CRF 16.05.23 How to Achieve Holistic Care for Patients in the NHS in 2023, Dr Charlotte Benjamin, Chief Medical Officer NHS North West London & GP



This on-demand teaching session explores how to achieve holistic care for patients in 2023. Led by Charlotte, a GP and the Chief Medical Officer for Northwest London, she will discuss the nuances of various medical specialties, the impact of COVID in relation to morbidity and mortality rates, vaccine hesitancy and who could benefit from a holistic approach. She will provide insight into data relating to the UK and will encourage those in the chat to contribute with their own views from their countries.
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Learning objectives

Learning objectives: 1. Understand the benefits of holistic care in achieving the best health outcomes for patients in 2023. 2. Identify specialties which are more advanced in offering holistic care. 3. Analyze data to better understand the correlation between age, comorbidities, and mortality from COVID-19. 4. Identify populations who would benefit most from a holistic approach to care. 5. Identify patients who require complex and high frequency of care and create a model to deliver necessary care.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Thank you, Hannah. So good morning. So um it's Tuesday morning in the UK, it's 9 31. So welcome. So I'm really delighted to join you to be able to lecture to the Crisis Rescue Foundation to the elected program for medical students. And lovely to see in the chat that we've got people from across, represented, from across the world. Um So just to tell you a little bit about me. So my name is Charlotte. I am, I do two roles. I'm a GP, a general practitioner, but I'm also the Chief medical officer for Northwest London. So that's an area of London that looks after 2.5 million heat residents. Um and covers eight boroughs of London. And what I wanted to talk about to you today was about how to achieve holistic care for patient's um in 2023. So where that from who I can see where you come from will be from very, very different medical systems and medical systems in different amounts of stress and trauma. Um It might be that people look at the UK system and think it's a perfect system. Um And actually I just want to really share with you that the system's often in the developed world, concentrate on one area of paper of medicine. And actually there are disadvantages to that. And actually what we benefit from is looking much more wider and holistically at patient's to actually try to get the best out health outcomes for them. So if we can move to the next slide, please, please feel free to put, can't ask any questions in the chat as we go along. Maybe Hannah, if you can help sign post, if we're getting questions, if you want to put your hands up, also piece, feel free to if there's anything you don't understand that I'm saying. So if we can move onto the next slide, please, I'm a not sure if there's a lag in moving onto the slides. Is it not showing the holistic care slide? It's got this the first slide it's not gone on to to the introduction. Has it not know? Is it now? Not yet? Ok. Let me sorry about that. Let me stop sharing and try. I don't worry. So I'll, I'll talk. Um That's don't worry. Thank you. So in terms of in terms of what holistic care is, so I don't know whether anyone wants to put their hands up and say out perfect what they think holistic care is, feel free to put your hands up. What does holistic sort of overall care mean for people? It's comprehensive health care. So it's physical mental um social well being, it's your entire well being, not just the physical health. Perfect. That's absolutely perfect. And we can see that jigsaw. So people aren't one different elements. People are human beings with lots of complexities and lots of different parts to their necessary to work well for their well being. And you've described that really well. So thank you. And that's the alliance with what we can see on the slide. Um in terms of do we do that well, if we can move onto the next slide, some areas and some disciplines do that better than others. So if we look at which specialties are more advanced in offering holistic care, it will be things like general practice disciplines like care, the elderly discipline, like end of life care, pediatrics, those often do it very well. But some of the other areas that become very super specialist, do the holistic care. Um it less well or they're less advanced in doing. It's not that they don't understand the need to do it, but they are less advanced in doing that in terms of the similarities with those specialties because does anyone want to volunteer what they think the similarities might be with those specialties that I picked? So what they do is they cover chunks of the population. So pediatrics, care of the elderly, those are covering rast sort of pediatrics, 0 to 16 or 18 care of the elderly. What's either defined in which country you live in over 65 or over 75 genera practices covering everybody from birth to death. These are, these are parts of systems that are covering entire, entire populations or entire age dreams populations. And they have been much further advanced in their understanding hedonistic care. Now, if we look to make it relevant for 2023 if we move on to the next slide and we see what that some of the lessons learned from COVID are. Um if you have just one medical problem. So something like diabetes, if you have one medical problem and you look at the morbidity mortality from COVID. If we look at the graph shows this is from paper from nature. If you look as you go up in age from 18, all the way up to plus 17/79 you have a really clear, really clear correlation of increasing age with increased mortality from COVID. If we look then at. So there's the darkest blue, the navy blue line. If we then look at the line above it, those are patient's who've got one co morbidity. So they'll have one thing wrong. So like diabetes or like inflammatory bowel disease or one issue, that's wrong with them. If we look at the next line up and people who have two or more co morbidities, then they have significantly increased risk of death from COVID. If we move on to the next slide, please, this is looking at a very different aspect of COVID. So um we were very fortunate to have uh within the year of having a new virus of having COVID in the world, we developed a very successful vaccine and there were vaccine programs rolled out across the world. But we actually saw that there were groups of residents who were very happy to accept the vaccine and that's shown on the left hand slide of the slide. And then as you move over to the right hand slide of the slide that there are people who have less degrees of acceptance, some patient, some residents refusing the vaccine and some who after discussion, they're not so sure they might you might be able to persuade them and some who despite any conversation won't want to have the vaccines. And there is a correlation of increased vaccine hesitancy. People who don't want to have the vaccine in deprived communities. What we also know is that people from deprived communities have more comorbidities than they have more illness. So not only do they have the extra risk of death because there are less, they have more comorbidities, they also have extra with of desk because there's less vaccine uptake. So if we can move onto the next slide, please, thank you. So what it says who would benefit from this holistic approach? So in an ideal world, everybody would benefit. But actually in all healthcare systems, even systems that are not under strain, which there aren't many, there's systems that you're presumably and that have the enormous amount of strain. But in say, the UK which have some element of strain, we can't offer that necessary to everybody. So who doesn't need it? Well, if you're fit and healthy and you have the occasional problem with you, you probably don't need to have somebody focusing on holistic care. Um, what we look to try to do is get you to be engaged in your own health and need as little input as possible. And we look to having a model where you have patient's having high volume, so lot lots of patient's but needing low, low frequency of care being offered to them and don't need a more complex approached. And one of the way there are different programs looking at that in the UK. So those that can benefit from having a going in and having a very uniform non personalized approach to healthcare that we can get through patient's really quickly, there's huge benefit to that because then we can cover a huge number of people and actually offer them healthcare next slide, please. So if we look at data and this is from the UK on what the number of comorbidities that people have. So one in three patient's that we see in healthcare settings have two or more chronic conditions. So that's a huge number. And I was actually shocked when I saw that data. So I thought it was probably going to be something like one in 10, but actually a third. So 33% patient's have two or more chronic conditions. And then if we look at people who go into having emergency care, so that's the unpredictable care that they need when they have an emergency. One in three, patient's have five or more comorbidities. And that's a really large figures. Well, five or more plus copa morbidities. So that's a bit of, that's a bit of intelligence on the data from the UK. I obviously don't know how that compares in other countries. Um Next slide, please. So what we want to get a sort of thought sense of is which patient's will get the most benefit from having holistic care. So it's really an ideal principle. But actually what we want to know is if it's we're living in the real world and we can't offer that to everybody. How do we look to see who would benefit most from holistic care? So what we can look to do is to stratify to divide up our population. So we have patient so that two thirds of patient's who don't have more than one co morbidity. People who have, who don't have lots of different healthcare issues, we could say are simple and they can have the current care that's offered in terms of who we want to concentrate on, in terms of the complex patient's. Those are people with multiple comorbidities. So more than one long term conditions. So, um I don't know if you want to write in the chat, what long term conditions you can think of, but we can probably get a huge number of conditions that we build up. That may be right in the chat. What you think are the commonest, long term conditions that we see and interested to hear perspective from you at the countries that you're from. Also. What you see is the commonest long term conditions and comorbidities. So I'll be really interested to see that from the chat. Um So diabetes and hypertension. Thank you and I'll see the others coming through. So thank you for contributing. Um often complex patient's have mental health difficulties. So this may be a result of charter trauma or you're coming from countries that will be seeing a lot more trauma than we are seeing in terms of physical or emotional trauma. People often have social difficulties. Um So we see homelessness in the UK, um uh which is a huge cause of reduced lauter life expectancy, but other social difficulties of not having a stable housing environment. And that is something presumably you'll see more in your home countries, but also drug and alcohol addiction will make patient's more complex and mean that they benefit more from a much more holistic approach. So let's just have a look and see what else people have suggested. Um So COPD asthma, depression, anxiety. Yep, those are all common things um So every specialty will have also long term conditions. We have neuro degenerative conditions and multiple sclerosis, motor neuron disease. We have um from the gastrointestinal system. People with inflammatory bowel disease, every discipline will have its area of patient's who have a co morbidity and what the traditional teaching, which will be on presumably electoral courses like this. And certainly when I was in training and certainly the training that I give to the students that I teach in general practice, we always are asked to pick a specialty to discuss. But actually, patient's don't just fit one specialty. And we know that from the data and you'll know that from any experience you've got of seeing patient's and you'll know that from your own experience. And you also know that from your family's experience that people are complicated and people have more than one problem. So where we look to apply the best in terms of research and the best in terms of evidence and give the best medicines to deal with one issue. Sometimes when we're trying to deal with one issue, we actually can create a solution that impacts on another part of somebody's health. And if we're looking more holistically, we'll reduce the chances of that happening. So if we can move to the next slide, please. So in terms of the holistic approach, what would the benefits be? So patient's like it more because patient's feel if we're dealing with a really narrow part of their world, it doesn't feel hugely helpful and we know when it doesn't feel helpful what that means. And that often means that doctors can suggest the treatment and actually only 30% of prescriptions and medicines that we prescribe ever get taken in the first place. And of those that get taken, only about 50% get taken as we intend. So actually, the more we understand the patient and understand where they're coming from and understand the issues that are facing them, the better patient satisfaction, they'll be, the more they'll be pleased with what the intervention being offered and the more likely they are to then participate in it that will need hopefully to better health outcomes, which is reduced mortality and morbidity. And certainly those COVID graphs are really stark in terms of the impact of co morbidities with, with mortality from COVID. That's one of the really, really clear examples in modern life. If we get it right, then we'll see reduced medication use. And we know that medications are fantastic and it might be that in the background you're from, you have reduced access to medications. But where we have easier access to medications in the country like the UK, we actually caused quite a lot of illness and I a tra genic disease from the medications we give. So actually getting it right and giving just the right medicines to patients' is really beneficial. If we're better managing chronic diseases are individual outcomes from it, chronic diseases will improve. So if you're talking about diabetes, HBA one C improving, which will improve your impact on the macro vascular and micro vascular conditions. But what's really the second to last point about increased patient empowerment, really important. The better patient's understand the illnesses that they have or the conditions they have, the more likely