In our 106th edition, Liz takes us through five taxing days, Nigel has some top tips for locums on getting a mortgage, Louise reviews the latest SIGN guidance on alcohol in pregnancy, Sara highlights the roles of locums in quality improvement, Rachel looks at the risks around burnout, Kate on mental health safety, Judith rounds off with singing in the brain, all interspersed with some beautiful paintings by Claire.
The Sessional GP
Supporting sessional GPs to improve patient care
Preview attachment 8385 BMJ Live NASGP Avdert AW (3).pdf 8385 BMJ Live NASGP Avdert AW (3).pdf 117 KB
image © Claire de Mortimer
April 2019
Small changes have the most impact
Sara Chambers takes a look at how emerging research suggests that small, simple tactics can make larger sustainable improvements in healthcare, and how we as locums can be an integral part of this change. Here’s a story you may be familiar with: an organisation discovers they face a vexing issue involving some form of poor performance that needs improving. A top-down plan emerges to invest lots of resources in making a grand change to something tangible [Insert new care pathway, new IT system, new project team etc.] and wait for the benefits to trickle down to the delivery interface. But what then plays out over the following weeks and months? After the initial fanfare, we often end up back where we started. And this is the key dilemma that any health system faces. How can organisations make meaningful, sustainable improvements? There is growing research into what works in change management and improvement. A recent article in NEJM Catalyst, a hub for innovations and practical applications in health care delivery improvement, discussed the results of some pilot studies led by the Institute of Health Improvement (IHI) in various settings, including NHS clinics, deploying some pretty simple ‘everyday management tactics’. It’s an interesting read: amidst the dry improvement science terminology of ‘costs per patient’ and % increases in productivity, the results were heartening, with the golden triple win of increases in productivity, staff morale and patient safety. Of most interest to me as a GP locum, and the apparent key to the sustained success of these pilot studies, is that they were building on previous change management research which had identified that the key change in any improvement process is changing the culture. Cultural change Culture is the sum total of the prevailing thoughts and feelings that the people working in a system carry with them, often subconsciously, or have about an issue or a problem that’s facing them, and is the invisible glue that makes a change in behaviour stick. It’s easy to see why culture is overlooked; it’s nebulous, intangible, difficult to measure. How do you change such an omnipresent, amorphous ‘thing’? That was what these pilot studies set out to investigate. The IHI researchers started out by using years of study into the practices of high performing teams, identifying core features, and borrowed and bent their techniques to come up with what they termed ‘Everyday Management Tactics’, aimed at fostering a change of the hearts and minds amongst different layers of a healthcare team, from management to frontline clinicians. What were these Everyday Management Tactics? Standardisation - everyone understood the work involved in their role. Visual guides - that help performance and can be understood at a glance. Escalation - the development of clear processes for identifying problems. Integration - sharing all the Everyday Management Tactics with all levels of management and team; managers and clinicians talking and problem solving together regularly. Then applying these tactics, through things like visual display boards, daily huddles between clinicians and managers, it is humbling to learn that these small steps forward accumulate in time to a much larger benefit for many patients: the endoscopy team that reduced late starts from a median of 100 minutes per week to zero; the inpatient respiratory ward that reduced falls in patients from 51 to 27 per year. Note that these were long-term, maintained improvements brought about by existing staff being shown how to work differently together. Most remarkably, in the latter example of falls reduction, once they had the bit between their teeth, the staff were taking the initiative to drive continuous improvement to get falls down to zero. And the staff morale and enjoyment in their job improved too. What lessons for GP locums and practices? Changing culture is key to maintaining improvement. Culture can be changed by consistent use of management tactics such as standard work, clear processes for escalating concerns designed to promote a culture of collaboration, and proactive problem-solving. The other take home is that these pilots were focusing on seemingly small gains. But cumulatively, these add up to large benefits over time and are spurs to further ongoing improvement. And this is where this article starts to feel very relevant to our situation as GP locums. This interchange between culture and the small, preventable glitches we face in our daily work which can accumulate into enforced underperformances. The idea that culture and behaviour feed off each other: the possibility that if we introduce some simple tactics to make some achievable small wins, we may start to improve the culture of engagement to one that is more about seeing GP locums as collaborative partners rather than the bain of general practice. The story of a locum session To illustrate, when NASGP published our article The story of a locum session; missing out on marginal gains, we were inundated with responses from GP locums who recognised the issues and risks of the seemingly small omissions and glitches between the locum and practice in the organisation and preparation for a ‘typical’ locum session. This suggests that these issues are indeed typical between many practices and locums. Where does this