Community Orientation How to show the evidence in your eportfolio

1. Community Orientation How to show the evidence in your eportfolio Group Smarties

2. Aim By the end of the session trainees should feel confident that they can show evidence for the community orientation competence in their eportfolios By the end of the session trainers should feel confident that they can recognise when their trainees are trying to show evidence for the community orientation competence in their eportfolios(apart from trainees use of the comments box to “suggest”!)

3. Objectives • To look at the definition of this competence • To break it down into 3 related themes • To use cases and discussion to demonstrate how evidence can be shown in eportfolios

4. Community Orientation • This competency is about the management of the health and social care of the practice population and local community • There are 3 separate but related themes that build progressively on each other, which we will consider

5. Community Orientation • Understanding the features of the local community • Understanding the nature and availability of local health care resources • Managing resources, in particular the tension between the needs of the individual patients and the wider patient community

6. 1) Understanding the features of thelocal community The first progression is about the importance of understanding the local community and how doctors tailor their services to meet the community’s needs.

7. 1) Understanding the features of the local community

8. 2) Understanding the nature and availability of local health care resources The second progression is about the resources that are available to the local patient population.

9. 2) Understanding the nature and availability of local health care resources

10. 3) Managing resources, in particular the tension between the needs of the individual patients and the wider patient community The third progression is about our role in ‘rationing’ or how to make the best use of limited resources.

11. 3) Managing resources, in particular the tension between the needs of the individual patients and the wider patient community

12. RCGP curriculum statements for Community Orientation

13. Clinical Governance GPs have a responsibility for the community in which they work that extends beyond the consultation with an individual patient. • Demonstrate how to involve patients and carers in their care, in decision-making and in quality improvement processes • Describe why GPs should involve patients from a wide spread of backgrounds that reflect the population that they serve • Describe the problems resulting from inequalities in healthcare provision and how involvement of patients will assist in planning services to address the inequalities • Describe the importance of practice- and community-based information in the quality assurance of each doctor’s practice

14. Patient Safety • Demonstrate the ability to involve and communicate with patients and the public by practising the Being Open approach • Be able to make contact with the local Patient Advocacy Liaison Service (PALS) or equivalent support team and be aware of the current pattern of patient comments • Describe the ways in which general practice and community pharmacy can minimise the potential for PSIs • Describe how patient groups may be put at increased risk of mishap by virtue of their particular characteristics, such as language, literacy, culture and health beliefs - the latter may be manifest through the patient’s ability and willingness to work in partnership with the doctor in the management of the problem. • Describe any new roles that have emerged in the community setting (e.g. community matrons) and give examples of how these new roles have impacted on patient safety

15. Ethics and Values Based Medicine • Understanding of the different conceptions of distributive justice that are used in resource allocation debates • Recognition of the range of values that influence choices about healthcare provision • Awareness of the obligation to use public resources in a prudent manner to benefit the whole community • Ability to give morally relevant reasons for decisions that balance individual patient needs with the needs of the wider community

16. Evidence-based Practice • Demonstrate awareness that poverty is a common cause of poor health and poor health of poverty with significant co-morbidity • Demonstrate understanding of the dangers of health inequalities in applying evidence to minorities • Demonstrate awareness that the majority of evidence-based guidelines do not include ethnicity or socioeconomic status as risk factors • Include the cultural values of the patient and his circumstances in the discussion

17. Research and academic activity • A great deal of research is conducted in secondary care settings; the results are not necessarily applicable in general practice. All GPs must, therefore, be able to judge relevance, applicability and validity of research findings to their own practice. GPs must be able to interpret good teaching practice in the light of conditions prevalent in primary care.

18. Management in Primary Care GPs have a responsibility for the individual patient, their family and the wider community. • The importance of involving the public and communities in managing health services - e.g. encouraging patient participation in decisions about the local provision of health care. • The local, national and UK health priorities and how they impact on the delivery of health care • The need to reconcile health needs of individual patients with the health needs of the community in which they live, balancing these with available resources • The need to reconcile the needs of the individual GP and practice with the needs of the wider health economy

19. Information Management & Technology • Demonstrate an ability to use IM&T to gain an understanding of the health needs of communities through the epidemiological characteristics of their population • Demonstrate an understanding of the IM&T strategies put forward by the NHS and understand the implications of that strategy for their local health economy • Demonstrate understanding of the importance of practice- and community-based information in the quality assurance of each doctor’s practice • Demonstrate the use of IM&T to access community-based resources - E.g. voluntary organisations and self-help groups.

