I am so excited by this blog post! I managed to capture half an hour with Dr Vikesh Sharma during the THET conference and got a brilliant interview with him about the fantastic work he is doing with the Portuguese population in South London. Its such an exciting project that he was interviewed for 2 GPs in a Pod too! He was a core committee member of the JIC until 2013 and his face and name crops up regularly on the global health scene whether that is through his twinning project with a GP in Ghana or through local social prescribing enterprises. I’ve kept the chronological order of events only because it shows how a small idea made it big. Read to the end if you want to know what happened!
“I became a partner in Stockwell in 2013 and the reason why I chose to work here was because it was ethnically diverse and there was global health on my doorstep. I chose the practice because it was long-standing in the community with which I knew that it had very strong links and it was very well-liked by its patients.”
For those of you who are not familiar with Stockwell, it is part of the borough of Lambeth in South London. Nicknamed “Little Portugal” following an economic migration in the 1970s which has continued to the present day, Stockwell is home to the largest Portuguese population in the UK. You can imagine the street parties following the Euro 2016 Finals. Café culture is an integral part to Portuguese life and the Lambeth streets are filled with cafés selling, amongst other things, the sweet custard tarts, pasteis de nata – my love for these custard tarts is unparalleled and, for your information, they act as an excellent bribery tool if you ever need something from me.
On the other hand, just down the road, Brixton was a popular destination point, along with Notting Hill, Harlesden and Dalston, for the huge Caribbean economic migration in the 1940’s, via a programme endorsed by the UK government. The vibrancy of Caribbean culture has somewhat diminished since its gentrification over recent years but it’s hard not to spot all the exotic ingredients in the market or hear the occasional steel drum band at the station. It’s a really multi-ethnic corner of London.
“So when I got there, I started to ask fellow colleagues in Stockwell about issues around culture, language, access and inequalities in health and very quickly it transpired that the Portuguese-speaking community was where it’s at. One in six people speak Portuguese as their native tongue and there was emerging evidence through local GP databases that they were the highest users of A&E compared to any other ethnic demographic group. There was just a sense amongst the GPs that we weren’t doing a good job by them. Consultations weren’t going very well. Lots of chronic disease management wasn’t very good. There was a lot of disjointed care because the expectations of healthcare wasn’t the same as where they’d come from. They were bypassing it by going to private GPs, or pregnant women were flying to Portugal to receive their antenatal care and then fly back again. There was all this anecdotal evidence so I thought right this is where I’m going to do my global health stuff.”
With the multi-culturedness of London, similar frustration are experienced with people accustomed to different health care systems. Adapting to each cultural health expectation is tricky especially when their norm is not known. My Japanese friends have a distinct distrust of the British GP as they don’t understand the concept. Who can blame them for thinking that we’re an unnecessary step when they come from a country where you have direct access to specialists? But reaching out and trying to integrate an entire population is not easy. I’ve visited a practice in the outskirts of Boston, U.S, who deal with a similar problem using advocates, who initially translate for patients but, once a rapport is established, eventually coach patients in how to use the American health system appropriately – a successful but rather individualistic approach. So how did Vikesh approach this challenge?
“I was put in touch with the Portuguese-speaking centre in Kennington and that was my first sort of win because I got to talk to the manager and she was really pleased that a GP was coming to say ‘I want to do some work with you’. The centre is for Portuguese people who need support for benefits, to navigate the system or had rocked up to the UK and don’t have any support so they had a base of people who use them regularly. She said, ‘I’m going to set up a date and get people to come and talk about the NHS and their frustrations with it and you can learn how we can help them better’“.
In order to gain the trust of the Portuguese community, he knew that he would have to be legitimate in their eyes and have some sort of validity. For those of you who have worked in the field, you will understand the feeling of breaking down that “me to them” divide and promoting the sense of inclusion and horizontal collaboration.
“So I went to the JIC Exchange lead, who was Katrina at the time, and asked her if she knew of any Portuguese doctors who wanted to do an exchange in London. Katrina had a pivotal role in this as she introduced me to this guy called Cristiano who had just done an exchange in Germany – his write-up was amazing and she thought he would be really good for the thing that I was doing. So it was Katrina’s thoughts around this that put me in touch with Cristiano and it all kicked off from there.”