poor engagement stem from? I would argue that it starts with culture - a set of misunderstandings, misplaced thoughts and beliefs. The engagement of locums is often delegated to practice administrative staff who are typically only accustomed to their practice 'bubble', familiar with dealing with only practice-based GPs. Assumptions are made. As one practice manager put it, 'we don’t know what you don’t know.' And what about us as GP locums? What part do we play in enabling these moments of enforced underperformance? If practices 'don’t know what we don’t know', why aren’t we telling them? Again, it’s culture. The prevailing culture of overlooking locums means that GPs get little training in working as a locum, and it sometimes seems that each locum has an uphill battle in finding their own feet in how to make safe bookings, sometimes turning to agencies and online platforms. Own worst enemy It is a great irony that the demand for GP capacity is so high, and yet the engagement with locums can be so haphazard and chaotic. The profit-minded eye this 'space' between desperate practices and GP locums as the 'Wild West'. Agencies and online platforms spring up to serve the hungry practice customers. So the culture shifts to GP locums becoming the product now working under the T&Cs of the intermediary party - who can be booked the quickest, with the lowest fee payable to the locum, while the GP locum becomes resented and still seen as expensive because of the booking fee incurred. Playing our part How can we as locums play our part in improving this culture of engagement and avoid the preventable pitfalls detailed in the regrettable Story of a locum session? Doing so will improve not just our working lives and morale, but the quality of service to practices and patients. It’s hard to be a doctor in any setting. We face many external challenges and most of us know that the culture of the NHS towards health professionals is not always kind and supportive. But it is saddest of all when we, as a profession, set ourselves up to fail because of small preventable, easily modifiable factors - so-called marginal gains - stemming from a culture of not pulling together, not respecting and recognising that we are all colleagues trying to pull in the same direction in a system that needs improving. We as locums can start the cultural change and help our practice colleagues ' know what we don’t know' and point them towards the marginal gains, helping them to make best use of us so we can help them. In a follow up companion piece to this piece, I shall borrow from the research and evidence-base and adapt some of the simple everyday management tactics to our locum work scenario to lead this cultural change. Sara Chambers is a GP locum and is quality lead of the National Association of Sessional GPs. Sara Chambers sara@nasgp.org.uk
By Sara Chambers @sara71chambers
the locum’s role in the culture of improvement
"If practices “don’t know what we don’t know”, why aren’t we telling them?"
five taxing days
"The cost of a new car is only fully deductible (the business proportion thereof) if it is a brand new very low emissions car."
All those tax claims you can claim on-the-go
By Liz Densley @honey_barrett
Jess is a sessional GP on a budget, saving for her wedding so she’s recording every single penny she spends – let’s look at what she can get tax relief for (and why or why not). Day one 6 am – Jess’s brand new mobile phone alarm wakes her up. Claim tax relief on the estimated business proportion of the cost of the mobile phone. She gets dressed in her work clothes. Cannot claim for normal clothes.If protective clothing were required (white coats) that would be claimable. She picks up her dry-cleaning to drop off later. Cannot claim for normal dry cleaning. Grabs some fruit and a cereal bar and her water bottle for breakfast. Cannot claim for normal meals. 7.30am – gets into her car and checks the postcode of the locum practice she’s working at today, puts it into her satnav and sets off. Can claim for the satnav – if it is predominantly for business – or a business proportion if there is shared usage. Realises she’s short on petrol, and stops off to fill up, picks up a sandwich for lunch at the same time. There are two ways to claim relief for motor expenses: a % of business usage, or 45p per business mile. Sandwich is not deductible. 8 am - arrives at new practice and goes in to start work. This is a genuine locum post – business is run from home, so home to here (and back) is a business journey. Uses her iPad to issue invoice to practice from LocumDeck for the work done at the end of the session. The cost of the tablet (and accessories) can be claimed (a business proportion if there is shared usage). Lunch time spent driving to next practice, no spare parking spaces so has to pay to park. Travel to the next practice and the parking cost will be allowable Deal with messages on her phone and new locum bookings before she starts her afternoon session. The call/data charges on the phone are claimable – a reasonable % split between business and personal. Drives home dropping off dry-cleaning on the way. Dropping off the dry cleaning is an incidental part of the journey, so the journey is still allowable. Day two This is a day at her salaried practice so she doesn’t need to worry about working out where to go, paying for parking or invoicing. So nice and simple from an expenses point of view (shame the job isn’t so simple!). No relief due on travel to the salaried job and back. If she’d done any visits then she could claim 45p/mile for these. Lunch time CPD session – no food provided, and she can’t eat last night’s strong smelling curry that she brought in to heat up for lunch forgetting she had a training session, so she has to buy a sandwich and a Mars bar. Here the lunch cost would be an incidental part of the training, and outside the normal pattern, so should be allowable. Spends a few hours in the evening researching some