Good morning - welcome to Liverpool!
Welcome to the start of the 11th RCGP Annual Primary Care Conference.
Welcome to the finest GP conference in the world – a smorgasbord of inspiring speakers, the highest quality CPD, and of course, sparkling networking.
I’m Helen Stokes-Lampard, and I have had the great privilege to be your Chair for almost a year now – it has been a remarkable time.
I’m not just your Chair. I’m a GP, a partner in a surgery in Lichfield, Staffordshire and I know all too well the challenges we are all facing.
It has never been tougher.
But we are also at a time of great opportunity – as long as general practice receives the investment it deserves, and GPs receive the support we need – there can be joy in the consultation.
I had planned to deliver a normal, sort of ‘Chair of the College type speech’ but instead I want to tell you story, I want to tell you about Enid…
All of you working in general practice sort of know Enid – you will all recognise her in your own surgeries; your own communities; your own lives.
Enid is 84. She has hypertension, which is pretty well controlled.
She has type 2 diabetes, which she is managing with diet and she has intermittent flares of osteoarthritis pain in both her hips.
Enid has kind eyes, a warm smile and always ‘dresses up’ to come and see us at the surgery.
Last year Enid lost Brian - her husband of 62 years.
They always used to attend their appointments together, sitting in on each other’s consultations – sometimes chiming in, sometimes holding hands anxiously if they anticipated bad news.
And we have had our fair share of bad news to work through together as Brian’s prostate cancer gradually took over.
Brian was her rock; her best friend and the butt of so many of her little jokes.
But now he is gone, she is living alone and society is a bit uncomfortable about Enid – an ageing widow who’s just a bit frail.
Let’s be clear: Enid a lovely lady. She has her own home – it’s small and manageable. She copes on her widow’s pension.
She has family - a daughter and some grand children living 180 miles away, and they all work full time.
Enid is fiercely independent. She’s getting a little bit forgetful - but she is certainly coping. She doesn’t fit the diagnostic criteria for dementia and she doesn’t want to be messed around with unnecessary testing or screening anyhow.
She got a bit snappy with the reception staff a few months ago. She became a bit more demanding on practice time and resources than she had ever been before.
The guidelines say - indeed the computer alerts flash at me - that I should be taking Enid to task about her weight, that I should nag her more about her exercise and be prescribing her more medication.
But I am sure we can all see that Enid’s main problem isn’t medical. She’s lonely…
After a life spent living with another person, she is now alone. When she wakes up, the house is silent - when she goes to bed, there is no-one to say good night to.
So, I didn’t follow the rules. I chatted to her, I listened. I did what all good GPs do – I saw the world through Enid’s eyes for our precious few minutes together.
I prioritised what Enid wanted over QOF, over NICE, and over the CCG guidelines – after all, they are only guidelines. Sometimes I offered advice about a new class, group, or a charity that I thought might suit her, might benefit her health and wellbeing.
I gave her permission to miss Brian - permission to move on with her own life. Permission to carve out a new normal.
And then in the final moments of our encounter, I do turn to the screen. I update her record as accurately as I can; tick the boxes that need ticking; and quickly consider everything else that the computer - in its well-intentioned but binary way - is telling me I should be doing.
Because someone will be watching. Processing the data to see if I am a ‘good’ GP - to see if I am using the consultation ‘wisely’. To see whether I am ‘minimising variation’ between my practice and nationally-determined best practice.
Nowadays, someone is always looking over our shoulders.
In the end, Enid connected with a local primary school that is linking mature women with young mums who are a long way from their own families.
Social isolation and loneliness are not the exclusive preserve of the elderly…
So, this project, recognising that the life experience of these older women - who have brought up children themselves and who now have the time and desire to help others - was exactly what Enid needed.
A couple of hours, twice a week where she has purpose, is needed and appreciated. Where she can use a lifetime of experiences to help others.
Enid isn’t making GP appointments as regularly anymore – she is not taking up space in a hospital bed for a hip replacement she didn’t really need. She’s not taking anti-depressants and actually, she’s not taking much medication at all.
She did come in to see me a couple of weeks ago. Something routine. I noticed that Enid has started to wear make up again. She’s had her hair done properly for the first time since Brian died. You get the picture.
Social isolation and loneliness are akin to a chronic long-term condition in terms of the impact they have on our patients’ health and wellbeing.
They are not medical conditions. They are not something that can be treated with pharmaceuticals or that can be referred for further treatment in secondary care.
