Search Results

While preparing for a teaching session on complex problem-solving, I recounted some WiseWords that colleagues had shared with me. Many communicated the hidden wisdom that informs our everyday practice. To explore this further, I asked GPs on a social media group to share their own WiseWords and was pleasantly surprised by the response! Statements, such as “trust your gut”, have been pivotal to our work for decades. Skills such as our gut instinct can be hard to define. They inform our most complex interactions with patients and are developed over thousands of encounters. They enable us to navigate some of the most complex problems we face in everyday practice, through a process known as knowledge work .   Working on WiseGP, I felt a collection of these WiseWords could provide a thought-provoking resource for reflection and learning, to showcase our hidden professional wisdom.   To build this resource, we joined with the Primary care Academic CollaboraTive ( PACT ) to share a survey, asking clinicians to contribute their own WiseWords . The responses have now been condensed into 6 books, offering insights into different aspects of our everyday practice. The key learning from these WiseWords  will come from understanding their application, so we’d encourage you to critically reflect on the statements. Consider where these ideas come from, how they may or may not be applied and why they aren’t reflected in our guidelines for practice.   You can explore the WiseWords collection on our new webpage, where there's an introduction and video collection . Hopefully they’ll inspire you to share reflections on how you apply your wisdom in practice, or perhaps spark you to record your own book of WiseWords- a legacy to share with current and future colleagues!   Dr Annabelle Machin

Doctors have become renowned for their illegible handwriting, something they perfect while having no time to write as a trainee on ward rounds! Fast forward to the present day and electronic records mean we don’t have to worry so much about our handwriting, though the spoken word has always been our most valued form of communication- with our patients and colleagues. This includes words of wisdom we share amongst our teams. These are often based around stories from everyday practice.   While preparing a teaching session, I recently asked GPs on a social media group to share their words of wisdom- I was pleasantly surprised by the number of responses! While some wise words  reflected the current political landscape, others were of steadfast relevance. For instance, on sharing some anecdotes with a senior colleague, they remarked how wise words , such as “ trusting your spidey sense ” , haven’t changed for 30 years.   Such skills, our gut instinct, can be hard to define. They strongly inform some of our most complex interactions with patients and are skills we build on over thousands of patient encounters. They enable us to solve complex problems as experts in whole-person centred care and are a core aspect of our skillset as expert generalists.   There is a common misconception of GPs managing some of the simplest medical problems and referring complex issues onto hospital specialists. At times, I suspect GPs are guilty of underselling their expertise, perhaps in part, as it’s hard to describe our most complex work, negotiating uncertainty and helping patients to navigate on the path between illness and disease. WiseGP defines these complex problem-solving skills as knowledge work. (You can read more about these distinct skills on our knowledge work page .)   One way we share the bounty of our knowledge work with colleagues is through wise words , so WiseGP now plans to showcase this plethora of wisdom within a new section being developed on our website.   These include tips on dealing with complexity, avoiding over-investigation, managing risk, including spotting patients who need extra focus and setting boundaries on our workload to avoid burnout. There are also some powerful insights into the practice and wider political changes needed to enable general practice to thrive in the future.   If you have any wise words  to contribute, please get in touch via email: wisegpcouk@gmail.com Dr Annabelle Machin

The art of medicine is often discussed as the skills beyond our factual knowledge that aid our interactions with patients. The way we connect with people, empathise and communicate. At WiseGP we discuss the creative art within and beyond our consultations as an aspect of knowledge work . After exploring a patient’s illness experience, we creatively work with them to co-develop an explanation for their symptoms, which informs our management. We then evaluate their response, so we can creatively adapt our explanations and plans if needed.   Many doctors have a creative aspect to their personality. If you are musical, artistic, enjoy films or poetry, you may miss these creative outlets in your work, but do they need to be absent?   Art can be a fantastic learning tool in medicine, to help explore our unconscious biases, broaden our perspectives and help us to understand different cultures. More-so, it can offer us insights into people’s illness experiences, encourage compassion in our work and help us think differently about how we apply our knowledge.   On my recent travels I’ve enjoyed exploring art and medical history. Here are some well-known examples that might inspire you to explore the links between art and medicine further, in tutorials, everyday practice, or your wider life. Here I’ve focused on mental health, but there are a multitude of topics represented through the arts.   Painting The Scream, Edvard Munch (1983) "The Scream" is a universally recognised piece of art, portraying the essence of anxiety, panic and fear. Did you know Munch wrote on his painting, “Can only have been painted by a madman”? What do you think when you look at “The Scream”? Salvador Dali, painting "The face of war", 1941 Salvador Dali, famed for his surrealist art, was strongly Influenced by Freudian psychoanalysis, believing in the power of dreams as untapped reservoirs of the mind, with many of his paintings symbolising distorted memories from dreams. His work “The Face of War”, captured the essence of human emotions during the tumultuous second World War.   