So during his two-week stay in the London, Cristiano observed Vikesh and UK general practice for four days of the week and then attended the community centre on their day off. They ran open and informal focus groups and talks around the NHS and its infrastructure and then collated that data. Although Cristiano had to return to Portugal, they continued their collaboration virtually.
“We designed a survey looking at where do patients go when the GPs are closed, what are the health topics that are most important to them, and what are the health topics that are important to their community. And there is an interesting difference in their answers. When it was about yourself it was cancer, diabetes – all the usual stuff. As soon as you create a disconnect and you talk about the community, it was alcohol, depression, domestic violence so there was an affirmation of what GPs and health care professionals were feeling at the time. Also, in our survey, we found out that people were worried about registering with a GP because the authority would find out that there were 12 people living at an address and that would be reported. So there was something about trust-building between the community and GP’s.”
“Cristiano and I were doing all this stuff voluntarily so we thought ‘what quick wins can we do that would maybe show that we are truly engaging and learning from this?’“
Cristiano translated public health posters into Portuguese and these were pinned up in GP practices and the local bus stops in Lambeth. He also negotiated with the Portuguese equivalent of the RCGP for permission to distribute their patient information leaflets to UK practices and catalogued each one – all 200 of them – in English and sent them to Vikesh. So if a Portuguese patient came in, for example, with back pain, they could go home with a leaflet educating them about back pain in their mother tongue.
“So for me the win was straight away as you could see the dynamic of my consultations changed immediately because we were communicating in a relevant way. And there was a couple of other supportive GPs who used the leaflets and they told me stories of patients hugging them at the end of the consultations because they were giving them something in Portuguese. So there was a legitimacy within the eyes in the community but the next stage was getting legitimacy within my peers and within the infrastructure of what I do.”
The local CCG at that point had just started look at engaging with the community and addressing health inequalities and were sending out GP liaisons to each of the surgeries to find out about anything that was new or exciting. When Vikesh told them about this project, it ticked a lot of their boxes and they were keen to support. The patient information leaflets was uploaded on the Lambeth-wide database so any Lambeth GP could download a copy straight away.
“More than that, the CCG were developing a local care network which was at a much more strategic level, looking at how you can get different silo service providers – so social care, primary care, secondary care, community sector etc – and bring them together in one room to work together. The plan is to top-slice some of the money in the individual contracts and put it back in a joint agreement where all of us would have to work towards a shared health target. So this was right at the beginning of that process and it was a great time for me to get involved. Practically, no one was sure what to do next and there was this stuff that I was doing – so they said ‘well why don’t you become GP lead for the local care network and here’s some resource that frees you up for half a day to work on this’. So it suddenly escalated.”
First stop, secondary care…
“So I was suddenly talking to secondary care people – I was having meetings with A&E at St Thomas’ about how can we shift some of that traffic that goes to A&E – how can we re-educate people not to use A&E by giving them Portuguese leaflets.”
“What really interests me about this stuff is the complexity of demand behaviour but when you start talking to secondary care, quite rightly, their focus is on access and point of care – which is number of people attending A&E or number of beds used etc. It’s really difficult to pin the two together. So I’m here, I’m a GP partner for the next 15-20 years in one place, I’m happy to see things grow over a long period of time and I don’t need any quick outcome measures. Whereas when you’re talking to secondary care and you say I’m producing this leaflet, they say well we need to see how this reduces A&E admission in the next 6 months to a year and I can’t guarantee that. So that’s the challenge when dealing with this approach and secondary care.”
Work continued at the community centre where Vikesh, now funded for his time, would run drop-in sessions where he would talk about a health topic identified from their survey. It was all very run informally so attendees didn’t need to be suffering from, for example, depression or alcohol abuse in order to attend. A Portuguese health professional was always there to translate but Vikesh would be the NHS representative – breaking down that divide.
