Insight: In at the '˜Deep End' of GP practices

Community links practitioner Colette Mason at Possilpark Health Centre. Picture: John Devlin

In a consulting room in Dr Susan Langridge’s surgery, John sits, his legs twitching as if he’s playing an imaginary drum, and talks about the events that have brought him to this state of agitation. He begins with the prescription he’s just received from a locum GP. “I wanted diazepam. I need diazepam, but he’s gi’ed me somethin’ else. I had to walk oot before I lost the plot,” he says.

But the prescription is just a hook on which to fix his panic. Eventually, it all spills out. John has mounting debts, faces eviction, is not seeing his young daughter and is numbing the pain with cocaine. Four years ago, he had a steady job and no issues with his mental health. But then his mother died and he was pitched into darkness. “I disgust myself. I am turning into a nasty, evil prick,” he says. “Sometimes, I wish I could go away and not come back. You’re the only person I can talk to.”

The “you” he is referring to is Colette Mason, a slim 31-year-old with a bright tattoo sleeve – a psychedelic explosion of mandalas, swallows and Jackson Pollock-inspired spatters – who radiates calm in the face of John’s pent-up aggression. She knows him of old; has steered him through several crises before. After listening and jotting down notes, she divides up his problems into manageable chunks. She promises to liaise with the Citizens’ Advice Bureau over debt consolidation, the housing association over his threatened eviction and community mental health over his suicidal ideation.

Dr Susan Langridge during a consultation with a baby and her mother. Picture: John Devlin

By the end of the appointment, John’s anger has ebbed away. He has stopped rubbing his hands up and down his face and started yawning. Before he goes, though, Mason checks on his emotional state. “Are you likely to hurt yourself or anyone else today?” she asks. Reassured by his reply, she reminds him to focus on thoughts of his daughter. “His daughter is his protective factor,” she tells me afterwards. She is his saving grace.

Mason is one of seven “community links practitioners” currently attached to Deep End GP practices in Glasgow. Deep End practices are those serving the country’s 100 most deprived populations. The role of the links practitioners is to take responsibility for patients’ social needs, freeing up doctors to focus on the clinical ones.

As in the rest of the UK, the NHS in Scotland is struggling to deal with the demands of an ageing population and austerity. But the pressure is most profound in areas of disadvantage, where job insecurity, inadequate housing, bereavement, isolation and benefits sanctions all impact negatively on health. A recent study funded by the Chief Scientist’s Office found GP practices in the poorest areas have, on average, 38 per cent more patients with two or more long-term conditions, and 124 per cent more patients with combined mental and physical health problems than those in the most affluent populations.

This places a huge burden on GPs. With ten-minute appointment slots and packed waiting rooms, they have no time to listen to patients like John and are, in any case, ill-equipped to tackle their wider problems. So, they write out another prescription, adding to NHS Scotland’s £40 million-a-year antidepressant bill, or refer them to already oversubscribed mental health services. Meanwhile, the underlying causes go unaddressed.

The point of the pilots is that, instead of lying awake at night worrying, GPs will now be able to refer patients with complex needs to the community links practitioners. Recruited from the third sector by Health and Social Care Alliance Scotland, the links practitioners have the skills to help those individuals access services, fill out forms, attend capacity-to-work assessments or support them as they take the first difficult step towards joining a club. With lengthier appointments they have a better chance of “unpeeling the onion” and understanding the roots of people’s unhappiness. In the three years the pilots have been running, the links practitioners have been party to many first-time disclosures of sexual abuse.

They are also tasked with improving the well-being of the other people who work in the practice: the GPs, practice managers and receptionists. And so, now, the staff at Dr Langridge’s surgery, which has 2,300 patients, often spend their lunch breaks tending vegetables in a plot at a nearby park.

An evaluation of the programme is under way, but Audit Scotland has acknowledged the pilots’ potential value and the Scottish Government is committed to recruiting 250 more links practitioners in deprived areas across the country.

Mason, a psychology graduate, worked in youth employability and with addicts, before taking on her role in Possilpark, where life expectancy for a man is just 66 – ten years less than the national average.

“Sometimes all people need is someone to listen to them, and one appointment is enough. Other times their needs will be complicated and I will have to work with them over a long period,” she says.

“Then there are the patients who cry so uncontrollably you can’t make out what they are saying and you have to see them several times before you can begin to understand how you can help.”

Sharon Ali, 45, was one of those patients. “Battered” by her mother, she moved into a hostel at the age of 15 and has suffered from depression ever since. But after the death of her father and a split from a long-term partner, her suicidal tendencies became more pronounced. When she was first referred to Mason, she was repeatedly turning up at police stations and A&E departments threatening to kill herself.

Mason worked closely with Ali, accompanying her to self-esteem classes and encouraging her to join social clubs, and gradually her mental health improved. She fires up her computer to check Ali’s appointment history. In 2015, she came into the surgery 21 times; in 2016, just once.

A few days later, I am meandering along the Forth and Clyde canal at Maryhill with Mason, Ali and other members of the North West Women’s Centre’s walking group. An older woman, Ann, who is recently widowed, has taken her arm and is monopolising her attention. Ali has curly black hair and sparkly boots and is clearly pleased to have been singled out as a companion. Though she hardly sees Mason these days, when she talks about how well she is doing, she looks to her for affirmation.

“I wasn’t very good with people,” Ali says. “I felt discarded. My confidence was shattered. Colette talked to me about mindfulness, got me to go places, even though the thought of being with large groups made me panic. Now, I am out almost every day.”

