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Presidential Address given to the Glasgow Southern Medical Society on 24th October 2013. In her lecture, Dr Andrea Williamson discusses health inequalities and homelessness from the viewpoint of a general practitioner in Glasgow. Two videos are discussed during the meeting: The first is Isha and the Poverty Truth Commission: http://www.youtube.com/watch?v=CKGMok5s2Rs&noredirect=1 The second is Brian and the Housing First pilot in Glasgow: http://www.youtube.com/watch?v=iKyNhAaCsE0
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Andrea WilliamsonSouthern Medical Society Presidential Address 2013
Messy, not smelling of roses: and a tilted view
required
Biomedical positivism: graphs, gradients, life expectancy
Qualitative interpretivism: perspectives and explanations
The experience of the interpersonal and relationship
Knowledge claims: some isms
Social determinants of health
“the conditions in which people are born, grow, live, work and age…” (WHO)
People risk markers: age, sex, ethnicity, sexual orientation, education
Place risk markers: geography, community, workplace
Meta-risk marker: SOCIO-ECONOMIC POSITION
*All are interlocked and socially patterned*
Health inequalities
Poverty truth commission video: Isha from Govanhill
“the conditions in which people are born, grow, live, work and age, including the health system” (WHO)
“Health equity through action on the social determinants of health”
=tackling health inequalities
45,000 households applied as homeless, Scotland, 2011-12 42% single men 22% single women 17%single parents (women) 7% single parent (men) 5% couples with children
(Source Shelter Scotland)
Homelessness in Scotland
Refused asylum seekers
‘no recourse to public funds’ Numbers unknown, survey March 2012:
78/112 Rough sleeping Sofa surfing Night shelter and voluntary sector support Right to full NHS care if ever applied for
asylum
(Scottish Refugee Council 2012, 2013)
‘New’ Homelessness
Your experience of working with a person who is homeless?
All people are individuals and have their own storyHowever many people have had the following experiences: Disrupted family life (poverty, abuse,
into care) Poor educational attainment Poverty Experiences of violence Addictions Mental health problems On-going risky relationships
(Source National Mental Health Development Unit 2010)
Chronic homelessness
Mortality X6 risk of death than general
population 1.4 times more likely to die than the
most deprived housed person Drug misuse Circulatory disease Respiratory disease Importance of psychiatric morbidity
(Neilson et al 2011,Morrison 2009)
Housing First video: Brian
Adult attachment Personality disorder Complex trauma
Important concepts for
effective consultations
Impact on Thinking Feeling Behaving
Impulsiveness…self sabotaging…self harm…emotional lability….dissociation...unexplained physical symptoms
Features
Listen to what your emotions tell you when you interact with patients: frustration, anger, disgust, fear
Accept your response is often a reaction to patients psychological function (not always)
Encourage safety: physical, emotional and social: for you and patients
Be very careful of verbal and non verbal leakage (including psychological environments)
How to respond?
Patients respond, feel safe and function better (so you might actually get to addressing health issues)
Professional patient relationships are key to an effective health service
You will waste less emotional energy getting angry, frustrated, upset
Why?
life course approach– attachment– adverse life events– Resilience
Patient at the centre of care Involving wider health and social care
team Snap shot versus the long view Role of the therapeutic alliance
Trust Boundaries Longitudinally over time
Key homelessness health care
concepts
“revolving door” patients in general practice
Serial missed appointments in the NHS
Evaluation of vulnerable women’s addiction clinic in South Glasgow
Research interests
[Barnett, Mercer, Norbury, Watt, Wyke, Guthrie, 2012]
T, mid 40s. She has chronic depression with multiple previous suicide attempts. She suffers from angina and has had an MI in the past. She lives in a flat with her boyfriend. T has recently been deemed fit for work, but is appealing this decision. Money is extremely tight, and she and her boyfriend are currently surviving on his benefits alone. T has suffered from physical, sexual and emotional abuse all her life and her current relationship is no exception. T wants to visit her daughter (whose young child has recently been removed from her care), but can’t afford the coach fare – her partner (not the daughter’s father) won’t pay, as he will not allow T to leave him, even to see her own family. T is waiting for her daughter to pay for the coach ticket. The daughter in turn is waiting for her own benefits to come through. Another daughter is homeless.
[case study extract, Deep End Austerity report 2012]
GPs at the Deep End
Role of health care at its best where its needed most Arrangements and resources
reflecting the epidemiology of multi-morbidity
General practice as the natural hub Importance of serial encounters
Time Relationships
With patients With other professionals in
healthcare Outside health care (social
prescribing and advocacy) Connectedness of care
GPs at the Deep End
Within the health system Relationship work in consultations Relationship work with other
professionals Social prescribing and community
engagement Influencing health policy (research,
teaching and Deep End work)
Being an engaged citizen and advocate for change
Action
Andrea WilliamsonSouthern Medical Society Presidential Address 2013
Messy, not smelling of roses: and a tilted view
required