We may consult veterans experiencing post-traumatic stress, or patients with mental health problems that find a creative outlet through art. Exploring these works can provide an insight to the mind of someone experiencing a mental illness. Music Beethoven cabinet at the Josephinum Medical Museum, Vienna When Beethoven began to lose his hearing, he was forced to use an ear trumpet and bite a metal rod on his piano, in order to experience music. As he became deaf, he contemplated suicide, before he later died of liver cirrhosis, contributed to by excessive alcohol. I saw his skull on display at the Josephinum Museum in Vienna, where the cause of his deafness had been investigated, after his remains were donated to the museum by his family.   Music can have a great healing power- I have patients who have coped with bereavement through playing music and joining a choir, while others use favourite playlists as a mechanism to manage self-harm thoughts. Beethoven’s story highlights the connection between physical and mental health and how important the senses are to our wellbeing. He also demonstrates how music can be experienced in different ways by people with hearing loss.   Classics Psyche revived by Cupid's Kiss (1987-93), Antonio Canova, The Louvre, Paris Psyche was a mortal woman from Greek Mythology. After falling in love with Eros, god of desire, she was manipulated by her sisters into betraying him. Seeking forgiveness, she was given a series of impossible tasks to complete by Aphrodite, the goddess of love, who envied her beauty. Through perseverance she was able to complete the tasks and be reunited with Eros, when she was transformed into a goddess. The Greek word psyche means soul, with Pysche representing the human soul’s triumph over life’s misfortunes in pursuit of happiness.   Psyche’s myth is a reminder of the challenges people face in life, that can be overcome with determination. It’s also a prompt to consider how often you explore love and relationships in people presenting with mental health problems.   History Corridor in the Narrenturm Anatomical Museum, Vienna The Narrenturm (Fool's Tower) in Vienna, is Europe's oldest psychiatric hospital, built in 1784. It’s now home to a museum housing anatomical specimens within cold, dank rooms where patients once slept- when I wandered down this corridor, the rooms were reminiscent of prison-cells.   A reminder of how historically, people with mental health problems were stripped of their liberties and often confined to eerie buildings like this. Do we still carry stigmas that we should reflect on? Poetry   I was recently contacted by a retired colleague who is writing a book of poetry, combining this with her artwork. Alone by Edgar Allan Poe  is a famous poem, offering reflections on a solitary childhood.   We know how mental health problems can often stem from childhood experiences, a reminder to explore these in patients who present with complex problems. Film Joker, played by Heath Ledger Hopefully you’re familiar with Batman! Many have tried to decipher what condition the Joker has - he has features of certain personality traits, including psychopathy and narcissism. Some portrayals  of the joker perpetuate a misconception that severe mental illness is always linked to violence, when in fact, people with severe mental illness can be more vulnerable to violence  from  others. How do you respond to people with severe mental illness?   The film Ordinary People, traces the recovery of Conrad from a severe bout of depression and attempted suicide. We discover this is brought on by his brother's death, for which he feels responsible. Loss can be a powerful force and often people can inappropriately blame themselves, like children who experience parental separation. This film focuses on the positive input of a psychiatrist- the difference a compassionate clinician can make. Books The book, ‘One Flew Over the Cuckoo's Nest’, centres on a man diagnosed with paranoid schizophrenia who struggles when confined to an institution, where he is frustrated by the rigid treatments imposed on him and other patients. The story reminds us there is not always one way to treat those with mental health issues- a creative, individualised approach is needed to best support someone’s recovery. Hopefully this blog has sparked you to consider further exploring the links between art and medicine, not just on the theme of mental health, but on a multitude of other topics. These few examples demonstrate how valuable connecting with the arts can be for our patients too. If you’d like to submit a blog to WiseGP, please get in touch! Dr Annabelle Machin, WiseGP Fellow

Rupal Shah and Jens Foell Jens and I have been GPs for a very long time- forty years between us. Are we deluding ourselves though to suggest that general practice has a soul and if it does, that we should fight for it? This idea for our podcast series came out of the eponymous book , in an effort to spark a conversation within our profession about this question and others, like:   What kind of future should general practice aspire to? How do we provide personalised care in a context that is designed to be generic? Do relationships have a role in care anymore? How do we balance risk and make care fit for individual patients? Are guidelines tramlines? How do we navigate total triage? We have been lucky enough to be joined by guests like Iona Heath, Rowena Christmas (Chair RCGP Wales), Victor Montori (founder of the Patient Revolution movement) and Minna Johanssen (who came up with the ‘clinican time needed to treat’ metric). We have an episode about flourishing and another about total triage.  We have many more planned. You are the future of General Practice, so we would love you to listen  and feedback to us, to your peers and other colleagues about how we can effect change and enter Don Berwick’s ‘era 3’. We want a General Practice that we can be proud of and that cares for patients and for staff. If you’d be interested in recording a podcast with us, please get in touch using the contact details below! Access the podcast here : https://www.youtube.com/playlist?list=PLQ7L4Dw8A266inuM0fN_MwCw5OIyinPWp Contact: Rupal Shah, rupal.shah12@nhs