they are to engage in supportive, helpful treatment for themselves and the more likely they are to have better outcomes. And that's really important. There are things that we can do to help influence that. And then in turn, there would be lower health care costs. Now, for all countries, even the US, which, which probably has a lot, one of the largest spends on health in the developed world have a challenge that healthcare becomes more expensive with each year. So we would spend more taxation on healthcare per year. And there are other things that require taxation as well. So it's a challenge for all countries and particularly you'll be feeling it in countries where there's conflict, but lower health care costs will be beneficial to the country because healthcare is just a small part of people's well being. So as we looked in the beginning and we have one of the answers in terms of the questions I asked what sadistic care health is just one of the parts of that. So actually, if we just put all our money into health and not into the other parts of the system, then actually, we won't be doing the optimum for the patient. So actually, lower health care costs is very important in terms of getting optimal holistic treatment for patient's next slide, please just looking at the messages as well. So in terms of what are the elements to holistic health and you won't find many people who are doctors or nurses who are working in healthcare that don't understand that that's an important part of it. But we're often really busy. And so we miss out how to do it. So you'll know through your teaching that history is the most important part of trying to assess the patient. So that's the discussion with them. So an assessment of their health and lifestyle and really understanding them and time after time when we do work with patient's, what we hear is they often don't feel understood by the medical community treating them. We don't understand their lifestyle well enough. We don't understand their concerns well enough and actually spending those extra couple of minutes to actually do it will really help us in the long term because the more we understand our patient's, the more we can hopefully help influence them to be making the right health choices for them. And the more we can understand also how to tailor our services for them. And I presume that's really key in conflict with driven countries as well where you have a lot of conflicts of really understanding what would the barriers be to the patient's seeking healthcare? Be it? From geography? Getting to the healthcare place affordability, there'll be a whole huge number of issues making that complex. But the more we understand the patient's and not just the story about what's wrong with them, the particular problem they might be coming to us with, but understanding what might the barriers be for them accessing good care. They're looking to try to personalize things. Once you understand what's wrong, you can help what the issues are for a patient, you can help trying to personalize and saying what, what will be beneficial and it will be different things. Every human beings, individual, obviously, we're all individual. Actually, there'll be individual things that can be helpful that you can do on the individual level. An emphasis on self care is really important. And again, in, in, in the in more conflict, risen zones where there is less access to medical treatment that more patient's can selfcare and do the right thing. And more we can educate our patient's the better. And in educating our patient's, we can also help to shift the focus. So patient's often come to us really down the end of the line when they're feeling quite unwell. What we want to try to do is try to help influence earlier on so that we can have more impact on ill health. And we know that so if we look at the example of cardiovascular days. So if you take the example, say of stroke, if you look at one of the main causes, one of the causes of hypertension or high BP, we look at tackling, reducing high BP, a population level will have a huge impact on the number of strokes. When patient's come into our clinic, we may not think that BP is the most important thing to be dealing with. And if you're in conflict zone and you've got somebody acutely bleeding in front of you, it is, it's managing their blood pressures. Part of trauma is important, but actually longer term is less important. But if you're in a system that is not in every, you're not dealing in emergency, actually looking at that prevention and saying actually you've come about see your asthma, but I can see you haven't had your BP checked in the last five years, let's check in and see what's going on. And if they have a BP that's really high actually will have a bigger impact on their health by starting to tackle that. And if it's not us that can do it cause we don't have the skill sets, asking the people with the clinicians with the relevant skill sets to see them actually fine tweaking of their asthma medicine versus actually addressing their BP. Both are really important to prevention is really important. Um I don't know what the hell high of the healthcare systems are arranged in the different countries where the representation that you come from. But in the UK, we have health gest's that separates different parts of the system. So collaborating with different parts of the health system. So we have the hospitals that deal with the physical health problems. We have mental health trusts that deal with mental health problems. We have community trust that helps support people who sit in the community. So people who are elderly, having nurses come to visit them to give them support at home as an example. And then we have things like general practice which spans the entire system. But it's interesting that we don't share the same were mostly digital, were mostly on a digital system. We're not completely and we don't have the same systems it system. So we can't see into the diff. So from general practice, historically, you haven't been able to see into the notes from the mental health trust or into the hospital for acute diseases that's changed over the last two years. And there are programs that we can now read into parts of the system. And the more we can understand what other parts of system are doing, the more we can understand how, what they're doing to give the best approach we can do to help support a patient holistically. And what we also need to look at is the non medical support to look at wider determinants of health. So I wonder in the chat if you want to write down what you think are the wider determinants of health. So that's the non health part of the things that help influence a good outcome for somebody. So it's not just health, it's wider things. So maybe if you want to write in the chat, what you think are the major, wider determinants of health education. Yes. Education is one of them lifestyle. Yes. So poor lifestyle touches into the drugs and the alcohol being, having a lifestyle where you have access to regular, you can, you can have a treatment regularly. You can take a medicine regularly, healthy diet. Absolutely good sleep. Yeah. Absolutely. Socioeconomic status yet. So even in the UK, where we've got free access to healthcare, what we really understood from COVID where we see actually patient's from deprived populations, access healthcare much less than patient's from, um, from non deprived populations. And you might think, well, why is that