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Rewiggling General Practice

Tim Sanders is a GP in Rural Cumbria and Senior Clinical Lecturer in Rural Medicine and Urgent Care at the University of Central Lancashire. He volunteers for Penrith Mountain Rescue Team.

Back in 2016, landowners and interested groups invested in a project to reintroduce the meanders of the Swindale Beck that flows through parts of the Lake District. This project sought to reverse the straightening of the beck that had taken place some 200 years earlier.1

However, the consequences of increased flood risk that happen when pulses of water from heavy rainfall are flushed quickly downstream were not understood.

Back then, the community knew that speeding the drainage of water from the valley would create productive farmland from natural valley margin wetlands and floodplains. This in turn lead to a managed landscape of dry-stone walls and regular shaped pastures. However, the consequences of increased flood risk that happen when pulses of water from heavy rainfall are flushed quickly downstream were not understood. Faster-flowing water carries more sediment too, damaging habitats and making the water murky and inhospitable to spawning fish and other wildlife.2

The reintroduction of natural features like meanders “rewiggling” has been shown to slow the flow of water. This, together with an increase in depositing sediment on the banks, leads to a decrease in flood risk. The re-creation of habitats also has the potential to increase fish stock and the return of other wildlife to the area.

In recent years there have been efforts made to straighten out the delivery of primary care. Remote consultations, extensive use of clinical guidelines and the wider roles for other health care professionals, have been introduced, aiming to increase productivity. There has been a shift in focus towards the management of problems on the same day that they present.

This, like the pastures of Swindale, looks attractive and carries great appeal in times of high patient demand.

But, like the inhabitants of the valley all those centuries ago, has sufficient consideration been given to what might be lost from a primary care that meanders?
In their 1999 BJGP paper “The physician healer: ancient magic or modern science?” Dixon, Sweeney and Pereira-Gray refer to the healing effect of the doctor-patient relationship and its 30-40% therapeutic effect as placebo. The authors highlight benefits of time, personal care and the development of a therapeutic relationship.3 Like the rewiggled beck, clinical practice done well isn’t always neat and linear. The meanders are vital to slow the flow and enable us to see problems that might otherwise remain unidentified.

In these times of high demand, the message is clear: unidentified, unmet need eventually “washes downstream”, flooding specialist and emergency services.

Whilst delivering high quality, reproducible, and evidence-based care to our patients, we must simultaneously take the time to move slowly enough to foster healing relationships and prioritise the continuity of care that enables us to see through to what lies beneath the surface. Longitudinal, relationship-based support facilitates the identification of unmet need and empowers the patient to confidently manage their own conditions. This results in better concordance with treatment plans, and reduction in investigation, prescribing, hospital referral, admissions, and use of A&E.4

In these times of high demand, the message is clear: unidentified, unmet need eventually “washes downstream”, flooding specialist and emergency services.

Primary care is the valley margin wetland and floodplain of the national health service. Perhaps like the Swindale beck its meanders are essential for a successful future?

References:

  1. How ‘rewiggling’ Swindale Beck brought its fish back. BBC News [Internet]. 2023 Apr 25 [cited 2023 Jun 10]; Available from: https://www.bbc.com/news/science-environment-65341994
  2. wildhaweswater. More wiggles and wetland for Haweswater [Internet]. Wild Haweswater. 2020 [cited 2023 Jun 10]. Available from: https://wildhaweswater.co.uk/2020/10/22/more-wiggles-and-wetland-for-haweswater/
  3. Dixon DM, Sweeney KG, Periera-Gray DJ. The physician healer: ancient magic or modern science? Br J Gen Pract. 1999 Apr;49(441):309–12.
  4. Hill A, Freeman G. Promoting Continuity of Care in General Practice [Internet]. 2011 [cited 2023 Jun 10]. Available from: https://www.rcgp.org.uk/getmedia/bda9fb5b-e52b-454d-af1f-e27f3df4100f/RCGP-Continuity-of-Care.pdf

 

Featured Photo by Steve Taylor on Unsplash

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Ben Hoban
Ben Hoban
8 months ago

What a fantastic picture of primary care! Increased flow muddies the waters and causes unforeseen consequences downstream.

Dr Jane Baxter
Dr Jane Baxter
7 months ago

‘Whilst delivering high quality, reproducible, and evidence-based care to our patients, we must simultaneously take the time to move slowly enough to foster healing relationships and prioritise the continuity of care that enables us to see through to what lies beneath the surface. Longitudinal, relationship-based support facilitates the identification of unmet need and empowers the patient to confidently manage their own conditions. This results in better concordance with treatment plans, and reduction in investigation, prescribing, hospital referral, admissions, and use of A&E.4 ‘  

All so true. I absolutely love this. 

Continuity of care and building relationships, with effective working together with the patient to thoroughly sort out the patient’s problem(s) –  by a trusted clinician providing holistic care,  who has enough time to really listen and hear the patient,  and who will take ownership and follow the clinical case through 
–  is not only proven to provide better patient care and outcomes, and to reduce demands on the system later downstream, but vitally is so much more satisfying and rewarding a way of practising, hence reducing risk of burn out and loss of GPs from NHS General Practice. 

Absolutely why I became a GP 23 years ago. 

However,  sadly this model of General Practice is not at all supported by the current drive to a wholly access focussed, transactional,  demand based,  ‘those patients who shout loudest get all the resource’ model of care which is this Government’s direction of travel. 

I mourn its loss, both as a GP and as a patient, and I fear for the vulnerable and marginalised of society. 

I hope for a future where that meandering river in General Practice that provides continuity and holistic care is cherished and supported.

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