All about Gemma

Parity of esteem. A big phrase. We are all signed up to it. But what does it really mean? I was thinking about this after hearing of Robin Williams’ death. Such a tragedy. Depression is a life threatening illness in its most severe forms. A man who seemingly has so much felt such despair that death was the only deliverance from the pain. WE don’t treat it as such and yet mental illness kills people just like cancer does.


When we talk about illness and pain we still divide our thinking into physical and mental causes. