Public Health Articles

The view from Frome

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More than a doctor’s surgery, this compassionate Health Hub in Somerset is the poster child for modern ecosystem thinking

As befits the town that won The Times newspaper award “Best Place to Live in the Southwest 2021“ Frome has a pretty impressive GP surgery. It’s a large, airy and light building faced with pale Bath stone up near what used to be The Cheese Showground. However, to call The Frome Practice a GP surgery is way to underestimate what it represents. It’s more than a doctor’s surgery. It’s a thoroughly modern Health Hub. And it’s the future.

For a start, when moving at non-COVID full pelt it has more than 150 staff and 30,000 patients on its list. It has a cafe, extensive outside space that can be used for exercise or even meetings. A surgical centre does minor operations including a variety of ENT procedures. You can even pop in for a vasectomy. Group Consultations are offered for those suffering from back pain, diabetes and arthritis – you get more time with the specialist and can exchange ideas about better coping with your condition. It even boasts a Green Health Connector – a 2-year project funded by the National Lottery and their dedicated Climate Action Fund to explore how the Practice can create a climate and health “win-win” by working together as a community.

Frome is different for other reasons. They like doing things differently in the Somerset town which is far less showy than its ritzy neighbour to the North, Bath. Back in 2011, the town council – which had a modest budget of around £1m – was won over from established political parties by a new group of self-styled independents who then began running things, with a focus on participation, sustainability and community wellbeing. The same basic idea has now spread to about 15 other areas across the UK: its name, coined by Frome’s inspirational councillor called Peter Macfadyen, is “flatpack democracy.” The council and the medical Practice are very close.

This approach proved ideal when the pandemic struck. The agile, open way in which the town council now works came into its own. The town centre venue previously used for gigs and indoor markets was turned into a food depot. Banners suddenly appeared everywhere, suggesting residents all check in on five of their neighbours. Things “connected up.” Bikes criss-crossed the hilly town dropping off food and prescriptions. This work, which also includes help for local businesses, has carried on; the town council is now thinking hard about how to sustain it beyond the pandemic.

To call The Frome Practice a GP surgery is way to underestimate what it represents. It’s more than a doctor’s surgery. It’s a thoroughly modern Health Hub. And it’s the future.

The Practice became a centre for vaccination and they set off at a pace. This connecting up for the good of the community’s health is a collective dream realised but the individual who first dared to dream of something a bit different is Dr Helen Kingston, 56, the senior GP partner. The practice has 5 partners, 12 salaried partners and five registrars or trainee GPs.

At Cambridge where Dr Kingston studied, she decided general practice as the route for her. “I like people and being with them rather than science.” The thought of gowning up for yet another hernia list didn’t appeal. She realised that general practice would allow her to have three children with her husband, a potter. The last of them was born in 1999. She works 8 am – 7 pm, five days a week and often into the evenings. Her on-call duty is one in five. She still has the benefit of the Community Hospital next door and does the ward round there when it’s her turn. You don’t get into the building to speak to her without a tonsil-swabbing COVID test.

The last year has been odd, she acknowledges. And exhausting. For GPs consulting with their patients remotely has become the norm. Dr Kingston sees that for straightforward issues this is fine. The young, after all, communicate mainly by smartphone anyway. “However, some young people will give you a far fuller story, talk about what’s really going on in their lives, if you see them face to face,” she says. “It’s the pauses, the look in the eyes that often give clues. Just words can be very transactional. When there are issues with mental health to consider you really do need to eyeball people.”

She also knows from long experience that complexity is at the heart of a lot of medicine. Things need careful unbundling. “Lots of life isn’t black and white especially as you grow older. If you’re 94 with diabetes, dementia and your only relative in Sheffield…there’s a limit to what certainty technology and guidelines can offer.” These are the sort of situations where the talent, experience and honesty of a good GP are of huge value.

Dr Kingston was always interested in health beyond the one-to-one doctor patient consultation. In 2013, Kingston applied for and was granted £110,000 of “innovation” funding from her local Clinical Commissioning Group (CCG). She used it to hire someone to help manage patients who were being discharged from the hospital and into her care. But she also hired Jenny Hartnoll to map out community resources in Mendip region, which has a population of 115,000. There were many out there: choirs, stroke support groups, exercise classes for people with health challenges, even Men’s Sheds, places – in the UK and worldwide where men gather to chew the fat, complete tasks together and do that thing that men often find tricky – bond. Hartnoll built a website cataloging all of them. Kingston knows that fully a fifth of those who consult their GP do so for what are primarily social problems. Some estimates think this may even be as many as half. People who struggle with life alongside their health are less able to cope with ill health, or they find themselves ‘medicalizing’ this struggle in order to get help. In 2015, Kingston secured more funding (£309,000), including a chunk from the independent Frome town council, and the CCG. They hired almost half a dozen health connectors and two district leads, professionals trained to help patients who might have three of four conditions and need help managing them.