clinical matters using her new superfast broadband connection (while her fiancé relaxes watching Netflix). Can claim a reasonable proportion of the internet connection. Can claim either a flat rate amount for use of home based on hours worked – or a more complicated calculation of the actual business element of the total home running costs. Day 3 Today is her regular locum slot at a practice 20 miles away. They are short of doctors so she always works there on a Wednesday. Decides to do a big supermarket shop on the way home, and while she’s there buys some new printer cartridges. Journey to a regular place of work is not deductible. The purchase of printer cartridges, assuming used for work, is allowable, but the mileage won’t be as it is just an incidental part of a non-allowable journey. Gets home, checks her bank for payments due from practices. Can claim relief for bank charges for the business account. Does her pensions paperwork for the last month’s locum work on LocumDeck and issues a ‘Send reminder’ to a practice who hasn’t paid her yet. Can claim for pension contributions. Pays her accountant for last year’s tax return and checks that her payment for her GMC subscription has gone through ok. Can claim for accountancy fees for accounts and tax return. Can claim for all relevant professional subscriptions, including NASGP membership, and technical reading. Checks LocumDeck for what work is coming up and to see if any new bookings have been made. Can claim for the subscription to her locum booking service and invoicing system. Pays some household bills. Record the hours spent to maximise the claim for household expenses (see above). Notes that car needs servicing and that must mean road tax and MOT is due too. If claiming mileage at 45p per mile, then no extra claim for repairs, road tax, MOT, insurance etc – but if claiming on the basis of a proportion of total costs, then these costs are all proportionately tax deductible. Wonders whether it is time to consider buying a new car – she dreams about a brand new electric car, but the reality is she can only sensibly afford a second hand basic Fiesta. The cost of a new car is only fully deductible (the business proportion thereof) if it is a brand new very low emissions car. Capital allowances on other cars are given at 18% or 8% - depending on emissions level – and then only on the business percentage – and then only if claiming on a proportion of total costs basis, not a big enough figure to influence what she wants to buy. Day 4 Morning at her salaried job and a half day off planned – but receives a call on her mobile from her salaried practice as she drives in asking if she can do an afternoon session today as one of the partners are off sick. She expects to be paid her locum rate for this. Journey to work not allowable. Fee should be paid as overtime through the payroll not as self employed locum work (but still at locum rate if that is what was agreed). Meets up with some fellow locums in the evening for a pizza, and discusses some tricky patients. Is the pizza an incidental cost of a technical meeting (allowable) or is it a meet up of friends where they talk shop (not allowable)? Day 5 Another locum day – to a local practice she has occasionally worked for before. First patient, a baby, throws up all over her new dry-clean only top – note to self, only buy washable things for work. Travel here is allowable. Dry-cleaning of items soiled in the course of work is allowable. Wipes and similar, not provided by the practice, would be tax deductible. Training session in the evening – costs £50, but it includes an evening meal. As the meal is an incidental cost of the training session cost, the whole is allowable. Liz Densley is medical specialist Director with Sussex Chartered Accountants, Honey Barrett and secretary of aisma (the association of independent specialist medical accountants). Contact her on 01424 730345 or at liz.densley@honeybarrett.co.uk
It's much easier if you know what to do and who to speak to,
mortgage tips for GP locums
"If you haven’t got a terribly good credit rating or maybe haven’t used credit at all, and therefore have a non-existent rating, there are things you can do to improve your score..."
By Nigel Farrar www.legalandmedical.co.uk
Despite the weirdness that is Brexit, the traditional increase in the number of new mortgage applications in springtime continues. There are plenty of decent rates out there, particularly fixed rates. But what if you are a locum? It may be great to have the flexibility and autonomy of working patterns, but if it stops you having a mortgage it can cause a real headache. All locum roles are not the same in the eyes of a mortgage underwriter. There are differences in the way that types of locum roles are assessed. For example, they will assess a ‘salaried’ locum differently to a self-employed portfolio locum working in various practices in short term roles. It is worth taking specialist advise before you start the application process. But fear not, it’s not as hard as you might have heard. Here’s my top tips for getting a mortgage…even if you have only been a locum for six months! 1. If you are a locum in the early days of your locum career In your first year as a locum, your income will have been employed for part of the year while you complete your training, and then become self-employed after becoming a locum. Sounds complicated, but it’s not necessarily impossible to get a mortgage. The key thing here is the involvement of an accountant. Not just any old accountant. Choose someone who deals with other medics and specifically locums. The reason this is vital is that there are a few mortgage companies who will consider lending if a suitable accountant can project forward and give an estimate of your whole year’s locum earnings. They will not take your own projections into account. Specialist medical accountants are a jolly good idea when you are a locum. They can work wonders wrestling your sometimes-complicated earnings into a standard tax return while claiming back fees and allowable expenditure along the way. Add to this their ability to help with mortgages and they rapidly become a vital part of your financial team. But do bear in mind very few mortgage companies will consider lending to you even with an accountant’s projection so speak to your specialist financial adviser to make sure you don’t waste your time applying to unreceptive lenders. 