20. Healthy People • The scale of health problems in a locality in terms of incidence and prevalence, and be able to make comparisons with other populations • The interrelationships between health and social care including the wider determinants of health within communities - E.g. housing, employment and education. • The impact of poverty, genetics, ethnicity and local epidemiology on an individual and a local community’s health • The impact of inequalities and discrimination on health • The inequalities in healthcare provision: the ‘inverse care law’ • The roles of the other professionals involved in public health - E.g. school nurses, health visitors and public health specialists. • The importance of involving the public and communities in improving health and reducing inequalities

21. Genetics in Primary Care • Demonstrate awareness that the makeup of the local population may affect the prevalence of genetic conditions and attitudes towards genetic disease

22. Care of Acutely Ill People • Demonstrate an ability to use knowledge of patient and family, and the availability of specialist community resources, to decide whether a patient should be referred for acute care or less acute assessment or rehabilitation: thus using resources appropriately • Deal with situational crises and manipulative patients, avoiding the inappropriate use of healthcare resources

23. Care of Children and Young People Reconcile the health needs of patients and their families, and of the community in which they live, in balance with available resources. This requires: • Understanding the legal and political context of child and adolescent care • Assessing needs (of parents and families), including the assessment framework • Understanding the organisation of care – care pathways and local systems of care

24. Care of Older Adults • To reconcile the health needs of individual older patients and the health needs of the community in which they live, balancing these with available resources • Awareness of inequalities in healthcare provision relating to older people • Understanding of how the healthcare system can be used by the older patient and the doctor in their own context - E.g. disabled parking badge application, fitness to drive, etc. • Understanding of the interrelationships between health and social care for older people

25. Women's Health • Understand the issues of equity and access to health information and services for women • Evaluate the effectiveness of the primary care service you provide from the female patient’s point of view • Appraise the role of well-woman clinics in primary care

26. Men's Health • Describe the features of a successful men’s health service • Evaluate the effectiveness of the primary care service you provide from the male patient’s point of view • Develop practical means of engaging with men more effectively regarding their health • Appraise the role of well-man clinics in primary care • Recognise that violence and aggression are more common amongst men, assess the risk of harm to others and act appropriately • Evaluate the arguments for and against a national PSA screening programme

27. Sexual Health • Describe the epidemiology of sexual health problems and how it is reflected in their local community • Recognise that the prevalence of sexual health problems, including HIV, will be affected by the makeup of the local population • Describe the principles of, and current guidance for, partner notification • Describe how to access local sexual health services (e.g. specialist contraceptive care; termination of pregnancy; STI diagnosis and management; HIV management; and services for relationship problems and sexual dysfunction.)

28. Care of People with Cancer & Palliative Care • Be aware of the social benefits and services available to patients and carer(s) • Understand the current population trends in the prevalence of risk factors and cancer in the community • Appreciate the importance of the social and psychological impact of cancer on the patient’s family, friends, dependants and employers

29. Care of People with Mental Health Problems • Describe the extent and implications of stigma and social exclusion • Demonstrate how to work in partnership with other agencies to secure appropriate social interventions for individuals with mental health problems • Describe how to work in partnership with other agencies to secure wider public health of the local population (relating to mental health) • Demonstrate the ability to contribute to the health improvement programme that reflects the perspective of the local population • Describe the importance of avoiding medicalising some mental distresses • Describe the ethical dilemma of the use of psychotropic drugs to sedate people for social reasons

30. Care of People with Learning Disabilities • Demonstrate an awareness that the health needs of patients with learning disabilities are met appropriately by primary care and community services • Describe the roles of paid carers, respite care opportunities, voluntary and statutory agencies and an ability to work in partnership with them so there is cooperation without duplication

31. Cardiovascular Problems • Describe the rationale for restricting certain investigations and treatments in the management of cardiovascular problems - E.g. open-access echocardiography, statin prescribing • Advise patients appropriately regarding driving according to their cardiovascular risk and DVLA guidelines

32. Digestive Problems • Evaluate the arguments for and against a national screening programme for colorectal cancer • Describe the rationale for restricting referrals for upper gastrointestinal endoscopy in the management of dyspepsia • Recognise the need for increased availability of lower gastrointestinal endoscopy for the diagnosis of colorectal cancer • Recognise the place of simple therapy and expectant measures in cost-effective management of digestive problems

33. Drug and Alcohol Problems • Demonstrate awareness of the extent and implications of stigma and social exclusion (in relation to drug/alcohol misuse) • Demonstrate understanding of how to challenge inequality (in relation to the management of drug/alcohol misuse) - by working in partnership with other agencies to secure appropriate health and social interventions for individuals; contributing to the health improvement programme that reflects the perspective of the local population.

