this effectively, and at scale, GPs and patients need community social and mental health services to be co-ordinated with them so patients, and staff don't feel bounced from pillar to post. There is a welter of long-established evidence dating back decades that this model works. But only if 'the system' is prepared to recognise and value its values. And therein lies our professional struggle. In this world where, 'Big is Beautiful', and 'Global is Good' (or is it 'God'?) and the 'Consumer is Core', recognise that 'Small is Spectacular', 'Holistic is Human', and 'Less is More'. Transform the NHS on our GP values Mssrs Hunt, Osborne and Cameron, and you might just save it.
My Christmas pledge. I will continue to make the case for tackling health inequalities and highlighting policies which promote the inverse care law, and I will continue to be a beacon for the case that the wider determinants of health and wellbeing are fundamental to health and general practice, where relationship continuity is a paramount. Will you join me?