2. More established locums Once you have two to three years of self-employment, things get much more straight forward. But not as easy as when you were in hospital service and you just had to present three months pay slips of course. Because of your fluctuations in income, mortgage companies want to see a longer snapshot of your earnings to decide if you can afford the mortgage. To give you the maximum number of lenders that will consider lending to you in the future, try and keep your records carefully as you go along. Ideally you need: Three years accounts and/or SA302s (ask your financial adviser or account if you don’t know what these are) Three months bank statements 3. Don’t underestimate the costs of buying…it’s not just about the deposit! Here’s a few areas to check you have considered and budgeted for. Surveyor fees Legal and solicitor costs Valuation fees Estate agent fees Stamp duty Electronic transfer fees Removal costs Once you have these all estimated, you will really know the deposit you have left and therefore the mortgage you can reasonably expect. If in doubt, ask your financial adviser to help with working out your maximum borrowing figure. 4. Check your credit scores and history. Granted it’s not the most exciting way to spend 10 minutes, but it’s not hard and if you have a problem you can try and sort it out in advance rather than falling for your dream home or needing to move to get children into a certain school and finding you can’t. There are several credit check agencies out there. I use Experian. If you request a statutory credit report its either free or costs only a few pounds, and you don’t need to sign up to any other services. If you haven’t got a terribly good credit rating or maybe haven’t used credit at all, and therefore have a non-existent rating, there are things you can do to improve your score such as: Register on the electoral roll Pay bills on time Check for mistakes on your credit report Check for any fraudulent activity on your file Check to see if you are linked to another person Don’t have County Court Judgements against your name Don’t have high levels of existing debt Don’t move home a lot 5. Clean up your outgoings! How much you can borrow is based on your earning but, almost more importantly, what you spend and what will be left over to repay the mortgage. So, take a look at your bank statement and be ruthless with those seldom-used gym memberships, consider switching to paying for things annually instead of every month, and check all your direct debits for possible cost savings such as with your utilities. 6. Give some thought to what type of deal you want. Fixed or tracker/variable are the main choices. With a fixed rate you have total security knowing the rate wont change while you are on a deal. That’s great if interest rates rise, as your rate won’t, but if they go down you wont benefit either. A tacker or variable rate will change over the deal’s lifetime. When rates reduce you can smugly think about all the money you are saving, but if they rise you could see your mortgage repayment getting expensive. It really is a personal thing. Discuss it carefully with anyone else that you will be taking out the mortgage with and your adviser. 7. Consider how long you want to be tied to one lender. When you decide on a mortgage deal, most will have a penalty if you leave them either by remortgaging to another lender or sell up and repaying the mortgage before the end of the deal. After a few years you may want to switch lenders to get a better deal, or move and need to borrow more. Not getting stuck in a deal when you will need flexibility can save money and frustration, so think ahead to when you might need to make a change due to schools, work or just because you fancy it! 8. Make sure your adviser understands how locums work. Without knowledge of how you work, your adviser could present your mortgage application to lenders that takes no account of the fact you worked within the NHS for years before becoming a locum. Also, unless the mortgage company has dealt with lots of locums (which most don’t), they won’t know what to make of your varying hours and income and decline the application. A declined application can make your chances of getting a future mortgage approved less as it can affect your credit rating, and you must declare if you have been declined for a mortgage elsewhere. Next steps So, what now? If you are planning on buying in the next year, start shaping up your finances now to make it easier in the future. But if you need to find a mortgage now find the right specialists to help you as soon as you can. Mortgages are not a quick, overnight process! Please remember that your home may be repossessed if you do not keep up repayments on your mortgage. Nigel Farrar nigel@legalandmedical.co.uk 01392 832696 Legal & Medical Investments Ltd is registered in England & Wales No. 3429678 Registered Office; Splatford Barton, Kennford, Exeter EX6 7XY Tel: 01392 832696. www.legalandmedical.co.uk We are authorised and regulated by the Financial Conduct Authority. Entered on the Financial Services Register under reference 185193. The Financial Conduct Authority does not regulate offshore investments, tax advice, estate planning and some forms of mortgages. The tax reliefs referred to on our articles are those currently applying in the United Kingdom to UK Tax Residents. These tax reliefs are liable to change. The value of any tax relief available will depend upon the individual circumstances of the taxpayer.