Sometimes I feel a bit of a fraud working on the WiseGP project- it implies I’m particularly wise, or maybe have a skillset beyond other GPs. It’s not the case- there are skills all GPs possess that WiseGP aims to support and highlight. So, what do I think it takes to be a ‘wise’ GP?   Knowledge Knowledge is important, but the internet has made this available to all. Memorising facts helps to speed-up our clinical reasoning, while building patient confidence in our clinical acumen. However, knowing all the required facts is impossible, since medical knowledge is constantly evolving.   The GP curriculum is several hundred pages long. I’ve recently assisted with updates to this, which have expanded it even further.  The breadth of knowledge needed can be intimidating, particularly when newspaper headlines vilify certain GPs for missing a rare diagnosis, leaving the public asking, would a wiser GP have recognised it?     Experience   The phrase, “ with age comes wisdom ”, holds some truth. Through our work, family and social lives, we gain experiences of value to our professional work. Experience can particularly help with pattern recognition, but when a condition is rare, being open about what we don’t know can reflect true wisdom. Socrates once said, “ The only true wisdom is in knowing you know nothing ”. To be wise, we need an open mind to consider new concepts or to ask for advice when needed.   Whole-person approach   Often there may not be a disease diagnosis to make- this is where a pivotal aspect of a GPs wisdom comes into play. GPs apply their knowledge to an individual’s context, to help decide whether to medicalise an illness. When appropriate, we avoid harm through medicalisation of distress. Informed by our knowledge and experiences, our gut feelings help us to negotiate complex decisions, reflecting an integral part of our wisdom.   Complex problem-solving skills help us to work with patients to develop potential explanations for their symptoms and plans to manage them, which we review and revise over time. These are key expert generalist skills emphasised by WiseGP. Skills that make us wise, that the newspaper headlines fail to feature.   Critical reflection and caring   Having the time and headspace to reflect on our work is integral to developing these skills, but it isn’t built into our contracts. I used my limited study leave this year to learn how to give joint injections, which has meant I’ve had to use my evenings and weekends to complete other professional development work. My commute provides some time and headspace to contemplate decisions I’ve made, but there are still occasions after 13 years as a doctor that I sit at home wondering if I’ve done the right thing. This is part of why I think a caring nature is key to being a wise doctor- it drives us to critically reflect on our decisions and experiences. It drives us to recognise our weaknesses and improve. How we learn from experiences is integral to our wisdom.   Teaching and learning   Teaching is intrinsically linked with learning and wisdom- the word ‘doctor’ is Latin for ‘teacher’. I still recall lectures at medical school that were poorly attended, while others attracted a packed hall. The best lectures were delivered by doctors who understood the challenges we faced and had the wisdom of practical experience to share. They went beyond what we could learn from reading presentation slides and talking to patients, by sharing powerful anecdotes that I still pass onto students today. We can learn continue to learn beyond our experiences as individuals, through teaching others and sharing our experiences with colleagues. Leading improvements   Supportive general practice teams can build their wisdom by developing and evaluating new approaches to delivering care for complex patients. Across my Primary Care Network, I've observed how practices could enhance their systems of care through mutual learning. As an aspiring WiseGP, I'd like to have the opportunity to discuss and help implement changes, but this would demand additional time beyond what is supported in my roles as a salaried and extended access GP. Supporting the profession   This is why I’m glad to be involved in the Wise Provocations work. We aim to challenge common misconceptions about general practice and help the public, policy makers and politicians understand the depth of wisdom involved in a WiseGP's everyday work. We hope this understanding will drive the changes needed to enable GPs to deliver whole person centred care and lead, rather than react to imposed changes, to improve frontline care.   I hope that WiseGPs will be given the voice they deserve to help shape our future health service. In the meantime, I’ll continue my drive to be a better WiseGP! Dr Annabelle Machin

Could a global outlook inspire change? Everyone agrees we need change, but with how busy we are, there’s usually no time or headspace to think about what could improve life for us and our patients. Then there’s the challenge of engaging others with ideas who are already close to burnout- it’s not surprising we struggle to start! Can the experience of colleagues working overseas, combined with the expertise of WiseGP, help us to think – and do things – differently? Often simple healthcare innovations can be cheap and effective. However, they can carry the risk of unintended consequences, which may be a barrier to change. Some of the best innovations are made during emergencies when certain resources aren’t available, or in remote places where there is a lack of medical support or funding. I’ve continued to work as a GP in the same community that I grew up in. It has advantages-for example, when someone tells me walking between a local supermarket and a particular high street shop makes them breathless, I know exactly what distance they mean. Familiarity can be comforting, but comfort in the status quo can be a barrier to change- to thrive in the modern healthcare environment we have to be innovative, since the workload has risen, resources have fallen and the goalposts keep changing. Change may come more easily to people who have experienced working in different healthcare settings. Consider being based in a community clinic in rural Africa. To save lives, you may have to innovate. Hopefully not as extreme as on Dr House, when a carpenters’ drill was used to drain an extradural haematoma, but