But they must be addressed if we are to be patient-centred in our approach.
Of course, I’m not the first person to be speaking about this. When the NHS was established society was different. Generations of families lived closer together – people knew who their neighbours were and felt part of their communities
Over 30 years ago, a study in the College’s own academic journal - the excellent British Journal of General Practice - considered the impact of loneliness on older people’s health and wellbeing.
It mainly looked at people a bit like Enid - over 70, some widowed - and it found that the lonely did consult their GP more often, and in many cases their GP was the person they would come into contact with most frequently.
Back then the focus was on physical limitations associated with loneliness - loss of hearing, decreased mobility - nowadays, as we strive for parity of esteem between physical and mental health, it’s hard to ignore the impact on mental health as well.
Another BJGP study from 1999 also found that lonely and social-isolated patients visited their GP more often – in some cases not because they were more poorly, but they wanted someone to talk to.
They just wanted human contact.
In 2010 research published in PLOS Medicine looked at 158 studies into the health effects of social isolation and loneliness involving over 300,000 people.
The findings indicated that lonely people had a 50% increased risk of early death compared to those with good social connections.
More recently – just two years ago - a US meta-analysis of 70 studies, involving nearly three and a half million participants - published in Perspectives on Psychological Science - looked at how social isolation, loneliness and living alone affects premature mortality.
It found that for those who reported being lonely, the likelihood of early death was increased by 26%, for social isolation it was 29% and for those living alone likelihood of early death increased by 32%.
It concluded that these three risk factors for mortality were comparable to those well-established risk factors of lack of physical activity or obesity, or mental health disorders.
And it doesn’t just impact on general practice – but secondary care too
There are patients in hospitals up and down the country where patients just don’t want to go home – despite the indignities and lack of freedom, they have a community in hospital, they are not alone….
Loneliness inevitably takes its toll on the entire healthcare system
There will be robust debate as to whether addressing loneliness and social isolation is the role of the GP – or indeed the NHS at all - particularly at a time when we have so much to do anyway, and our responsibilities keep growing.
And some might say that by GPs even considering the impact of loneliness then we are medicalising perfectly 'normal' life experiences.
That's not what I'm saying.
My view is that if something is adversely impacting on our patients’ health and wellbeing, then we have a duty to recognise it and seek solutions.
Enid didn't need more drugs to cheer her up or mask her pain – she needed a cure for her loneliness.
She needed human contact - and I was happy that I could signpost her to a scheme that would allow just that…
Enid’s story is ongoing, but right now is going well.
But it is not always possible right now to deliver this level of person-centred care.
We need the time, the staffing and the resources to do it.
In another practice - one that’s larger than my own - I might have been able to get Enid some time with a Care Navigator, or someone who can ‘socially prescribe’.
Someone who can spend the time she needs with her - and find opportunities for an Enid-shaped space in society.
I’d really like that, I’m looking forward to that.
And actually, there are a remarkable number of initiatives to help with social isolation - and minimise the impact it has on health - especially that associated with advancing age.
If you have some time to read some of the amazing Bright Ideas submitted to our Clinical Innovation and Research Centre – CIRC.
You might come across ‘Prime 75’. This initiative, shared by Di Whaller, the Manager at Arden Medical Centre in Stratford Upon Avon, identified that their ageing population was a cause for concern.
They commissioned a service to identify over-75s at risk of being lonely, socially isolated or simply frail, and set up services for them to empower them to take more control of their health and wellbeing
Another was submitted by Claire Kaye, a GP at the Schopwick Surgery in Hertfordshire. They launched the Housebound Service – so that looking after their housebound patients didn’t become a tick-box exercise. To ensure they received holistic care - simple and brilliant.
I’m not sure how many of you caught a wonderful Channel 4 documentary this summer? It followed a group of children whose nursery was moved into an old people’s home in Bristol for six weeks.
The experiment aimed to explore the impact of this mix of generations on the health of the residents, many of whom had no immediate family and reported feeling lonely. There was scepticism - not least from the residents, one predicting that it would be ‘a total disaster’.
But actually, there was marked improvements in both their physical and mental health and wellbeing over the course of the experiment. They walked faster, got more involved in life and were happier.
These examples are what I mean when I talk about joy in the consultation - joy and reward in our professional live.
They also showcase the fantastic potential of general practice - of healthcare in general - to innovate, when we have the time and resources to do so.
