Sam Everington: Creating a community-based primary care model

Five year forward plan has I think, at its heart two purposes. Firstly to shift care from the acute sector into primary care and secondly to shift care from primary care to the patient, and it’s the latter one I will be focussing most on when I talk about Bromley by Bow, Tower Hamlets, but specifically social prescribing.

It’s also, by the way, acknowledged for the first time that the Royal London Hospital in Tower Hamlets, where I come from, might have 675 beds but as a GP community we have 300,000 beds. That’s a much bigger task, isn’t it?  And yet as Maureen mentioned earlier on, we still only something like 8% of the funding.

It also acknowledges for the first time, that the direction of travel over the years, which was towards specialisation, actually I don’t call them specialists any more, I call them partialists, is now towards generalists, which is you.

In fact actually you talk to any politician of any party, or any party maker, they talk about primary care as Plan A, Plan B, Plan C.

So what I wanted to do was give you a brief introduction to Tower Hamlets and then tell you what we’re doing on social prescribing and also as chair of Tower Hamlets’ CCG how, at a cost of £1 per patient, you could make this happen in any health economy.

So, first of all, this is Tower Hamlets, yes it’s the Olympic site, it’s Canary Wharf, it’s the Olympic Stadium, but also it’s an area of high deprivation and poverty. Because we share all our data across Tower Hamlets and the East End of London, million population EMIS thing, we produce fantastic dashboards, but we’re able not just to show that this 11 year life expectancy between rich and poor, but worse than that a 55 year old in Tower Hamlets is a 75 year old elsewhere.  And, I would ask for you to think about that in all your communities because we’re all going to die eventually.  Actually to me it’s the quality of life that matters most of all, and guess what, the changes we need in quality and length of life is not going to come from genomes, drugs or any of the normal things we do as GPs and the health service, it is going to come from lifestyle changes, social prescribing and shifting care into the community.

It’s why one of the things we’ve done in Tower Hamlets, despite the deprivation and challenges, is to get the best blood pressure and cholesterol control in the country with patients with diabetes and heart disease with early evidence reduction in stroke, myocardial infarction and complications of diabetes by intervening much earlier in the journey.

But a typical 5 year old in Tower Hamlets is, 50% of them are vitamin D deficiency, 50% of them dental caries, cognitive development 10% below the national average, obesity levels 11% doubled by the age of 11. You get the picture, don’t you? You get the seriousness of the situation and guess what, actually one of our biggest problems is chicken shops and Mile End Road in Tower Hamlets, known as chicken shop mile, 42 chicken shops per secondary school in Tower Hamlets and I just, not when I say McDonalds is the healthy end of the market and that’s what I recommend to my patients.

So social determines of health. When I was at medical school we were taught about what matters.  What’s the matter with patients, okay, that’s what we were taught.  It’s still being taught, isn’t it, actually? But what are the social determents of health, is something, a change of words but a big significant shift.  It’s what matters to patients.  If you ever hear Professor Marmot, he will tell you that only 30% of health and wellbeing is managed by us in the NHS.  The determinants of health are critically important to people’s health and wellbeing and often much more important.  And what do I mean by that? I mean people’s jobs, education, their environment and their creativity.  I remember a patient years ago saying to me when I, why is the suggested they, that I referred them to a social worker and they said, in true East End fashion, “Sam I don’t need a effing social worker, I need a social worker’s wage”.  And that’s what social prescribing is all about.

And if you came to Bromley by Bow, and you’re very welcome to come, because we have courses there every month, you will taste some of the 100 projects under one roof. You will learn what we’ve done, where it went well, where it went badly, but most importantly hopefully you’ll go back and do something different.  A friend of mine, a GP in Leicester has a police station in her waiting room, reduced the crime rate to 20% of what it was, has people queuing up to go on the housing estate.  Just think what she’s done for the health of that community.

So we are a slightly unusual practice, just to tell you briefly about that. We have a partnership of ten, actually the director of the charity who’s not a doctor is also a partner of the practice.  One of the practice nurses is a full profit sharing partner of the practice, she earns the same as me, slightly different practice.  And the chair of the partnership is deputy director of the charity.  So a lot of intermingling.  A lot of sharing of space, a lot of sharing of ideas.  This is how you make things work.  It’s the relationships and leadership as one of the early speakers clearly talked about.  And of course your team is quite critical.

Now I thought I’d show you this picture because they were raising money for cancer. One of our social prescribing projects is with the MacMillan service, and here in this team, there’s that practice nurse, full profit sharing partner.  There’s the nurse practitioner who knows, and visits all the patients with terminal illness who are housebound, who have complex care and I am on call on Monday’s and Friday’s, the worst slot.  It’s unusual in a practice of 11,000 patients for me to have a home visit. There’s a message there isn’t there, about managing things in a very different way, and yes we have pharmacists that work in the practice, health care assistants, phlebotomists, a whole raft of different people.  And we have doctors who do things in a very different way.

This is Rosie, one of our doctors and she’s running a project with young kids with eczema, it’s called Eczemasaurus. So she got them to all draw pictures of dinosaurs but in the process of course, learnt how to manage their eczema, and why shouldn’t every kid be able to do that.

One of nurses is a nurse artist, done an art and asthma course. 10 year old comes into me and says “Sam my peak flows gone down 50, you need to step up my treatment, please prescribe me this” and why shouldn’t that be the norm.

These are the sorts of things that happen when you share space and you start focussing on the wider social determents of health.

On the desk top of every general practice in our area, in our confederation, that’s six general practice, you will see a referral form, along with a two week referral form. You can tick the box “frequent attender” “depressed” “lonely” “needs legal advice” “needs employment advice” or you can just write at the bottom as a GP “help”.  This then goes to the social prescribing team and the social prescribing team will meet the person for about an hour over coffee at the Bromley by Bow Centre and have a conversation with them about what matters to them and potentially connect them to 1500 voluntary sector organisations in Tower Hamlets.  The doctors love it.

Even if you are a biomedical doctor, help is at hand, one click away. The patients love it because it’s about what matters to them.  And guess what, I often tick the wrong box because by the time they got to the social prescribing team, actually far greater focus on what matters to them.  That’s okay, the voluntary sector absolutely love it because they don’t need to market their wares.  As GPs, just imagine all the leaflets you get and you know, you’re supposed to remember all the options, you know you get told about something, ten minutes later you’ve forgot it.  You don’t need to think, you don’t need to worry about that.  And the voluntary sector adore it because they don’t need to market their wares anymore. And as a CCG chair I love it, because anything that diverts a patient from the NHS has to be good value for money.

And we are now about to put this into every practice in Tower Hamlets at a cost of £1 per patient. I shouldn’t say this, but my finance director calls that back pocket money.  It’s back pocket money because it’s worth every single penny.  Not just in what it delivers, but actually the financial case, absolutely stacks up.

I wanted to end here and just say, so what’s our vision and ethos? What’s this all about?  How do we describe ourselves? Good general practice, great outcomes, no, it’s as simple as compassion, friendship, having fun and asssuming it’s possible.