because it's all free? But actually patient's who are from deprived populations, more of them might be working on and not have a work contract or not be able to take time off for sickness or for health. So they might be doing a job where their employer would say to them, you can't go for that appointment. If you go to that, we're going to sack you. Um, and that happens a lot and that's responsible for a lot of the times that people can't go for appointments that have been made for them. It's not necessary that they don't want to, but actually they're not able to from a work perspective or it might be, they're tied up with family responsibilities and there's nobody else that can help or that they have a very chaotic lifestyle. And actually the less, the less healthier lifestyle you have, the more chaotic it is, the less likely you are to actually remember an appointment to go to it in the first place. I mean, if your housing is poor, that's going to have a huge impact on your health as well. And I recognize huge differences between developed and the developing world. Thank you. Next slide, please. So in terms of what a comprehensive assessment could look like, so it's taking into account the things that we've discussed. So that's the patient's physical health and majority of the lectures you'll have over medical school, be really concentrating on that. You'll probably have some element of looking at the emotional, the mental health side of things and some countries are further involved than others. And we recognize in 2023 that actually mental health is a enormous, has an enormous impact on people's lives and if you have a long term condition, so the things that you've helpfully listed, so diabetes COPD asthma, if you have a mental health condition with that as well, your outcomes are going to be poorer, they're going to be less good. So for some of the reasons that we've discussed, you'll be less able to, um, get your prescription, you'll be less able to take it regularly. So in terms of, if you have a more chaotic lifestyle, um, in terms of social and spiritual health, that's something probably that's not, that's much more neglected. That certainly is in UK and be really interested to see what if you want to write in the chat, any of your experiences with your training that looks at developing social and spiritual health history on a patient. And it might not necessarily something that you have to spend a long time talking about, but just maybe asking them a patient, are there any things that might impact on your ability, your ability to be able to take this particular medication or to come and see us regularly and the more you understand from the patient, the better you are going to be able to tailor the right approach to them. So you're gathering the history, as I said, their medical history, their lifestyle, also their family history is really important. Um So their family's history important to know what their genetic predisposition is. Two diseases. But it's also important to know family history from a social perspective. If somebody has come from a background where they've had parents who have a chaotic lifestyle, if they take drugs, if they have been in prison, if they haven't been able to give them stable backgrounds, that helps us understand the context of the patient and helps us understand what the patient might need and the patient's that have the most difficulty can actually articulate and tell you their needs, the niece. Well, so I'm a GP and actually we are we as GPS sometimes describe patient's in historically, in a way that's not nice when we look at our list in the morning and see who are going to speak to. Historically, some patient's have been described as heart sink patient. So you look at the list, you say their name on the list and you think, gosh, they're coming in to see me and it's not going to be because they're not a nice person, it's not going to be because you don't want to see them because you don't want to help them. But actually, you don't necessarily know how to help them and there aren't the structures in the system to help do it. But building that relationship with the patient and understanding with them is the first step to actually be able to do that. And actually, sometimes we can't offer every solution for a patient that's going to make them get them the best outcome. But the more we share an understanding what's going on and share and understand the trauma that they've been through, that can be very helpful for starting to build up a relationship, a therapeutic relationship with them. There are some tools and some questionnaires to help us and they're obviously the physical examinations that we learn traditionally through medical school. And as I've said, also considering their cultural and social backgrounds and you all all know as well as I do that. Actually, when you look at cultural groups, they're not, we look at, sometimes people look at cultural groups and see that everything, everybody is the same. But actually within cultural groups, there's huge amounts of variation. So actually spending the time to understand the patient and understand their background is of in credible importance. Next slide, please. Thank you very much. So, in terms of then how you would personalize a treatment plan. So there isn't, these are sort of key themes of what can be helpful. So we've already spoken about identifying what are the issues and share, having the patient's feel that they've been heard. And a lot of the time I speak, we speak to patient's and do pieces of work hearing from them. They don't feel well enough heard at the beginning. And if they don't feel well enough heard, we're not going to understand their issues and we're not going to be able to stand how to help and how to engage them. And that's particularly important with patient's with long term health problems. So with patient's with long term health problems, we're not going to get it. All right. In one consultation, we're not going to change everything. They need regular input from us to be able to have the best outcomes and actually understanding the risk of key importance. So we need to consider their health. We need to be speaking them to understand their preferences and their values. And it might be things that we really understand and we can identify with. So it might be that somebody says I can't come for an appointment on a particular day of the week because I have to look after my elderly parents on that day, which might be quite easy to find a solution to. Or it might be things that we actually don't understand. And they say we have different, we have a different belief system and actually we don't, we want to or we don't want to engage in a particular treatment where possible. We want to try to include complimentary therapies. So all our training focuses very much on the medicines and the medical part of it. But there, there are other parts of the system such as um for patients with back pain, seeing osteopath, lots of evidence based systems that can actually help. There are things that patient's have that, that families can offer them things if you have back pain, having massage can be supportive. Um It might be something in a developed country that somebody might choose to pay for. It might be something that one of their friends or families can do to help. But these are small things that can actually help in terms of the overall management and if you have a patient who is suffering and has one or two or three long