Human beings are spiritual creatures. What makes us unique and special is more than our genetics and our environment – it’s the things that make our hearts beat faster, and our minds buzz with anticipation. The things we love, the things we hate, what we dread and what we get excited about.
It may be the love or touch of another person, soaring music, great wine or a magnificent view. But to deny our spirituality diminishes us.
Earlier this year I visited the Bromley by Bow Centre in East London, with the Centre’s founder and GP, Sir Sam Everington.
As well as a thriving GP surgery, the Centre is also the home to several social enterprises, a park, beautiful gardens, a church and numerous other facilities.
Several artists are based there, working alongside a large social prescribing team, who use a motivational interviewing approach to help members of the community. This has been found to help reduce dependence on GPs for issues that are more social than physical and psychological.
As GPs we cannot fix all of society’s problems – but we do get to see them and feel them – and we need to recognise their impact on health and have strategies to help our patients whilst protecting time to be doctors.
If we attempt to fix everything we will burn out - in many cases at the moment we are burning out. The GP Health Service launched this year in England as part of the GP Forward View and run by our fabulous former Chair Clare Gerada, already has over 800 GPs subscribed… we understand the scale of the problem.
That is why we need the £2.4bn a year extra for general practice - promised in the GP Forward View - delivered in England, in full. And we need equivalent settlements for Scotland, Wales and Northern Ireland. We need them fast.
To boost our workforce. To give us the appropriate numbers of GPs, and members of the wider healthcare team, to ensure we can do our jobs safely, for the benefit of our patients and our own wellbeing.
The NHS is there to provide high quality healthcare for all, free at the point of need. And as GPs, as expert medical generalists, as consultants in general practice we are there to ensure that care takes place at the front line, and to act as gatekeepers for the rest of the NHS
We are the bedrock of the NHS.
So, let me take you back to Enid.
I am not her friend, I am not her daughter, I am not her counsellor. But I am her doctor.
During our moments together in consultations, Enid is the focus of my professional world. She knows I will do everything I can to get the right outcomes for her.
That may not be longer life - that may not be the medication or treatment recommended by clinical guidelines, or my computer… But it will be Enid-shaped care.
This is what we should aspire to. This should be the future of general practice - Enid shaped care…
In February, our RCGP Council – made up of members elected from right across the UK, frontline GPs - passed the College’s updated position statement on quality. You can read the full report on our website.
But in summary it says that we should act with ‘kindness, empathy, honesty and integrity’ that we should ‘listen and share decisions in line with patient preferences’.
It talks about quality as ‘Providing person-centred and co-ordinated care, understanding the interaction between physical, psychological and social issues and working closely with key partners, such as the extended Primary Care Team, and the voluntary, community and social care sectors.’
Mahatma Gandhi once said that a nation’s greatness is measured on how it treats its weakest members. That is our most vulnerable - our elderly, our frail, our isolated.
We live in a civilised, affluent society in the UK. However hard things get, however tough things are in our daily practice, we must remember that.
Cum Scientia Caritas - the college’s motto - scientific knowledge … applied with compassion. It really has stood the test of time.
So I call, right here right now upon the four governments of the UK for the time, the resources, and the freedom we need to do what is right for our patients.
To innovate in their best interests. To act in their best interests. To allow us to deliver Enid-shaped care to Enid.
And I want to deliver personalised care to every single one of my patients.To restore the joy in general practice.
Deliver the GP Forward View in England in full; as the College has repeatedly said, we know there is progress but GPs on the frtonline are NOT feeling it so we need it fast. In Wales, Scotland and Northern Ireland - give us equivalent promises fast, and deliver them.
But resources and workforce aren't everything… Give us the freedom to deliver the care our patients need. Give us the time to care - don’t make us spend it ticking boxes, preparing for inspections, or worrying that we haven't followed guidelines for fear of repercussions.
Trust us to be doctors - let us treat our patients like human beings, and tailor treatment to their needs.
Let us have the resources we need so we can spend longer with those patients who need it.
I am not asking for generosity or excess: give us enough resource, enough time, enough people and enough professional support and encouragement.
And I - we – we will give you great general practice.
I want to give great care. Enid shaped care…
That’s why I became a doctor.
That’s why I am a GP.
That’s why I will do everything in my power while I am your chair to restore the good days to general practice.
To make our profession a place where practising GPs are supported and given the respect that we deserve.
The medical profession of choice – where GPs can enjoy working throughout their entire careers.
A profession we can all be proud of.