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Wednesday 26 October 2016
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Supporting social issues

Patients’ non-medical needs are being brought to the forefront of general practice, and some surgeries across the UK are doing their best to ensure these requirements are met

GPs and their staff can do wonders for patients with clinical needs – whether it is diagnosing and treating them in-house or referring them onto the right specialist. But they are also acutely aware that sometimes the sort of help patients need isn’t a prescription or a procedure.
Many practices are trying to meet these non-medical needs of patients as well. From referring someone onto a foodbank to helping a frequent attender access befriending services, practices are adopting a holistic approach to patients.
Michael Orozco, managing partner at Peacock Healthcare in Nottingham and an NHS Alliance national executive member, says it can be challenging – but worthwhile – to try to tackle some of these needs.
“There’s lots of good work that practices do, although they are restricted by their own resources,” he says. “Some of the small practices will not be able to do anything but signpost patients.”
His practice hosts yoga and pilates classes for patients, and also has a horticultural group that plants and maintains part of the surgery grounds, and is popular with mental health patients. But he points out that the practice was lucky in that it had space to run these classes, which may not be the case for all practices. The practice was also willing to fund the lessons initially but it has now established a charity to take them over and raise money.
But do these approaches pay dividends for practices that get involved – and also for the wider health system? Orozco thinks so: many of the people taking these classes are elderly and they are helping to keep them more mobile and independent – and potentially out of hospital. “The other very important factor is that there are people meeting each other and having great interaction, which some of them may not have if they are living on their own,” he explains.
There is an abundance of evidence that GPs are seeing patients whose needs are partly or wholly non-clinical and need a different approach. A poll of 1,001 GPs in 2014, for the Legal Action Group (LAG), showed that many felt they were seeing more patients who would benefit from social welfare legal advice than a year ago. Of the polled GPs, 95% of them felt not having access to this advice could have a negative impact on their patients’ health.  
The Low Commission, a commission set up by the LAG established to develop a strategy for access to advice and support on Social Welfare Law in England and Wales, to look into this outcome. It found that approaches that delivered advice in convenient settings such as surgeries were more likely to reach people at an earlier stage than other methods. It said that advice services can contribute to health and wellbeing, and clinical commissioning groups (CCGs) should consider commissioning them and setting up referral pathways for healthcare professionals to refer patients into.
In May 2015, a report from Citizens Advice suggested that GPs in England spend almost a fifth of their time on social issues, which are not principally about health and they often felt ill-equipped to deal with them. Hugh Stickland, Citizens Advice’s chief economist, says it has around 600 staff working from GP practices and research shows that people who attend these are generally in less good health and poorer than those who attend its other sites.
“We genuinely think that advice has a positive impact on people’s health even if they are not referred by their GP,” he says. “A person may present with stress but the root problem may be something like debt.”

Derbyshire does it well
In Derbyshire, from 2014 to 2015, 7,778 people were helped by Citizens Advice with more than 30,000 issues – principally those involving benefits, debt and housing. More than £12 million in extra income was obtained for them and nearly £6 million in debt written off. Almost every practice in Derbyshire now has Citizens Advice.
For practices, the service is a welcome alternative pathway. David Doig, practice manager at Buxton Medical Centre, says: “The feedback is very positive, it is helping a number of our patients dramatically. I see it as a worthwhile service to have on board.
“Our doctors and nurses can pass patients on to the advisor when they know it is a social or benefits issue. If you are ill and have these problems, it won’t make you any better.”
The service reduces pressure on the practice, he says. People sometimes see the practice as the ‘first port of call’ for a wide range of issues and this gives it another option to resolve these non-medical problems.   
The Citizens Advice advisor sees patients in private. Patients can either self-refer or will be referred on by the doctors and nurses in the practice. An appointment can be made for them at reception.
Alice Jannetta, the advisor at Buxton and two other practices, sees a lot of cases where patients have had applications for disability-related benefits refused. “My relationship with GPs and practice managers in the surgeries I work in is very good and I can get information and letters of support for the client from the GPs where necessary,” she says. She has also worked with newly qualified GPs to give them an understanding of the benefits system and how they can best help patients.

Across the country
Liverpool CCG has experimented with ‘prescribing’ a specialist advice session where it is felt that a patients’ health is being affected by non-health issues. Other initiatives across the country have included providing employment support and advice through surgeries, which is being piloted in Islington.
Some CCGs are actively engaged in promoting such approaches but in other areas it is up to individual practices to take the lead. One of the easiest things a practice can do is signpost patients to other organisations that can help. This can be as simple as putting up posters or making leaflets available in the surgery. Putting details on the practice website can also help although this may not reach all patients and elderly patients in particular may not use it.
Practices may also want to keep a directory of services that could help patients – perhaps working with other practices to share information, and compile an electronic directory.
Age UK will have services in many areas, usually run by its network of local organisations. “What is available depends on what local organisations are there and what capacity they have to provide support,” says Tim Gentry, policy advisor for health at Age UK. “But in England almost every postcode is covered by an Age UK group.
“Small organisations can have very tight funding so make sure that the services that were there six months ago is still there.”
GPs need to first establish that there is not a hidden clinical reason why someone is lonely or feeling low. “A very treatable clinical condition may underlie the reason that someone is not leaving the house. People who are living with frailty may have some level of anxiety or depression, for example. When people’s conditions are not diagnosed they often end up with a [hospital] admission,” says Gentry.
Once GPs are satisfied that the real problem is non-clinical, these services really come into their own. “The more people that get engaged with these alternative approaches to manage day-to-day needs, the less they medicalise it,” he says. “Start with what is most important to the person and try to achieve that.”

Alison Moore, freelance health reporter.

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