it could be designing a triage system that only allocates appointments and resources to those most in need, or establishing a rota of community volunteers who can provide emergency hospital transport. Such innovations may happen through necessity, supported by a lack of red tape that could hold us back in the UK. So as resources become scarcer in the UK, should we be looking to our colleagues with experience working in different healthcare settings for inspiration? I recently read about a community outreach project in Westminster, inspired by the experiences of a GP working in Brazil. While in Brazil, community health workers had been their eyes and ears, identifying problems early, connecting people to health and social services and building an understanding of the neighbourhood as a whole. The UK-based pilot involved healthcare workers directly visiting members of the community in their homes to build bridges and connect them with services. They improved uptake of healthcare screening and vaccinations, while insights into the community’s needs helped practices to direct resources to fit the needs of their population. Here’s a video about the successful pilot. How does this compare with the work Social Prescribers do within your PCN? Every community is different, so perhaps you have a better system that suits your population’s needs. In a previous blog, we highlighted the work of a WiseGP using technology to identify and address underlying health inequalities in their practice community. We know by addressing underlying inequalities, we can improve a population’s health, hence reduce appointment demand- a change in practice that benefits staff and patients. Given the community outreach pilot was inspired by the experiences of a GP working in Brazil, perhaps you might reach out to members of your own team... Do you have colleagues with experience of working in international healthcare settings? Could you draw on their diverse experiences for inspiration? Given how many GPs are currently lacking time and headspace, are there other members of your practice team who could lead changes with support? Over half of new GP trainees this year were international medical graduates (1)- perhaps they could inspire and lead new innovative approaches in your everyday practice- to benefit you and your patients? Dr Annabelle Machin https://www.gponline.com/nhs-risks-losing-thousands-new-gps-visa-sponsor-shortfall/article/1862214

Have you heard of the gut microbiome? The microbiome refers to the trillions of bacteria, fungi and other microorganisms living in our gut.1,2 Lately, it’s made newspaper headlines and now celebrities are endorsing microbiome tests to inform personalised dietary advice. It sounds like science fiction, but recent animal experiments have found the bacteria in our gut could influence our behaviour, with an intact microbiome being associated with more social behaviour in mice and shoaling of zebrafish.3,4 It sounds logical that bacteria would want us to spend more time together to aid their spread… and evidence suggests our microbiota could be influencing far more than how sociable we feel! Changes to our microbiota are potentially associated with mental health conditions.5 For example, bacteria producing certain fatty acids have been linked to improved wellbeing and quality of life.6 Adverse changes to the microbiota could also be associated with the development of neurological conditions, from Alzheimer’s and Parkinson’s disease to migraines.7,8 Beyond neurological connections, changes in our gut microbiota have also been linked with obesity, type 2 diabetes, hepatic steatosis and inflammatory bowel disease, with evidence that the microorganisms in our gut could be influencing our immune pathways, lipid and glucose metabolism.9 Supporting the gut microbiota Discovering all these potential links between our microbiota and whole person health, has perhaps made you wonder about the potential impact of antibiotics? Well, evidence suggests there is an association between antibiotic use and colon cancer risk,10, 11 but further research is needed. Perhaps this could inspire an advanced generalist review of antibiotic prescribing in your practice?  You can read more on this in a WiseGP GEM about antibiotics and colon cancer… So apart from avoiding antibiotics wherever possible, what else can we do to support our microbiota? You may be wondering whether probiotics could help? Well, a recent systematic review found existing evidence to be inconclusive!12 We do know a Mediterranean diet high in fibre, particularly from vegetables is likely to help our gut health.2 Some sources also advocate fermented foods, such as sauerkraut or kimchi.13 Studies are currently exploring the potential benefits of faecal transplants, for instance, in people with Parkinson’s disease.14 Research to uncover the complex interactions between our microbiota and health could help to inform the future treatments of a range of linked conditions. Considering the gut microbiota in everyday consultations… So, how would you respond if a 25-year-old patient with irritable bowel syndrome (IBS) presented to you for advice about a video on TikTok recommending home microbiome test-kits and “DIY” faecal transplants for bowel problems? There are various approaches you could take. What would be your WiseGP instinct? You could highlight the lack of strong evidence to inform this approach in IBS and warn about the potential risks. You might offer to explore the evidence behind these suggestions to inform a follow-up call. However, would you have the time to dedicate to a literature search? You could speak with your colleagues. Following recent rises in consultations about suspected ADHD and weight-loss injections, you may have taken a practice-led approach to managing trending problems. Sharing learning across your team can save time and ensure consistent advice is offered, with information shared on practice social media or via set text messages to support consultations. You could explore with the patient what led them to consider experimental treatments. Have their symptoms changed, do they have red flags, or could their presentation suggest underlying anxiety you could support them to manage? Your exploration of their presentation could inform an explanation