term conditions, you're not going to be able to do things in one jump, that's going to make them completely better. It's about small gains and small things that can help, that can actually have a really helpful impact on their lives. We then want to monitor progress. So you don't want to just suggest something. And if you're in a situation where you're not in an emergency war zone, but actually you can see them again and measure progress and then you would want to be adjusting treatment plans as, as you need to next slide, please. So one of the things that I've mentioned is self care. So we want where possible to encourage patient's to take an active role in their health. So that's going to be the absolute best thing for them. Anything they can do to manage their with, we're only with them a tiny amount of time, they're with themselves 24 hours a day, seven days a week from the time they're born to the time they died. So the best advocate for health for a patient is actually themselves. So actually thinking about our role in educating them to understand what they can do to help themselves. So some of the things we've mentioned about, say diabetes, maybe if you want to write in the chat, are there any ideas you've got for what you can do to actually encourage them to look after their own health. If they've got diabetes, you want to write that in the chat. It's a healthy diet. Something definitely regular exercise, definitely educating them about their disease. Yep, these excellent ideas. And actually, if I think about what my trainings been as a doctor, proper footwear, really important because they're much more likely to have, um, feet and problems due to the vascular problems in the neurological problems they can have in diabetes. Yep, signs of hypoglycemia with respect to treatment that they might have. Absolutely. So we can't do it all for them. The more we at that point that Alan nudes made about educating them about their disease is really key. So when you start off with a patient with a chronic disease and if you start off somebody and if they have multiple issues and chronic chronic multiple code diseases, looking at, looking at them together rather than separating them out, the more they understand what it means, the more they can understand what they're trying to do. So I have a lot of patients that say to me, I've been to the hospital, I've been to see someone I can see, I've got these medicines to take or I've been told to do more exercise. I don't really understand why. But if you don't understand why, why would you bother going to the pharmacy to get the medicine? Why would you spend money, try and paying for the prescription if you have to pay for them, why would you end up betting the effort, storing them safely in your home if you need to exercise, if you're busy and you've got lots going on in your life, why would you, so patient's really need to understand what the disease is about and actually how they can influence them. And what I would like you now to do is to write, to write. What impact do you think on long term disease is, does health have in terms of your outcomes for health for for long term disease? So health has a role and a big role. How big do you think that role is of health? And how big do you think the role is of other parts of the system? So what I share is that health actually is only responsible for about up to about 20% of out consultations. So our training is all focused on health and health is really important and we're the ones to help deliver that as our other people in health, nurses, other health professionals as well. It's not just about doctors, but actually it's the other things that we've been talking about that have a bigger impact and they end up when you add them all together, that's what gets you to the 100%. So it will be about your accommodation and are you living somewhere safe and somewhere that that's not going to cause an impact on your health. Are you having exercise? Are you lonely? Are you interacting with other, with other people? If you add all of those together that gets you to 100%. Health by itself can't possibly get you to 100%. So actually encouraging patients to have an active role, they can activate that 80% of what they can do to actually help get good outcomes. So we've said about, about uh educations come up with lots of things you've said. So, educating patient's on healthy lifestyle habits. So finding out from them what they're doing and they might be simple things that they do that they don't understand. And the diabetes ones really interesting to go back to. I often see patient's who come, who, who have diabetes early on have high sugar and about to have a diagnosis of diabetes. And when I ask them the detail and I say, what do you drink? A lot of them say, oh, I drink lots of fruit juice, like the juice, mango juice, things like that because fruit juice is healthy and actually something very simple to explain to them. Actually, fruit juices are hugely high in sugar. So as they get diabetes, if they might get more thirsty than then drinking more of it, and that's going to then fuel the problem more. So actually explaining to them, they actually stopped the fruit juices and just have the water is an example of a very simple intervention that can have quite a big impact. But the more we understand about patient's lifestyle, the more we can help guide them, we want to give them resources. So we'll tell them some of the stuff. But actually, if we can give them resources and if we got access to printed things, we can give them, if it's digital, we can give them something on the phone that they can do or something, we can send them by email. But things that they can look to do when they go home, looking at the importance of preventative measures. So we've spoken about that, the more better prevention we do. So the footwear Mohammed said about, uh said about footwear. So if you've got diabetes have wearing good footwear is really important to reduce your chances of getting diabetic foot complications. And then what I've written down is about if we just go back. Thank you so much peer support. So peer support is where we gather patient's together. And I don't know if you're, you, you've been exposed to this at all, but the value of having patient's to help share their stories with other patient's. So I'll explain to you an example. So for prediabetes, so this is patient's who've got high blood sugar there in the prediabetic range, but it's not high enough to put them in the diabetes range. So what we know is evidence based tells us we can reverse. It doesn't mean that they're going to necessarily get diabetes. If they don't change their lifestyle, probably they will majority will end up tipping into diabetes. But actually they can switch this off and that's really powerful. So me as a doctor can say, what are the issues? What are you eating? How can I help you? How can I encourage you? And actually they might listen to me, but who they listen to even more are people who are similar to them who are in the same situation and they've managed to make changes. So if there's somebody who also has pre prediabetes and they've managed to become much more active and in doing so, have lost weight and have reversed their prediabetes. That's much more powerful than me sitting as a doctor in a room. Saying to them, I would like you to try doing three things. So peer support is really good. And in the UK, we're developing peer support groups more to help, um, it to help, actually