“This ambled on for about six to 12 months and then we decided that we wanted to do something quite big and thought wouldn’t it be great if we did a welcome brochure, like a pack – you’ve arrived in the UK, you have no idea how the system works and you have a brochure that will tell you how to register with your GP, dispel all the myths about what to do when the GP is closed, when to go to A&E and when not to go to A&E, and when to go to the pharmacy. We also did this tear-away section where you could write what your health care needs or concerns were in Portuguese and you could get a friend or someone from the community centre to translate it into English and tear it off and give it to a GP when you’re registering so it builds that trust.”
Now with funding behind them from the CCG but also GP Federations, these brochures could be disseminated through the churches and the cafes.
“I got invited to all sorts of amazing and privileged events like a church service in Clapham where it was literally like walking into Madeira. The pastor invited me up and I talked to the congregation of 300-400 people with Ana’s help about the work and the welcome pack. I met Dr Ana Luis Neves, who is also part of the Vasco da Gama network [network of European GPs early in their career], and she’s currently doing a PhD in London so she came on board and is now a very proactive member of this as well.”
I can already sense that this project is getting really big but then it stepped up to the next level when Vikesh met a guy called Will from a health start-up charity, the Health Foundry. They jointly organised an event, inviting all the stakeholders who were interested to a Portuguese well-being community event, including the Portuguese consulate, the Deputy Mayor of Lambeth who was Portuguese and various CCG’s (including CCG’s who weren’t involved who wanted to learn about the project) and various members of the voluntary sector.
“We recognised that there was this energy and this passion and everyone agreed on the values of how this came together. It felt very much grassroots up. We threw out an open call and we said ‘it’s December now. We’ll meet again in January and for those of you who believes in this way of working, please come back.’ Out of the 30 organisations attending, 20 came back in January in their own time.”
A design company, called Unboxed, also joined in. They do social pro bono work and they were linked up to Vikesh via the Health Foundry.
“They [Unboxed] really helped and they ran a workshop [with all the stakeholders] with us in January to find out what we can do that is unique using the skills in this room. We did this really cool thing called ‘persona work’ where we imagine an individual from the community and all talk about why we are concerned about that person. [click here to read about the workshop itself]. We started with a ten-year-old boy called José and we went round the group. So the GP said, ‘this ten-year-old is probably the only English-speaking person in the family and he’s advocating the health of his parents and he’s coming to talk to me talking about depression and alcohol in his family – how is that affecting him as a ten-year-old? Because he doesn’t have the infrastructure around him, what exposure is he having to risky health behaviours at this young age that would lead to sexual health issues and obesity in later life? Where’s his role-modeling and support around that?’ And the schools would say, ‘this is the kid that is performing really poorly at school because his parents wouldn’t have the confidence in helping him with his homework’. Stockwell Partnership, which is a charity set up on South Lambeth road which social support for vulnerable people in the community, said ‘he might be dropped off at a cafe before school because his parents are cleaners or shift-workers and he would be eating croissants and custard cakes until it was time to go to school’. So we truly started to address a need holistically, looking at the wider determinants of health. So from that point we decided on how to intervene with this boy and we came up with the idea of a breakfast homework club in one of the cafes that one of the charities has good connections with. I would go as the GP and talk to the café owners about healthy breakfasts, using Public Health England advice. There was a charity called ‘Native Scientists’ who are scientists working in the UK who would go to the schools with the aim of broadening horizons and ambitions for disadvantaged children. There was English For Action who work with communities around language skills and they had the teaching expertise to help them with homework. We had the school next door to the café where the teacher said that she would bring the kids across and tell the parents that this is happening. In April [only four months later], we ran it – so completely free, completely voluntary but it acted as a proof of concept that we could work together and provide a holistic intervention. The kids went back to school and were telling everyone about this cool new club that they went to. Parents came along and it gave us an opportunity to give them advice whilst the kids were there. It gave us something to go to bigger organisations and say ‘look –we believe in this new way of working‘. So then the next step was , how do we make this sustainable? We gave ourselves a deadline of this year to figure out what it is we do and start pushing it to people interested in supporting this.”