of their symptoms, as part of the 3E’s approach discussed in the newsletter linked to this blog, "Have you heard of it?". Looking beyond the biomedical evidence… If we look beyond biomedical evidence for IBS management, social sciences literature provides some valuable insights. For example, on exploring patient perspectives of IBS treatments, I came across a qualitative study considering how people with IBS seek and appraise different treatments.16 The study discussed how patients could get trapped in a cycle of hope and despair, while desperately searching for a cure. One suggestion was that GPs could work with patients with IBS to help them to develop acceptance and coping strategies to escape these vicious cycles. So beyond discussing the evidence surrounding microbiome testing and faecal transplants, would the most effective approach be to explore a patients’ illness perceptions and treatment aims, with a goal of supporting them to move from seeking a cure, to developing coping strategies? In the WiseGP newsletter, “Have I missed something?”, we discuss how using the concept of creative capacity could help patients to draw on their own resources to co-develop personalised management plans. Perhaps this is something you could test in your everyday practice? So, should we be considering the microbiota as part of whole person care? Perhaps… Like many areas of medicine, the evidence is rapidly progressing, so where new revelations are likely to be on the horizon, having the skills to respond to new information and guide patients towards productive discussions will prove invaluable. Hippocrates once said, “All disease begins in the gut”. I wonder how true that will prove to be? Dr Annabelle Machin WiseGP Fellow References 1.       Thursby E, Juge N. Introduction to the human gut microbiota. Biochem J. 2017;474(11):1823-1836. doi: 10.1042/BCJ20160510 2.       Frankel M, Warren M. Are you thinking clearly? London: Hachette UK, 2022. 3.       Crumeyrolle-Arias M, Jaglin M, Bruneau A et al. Absence of the gut microbiota enhances anxiety-like behavior and neuroendocrine response to acute stress in rats. Psychoneuroendocrinology. 2014;42:207-217. https://doi.org/10.1016/j.psyneuen.2014.01.014 4.       Sherwin E, Bordenstein SR, Quinn JL, Dinan TG, Cryan JF. Microbiota and the social brain. Science. 2019;366(6465). doi:10.1126/science.aar2016 5.       Shoubridge AP, Choo JM, Martin AM et al. The gut microbiome and mental health: advances in research and emerging priorities. Mol Psychiatry. 2022;27:1908–1919. https://doi.org/10.1038/s41380-022-01479-w 6.       Valles-Colomer M, Falony G, Darzi Y et al. The neuroactive potential of the human gut microbiota in quality of life and depression. Nat Microbiol. 2019;4: 623–632. https://doi.org/10.1038/s41564-018-0337-x 7.       Villavicencio-Tejo F, Olesen MA, Navarro L et al. Gut-Brain Axis Deregulation and Its Possible Contribution to Neurodegenerative Disorders. Neurotox Res. 2023;42(1):4. doi: 10.1007/s12640-023-00681-0. PMID: 38103074 8.       Risbud A, Abouzari M, Dialilian HR. Gut-Brain Connection, Myth or Reality? Singapore: World Scientific, 2021. 9.       de Vos WM, Tilg H, Van Hul M et al. Gut microbiome and health: mechanistic insights. Gut. 2022;71(5):1020-1032. doi: 10.1136/gutjnl-2021-326789 10.    Zhang J, Haines C, Watson AJM, et al. Oral antibiotic use and risk of colorectal cancer in the United Kingdom, 1989–2012: a matched case–control study.Gut. 2019;68:1971-1978. doi: 10.1136/gutjnl-2019-318593 11.    McDowell, R., Perrott, S., Murchie, P. et al. Oral antibiotic use and early-onset colorectal cancer: findings from a case-control study using a national clinical database. Br J Cancer. 2022;126:957–967. https://doi.org/10.1038/s41416-021-01665-7 12.    Madabushi JS, Khurana P, Gupta N, Gupta M. Gut Biome and Mental Health: Do Probiotics Work? Cureus. 2023;15(6):e40293. doi: 10.7759/cureus.40293 13.    Leeuwendaal NK, Stanton C, O’Toole PW, Beresford TP. Fermented foods, health and the gut microbiome. Nutrients. 2022; 14(7):1527. Doi:10.3390/nu14071527 14.    Vendrik KE, Chernova VO, Kuijper EJ, Terveer EM, van Hilten JJ, Contarino MF; FMT4PD study group. Safety and feasibility of faecal microbiota transplantation for patients with Parkinson's disease: a protocol for a self-controlled interventional donor-FMT pilot study. BMJ Open. 2023;13(10):e071766. doi: 10.1136/bmjopen-2023-071766 15.    Reeve J. Medical Generalism, Now! Reclaiming the Knowledge Work of Modern Practice. Boca Raton:CRC Press; 2023. 16.    Harvey JM, Sibelli A, Chalder T, Everitt H, Moss-Morris R, Bishop FL. Desperately seeking a cure: Treatment seeking and appraisal in irritable bowel syndrome. Br J Health Psychol. 2018;23:561-579. https://doi.org/10.1111/bjhp.12304

Home visits can offer GPs the most useful insights into people’s lives outside the consulting room. For me, being immersed in someone else’s environment - and gathering information through all my senses - can be a stark reminder of the wider determinants of health. Issuing a prescription can feel like a drop in the ocean, when a person is battling a storm of underlying health inequalities. Social prescribers were introduced to general practice to help support people facing wider socio-economic challenges impacting on their health and with the recent rise in the cost of living, their role has become even more important. However, linking social prescribers to the people who are most in need can be challenging - how do we identify them, since we don’t usually code data on many of the wider determinants of health, such as financial struggles and loneliness? Dr Kumar, a GP based in Slough, with the support of the Slough practices and place team, has led an innovative project to gain a deeper understanding of the socio-economic needs of her patient population and empower them to make positive changes to improve their overall health and wellbeing. Using the Connected Care population health intelligence platform, local social prescribers identified residents from deprived areas with multiple long-term conditions, deemed most likely to benefit from support. After preparatory training, the social prescribers then met with these residents to complete the DiPCare Questionnaire; a quick, reliable and validated tool used to measure deprivation in