activate patient's to want to do the most to look after themselves. So pre diabetes is one area and pain management is another area. So if you've had experience with patient's, you'll know in any specialty in any part of the system, we have the patient's who have ongoing chronic pain and chronic pain is often worse than patient's who've had trauma. And actually the medicines are often not helpful. So we put patient's on really strong medicine, opioid medicines. And actually there's very low evidence base of how much could they do, but we do have an evidence base about how much bad they do and they're very addictive. So often we can be adding to their problem. So supportive, peer groups of other things people can do to help manage pain, which are non medical can be hugely helpful if we can move onto the next slide, please. So looking about collaborating with other healthcare providers. So one of the things that I mentioned is that in the UK, we have our systems that quite separate. So physical health is separate to mental health and that's separate community care. If a patient is having care in different parts of the system, if we don't understand what's happening in the other parts of the system, we might be saying the opposite things which is really confusing for patient's. And actually what we need to do is work in partnership to be understanding what people in other parts of the healthcare system are doing. And I'm going to touch on in a minute, what we can do as a system to try to improve that. But you can, if your systems or you're coming from countries where that's not joined up, you can actually just ask the patient themselves and say what else is happening? What else have you been advised? What have you been advised with somebody from traditional health? And they might be seeking help from a relative or friends or a faith healer, they might be seeking help from someone else. So it's effective to find out from the patient's what's happening. So you can actually try to join that up with what you're looking to do. So the more coordinated are care is the more effective the treatment will be. And what we want to do is communicate openly and regularly with other providers and to seek feedback. So other parts of the system. So in England, where we describe say mental health and physical health difference. So somebody who say has chest pain, if they may be that they have heart disease, or maybe they don't have heart disease, even if they have heart disease, the impact of their emotional health will make that pain worse. Actually getting guidance from if they're under psychiatry or from their GP working together to try to help formulate a plan for a patient can be really helpful. Now, it's not possible to do this for every single patient because that takes a huge amount of time and in an ideal world, we would do it. But if we think back to one of the earliest slides that I mentioned, the patient's that most benefit from these are the really complicated patient's who have lots of health problems with lots of confusion about different doctors, different healthcare providers suggesting different treatments. So the patient's with the most multi morbidities benefit from this approach. Most and also those who have mental health problems next slide, please. Thank you. Um So in terms of what you can do, so as an individual, when you're qualified, what I've said is having a patient centred approach. So if you just think whenever you may have experienced healthcare, the more the person you're speaking to is really interested in you as an individual and trying to work out your story, what's important for you, the more you're going to connect with them, you're going to understand them and they'll understand you. So that's about good communication and that's about giving people enough time. And actually time is the most precious thing we actually have um when we're in busy clinics and whatever part of the world you'll be in, you'll have busy, busy clinics. It's trying to work out who are those patients that need that bit more time and working out that you give to those who will benefit the most from it being welcoming and calming. And actually, we can't necessarily do everything for all our patient's, we can't necessarily fix every patient. But if we're hearing what the issues are, we're understanding them were share ing what's going on with them. We're sharing that journey with them that in itself is therapeutic. And I sometimes have patients that say to me just by coming to the GP and it's not necessary just about me. But they often say when I come into the building, I often feel a bit better and we're really powerful as healthcare professionals to be able to help the patient's feel better just because they're coming and sharing their stories. And you can do that. That's not about money. That's about being calm, being welcoming and helping to really understand the patient's so educating your stealth and the staff you work with on the importance of having that wider approach and you might be hearing this and thinking that sounds quite interesting and then years will go on and you'll, you'll qualify. And it's really hard to remember that when you're in a pressurized environment. And yesterday afternoon, I had, I had to sort out 50 patient's in clinic and I was the duty doctor having to sort out emergencies. And I actually was working till really late in the night. And actually, I didn't have time to do that approach for absolutely everybody. But it's about looking at that list, 2 50 in thinking who needed those few minutes of extra time. So it's not necessarily hours and hours of time you're giving people, but that bit more time. And the patient's that don't need that encouraging them to manage themselves and to do self management as much as possible. Next slide, please. Then what I said I'd mention is how a system does it. So I'm a GP for two sessions a week, but actually for eight sessions of the week, I'm also the Chief medical officer across Northwest London. So that's eight bars in London. That's 2.5 million patients'. So part of my role, that's really exciting and it's a new job these jobs have just started last year is to work out. How do we get the system to work best to actually give that holistic approach, particularly to those patient's who need it the most. So, one of the things we're looking at is a shared platform where we can see what other parts of the system are right have, have done with patient's and I've written about patient's. So looking at shared clinical notes, we all have different it systems, we don't have the same system we would like to, but we don't and that we can't change that immediately. But what we can do is we have computer programs that enable us to look from one system into the other. So when I look, I'm really, really blessed and fortunate. But when I look in my practice is only over the last two years, I can see if the patient's been seen in the mental health trust, I can look in and see the notes that have been written that's really powerful. So I can see what's been done and I can add to that or I can support, I can add in terms of the patient reinforce what's been done and that can help inform what I do. So the more that we have shared visit, we have shared data platforms is better. What we also want to do is have accurate data sources. And obviously the more sophisticated the healthcare system in the country, the more you're able to do that, the importance of being able to collect data on