In July last year, Vikesh’s team and Guys and St Thomas’ Charity went into a learning partnership, where the charity wanted to understand more about this unconventional project. This led them to offering a further two-year grant in December 2017 with the aim of developing the organisation and this innovative model of care. So here we are in 2018, where in the space of two years, Vikesh and his collaborators have pulled together a funded multi-disciplinary project that empowers an entire community.
“What we think we are creating is a collaborative at grass roots where the GP is in equal partnership with various other community sector organisations and we are pro-actively, through our insights and assets, identifying people of risk through our different perspectives and simultaneously assessing them and creating an intervention that empowers them and creates resilience within their environment that therefore, down the line reduces crises. Our argument is that the current way that our health system commissions things is top heavy so we are looking at people who are already in crises and you are never dealing with how people end up there. It is very difficult to get investment through usual funding streams because the political pressure is to look at the outcomes in a years or two years time. Hopefully we can get the space and resources to develop this over three to four years and show the outcomes over a longer period of time.”
I am feeling inspired. I am loving Vikesh’s collaborative and horizontal approach and flexibility in this entire process.
“To me, what was really impressive as a GP, as an NHS provider, was that the process worked although it could feel quite unwieldly at times. As scientists we are not used to working in this way – we want to know ‘what’s the need?’, ‘what’s the intervention?’ and ‘whats the measurable outcome?’ and, as soon as we do that, we start to detach and close doors to people who have intangible evidence of what’s going on in the community… and the other thing is that when you go to CCG meetings or health meetings where it’s supposed to be representative of everyone, there is one person representing the voluntary sector. What was really interesting in this dynamic was that I was the one NHS provider and there was 18 other voluntary sector social sector housing sector people there. So I wasn’t allowed to dominate the process.”
“As an end-point, as a practice, wouldn’t it be great if we could create spaces were you walk in where the GP happens to be one of the experts in the building and you come in with a need and you have a wellbeing navigator who is helping you through this.”
You see efforts towards this occasionally with practices who may have a wellbeing officer who deals with housing or benefits issues who comes in once a week but they still feel quite doctor-centric. It often falls on the GP to deal with Sh*t Life Syndrome, something that we’re not trained in nor have much impact on and often eats away at the limited resources that we can provide. It is certainly the vision of collaboration that the Bromley-by-Bow Health Partnerships strive for and something that perhaps we need to seriously look into if we’re going to address the current/future shortage of GPs.
“I realise that as I’m saying this, this all sounds quite cool and impressive but I want to stress, I genuinely I had no idea that this was going to happen and I’m just a regular jackass [!]. At the risk of sounding evangelical, my experience of global health and the JIC really helped shape my career. The other thing that really empowered me was that I did a Masters in Clinical Leadership. The combination of those two things showed me not to be scared of the system, to get that wider perspective via global health and that things can be done and you don’t have to be given permission. Actually, the values that we have are very hard to argue against – when you talk about reducing inequalities and working with people. We have very strong arguments about what we want to do but we are hesitant on how to move forward from that. Just surround yourself with people who are like-minded and just have faith.”
This perspective is refreshing. So any final words for budding GP’s?
“This is something that I feel quite passionate about – for the new GP’s coming into the system theres’s a lot of doom and gloom. There’s a massive echo-chamber going on where because there is so much uncertainty it feels like we’ve chosen the wrong profession but actually it’s a great profession. It’s a great time for opportunity because no one knows what is coming along. So yes there’s lots of hard work – but us doctors are not afraid of hard work – and there’s lots of things you need to do in your own time to get the thing off the ground but very quickly if you can show proof of concept people are willing to listen because people are open to new ideas. So I would say don’t be too downhearted. See the current situation very much as an opportunity. Definitely step off the treadmill and break away from the hierarchy of thinking that people above you know something that means that you can’t step forward and do stuff because they don’t. No one knows what’s going on. And get perspective – which I got from global health. Step back, look at the system with a wider lens.”
“A really important thing I learnt from the JIC was that if you have an idea and a value set that you share with a group of people who are passionate with you then you don’t have to rely on institutions and organisations around you. Just get on and do it. And maybe look for energy outside the institutions.”
NB a little birdie tells me that his practice is recruiting for a salaried GP so, if you want to be part of this energy, I’m happy to pass on your details!