primary care. With the needs of individual residents identified, they were then directed onto different community services for support to address their problems. As of January 2023, over 3000 questionnaires had been completed and coded. Approximately 35% of residents received an intervention, including fuel vouchers, digital and housing support, mental health reviews and referrals onto various food banks. Hypertensive/diabetic residents who completed the questionnaire engaged more with their primary care health check-ups, with a reduction in A&E attendances (9%), NHS 111 calls (59%), 999 calls (3%) and inpatient admissions (15%) in the same cohort. It is hoped that over time, by building trust with these communities, care will move from being reactive to more proactive, with the core needs of residents being at the forefront of the solution. Dr Kumar’s work demonstrates some of the core skills WiseGP aims to support and celebrate, including use of the 3E’s (Explore, Explain, Evaluate) principle that can help you systematically describe, understand and so address your problem. Dr Kumar recognised a need in her community, particularly after the onset of the cost-of-living crisis, that was impacting on the health of her patients and responded to this by exploring how her team could help. With her team at Slough Place, she explained how a new system utilising digital technology could help to target those most in need and has since evaluated the impact. Implementation was supported by training and group sessions that helped to link services together. Looking at data drawn from the questionnaires and actions taken in response to them has facilitated insights into the needs of Slough residents at a personal and population level, to help inform future service development. Our everyday work can at times feel overwhelming, so a project like this may feel outside the scope of what you can achieve. At WiseGP we recently led a project named Lazarus(1), which explored the idea of giving mid-career GPs facilitated, funded time out-of-practice, where they would have the headspace to develop and implement meaningful changes in their everyday practice - ideas like Dr Kumar’s. It’s easy to see how these grass root initiatives targeting the needs of local populations could benefit the wider health system if properly supported - this is the culture shift called for by Fuller(2). Hopefully initiatives like Lazarus will gain support, so more GPs can have the time and headspace to apply their expert generalist skills beyond the consulting room. In the meantime, there are still small impactful changes you could make - for instance, just considering how you explore and code the wider determinants of health in your consultations could facilitate a better understanding of, and support for, the needs of your local population. If you’ve been inspired by Dr Kumar’s project, you can read more about her great work in her blog: https://www.england.nhs.uk/blog/addressing-health-inequalities-in-slough-through-social-prescribing/ You can follow Dr Kumar on twitter: @PKGP07 If you’d like to find out more about Lazarus, here’s a link to a blog on this WiseGP project: https://bjgplife.com/lazarus-working-together-to-re-claim-general-practice/ Machin A, Bennett J, Reeve J. Lazarus: working together to reclaim general practice. BJGP. 2023;75 (734): 410-411. DOI: 10.3399/bjgp23X734817 Fuller C. Next steps for integrating primary care: Fuller stocktake report. 2022. https://www.england.nhs.uk/wp-content/uploads/2022/05/next-steps-for-integrating-primary-care-fuller-stocktake-report.pdf (accessed 31 Aug 2023).

WiseGP is partnering with NIHR Learn to support knowledge work in every day practice. You’ll find a host of great resources on NIHR Learn to help you get involved. As part of our new partnership, we are delighted to announce the launch of the TAILOR On-line Learning resources on NIHR Learn. TAILOR offers evidence-based resources from new primary care led research that will help you tackle one of the biggest challenges we face in everyday practice – managing problematic polypharmacy. The TAILOR on-line learning package uses NIHR funded cutting edge research to offer you practical ideas and tools for dealing with everyday polypharmacy problems you face in clinical practice. We also offer you ideas for thinking about whole practice changes you might want to make – practical ideas for quality improvement projects you may want to consider. NIHR Learn is partnering with the national WiseGP programme to help promote your experiences of using NIHR Learn in everyday practice. Why not share your experiences of using TAILOR in a blog for the WiseGP website? The TAILOR evidence synthesis research project was conceived, developed and delivered by a primary care team. Professor Joanne Reeve, an inner city GP in the north of England, has worked with GPs, pharmacists, patients, and researchers over a number of years in research to understand how and why prescribing practice needs to change. Patients and clinicians both want to medicines to be tailored to individual needs. But there are many factors in everyday practice that stop this happening. When NIHR called for research to tackle this problem, this primary care team responded successfully and the TAILOR project was born. TAILOR combined innovative evidence synthesis methods with a distinct primary care perspective to describe if and how we can safely tailor the use of medicines to the needs of our individual patients. The research showed that tailored deprescribing of medicines is safe, effective and potentially acceptable if done using a structured, systematic approach. It also highlighted the changes needed in the way we run our practices to support this work. NIHR have published a user-focused summary of the work here. Our TAILOR e-learning program explores the findings in more detail and how you can use them in your own everyday practice to improve patient care. TAILOR provides valuable new evidence for practice from research, but also much more. Our partnership with NIHR Learn and WiseGP is providing practical ways that clinicians can use this research in their own practice, but also contribute to generating further new practice-based-understanding and evidence through QI work. We look forward to reading your blogs!