our patient's is to be able to understand actually who needs a different approach. So to understand which patient's are complex, we need to know who has multiple comorbidities, we need to know who's got, you know, three or more long term conditions also who comes from deprived population where they don't have access to regular meals where they're not, not having, they don't have, they can't afford to heat their homes up in the winter to know which of the patient's of them vulnerable populations. And if we have data on our patient's, we can collect that and then we can work out which areas. So across each, each borough that we're in it, which is a smaller system of the country who within that needs a different source of approach, who needs more support. Health is great and we're training in health. But actually there's people who do lots of other work that's really powerful and you're having your country's, you're from in also in England, what we call in England, the voluntary sector. So these are patient's who, these are people who work with communities and it might be people who do it who are doing programs to bring uh safe water drinking water to communities. People doing, working to try to increase the amount of vaccination being done in communities, it might be people visiting the elderly or people who are lonely and sometimes that will be organized in different. So in some countries, it's very organized and in other countries, it's not the better, it's organized and the better we can communicate with them, we can get to that 80% that we need to do to improve the patient's outcome that's not related to health. So voluntary sector and and people volunteering their services to support, they can help have a huge influence on patient's health. In terms of peer support have mentioned that. So peer support can be incredibly helpful in terms of being more powerful in terms of showing the patient the art of the possible. So if somebody were asking somebody who has COPD to stop smoking, I've never smoked. So I can, I know it's the right thing and they know it's the right thing for me to tell them to smoke. I can't share with them how difficult that is because I don't know, I haven't had that experience. But if I got patient in my practice who actually has stopped smoking and is willing to help other people stop. We have peer support workers and they have, they say actually I stopped. These are some of the things that I found really difficult. These are some of the some of the things it's much more powerful than just hearing it from the doctor by themselves. And the other thing I want to say is the multidisciplinary team approach. So whichever healthcare system you're in, there's more than just doctors, there's other parts of the system and the other parts had a richness to help. Actually look after a patient better. And the more we can work together to hear what they think will help the patient, what will they think will help the patient. And this is suitable for people who are really complicated to somebody who might have had violence to them in their childhood. They might be not living in secure accommodation, they might not have enough money to provide food for themselves. They might have um um uh any of the physical health problems that you learn about, they're going to be much harder to help influence and sort. And actually, if we just focus on the medical side of things and don't look at the rest of their lives will not be able to have much of an influence next slide, please. So this is the final one of my slides and I'm more than happy to open it up to questions and to see what your experiences are. So in terms of um the value of treating patients', realistically, we know as human beings that people are. There's not one parts to human, there's lots of different parts. We have our health, we have are the emotional needs, we have our community needs, our spiritual needs, we have lots of different needs, the more we understand them and treat them overall holistically, the better we're going to be able to improve their health and well being. And that statistic that I mentioned, I don't know if anyone knew it, but you didn't write in the chat. But that's a really powerful statistic health is only 20% of the picture. The rest of the picture was non health. And the more we're able to tap into it, the better we are to be able to improve a patient's well being to actually have the approach, we need to get the right assessment for them. We learn to then tailor treatments for them, try to encourage them to get self care for themselves and to try to do prevention and we need to collaborate and see what's the non medical side of things we need to use as well. It's not just about medicines, it's about other therapies and other things for them that also won't do things that will benefit them without doing harm. So I've discussed some practical tips and I say engaging, being calm and welcoming and really understanding your patient, understanding them. So they leave the consultation, feeling they've been heard and understood will give you much, much better approach. And that's whether you're injured practice or whether in your specialty. So if you're a cardiologist, if you're a neurosurgeon, if you're a psychiatrist, whatever you are, the more that you actually understand overall the holistic approach to your patient, the more you'll be able to help them. So my role at GPS do that at an individual level and then my role in the system and the work I do is the Chief medical Officer is to see what can the system due to support, whether it's from an it perspective or encouraging multidisciplinary team meetings. How do I help, try to influence that to actually be able to help enable that as many people as possible to have this integrated support. So it's come to the, that's the end of my slides and that's the end of the talk, so we can take the slides down. Thank you very much for having shared them. Hell. Uh um in terms of um what we do now, I'm more than happy to open it up to questions or really interested to see. Is this something you've thought of before? Is this a new approach and just really interested to hear what your, what your thoughts are over to you? I'm happy if people want to come in or they want to write in the chat. Okay. So I haven't got anybody who's brave enough to right to the chat, which is absolutely fine or nobody said anything that's absolutely fine. Is this something that you've heard before? Is this something a different way of thinking about things that would be interesting to know? Okay. So I can't see that anyone's writing anything? I mean, what I would say it's something. So somebody's saying it's different, someone saying we've learned before. So I would say is that I'm really pleased to the person. So s Agua, I'm not sure if I pronounce your name correctly. It's something you've learned before. I think that I'm really glad you've heard it before. And I said, you've heard it before when you're doing family medicine. The reason I chose to do it is because in my role in terms of supervising, um in terms of supervising the medical directors across the different hospitals in the system, although we learn about it when we're doing training and some, some of you haven't. But a lot of you have heard some of you have heard about it, which is really encouraging, we forget about it. So once you, once you're very busy in a clinic, it's really hard to have this sadistic approach. So that's why it's also about reinforcing it and