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Healthcare for vulnerable groups

During her BMA presidency, Professor the Baroness Hollins, hosted a series of focused seminars to look at a range of issues faced by vulnerable groups in the NHS. The seminars, supported by the BMJ, were held in the House of Lords during 2012 and 2013.

The series reflects the ongoing commitment to taking forward a programme of work to gather a wide range of stakeholders to consider policy options to tackle some of the hidden health challenges facing vulnerable groups.

 

  • Introduction: Learning through discomfort

    Introduction by Professor the Baroness Hollins

    Let's get uncomfortable.

    I have to admit that it’s not nice to feel uncomfortable but I’ve noticed you learn a lot about yourself and about your patients when you have your boundaries pushed beyond what you’re used to.

    In my career, the times I've learned the most are when I've found myself with people who have tested my comfort zone. Let's face it, as a doctor you can go through some really tough situations with patients and it's not always easy to talk about the experience of being uncomfortable. Isn't it usually when the patient is trying to tell you something that can't be put easily into words?

    Discomfort helps us learn

    How discomfort could be a real chance for professional learning and development was one of the key points that arose from a series of seminars in the House of Lords I ran during my presidency of the BMA. The seminars had the broad theme of improving the quality of healthcare for some particularly vulnerable or overlooked groups, and brought together figures from government, commissioners, educators, service users and healthcare professionals.  Discussion included whether practical training delivered in partnership with people with learning disabilities, people with mental illness or survivors of abuse could help doctors manage their discomfort better when they find their patients behaving in ways they are not familiar with.

    Series of seminars

    I chose improving the quality of healthcare for vulnerable groups as the theme of my seminars for a number of reasons. Historically, lots of attention has been given towards debate on NHS structure and processes but much less on quality. This seems to be changing somewhat, as recently, Winterbourne View and Mid Staffs have brought into sharp focus serious worries about healthcare especially for more vulnerable people. These were dreadful examples of poor care that should never have occurred and lessons are being learned.

    I wanted to put the spotlight on a range of issues faced by people whose needs are often overlooked.  My seminars covered four topics - the response to the Winterbourne View Hospital scandal, delays amongst doctors in recognising and responding to domestic abuse, the offender health pathway with a focus on the levels of learning difficulties amongst prisoners, and finally the provision of physical healthcare for those with mental health problems and learning disabilities. 

    Throughout these seminars, I raised the question, what can doctors do? What the topics have in common is that they raise human rights and competency issues for the clinical practice of all doctors in clinical practice. They are not just the business of specialists.

    Getting healthcare right for every patient

    My belief is that we should use that state of discomfort to address our training and support needs  to help us get the quality of healthcare right for every patient.  But it’s also about providing leadership in managing difficult situations and in making the reasonable adjustments each patient may need as required by the Equality Act.  Knowing that your patient or a prisoner can't read should prompt you to adapt your interview style and the way you provide health information. Recognising the risk of diagnostic overshadowing should prompt you to enquire whether you have investigated and treated this patient as well as any other. Lowering your threshold for asking about abuse could improve the present statistic – that victims of domestic abuse seek medical help more than 20 times before their abuse is recognised. And don't forget carer abuse.

  • Commissioning

    One seminar in the series looked at how to improve commissioning in vulnerable adults following the abuse of adults with serious learning disabilities and autism at Winterbourne View hospital. The seminar coincided with the release of the Department of Health’s final report into the abuse of patients at the hospital.

    Seminar attendees recognised there had been lost opportunities to provide better, more personalised and local care and that Winterbourne View and other such institutions represented 'a kind of commissioning failure'.

     

    Key points

    Winterbourne View hospital failed catastrophically to meet the needs of the extremely vulnerable adults entrusted to its care. Health and social care is being restructured and there is much for the commissioners of the future to learn from Winterbourne View. This includes:

    • Tackling the culture of ‘therapeutic disdain’ for people with learning disabilities
    • Refocusing commissioning around shared understanding of the person’s needs
    • Expecting the highest professional standards from clinicians working with patients
    • Identifying and managing conflicts of interest from commercial provision of services
    • Holding senior management responsible for institutional failure
    • Ensuring institutional memory of commissioning best practice is not lost in the NHS restructure in England.

    Read the seminar report

     

    Useful resources

    Further resources are available for doctors, other health professionals and the public on how to tackle health challenges in vulnerable patient groups following the abuse at Winterbourne View.

    BMJ Editorial, Managing the needs of patients with learning disabilities 

    View the Department of Health's response to Winterbourne View

    Follow Mencap's Out of Sight campaign 

     

  • Discrimination

    One seminar tackled discrimination in the provision of physical healthcare for people with intellectual disabilities and mental health problems.

    Speaking at the event, Care and Support Minister Norman Lamb said the NHS, at its best, was something people were immensely proud of but 'too often it falls short' for people with learning disabilities or severe mental health problems.  The extent to which people with learning disabilities were dying years before others for no good reason was 'an absolute scandal' that needed to be collectively addressed by a culture change across the system and society he added.

