ANNE WARD PLATT
Management Consultancy Director
Anne is the director of a management consultancy specialising in conciliation, complaints and conflict management. She is the author of Conciliation in Healthcare: managing and resolving complaints and conflict (2008). Anne is also a non-executive director and deputy chairman of Northumberland, Tyne and Wear NHS Foundation Trust
Trust is at the heart of effective clinical relationships. Patients need to feel confident that the personal details they divulge will be kept securely and will only be shared in very specific circumstances. However, many young people believe that different standards of confidentiality apply to them and this, among other concerns, can prevent them from accessing appropriate healthcare.
It was recognition of the barriers that deter young people from visiting their GP that influenced the 'You're Welcome' quality criteria included in the 2009/10 Operating Framework.(1) This built on national initiatives aimed at improving health services for adolescents in the context of the following issues:
Rates of teenage pregnancy in Britain remain the highest in western Europe.
Sexually transmitted infections are on the rise. Smoking and binge drinking, with their origins in adolescent behaviour, remain important adult public health problems. Mental health problems are a significant issue for young people.
The start of another financial year is inevitably a time to reflect on priorities. Where do you rank improving services for young people? If you have not yet developed a strategy for addressing this, the 'You're Welcome' self-assessment process can help to identify gaps in your current provision for young people.(2) Using the framework to develop plans for future action can be an inclusive activity for practice staff, providing a valuable training opportunity and enabling the practice to develop a shared ethos and culture in relation to younger patients.
Encouraging young people to feel comfortable about visiting your practice may help:
Is your practice young-person friendly?
This question is intended to prompt thoughts not only about the physical environment and the attitude of practice staff, but also about how your practice promotes itself with young people in mind. For young people, your website is the true 'front of house' for the practice, since obtaining leaflets and other literature requires a visit to the practice. Indeed, some practices have links to websites that relate specifically to their services for young people.
The language you use to describe the practice is important to all patients, but some practice websites and inhouse leaflets are very obviously written only with adults in mind. For example, there may be references to children needing to be accompanied by a parent or guardian; the sole reference to adolescents may be in a paragraph stating that they may be seen without an accompanying adult only if a medical professional considers they are capable of understanding the implications of any proposed course of treatment. This relates to issues of consent based on legal criteria often referred to as 'Gillick competence' or 'Fraser Guidelines'.(3) But to ensure absolute clarity for young people, as well as their parents and practice staff, it should be unequivocally stated that they have the right to at least one appointment without an accompanying adult.
Providing information that is aimed specifically at teenagers themselves will give you an opportunity to address them as individuals, rather than using impersonal references to 'young people' or 'adolescents'. You can show that the practice understands how young people feel by giving examples of some of the reasons why they may wish to see a doctor. These might include:
Young people should be made aware that they can specify the gender of the doctor they wish to see, even if it is not always possible to meet this request in the case of urgent appointments. It should also be clear that they can telephone a doctor directly. This may be important if they are unsure about how soon they should see a doctor. There should also be guidance on how to access out-of-hours or emergency care locally when necessary.
Young people should be reassured that the duty of confidentiality extends not only to health professionals but also to other practice staff such as receptionists. This point is not always made explicit, but it is vital that young people do not feel that there is any risk that personal details, including their contact with the practice, will be revealed by anyone.
Where receptionists and other practice staff live locally, and may have social relationships with the young person's family, friends or neighbours, this can act as a powerful deterrent to accessing healthcare. Information about confidentiality should also refer to the rare occasions in which confidential information may be shared, but should emphasise that, wherever possible, the young person's consent will be sought.(4,5)
As well as providing easily accessible information about the services offered by the practice, including how to raise complaints or concerns, consider signposting to other organisations locally. These may be better equipped to meet young peoples' needs, or they may provide services complementary to those of your practice. These might include voluntary-sector organisations, other healthcare providers (including drop-in centres), and both local and national confidential telephone lines.
Training for practice staff
Training for frontline practice staff, especially reception and clerical staff, should help them to develop a deeper understanding about young people and their particular needs, which may in turn ensure they are more empathic and welcoming in their attitudes towards them. Your practice will be better able to fulfil its obligations to young people if all staff have training that is specifically targeted at:
The first contact with the practice may be when a teenager telephones to make an appointment. Will they be offered an impersonal automated message, or will they receive a response that invites their call? Are you confident that your receptionists have the communication skills to respond appropriately? Would they have a moment's hesitation before making an appointment for a 14-year-old who wished to see a doctor, unaccompanied? And how do you think they would respond if a parent telephoned to ask whether their 13-year-old had made an appointment to see a doctor?
Receptionists should be careful not to create barriers to access; eg, by asking young people why they wish to see a doctor or by making judgements about the urgency or validity of such requests.
Receptionists need to be alert to occasions when they should suggest that the young person speaks directly to one of the clinical staff. They, like other practice staff, should also be aware of their duty with regard to safeguarding issues and how to pass on any serious concerns that a young person confides in them, or which they have otherwise become aware of, in the course of their work.(6)
You may find it helpful to identify gaps and prioritise actions in the practice by using the audit tool developed by the Royal College of GPs and the National Society for the Prevention of Cruelty to Children in their safeguarding toolkit.(7)
Training for practice staff should also include awareness of the physical and psychological changes that adolescents experience, as well as highlighting serious issues that might prompt a young person to ask to see a doctor. These could include concerns about a parent's physical or mental health, or behaviour such as domestic violence or alcohol abuse; or they may wish to disclose their own experience of physical or sexual abuse, or their thoughts about self-harm.
A welcoming culture
Staff attitudes and behaviours are key to encouraging a culture in which young people feel welcomed. Staff should come across as non-judgemental, approachable, friendly, empathic, trustworthy and professional. It is equally important to discourage patronising attitudes where staff talk down to a young person, or treat them 'as a kid'. It is worth emphasising that some young people, like some adults, may come across as offhand or impolite, but this behaviour may simply be a manifestation of their anxiety and apprehension in an unfamiliar and potentially frightening situation.
Feedback from patients who use your practice can provide a vital source of information, but how proactive are you in seeking the views of young people about the services you provide?
Using the 'You're Welcome' quality criteria, a group of practices in Newcastle-upon-Tyne set out to engage with young people so that their views could contribute directly to improvements in healthcare provision. The consultation process included a survey and a 'have your say' day. Among other initiatives, an outcome of this process was the development of a website specifically for young people, which can be directly accessed from each of the practice websites.(8) The project contributed to 'You're Welcome' accreditation for the practices involved.
Regularly including young people's issues on the agenda of practice meetings will:
Most young people will have their first experience of healthcare in their local practice. Ensuring that your practice is "young person friendly" will help make that experience a positive one.