© Claire de Mortimer, GP locum, detail, acrylic
burnout and how to avoid it
Burnout among GPs can be an occupational hazard and is believed to be increasingly common. Dr Rachel Birch, medicolegal consultant at Medical Protection, discusses burnout and the steps that sessional GPs can take to avoid it. Case scenario Dr A is a locum GP undertaking 5-6 sessions per week in different practices. She has chosen to do locum work, to balance her work life with that of bringing up her two small children. She has always felt passionately that, as a locum GP, she can contribute positively to practices by drawing on her experiences of working in different practices - ensuring that patients receive the same level of care from her that they would from their regular GP. However, recently Dr A has felt overwhelmed at work and has found herself coming home exhausted physically. She no longer looks forward to work and has started to doubt herself, believing that nothing she does makes a difference to patients. She no longer takes pride in her work and feels numb when she thinks about her patients. It is clear that Dr A is suffering from burnout. What is burnout? Burnout is an occupational hazard and can occur frequently among health professionals. According to mindtools.com, “burnout occurs when passionate, committed people become deeply disillusioned with a job or career from which they have previously derived much of their identity and meaning. It comes as the things that inspire passion and enthusiasm are stripped away, and tedious or unpleasant things crowd in”. The Maslach Burnout Inventory (MBI) describes three domains that make up burnout: Emotional exhaustion Depersonalisation - a cynical attitude with distancing behaviours Low sense of personal accomplishment. In the case scenario above, Dr A has symptoms in all three of the domains. How common is burnout in GPs? A survey of 500 GPs in the UK in 2012 found that 46% were emotionally exhausted, 42% were depersonalised and 34% felt that they were not achieving a great deal. A 2013 Pulse survey of 1,784 GPs revealed even higher levels of burnout - 74% were emotionally exhausted, 43% were depersonalised and 20% had a low sense of personal achievement. Since primary care continues to experience increases in both workload and expectation, it is likely that a high incidence of burnout remains. What are the causes of burnout? Research defines six key areas of work where an individual’s relationship with their working environment may be causing difficulty. Considering GP work, examples might be: Workload - too much work for the number of hours; unexpected emergencies; lack of resources. Control - micromanagement, lack of influence over decisions affecting their work. Reward- not enough pay for the level of responsibility, lack of thanks or acknowledgment of their work. Community - Isolation at work, conflict, lack of supportive relationships at work, difficulty with a colleague. Fairness - Feeling of discrimination, lack of transparency of pay scales. Values - Feeling that administrative aspects of work are meaningless, ethical conflicts. By examining these six key areas, it may be possible to identify one or more mismatches between the nature of the job and the individual’s own personality and attributes, which may lead to burnout. What are the risks of burnout in a GP? There are personal risks of suffering from burnout. If unrecognised or poorly addressed, burnout could predispose the individual to developing mental health problems such as anxiety or depression. Relationships and family life could also be adversely affected. The GP may feel disillusioned or develop feelings of low self-worth and this could lead to them leaving the profession. Experiencing burnout may also feel unpleasant. There may be risks to patients too, as an emotionally exhausted doctor may make mistakes or miss diagnoses. Patient satisfaction may be affected too, a GP who no longer enjoys their work may inadvertently project some of their dissatisfaction on to a patient, and lead the patient to believe the doctor lacks empathy. There are medicolegal risks too; doctors experiencing burnout may attract patient complaints or litigation, should a patient come to harm. How can sessional GPs prevent burnout? Prevention is better than cure. Being aware of burnout and its possible causes can help doctors to avoid it. It may be that salaried and locum GPs have lower incidences of burnout than GP principals. The reason being that they can vote with their feet and include variety in their working lives, as well as avoiding working in practices they feel don’t suit their working styles. Also many sessional GPs may be members of locum chambers or sessional GP groups, giving them opportunities to meet with their peers, discuss local practices, and obtain support when needed. If sessional GPs find themselves experiencing symptoms of burnout, then it is important to recognise this and consider making personal changes to build their individual resilience. However, since it is primarily the workplace environment that creates the occupational hazard of burnout, unless the practice makes changes too, it would be unlikely that the symptoms of burnout would be reversed. Sessional GPs would be advised to raise the issue with their employers. If they are reluctant to do so, or if the issue is met with apathy or adversity, then one option, although difficult, may be for them to leave and find a safer workplace. A safe working environment is a practice where there is a clear understanding of staff wellbeing, with procedures in place to support the GP’s own resilience strategies. By identifying possible contributing factors to burnout, the sessional GP could consider what they want from a practice. Examples of supportive measures could include: Workload - provide a manageable GP workload with built in break periods. Control - be flexible over start and finish times. Reward - have a culture of appreciation and thank staff for their hard work. Community - consider social events to enhance teamwork and a sense of belonging. Fairness - have a blame-free culture with regular meetings to learn from events. Values - celebrate achievements within the team. Personal changes that GPs may consider making involve developing self-compassion. This is not always easy for GPs, who pride themselves on caring for others and may neglect to care for themselves. GPs can take care of their physical wellbeing by making changes at work and home respectively; by taking breaks, remembering to stay hydrated and not skipping lunch, eating healthy meals, exercising regularly and having enough good quality sleep. As general practice can be stressful, GPs may also need to nurture their emotional wellbeing, perhaps through meditation or the practice of mindfulness. Finally, taking time to revisit their own sense of calling, the reason they chose to become a doctor, can be empowering and help sessional GPs to rediscover their passion and enthusiasm for their work and stay resilient. In conclusion, burnout is an occupational hazard for GPs, and sessional GPs need to maintain an awareness of the symptoms and causes. Salaried and locum GPs are an essential part of the GP workforce and should be valued as such. It is important to choose practices they can thrive in, for the good of both themselves and their patients. GPs that recognise feelings of burnout can contact Medical Protection to attend the building resilience and avoiding burnout workshop. Rachel Birch rachel.birch@medicalprotection.org
By Rachel Birch @MPSdoctors
It's harder to care for others when you're unable to care for yourself
"There are medicolegal risks too; doctors experiencing burnout may attract patient complaints or litigation, should a patient come to harm."