     

    Key points

    The seminar highlighted discriminatory attitudes that persisted across the health sector towards patients with mental health issues and learning disability.

    Funding and commissioning was also mentioned as an area of concern, with services for vulnerable groups some of the first to lose money in areas that were already short staffed. Poor quality data on the prevalence of mental health and intellectual disability compounded problems with commissioning, giving a limited understanding of its scale and how treatment related to outcomes.

    Policy recommendations from the seminar include:

    • Collecting and sharing data through effective cross-agency working
    • Training staff to identify and understand the needs of intellectual disability and mental health patients
    • Change the culture of the NHS away from unfounded, ill-informed judgements about mental health and intellectual disability patients
    • Ensure these patients are subject to the same access standards as physical health patients, including maximum waiting times and improved 24 hour crisis care
    • Commission mental health and intellectual disability services, including liaison psychiatry services and learning disability liaison nurses, as necessities, not luxuries
    • Launch a national mortality review process that considers mental health and intellectual disability as two groups that experience high morbidity and mortality rates.

    Read the seminar report

    Read our report 'Recognising the important of physical health in mental and intellectual disability: Achieving a parity of outcomes'

    Read our news story: Government commits to mental healthcare parity

     

    Useful resources

    Further reading and support is available for clinicians in increasing access to healthcare for vulnerable patient groups. 

    BMJ Editorial, Meeting the needs of patients with learning disabilities 

    Confidential Inquiry into the premature deaths of people with learning disabilities (CIPOLD)

    Government's response to CIPOLD

    Mind

    Rethink

    Mental Health Foundation

    Centre for Mental Health

    Royal College of Psychiatrists

    Mencap

    World Health Organisation resolution for improving care for people with disabilities 

  • Domestic abuse

    BMA domestic abuse report

    Through this report, the BMA aims to lead the way in encouraging all health professionals to raise awareness of domestic abuse and to develop strategies to identify and reduce the damage it does to the health and welfare of society.

    Read the report

     

    Seminar

    One seminar addressed the role healthcare professionals could take in identifying and responding to domestic abuse, including that of children and older people.

    The event highlighted the important role GPs can play in countering domestic abuse, with research suggesting many victims coming into contact with their family doctor long before the police become involved.

    Read the seminar report

    Key points

    More effective multi-agency working, where the medical profession is fully engaged in a holistic risk assessment process, would significantly improve the approach to tackling domestic abuse in the UK. Challenges for the medical profession include:

    • Training to feel confident in identifying abuse and providing adequate support
    • Raising awareness of the opportunity for early intervention, particularly for female victims
    • Supporting vulnerable groups, including those with disability and older people
    • Developing and sharing best practice
    • Improving referral services and minimising the impact of funding and resource cuts
    • Collecting and sharing data in an effective, robust multi-agency system
    • Providing mainstream healthcare services at the time of demand and need, such as weekends and bank holidays
    • Supporting doctors to allow them to speak to patients away from any partner

    Useful resources

    The following resources are available for doctors, other health professionals and the public tackling domestic abuse.

    BMA Board of Science report, Domestic abuse (2007)

    Global Alliance for Eliminating Domestic Violence 

    Royal College of General Practitioners’ resources on domestic violence

  • Offender health

    One seminar called for better partnerships between the health and justice systems to improve offender care.

    The seminar marked the launch of a new book, You’re in Prison, to help offenders with low literacy. Part of the Books Beyond Words series, the book tell stories with pictures to help people with learning and communication difficulties explore their own experiences.

    Baroness Hollins, who co-founded the series, said the publication was prompted by research showing that many prisoners had a reading age of less than five yet most information is presented to them in writing.

     

    Key points

    Better partnerships between health and justice are key to improvements in recognising and responding to vulnerability. Collaboration is essential if offender health pathways are to be viewed as continuous, starting at the pre-arrest stage, before an individual is even categorised as an ‘offender’, rather than being seen as only relevant to the prison setting in isolation. Commissioners, policy makers and health professionals should:

    • Ensure patients receive support from the ‘mainstream’ NHS, in particular by ensuring health professionals have somewhere to refer patients
    • Make sure national and local commissioning works in tandem, and retains the flexibility to deploy different solutions in different parts of the country while maintaining standards of care
    • Improve social care, especially for the homeless, to help prevent individuals getting to the point where prison is a likely outcome
    • Give serious consideration to the health needs of children of offenders who have been imprisoned
    • Highlight the need for all doctors to be aware of the issues affecting patients with mental illness of learning disability
    • Take into account the individual needs in prison culture, as we do in other areas of healthcare.

    Read the seminar report

     

    Useful resources

    Prison Reform Trust

    BMJ Editorial, Prison environment and health

    BMJ Editorial, Elderly prisoners

    BMJ Editorial, Dealing with mental disorder in prisoners

    BMJ Editorial, Women prisoners