Ali continues to take antidepressants, but she has lost a stone and a half and got better at managing her anxiety. “I have strategies I didn’t have before,” she says. “I watch my diet, I push myself to exercise, I try to think positively.”

Around six miles north-west of Possilpark lies Garscadden Burn Medical Practice, another of the pilot schemes. It is housed inside Drumchapel Health Centre which looks out on Drumchapel Shopping Centre, a depressingly familiar assortment of bookies, take-aways, a Jobcentre and pharmacies. The obligatory bars on the window panes above are Art Deco wavy in a half-hearted attempt to make them look less like a prison. At the back of the health centre, two spanking-new high rises stand next to an old one, half-demolished, its electrical entrails swaying in the breeze.

Angela Martin, GP partner at Garscadden Burn, is visibly harassed as she pops her head round the door of the consulting room to tell me the arrival of community links practitioner Margaret Ann Prentice was like a “wave of light” for the 5,500-patient practice.

“For a good proportion of our consultations, the patient doesn’t need to see a doctor. What they need is support in terms of family and friends, or advice about systems and processes they are unable to understand or navigate,” she says. “Classically, they might present to us with depression and anxiety and those things may well be there, but you have all these other pieces of the puzzle: the lack of money, of social interaction.

“Some of the patients I see, they are so down and desperate, and there’s no network behind them. I think of my own life and how fortunate I am in terms of my husband, my kids, my job. And it breaks my heart.

“But now, when I have one of those consultations, I have someone else to turn to; someone who has more time than I do, and a greater knowledge of local services and resources.”

Prentice, 51, a peculiarly west of Scotland blend of compassion and steel, has worked in the third sector for 30 years. She says the appeal of the community links role was the absence of tick boxes and a sense it represented “the true integration of health and social care at the coal-face”.

She takes me to visit the home of cancer patient Ann Harkin. The 61-year-old is swathed in a red dressing gown and blanket, and propped up in the worn armchair that has doubled as her bed for the past five months. Within easy reach, is a table cluttered with pill bottles and boxes.

Outside Harkin’s window, the sky is February grey, but her living room wallpaper is a blizzard of butterflies – red admirals, swallowtails and lycaenidae – a gift from her daughter Gemma, who decorated while she was in hospital. Gemma sits on the floor vaping and tells me how terrified she was the day her mother, who has facial lymphoma, was rushed in to the neurology department. “I thought her eye was going to come out of its socket,” she says. “I was sitting there, waiting, in case it did.”

Harkin is the perfect example of how health, poverty and government policy interact. Even in that state, she didn’t want to be admitted as an in-patient because the following day she had an appointment at the benefits office she was too afraid to miss.

It took Prentice to promise she would deal with the officials, and ensure Harkin didn’t fall into rent arrears, to convince her to go. Later, at the Beatson Institute, she was given chemotherapy, but she only had three sessions before she developed pneumonia and was diagnosed with chronic obstructive pulmonary disease (COPD), making further sessions impossible. Now Prentice has a new challenge: to mentally prepare Harkin, who is claustrophobic, for radiotherapy treatment, which will require her to wear a tight mask.

“Och, Margaret Ann’s a bully,” Harkin laughs when Prentice broaches the subject. But the reality is that without Prentice to transport her, Harkin wouldn’t make it to the hospital. “I am in so much pain and there are so many worries. Every time I score one off, more appear,” she says. “If Margaret Ann can take a couple away it makes life that wee bit easier.” One of her worries is that Gemma – who cares for Harkin as well as her four children – will have a break-down. But Prentice has helped Gemma too, relieving some of the pressure and helping her keep on top of her mother’s medication.

So desperate are the circumstances many of the patients at Deep End surgeries confront, so tragic their life stories, it would be unrealistic to expect the links workers to solve everything. They cannot raise the prematurely dead, nor eradicate the scars inflicted by poverty or violence. What they can do is listen, address their immediate problems and give them the tools to better cope with what is impossible to change.

Take Liz Scott and her granddaughter, Jade. Liz took custody of Jade when Jade’s mother died five years ago. Then Liz’s son Paul – Jade’s father – killed himself a year later. Paul, 27, started self-harming after leaving the Army. When the police came to tell Liz what had happened, Jade was riding up and down the street on her bike, oblivious.

Liz, 55, was already suffering from depression when Paul died, but after his suicide it became so intense she wouldn’t leave the house, except to visit her GP. Seeing Liz struggling, Jade, now 13, put her own grief aside to focus on her Nana. But after Prentice helped Liz get her life back on to a more even keel, it was Jade’s turn to break down. She too asked for Prentice’s support, and was helped to access bereavement counselling and the Royal Caledonian Education Trust, which supports the children of ex-servicemen.

Even now, the Scotts’ pain is palpable; sometimes Liz seems to embrace it as a means of keeping Paul close. She has RIP Son tattooed on her left arm and a large photo of him on her living room wall. “When I lost him, my life ended,” she says.

The pair of them fight sometimes; the usual tussles over mobile phones and homework, yet harder to handle, maybe, because of their shared unhappiness. But now, at least, they have a safety net: new friends and activities that offer respite from the past. Jade loves dancing and shows me photographs of her glitzy outfits on her phone. Liz plays tennis, does yoga, and has joined a gym.

Liz is also a member of Promising Links, a befriending group set up by socially isolated patients at the Garscadden Burn Practice. On a Tuesday morning, several of them are tucking into an upended box of Roses at Drumchapel Sports Centre.

But not Liz. She is playing tennis doubles with Prentice, me and a friend. Running across the court, and laughing, she is a woman transformed. “Andy Murray better watch out,” she yells, as she chases yet another stray ball. “He might no’ be Number One for long.”