"Making a safety plan is a way that we can help ourselves. It is a resource developed by others who have been through similar situations and who use it themselves at times when they feel unsafe. "
Many of us will have experienced a time of emotional crisis. It could follow a break-up of a relationship, a bereavement, a traumatic event, financial worries or an adjustment to a big change. We might feel inadequate, a failure, ashamed, angry, agitated, shocked or numb. These feelings may resolve with time, but they might instead be so intense that they either completely overwhelm us or we might even feel cut off from them. We might start to experience thoughts that we would be better off dead or that those we care about would be better off without us. Such suicidal ideation is quite common. It is generally associated with depression and other mood disorders. However, it may also have associations with adverse life and family events, all of which can increase our risk of suicidal thoughts. For many, these are fleeting thoughts that we get when we feel overwhelmed and want to escape the pain we are feeling at that moment in time. But for others, the feelings of distress, shame, guilt and low self-worth, are so devastating that these suicidal thoughts escalate and, without help, care and support can lead to disastrous consequences. What can we do when we feel this way? The first thing is to acknowledge that things are not going well. This may seem obvious, but when we are trapped in a situation, it is very easy to deny to ourselves and others that there is a problem. Or we might feel so hopeless, useless, numb and disconnected that we can’t see a positive way out. Sometimes our suicidal thoughts become so frequent that we almost don’t recognise them as we can’t remember not having them. This happened to me when I was spiralling down. It was only when I stopped, took time out and talked to others that I recognised the thoughts and realised how bad things had become. Reaching out for support This is the next step. There are many barriers to seeking support such as guilt and shame, made worse by the negative judgements and lack of compassion shown by some to those who do disclose suicidal thoughts. It can also be hard to open up. We might feel scared or embarrassed, but when we share how we are feeling, whether that be to a trusted friend, family member or colleague or to a trained health professional, we often find that others have gone through similar things and can understand what we are going through. Talking things through can help unburden a lot of the distressing feelings that we have kept bottled up inside and help us see things clearer. Making a safety plan Making a safety plan is a way that we can help ourselves. It is a resource developed by others who have been through similar situations and who use it themselves at times when they feel unsafe. StayingSafe.net, a website set up by 4 Mental Health and the inspiring psychiatrist Dr Alys King Cole, has a free safety plan that can be downloaded onto your phone or printed out. This fantastic website offers support and advice on how to manage suicidal feelings, as well as videos and stories from others who have struggled including Jonny Benjamin MBE. Well worth checking this out for yourself or to help others that are struggling. A safety plan includes: What you can do to get through right now - the next few seconds, the next few minutes. These might be photos or videos of people or animals that you love and care about. It might be thinking about a particular place or memory that gives you joy. It might be speaking to someone you trust and can open up to. How to make your situation safer. Is there anything in the house that you could harm yourself with? Have you too many medications at home that could present a risk? Would organising a weekly collection of your meds from the pharmacy be a safer option for you? Are there people that make you feel worse or trigger bad memories? Should you avoid them at this time? There are many horrifying websites, chat rooms and blogs that can be really distressing when you are at your most desperate. Is there a way to limit your access online to avoid these? Things to lift or calm your mood to help you get through tough times - activities such as going for a walk, watching an uplifting video or film, getting outside in nature or listening to music. Whatever helps you feel better. Or whatever allows you permission to hope, whether that be seeing friends, buying a lottery ticket or having a haircut. Things to distract you when it feels like nothing will lift your mood or calm you. This might again be listening to music, watching a film or box set or getting outside. Or it might be cognitive things such as counting backwards in 7s from 100, counting things in the room that begin with a particular letter or visualising being in a pleasant surrounding. Again choose things that will really work for you. People to support you. Include those that make you feel better just by hearing their voice without necessarily having to say how you are feeling. And those who perhaps know that you are feeling low or overwhelmed who allow you to feel comfortable without asking questions or having to talk. And those who you might want to open up to. People you can talk to when you are distressed or thinking about self-harm or suicide. These might be friends, family, colleagues, a support worker - someone that you trust and feel comfortable talking to. Emergency professional support. Keeping crisis numbers to hand in one safe place can be really helpful. The last thing you want to do when in crisis is spend time looking for numbers. These might be for the local mental health crisis line, your GP, your local safe haven or a helpline such as the Samaritans, Papyrus (for young people) or Childline. Helping someone else who is in crisis. Letting people know that you care and listening with kindness and compassion is key. Both Mind and Staying safe have some really helpful practical ways that you can support someone who is struggling and having end of life thoughts. As Staying Safe comment: “There IS hope – it is vital that people experiencing suicidal thoughts know that they are NOT alone and there are people who care about their situation.” Resources StayingSafe.net Feeling overwhelmed - helping you to stay safe. Mind - suicidal feelings Helplines and support These are just a few Samaritans - Call 116 123 for free 24/7 Papyrus - For people under 35 and those supporting them Papyrus HOPEline 0800 068 4141 (Mon-Fri 10am-10pm Sat-Sun 2pm-10pm and bank holidays 2pm–5pm text 07786 209 697 Dr Kate Little, a GP Clinical Champion for Physical Activity and the founder of physicianburnout.co.uk, a resource for doctors that are feeling fed-up, stressed, anxious, depressed or burnt-out. Kate has worked as a GP in the NHS for the last 16 years in a variety of roles – partner, salaried & locum. She has also worked in medical education as a GP trainer and facilitator, and as a GP appraiser.