34. ENT and Facial Problems • Send referrals accurately so people with minor conditions don’t compromise the care of those with more serious conditions • Describe the national screening programme for hearing loss • Understand that certain ENT services have limited availability - E.g. cochlear implants, digital hearing aids. • Understand the legal implications of the Disability Discrimination Act 1995 including the need for ‘reasonable adjustments’

35. Eye Problems • Describe the role of, and appropriate referral to, the community optician • Describe the DVLA driving regulations for people with visual problems • Facilitate patients’ access to sources of social support for the visually impaired child- Including the ‘statementing’ process for children with special educational needs; schooling requirements and role of peripatetic teachers; career guidance for visually impaired children. • Facilitate patients’ access to sources of social support for visually impaired adults- RNIB, talking-book services; Social Services; local services; low vision aids.

36. Metabolic Problems • Recognise that environmental and genetic factors affect the prevalence of metabolic problems - E.g. diabetes is more prevalent in the UK in patients of Asian and Afro-Caribbean origin, hyperuricaemia is more common in prosperous areas and is associated with obesity, diabetes, hypertension and dyslipidaemia. • Recognise that public health interventions are likely to have the largest impact on obesity and diabetes mellitus, and support such programmes where possible - E.g. exercise on prescription. • Describe the exemptions from prescription charges for patients with metabolic conditions

37. Neurological Problems • Describe the current medical standards of fitness to drive for neurological conditions, in particular epilepsy

38. Respiratory Problems • Understand the current population trends in the prevalence of allergic and respiratory conditions in the community • Appreciate the importance of the social and psychological impact of respiratory problems on the patient’s family, friends, dependants and employers • Consider safety issues when prescribing home oxygen therapy

39. Rheumatology, MSK & Trauma • Explain how to access available resources for people with musculoskeletal problems - E.g. educational material such as the ARC information leaflets, support groups. • Facilitate self-help strategies to empower the patient - E.g. self-treatment measures, the expert patient programme (Department of Health), Challenging Arthritis Programme (Arthritis Care) and local exercise programmes. • Avoid investigations or treatments that are unlikely to alter outcomes in musculoskeletal problems, so that availability of these resources is increased (e.g. imaging methods). • Appreciate the resource implications of incapacity for work due to musculoskeletal conditions. • Prioritise referrals accurately so people with minor conditions do not potentially compromise the care of those with more serious conditions - E.g. referrals for joint replacements, non-life threatening orthopaedic conditions.

40. Skin Problems • Describe the rationale for restricting certain investigations and treatments in the management of skin problems - E.g. prescribing of retenoids and access to phototherapy. • Describe the importance of occupational risk in the aetiology of skin disease

41. Case Studies

42. Scenarios for discussion

43. Case Study 1 What happened? • A 40 year old woman attended for follow up of her depression and anxiety. She had been started on an SSRI and referred for psychological therapy. She had attended some counselling sessions and other low intensity interventions and was assessed as likely to benefit from a high intensity intervention - the waiting list for CBT was unfortunately 9 months. She was not well off but had taken the decision to pay for private CBT since she explained that she really wanted to "do everything I can to feel better". I noted that she had not been given any self help CBT and after exploring her views on this, we agreed she would look at the free websites "MoodGYM" and "Living Life to the Full" and explore this option further with her private psychotherapist to ensure a contiguous therapy package. Lifestyle measures were also discussed and she expressed an interest in exercise but barriers identified were social isolation and lack of disposable income for gym membership (low income household). We explored local services available in the community and she opted for dance/exercise classes at Cafe West in Bradford.