As Kingston and Hartnoll built out the community connectors and health connectors, Kingston tried to weave the primary care model together to make it easier for different parts of the medical system to work together: district nurses, social care, GPs, mental health workers and hospital staff, health connectors. It was known as the Compassionate Frome project. And the word is well chosen. Sympathy and compassion mean fellow feeling – and those who are afflicted with a problem will more fully understand what individuals are going through. A problem shared can, indeed, prove a problem halved.

Then in 2018 came some research that raised Kingston and Hartnoll’s project from novel to national news: Emergency hospital admissions in Frome fell by 14% over three years. In Somerset county overall, where Frome is located, they rose 28.5%. George Monbiot, in The Guardian, wrote a piece under the headline – “The town that’s found a potent cure for illness – community.”

The gist of the project is that communities can build better ways to support individual needs. In part, that’s due to the reality that the modern medical industrial complex, and that includes what has been created in the UK since 1948, can’t solve every problem, and countries can’t afford trying. But it’s also, as another article suggested “an acknowledgement that modern society is conspiring against us a bit, leaving it to communities to try and build resilience and unlock what makes humans thrive.”

As emergency admissions fell, so did cost. From 2013-2014, the cost of unplanned admissions in Frome was £5.8 million; in 2016-2017 it was £4.6 million, a 20.8% reduction. Downing Street took notice and awarded Kingston a “Points of Light” award for public service and Camilla, the Duchess of Cornwall, paid a visit.

“I know from experience locality and a sense of place matters. People will do something for the good of their community.”

“Our practice size of thirty thousand is a good number,” says Kingston “It’s big enough to measure changes. But not unmanageable. You feel like you can own it. It’s tangible. I never felt we could fix everything all at once. But I know from experience locality and a sense of place matters. People will do something for the good of their community. Lockdown has really shown the value of networks – how people can support each other.”

Helen has become the receiver of many visitors from all over who want to observe and learn from her programme. They often ask Kingston what the governance framework of the system is. Where are the rules? How can we replicate this? She hints that it’s about more than hard and fast rules. “There were lots and lots of rules and guidance about what the evidence says you should do,” she has said, “but what happens is that is evidence for the disease, and not for the person.”

The newest – but not youngest – GP at Frome is Dan Cook. He has arrived after a Damascene vision which occurred in Camp Tombstone, Helmand, Afghanistan in 2006. He was working in the army as a nurse when he realised after working he had to become a doctor. He filled out his UCAS form and then lost it. Undeterred, he wound up on a special course at St George’s in London for late developers after grinding his way through 6 A/S levels. It has been a long haul. (Cooks original GCSEs were “rubbish”) He did resits, was diagnosed with dyslexia. “I had no choice,” he recalls. “I had to make it work.”

What Cook has, as a man in his mid-30s, is experience of life and people. He’s seen a fair bit already and such mileage on the clock is invaluable for a family doctor. And, he says, what makes his practice special is being surrounded by so many support staff to whom he can refer. He’s already looking for his special interest area where he can innovate, try something new and that is palliative care.

“Young people especially are really aware of wellbeing. Loads are teetotal, giving up on meat. Those work hard/play hard philosophies are starting to look old school.” And the long-term effects of covid? “We’re already seeing a big rise in poor mental health right across the age range. Some have coped with lockdown and isolation, but many haven’t. I’ve seen anxiety and depression that actually makes people vomit. Many who have been lying low are now presenting with a multitude of complex problems. The classic is when someone comes in and opens with a ‘I didn’t want to bother you…but’ and then it all spills out”. Never mind he’s got £80,000 worth of student debt and isn’t getting much sleep with a 3-month-old baby in the house. He’s on his way in his new career.

So, what of Frome’s patients? Shannon Trickett is in Year 13 at Frome College doing what she can during numerous lockdowns and school closures to keep it together and study for her A levels. 2020 was pretty bumpy but, all being well, she will win a place to study Criminology in Winchester.

“It’s been ups and downs” she admits, speaking from her bedroom on What’s App, her Japanese anime posters on the wall behind her. “Spending time away from people was OK but sometimes it was all awful. I felt like I was losing my mind. I live outside Frome so seeing my friends has been impossible.” She’s conscious that her generation isn’t always easy to deal with in general practice. “Younger people don’t find it easier to talk to their GP especially about their mental health.” She was part of a Young Person’s Participation group helping younger students at her school talk about problems. She had some unpleasant experiences with social media – “people will do anything to fit in and be liked online but so often it ends up destroying your self-confidence” – so she deleted lots of stuff and now only occasionally posts on Instagram. She’s finding her way in the world. “Despite everything I’m optimistic about my future. I want very much to go to university – to get away.”

The Great Isolation of the last year has been testing, especially for the young like Shannon. A famous paper published in the Public Library of Science in 2010 reviewed 148 studies, involving 300,000 people, and discovered that those with strong social relationships had a 50% lower chance of death across the average study period (7.5 years) than those with weak connections. “The magnitude of this effect,” the paper reported, “is comparable with quitting smoking.” Only Connect, as EM Forster, a non-smoker, said.

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