Addressing complex needs in the community: a GP trainee’s perspective

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I work as a GP trainee in an inner-city London practice. I’d like to tell the story of one of my patients to give some insight into the kinds of issues that primary care teams are at the heart of every day. 

Patients with a complex mix of health and social issues like this are what fills my day and demand for our services feels unprecedented. 

My patient* was a man in his 60s with an inherited condition that causes the muscles in his legs to spasm, cramp and weaken over time, seriously affecting his mobility. A friend of his from church had called the practice the day before with concerns about his deteriorating health. We hadn’t heard from the patient directly since before the pandemic started, but when he arrived at the practice with his friend and we started talking, the problems kept coming. The strength in his legs was declining to the point where he was now falling 4–5 times per day. He recently fell onto his hand and was having trouble moving it, making his mobility even more difficult. His psoriasis (an inflammatory skin condition) had flared up so that it was sore, active and angry all over his body. He was overweight and had previously been given written information on weight loss, but he can’t read or write. He could not reach his feet, which, as part of his condition he could not feel properly and had stood on a nail months before which was only just healing. On top of this the council flat he had been living in was now uninhabitable. I was shocked to see a video of the ceilings caving in, mould everywhere, skirting boards falling apart, rubbish piling up, and a tiny single bed for this man who is more than 6 foot tall. He lived alone without any support or input apart from his church community.   

I spent an hour with him (because I’m in training I’m given some extra time to see my patients, but this meant I was running very late). And while I could help my patient treat his psoriasis, I couldn’t improve his living conditions.  

Patients with a complex mix of health and social issues like this are what fills my day and demand for our services feels unprecedented. I’m seeing an increase in mental health problems especially as the economic impact of the Covid-19 pandemic is being felt and patients waiting for hospital appointments and procedures are also coming to our practice so we can help them manage their pain in the meantime.  

Despite this context, it was heartening to see that based on the recently published General Practice patient survey, 83 per cent of respondents reported an overall positive experience with their general practice, although this might have changed since March. More sobering, as reported by colleagues at The King’s Fund, is that satisfaction is inversely correlated with deprivation: those in more deprived areas are likely to report worse experiences. 

At a more micro level, health systems will need to work differently, working with multidisciplinary teams within primary care and beyond to address the complex needs that many of my patients and people across the country are facing.

What needs to change? At a macro level we need to invest in improving the social determinants of health, like providing better quality housing, reducing air pollution and creating well-paid and secure work, spending more where the needs are greatest. At a more micro level, health systems will need to work differently, working with multidisciplinary teams within primary care and beyond to address the complex needs that many of my patients and people across the country are facing. To help my patient, once I had dealt with some of his more immediate physical complaints, I referred him to the complex case management community frailty team and I also asked the practice’s expert pharmacist to talk to the patient about his medications given he couldn’t read the written instructions.  

Working together in these ways is great, but it takes time to understand new roles and relationships. The chronic excessive workload in general practice makes prioritising this very challenging but, combined with ongoing investment in addressing social determinants of health, it is the only way forward. 

*Details have been changed to preserve the patient's anonymity. 

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