Knowledge transformation in health and social care. Putting mindlines to work | John Gabbay and Andrée le May It is hard, working in general practice at the moment. The workload is huge, and can seem never ending. The problems we are dealing with feel ever more complex. The tools we have to deliver safe, effective and manageable person-centred healthcare don’t feel good enough for the job. All of which adds to the workload and work pressure. So where can we turn for help and inspiration? We set up WiseGP as one source of help. Our goal is to help front-line clinicians feel more confident in making sense of, managing, and learning from the complex problems we see in everyday practice. WiseGP recognises that a lot of what we are dealing with everyday can’t be explained or managed by a simple guideline or care pathway. Instead, we have to use our critical creative knowledge work skills to help our patients. Our WiseGP resources are designed to tackle the specific barriers you have told us you face in working beyond guidelines and simple pathways. Our WiseStories and short animations offer an understanding of knowledge work as a legitimate part of your everyday professional practice. Our Wise Newsletter and WiseGEMs both offer ideas and resources to help you get started in, or further develop, your knowledge work skills. Our Wise Blog invites you to share your stories of knowledge work in action with your wider general practice community. This new book from Professors John Gabbay and Andrée le May also looks at the knowledge work of everyday practice. It builds on their research, first published in the BMJ in 2004, in which they challenged the view that a GP’s job involves simply passively following published guidelines and pathways. Instead they described the skilled and complex (knowledge) work that front-line clinicians do every day to convert generic (simple) guidelines into a nuanced understanding of practice better suited to their local context and population. They described this work as the generation of “mindlines”. In this latest book, they offer eleven examples of mindlines in action – of clinicians working together to critically create new understanding-in-context and new ways of working for everyday practice through the generation of mindlines. Examples come from across clinical disciplines, including dentistry, physiotherapy, palliative care and general practice – though interestingly, most are community based; and across health service delivery, including guideline development and responses to the COVID pandemic. All describe clinicians taking ownership and control of managing real world challenges by creating the new tools they need for their daily work. We see clinicians creating and using the collective local wisdom they need to work safely and effectively within complex and uncertain situations. So what can this book offer to the time-poor, overworked front-line clinician? As Gabbay states, it is intentionally not a book that tells you what to do. It instead looks to legitimate and so support the work to generate and use collective wisdom at, and from, the front-line. First and foremost it is perhaps a resource for those involved in enabling practice redesign – clinical leaders, ICB members, educators, policy makers and academics. It challenges them to recognise that traditional research (such as that summarised in guidelines) is an important form of knowledge for practice – but is also insufficient. It highlights why and how we need to redesign practice to recognise and enable local knowledge generation as a crucial part of everyday professional practice. But it also describes the work done by front-line clinicians to address the real-world challenges they face every day. It is written by those clinicians and tells their stories. It shines a light on the practical work they are doing to change practice at the coalface. For me, this is an inspiring set of stories that remind us things can get better. If you feel inspired too, we’d love to hear your reflections – the ideas you have, the work you are doing to create the mindlines that can make your job better. Send us a blog with your thoughts and we’ll share them with the WiseGP community on here. Joanne Reeve GP, Professor of Primary Care and founder of WiseGP

Working as an academic GP for the past 3 years has been interesting and rewarding, and at times frustrating. Being directly involved with projects that are trying to help change the way that primary care currently works has given me motivation and a sense of professional purpose that it was hard to find from working in a solely patient facing role. As a trainee GP and then First5 I was all too aware of the increasingly challenging environment that is primary care, and was concerned to see how more experienced colleagues were finding it harder to cope with the demands of the system. So maybe it is the system that needs to change I hear you cry. Not a fast and easy solution for such a short question, and was it even possible for me to try and be part of that change? I started to realise that the evidence for change was there, and that we could make it possible. My frustration grew when I saw increasingly relevant research from the academic teams taking such a long time to have any influence on clinical practice. This is to an extent understandable; the necessary rigours of thorough research, peer review processes, and the need for bodies of evidence to influence policy. It all takes time. But then I saw my role as a clinical academic to help spread the message of important research in a relatively quick way that helps clinicians change their practice. Earlier this year the TAILOR medication synthesis was published. It delivered a comprehensive literature review examining what is known about deprescribing for patients with polypharmacy and how clinicians could try to achieve such a complex and challenging goal with their patients. A large team of experienced researchers spent hundreds of hours applying research methods I had never before heard of to deliver the vitally important understanding and reassurance to prescribers. Deprescribing is safe, effective and acceptable for clinicians. Furthermore, there is no single best approach to this, which is a liberating concept. It tells us not only is deprescribing something we should be doing but we can find our own structured ways to implement it locally. It doesn’t