then looking to see what systems can actually do to try and help support it because it's hard to do by yourself. But in essence, it makes, you know, anyone that I'm speaking to about this, it makes absolute sense. The patient doesn't just have one problem wrong with them. And there's nobody that just has a single thing and nothing else going on giving any complexity to their life. So everybody has complexity. But we kind of ignore that because the training is get patient's through really quickly. We've got lots of patient's with lots of needs. And that what I'm, what I want to really suggest to you that might be different. And what might be, what you haven't heard before is that we can't do this approach for everybody because there isn't enough time. So it's about working out which patient's have the greatest need. And just that's likely to be those who have more health problems. So the more health problems you collect, the more need you'll have, but also those who have mental health problems. So if you have mental health problems and you're more likely to have difficulty in regular access to treatment, you'll have more than possibly more of a chaotic life. You're going to find it harder to then actually be able to put in place the sensible strategies in life. Okay. So it's 25 past. So that's coming to towards the end. Are there any questions anyone wants to ask about this or you can ask me about health care in the UK or about the rules that I do as a GP or is the chief medical officer? I'm more than happy to answer any questions or indeed, if, if you want to tell me actually, what's going on with you at the moment is also interesting to hear that we've got five minutes left. Um And we've got a question on here from either community workers. Are they linked to health professionals? So there's community trusts which are made of health professionals. So that's mostly nursing teams that go out to help people in the community. So if a patient has an ulcer on their leg, the community and they can't get to the hospital or to a GP surgery, the general practice surgery to have it treat it'd if they're frail or their house bounds, a nurse will go and visit them at home to be able to address that. That's what community services are in England. So our frailest patient's who are either are elderly frail patient's or patient's who've got disabilities, who are bedbound, who who have more have significant complex physical difficulties. We have community health teams to look after them. We then also have community workers who are people who are often volunteers who then work with different parts of the community. So it might be people through religion. So it might be through a church or through a mosque or through a synagogue or it might be people who support people from a particular area or say refugee council. Um There are lots of different community workers who then tap in very deeply into communities and his health, what we've learning and the slides that I showed on the vaccine hesitancy, the more we can understand. So in communities that don't or not have a lot of vaccine hesitancy say he didn't want the COVID vaccine actually understanding the community workers helping to share what what the issues are and actually why they what, what are the problems and why they looking to actually why they don't want to have the vaccine will help influence how we can actually encourage them. Um Then we've got a question. What about patient's who reside in crisis areas? Is it important to approach holistic, all care care, their physical health? More? That's a really interesting question. And that's really about triage. And I did when I was doing one of the slides, I did make the comment. If, if you've got an emergency situation in front of you, you're not going to be dealing with the prevention side of things. I think if you're in a crisis area and you will know more about this than I do. That holistic approach is going to be much more difficult because you're about getting three people quickly to try to get through the maximum number of patient's. This isn't more in a non crisis situation. The difficulty is you'd say you would think, well, England's not in a crisis in a way the world is in crisis. I mean, we've had um 6 million people across the world's die from COVID. We've had 735 million people affected. That's who criteria for statistics on COVID. So in a way, you could say in a way, oops, if someone could just go on mute, someone's just broken. Yeah, I'm sorry, there's someone I think they've stopped now. I wasn't able to um use them for the commute for some reason. Sorry. No, no, don't worry. Thank you. So, you know, in a way the world is still in crisis were just coming out. We're just coming to at the end and just the World Health Organization's just defining were coming to the end of the actual crisis of COVID thankfully, but we're the whole world is recovering from that. But actually this is about saying when you're not got a an emergency situation right in front of you really trying to shift the focus on to thinking who needs more realistic approach and how do we offer that? Because if we don't do that, those patient's not only will they have bad outcomes to themselves, but actually, they'll use a lot of healthcare time. So and then using the loss of healthcare time that will restrict other people's abilities to access healthcare. So the patient's who we don't look after, well, go into casualty in the emergency department a lot looking for support when they go into crisis. So the more we can try and shift that down and actually shift them into more prevention that's helpful. Um There's a couple more messages, okay. That's asking for feedback. Okay. So it's the first time that I've done that this. Um So I hope that that's been helpful for you. I hope I've pitched it to the right level and be really interested to see the feedback for what's helpful and what uh we'll need refining and improving for the next time. Um Just really want to say that I really, you know, it's a really, really nice experience to be able to do this and share with you and hope that this is some benefit because aware that you're in a much more challenging scenario that I'm in, I'm sitting in an office in London, but actually you're in much more challenging scenarios. So I really wish you good luck in what you're doing and you're supporting yourselves. You'll be supporting people from your countries and your BCE ultimately providing healthcare. And actually really pleased for the crisis Rescue Foundation of being able to enable this program. So many thanks to your, thank you to Hannah for facilitating. Thank you very much doctor. It was an honor to have you. This is uh for those of you who joined us late. This is Doctor Charlotte Benjamin, who's the Chief medical officer of the NHS in Northwest London. So, so you just need to have her with us. And thank you very much for an amazing lecture. Um I just like to remind everyone like I said in the chat a few times to please fill in the feedback form. It's very important for us for crisis Rescue Foundation to continue to have the feedback so we can continue giving these um free online medical lectures. So please do that. Also reminder that you will receive the certificate, the attendance certificate template by email if you're registered for term for. So there won't be, um, individual certificates, you'll be able to fit it in yourself. So, just keep a note of the lectures you attend. Um, sorry, I'll stop the recording now.