By Kate Little @katelittle71
staying safe
Easy steps to avert a personal crisis
Music to massage lost memories
London’s Wigmore Hall is a temple of high culture. The audience is packed with musicians. Sometimes I feel I’m the only person who couldn’t be up there performing the work. But recently I joined forty people, some able, some less able, in mind and body, for a ‘Big Sing’. Everyone seemed to feel at home. In the morning we learned to sing simple songs in four parts, and in the afternoon we went up on stage and sang them. I’m no singer but the opportunity was fun and boosted my morale. So how much more it must have done for the participants with dementia. Everyone, everywhere, responds to music. We hear it in the womb, it accompanies the important events in our lives, it modulates our emotions. Hearing is the last sense we lose as we die. People with advanced dementia who haven’t spoken for months may perk up when they hear Vera Lynn singing The White Cliffs of Dover. They may even venture into a solo, or go to the piano and play with an ability no-one knew they had. Thinking skills may have atrophied, but musical skills remain. Given the right stimulus, they surface from the depths of a failing brain. There is currently no prospect of effective medication for dementia. Reluctantly, we prescribe agitated patients chemical coshes. But does music sooth agitation – and more? Neuroimaging shows that, unlike speech, music lights up lots of different areas of the brain. It finds a back door into even a ramshackle brain. Music may even help to keep neural pathways in the brain open. So far, studies of the effect of music on people with dementia, though small and short-term, are encouraging. But research projects are seeking robust evidence. Can biochemical changes be linked to our responses to music? What psychological measures can be used to assess benefit? How can music most effectively be used? What opportunities does it offer for carers, care homes, musicians and institutions? Music therapy is a well established profession, although few care homes can afford a therapist. But graduate courses in using performance arts to help people with brain failure are burgeoning, and charities, local authorities, music schools, music groups, orchestras, arts and religious venues are trying out different interventions. With phone calls and a few visits, I discovered how much there is on offer. Residents of care homes respond when amateur choirs come to sing. They may join in, although perhaps not singing the same song as the performers. They may rattle a teaspoon throughout the concert, or stand behind the conductor waving their arms. The benefits are fleeting, but any enrichment of barren lives, however temporary, is worthwhile. Repetition helps. And not surprisingly, participation increases the benefits, too. So a musician, squatting down in front of a wheelchair to encourage someone to make simple music, singing or playing instruments may stir her from apathy for longer. She may start chatting. And so change the atmosphere of the home. For people with dementia still living in the community there are ‘relaxed concerts’ where no-one minds if you are restless. Other events encourage people to take part. Alzheimer’s Society’s Singing for the Brain is a model: experienced singing leaders run weekly sessions. Volunteer helpers ensure that carers also have some fun and a break – a crucial benefit of community events. There’s a welcome, action songs, familiar numbers and new ones, opportunities to shake a tambourine, to dance, to sing a solo, followed by socialising over tea and biscuits. An early casualty of dementia is self-worth. Taking part in events restores confidence. An art gallery invites musicians to work with local people to devise and stage musical events based on a painting. A retired doctor organises regular rehearsals for village hall concerts. The performers dress up for the occasion, their community applauds them. Everyone feels a sense of achievement. Care home staff are poorly paid for work no-one else wants to do. It can be hard to maintain respect for people with dementia. But if music can revive the person inside the fading brain and restore some of their dignity, the job will be more rewarding. Staff retention and standards of care might improve. Through music, families can glimpse the individual their relative once was: the loving partner, the caring parent, the delightful aunt, the indulgent gran. Once again they can share pleasant experiences. Such events introduce new audiences to arts venues, but these must adjust to special needs. Improve the signage and make sure the locks on the loo doors are easy to manage. Don’t aim to fill the hall; people who may become disturbed need space. Explain to the audience what is going on. Incorporate toilet breaks. And, as ever, provide tea and biscuits for everyone. Train staff. Anyone working closely with people with dementia for the first time will be apprehensive. But performing for and with people with memory problems can be eye-opening and very rewarding. A full hall of concert-goers may applaud appreciatively, but there is nothing so heartwarming as seeing someone initially crumpled and withdrawn begin to take notice, smile, and maybe join in. Music can also help people whose dementia is so advanced they can’t take part in concerts. In Where Memories Go, Sally Magnusson, daughter of Mastermind presenter Magnus, records her mother’s dementia. It’s a heartbreaking story, but from that harrowing experience came Playlist for Life. Sally could see how, through music, her mother in some measure returned to her, and she wanted everyone living with dementia to have that opportunity. It’s a simple idea: you build up a soundtrack of a dementia sufferer’s life. They listen to it, through headphones or via speakers, and are engaged. Some GPs are already prescribing playlists and finding patients need less medication. Building a playlist is like choosing your Desert Island Discs, but you can have as many as you want. Making one for someone else involves detective work to find the tunes that meant something to them, particularly during that crucial time of adolescence and young adulthood. The BBC’s Music Memories is a good resource. Classical, pop, advertising jingles, hymns, theme tunes, anything that provides a flashback to the past. The theme from Z Cars or Match of the Day? Twist and Shout? Bob Dylan? Miles Davis? Stockhausen? (Well, maybe not.) Most of us won’t develop dementia - the lifetime risk of people under 65 is less than 5%, thank goodness, but as we plan for ageing perhaps should include guideposts for our own journey down memory lane. It’s never too early to start creating your own feel-good musical. Thanks to those who gave me the benefit of their experience of music and dementia in putting together this article. Judith Harvey judithharvey12@gmail.com
By Judith Harvey @judithharvey12
singing in the brain
"Through music, families can glimpse the individual their relative once was: the loving partner, the caring parent, the delightful aunt, the indulgent gran. Once again they can share pleasant experiences."