invite a free for all or encourage reckless medicines management. Instead TAILOR highlights the need to personalise medication regimes and encourages clinicians to feel confident working outside of guidelines where appropriate, and to collaborate with colleagues across our expanding MDT to deliver this in a way that suits our local populations. I excitedly shared this with colleagues, only to find none had heard of TAILOR outside of academic circles. Again, the frustration of the delays between academia and practice. Then Joanne Reeve offered me the chance to work with Clare Fozard in translating TAILOR into a bitesize educational resource. It seemed like the perfect opportunity to try and break down some of the barriers preventing GPs from accessing the messages from TAILOR. Indeed it has been another example of why clinicians working in research can directly improve the accessibility of up to date evidence based information that can both influence practice and improve patient care. My own clinical practice has changed, and I feel the care I give to polypharmacy patients has improved. Our hope is that TAILOR and the DExTruS model of care it created will inspire changes in practice across the NHS and wider afield. I challenge you to try the modules for yourself, access the TAILOR report, and drive that change wherever you are. https://www.journalslibrary.nihr.ac.uk/hta/AAFO2475/#/full-report https://learn.nihr.ac.uk/course/view.php?id=1069 James Bennett

If you’re puzzled by the concept of knowledge work, hopefully this blog will provide you some clarity on this important concept! Knowledge work is about managing complex problems. A problem is ‘complex’ when there are multiple different ways we can- and indeed need to- look at that problem. Things get even harder when these different perspectives contradict each other. A complex problem will have multiple possible outcomes. The distinct skill of the knowledge worker(1) is to create understanding when working with complex problems. Creating understanding needs 3 elements: critical creative Exploration, to construct an Explanation that guides action, and Evaluation to determine the value and impact of this. This concept of knowledge work describes the everyday work of clinicians using expert generalist skills to deliver whole person care. To do that the generalist clinician first explores the multiple perspectives on the problem - the patient’s understanding, the scientific evidence enshrined within healthcare guidelines, and their knowledge of the local context and determinants of health - including, but not exclusively, healthcare factors. This exploration takes place in the consultation between the clinician and patient; through review of clinical records and published evidence, and via multidisciplinary team discussions within daily practice. With the patient, the clinician constructs an explanation of the problem and agrees a plan to manage it. This might involve some further tests (collecting more data), or a plan to try a course of treatment and review its effect (a ‘trial and learn’ approach). Using knowledge work to manage complex problems therefore relies on a 3rd stage – evaluating the impact of applying the explanation. This might involve ‘safety netting’, which is commonly used in practice (if it doesn’t get better by a certain time, come back). Sometimes, it needs a specific plan to meet, review and revise the explanation, for instance, a follow-up consultation in a month to re-evaluate the situation. Knowledge work is therefore integral to multiple everyday decisions in our daily practice, in our work to to explore a concern, tailor an explanation and management plan and evaluate the outcome (2,3). Knowledge work can help us to explain an illness, negotiate whether to start or stop a treatment, refer someone for a test or arrange a consultant review. Knowledge work can support us in taking a whole person focus when negotiating a management plan in someone with multiple health problems, or when approaching a single health problem with a challenging context. Beyond our everyday work seeing patients, knowledge work is used everyday by GPs teaching, performing vital research and leading and developing our healthcare services. Peter Drucker first described the concept of a knowledge worker1 and his ideas are widely recognised in professions outside of medicine, such as IT and engineering. A knowledge worker knows about their field of expertise, but is also able to apply what they know in a personal, social, and organisational context. WiseGP champions this way of thinking within the work of medical practice. General Practice has often been described as a discipline that knows “a little about a lot”. However, when we consider the complex problems solved through knowledge work in everyday clinical practice, we can see it’s not just about what you know, but how you use what you know(4). Knowledge can’t simply be defined as the facts we have learned from textbooks and guidelines. It encompasses a ‘tacit dimension’, shaped by our internal beliefs, thoughts and ideas, expertise and professional judgement; knowledge that we don’t always know we know(5). Whilst some decisions we make may seem straightforward on the surface, there is often a huge amount of tacit judgement involved. Consider the decision about whether to send an unwell child to hospital. We can refer to guidelines, but a huge number of other factors influence our decision making, such as how worried the parents are, our ‘gut feelings’ and our past experiences managing similar situations. Our role is to integrate all these pieces of information to create a new understanding of the situation. This is knowledge work. References 1. Drucker, P. (1959). The Landmarks of Tomorrow. Harper: University of Virginia. 2. Reeve, J. (2022). Rethinking generalist healthcare: opportunities from challenges. BJGP. 72 (720): 338-339. https://bjgp.org/content/72/720/338 3. Reeve, J. (2022). Rethinking generalist healthcare: opportunities from challenges. BJGP Life. https://bjgplife.com/rethinking-generalist-healthcare-opportunities-from-challenges/ 4. Wenzel, RP. (2017). Medical education in the era of alternate facts. New Engl J Med. 377 (7), 607-609. 5. Ray, T. (2009). Rethinking Polanyi’s Concept of Tacit Knowledge: From Personal Knowing to Imagined Institutions. Minerva. 47(1), 75–92. https://doi.org/10.1007/s11024-009-9119-1