44. What, if anything, happened subsequently? What did you learn? (proposed learning log entry)This case exemplified several things to me: • The resource allocation for CBT therapy is well known in Bradford to be far below the demand. The National Service Framework in 1999 stated that the provision of mental health services should focus on those with severe and enduring mental illness and it strikes me that some of the disparities in health care provisioning for more "routine" and less "enduring" mental health issues may have come from national policy amongst other factors. • I note that the RCGP curriculum states that "The principal aims of clinical governance are to improve the quality and the accountability of health care." It strikes me that provision of CBT services is an area that has room for improvement for our local community and exploring this with our LMC might be useful. • The role for social prescribing here: in promoting access to other local non medical services such as other physical activity resources, arts/creativity to aid in overcoming social exclusion, mutual support groups, and to check that she was getting all the state financial support that she was entitled to on a low income. • Ethically, there is a balance to be made between the needs of individuals in a community and those of the community as a whole, and rationing here raised for me both the need for ethical "justice" for all whilst balancing autonomy and beneficence for the individual patient.

45. What will you do differently in future? Be aware of the wider issues that a simple fact of a "long waiting list" can represent, both in community, ethical, organisational and even clinical governance terms. Also remember the role for social prescribers and try to use this service more; bear in mind free local resources, as well as free self-directed self help resources for mental health problems.

46. Case Study 2 A 32 year old lady comes to your surgery 10 minutes late into her 15 minute appointment as she says she missed the bus. She informs you that she suffers with head lice and would like a prescription for some head lice shampoo. When you ask her if she’d tried any over the counter preparations or if she was aware that she could buy the shampoo without needing a prescription, she tells you that she is aware of this but would prefer to get it on prescription as it means that she wouldn’t have to pay for it due to her being on benefits. You issue the prescription for the shampoo. What issues does this raise? (socio-ecenomic deprivation, cost effective prescribing [wet comb vsdimeticonevspermethrin], ethical factors from community orientation perspective) How to construct a log entry to show community orientation?

47. Case Study 3 Genetic Case Study Your next patient is Samina who is 24 years old. She is married to her first cousin who moved to Bradford from Pakistan less than a year ago. Samina’s family is originally from the north of Pakistan. There is a strong family history of primary microcephaly. Samina and her husband have attended today because they have been trying for a pregnancy and wanted to discuss the risk of this condition. • What is the inheritance pattern? • What is the prevalence of this condition worldwide? How does this affect the local population in Bradford? • What other characteristics does the Bradford South Asian population have?

48. You decide to refer Samina and her husband for genetic counselling due to the strong family history of primary microcephaly. • Where would you refer her? • What issues may arise when providing genetic counselling in this population group? Samina has had genetic counselling and is now pregnant. She was informed that there is no reliable genetic testing available for this condition and the reduction in brain size can only be detected late in pregnancy. Despite this information Samina decided to continue the pregnancy. You see her again 6 months after the delivery. The baby is doing well and is only slightly behind on his milestones. Samina tells you that she is keen to find out more about what to expect in the future. • What support is available to her locally and nationally?

49. Answers What is the inheritance pattern? • Autosomal recessive • Can result from mutations in at least seven genes. Mutations in the ASPM gene are the most common cause of the disorder, accounting for about half of all cases. What is the prevalence of this condition worldwide? How does this affect the local population? • The prevalence of all forms of primary microcephaly ranges from 1 in 30,000 to 1 in 250,000 newborns worldwide. • About 200 families with MCPH have been reported in the medical literature. • This condition is more common in several specific populations, such as in northern Pakistan, where it affects an estimated 1 in 10,000 newborns. (i.e. up to 25 times more common than the rest of the world)

50. What other characteristics does the Bradford Asian population have? • Autosomal recessive disorders are more than 10 times more prevalent in Bradford’s Pakistani children. This is thought to be secondary to rate of consanguinity in this population (20 -88%). • Increased risk of abnormalities 3% - more if complex consanguinity • Non-lethal disorders 4X higher in Pakistani population in Bradford than indigenous white • Nearly 150 of these conditions have been identified. Inborn errors of metabolism, deafness, primary microcephaly, platelet and coagulation disorders all show large increases. • A British study of neurodegenerative disorders notes that 8% of UK cases are from Bradford. However health service funding often fails to reflect these numbers. • Clustering of otherwise very rare conditions enables clinical and genetic research. For instance, major advances in the understanding of human brain development have followed local research into the causes of primary microcephaly. • Genetic testing only available for small proportion of cases