New guideline from SIGN
"If women are drinking above advised levels, then we should offer early brief interventions (e.g. referral or a brief structured conversation about alcohol - whatever is appropriate to her level of drinking)."
alcohol exposure prenatally and its effects on children and young people
By Louise Hudman
This is a new guideline from SIGN outlining the assessment and management of children who have had prenatal alcohol exposure (PAE). It was published in Jan 2019. Prenatal alcohol exposure is important because it causes Fetal Alcohol Spectrum Disorder (FASD). A big take home message for me is to think about prenatal alcohol exposure when seeing any child with a neurodevelopmental problem. I'm going to outline the bits of the guideline that are of most relevance to us. Why is this important for us as GPs? It is thought that about 32 per 1000 children have FASD and it is very likely that it is significantly underdiagnosed. It may not be picked up for several reasons. Firstly we just don't consider it when we see a child with problems. Secondly it is thought that children who have FASD may often end up with other diagnoses instead, such as ADHD or ASD. If it isn't picked up, children with FASD can go on to have a higher rate of mental health problems, substance misuse, crime, low educational achievement and a higher rate of premature death from violence, crime or accidents. If picked up, educational adjustments can be made and the child's outcome is much better. What is FASD? Fetal alcohol spectrum disorder encompasses fetal alcohol syndrome and some other related syndromes and disorders. Fetal alcohol syndrome is characterised by the following specific diagnostic criteria: Evidence of prenatal alcohol exposure. Evidence of structural or functional CNS abnormalities (eg problems with motor skills, cognition, language, memory, attention and affect regulation among other areas). A specific pattern of 3 sentinel facial abnormalities (see below). Growth impairment (prenatally and/or postnatally). The sentinel facial abnormalities: Short palpebral fissures Smooth philtrum. Thin upper lip. The latter two of these can be classified using guides from Washington University. There are quite specific criteria for all of these elements, but we don't really need to know them. We just need to spot that a child may be at risk. What is the current advice we should be giving mothers about alcohol in pregnancy? The Chief Medical Officer's advice regarding alcohol in pregnancy is basically don't drink at all: If you are pregnant or think you could become pregnant, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk. The risk of harm to the baby is likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy. If you find out you are pregnant after you have drunk alcohol during early pregnancy, you should avoid further drinking. You should be aware that it is unlikely in most cases that your baby has been affected. If you are worried about alcohol use during pregnancy do talk to your doctor or midwife. Why is the advice not to drink at all? We used to think that surely the odd glass of wine a couple of times a week is OK for a pregnant mum. It is true that there is little evidence of harm to the fetus from low levels of drinking in pregnancy. However, there are few relevant and good quality studies in this area, which means that it is not possible to say that low level drinking carries no risk to the fetus. We know that drinking 1 to 2 units a day can increase the risk of low birth weight, preterm birth and being small for gestational age. It was also felt that it is very difficult to study the effects of low levels of alcohol on the fetus as mothers are often not aware when they are in the early stages of pregnancy. How should we screen women for alcohol use in pregnancy? All women should be assessed for alcohol use prenatally and postnatally. We should consider using a validated tool (eg T-ACE, TWEAK, AUDIT-C). These can all be found on the SIGN document on FASD assessment. If women are drinking above advised levels, then we should offer early brief interventions (eg referral or a brief structured conversation about alcohol - whatever is appropriate to her level of drinking). How should we assess for the risk of prenatal alcohol exposure? Studies often suggest that women either under report, or don't report their alcohol consumption in pregnancy. If you have a child sat in front of you with neurodevelopmental problems you should consider asking a mother about her alcohol use in pregnancy. You should also consider looking at other sources of information about her alcohol use (eg clinical observation, other reliable people, other clinical records or any other evidence of drinking). If all 3 sentinel facial features of FASD are present, then it is very specific for prenatal alcohol exposure, though there are a few other conditions that can cause them. Who should we be referring? We should refer children when there is: A probable history of prenatal alcohol exposure AND Significant physical, developmental or behavioural concerns. It is very important to note that SIGN advises that any such referral be done 'sensitively'. Louise Hudman louisehudman@gmail.com
www.nasgp.org.uk
Promises, promises
This magazine is supported by an educational grant from the Medical Protection Society.
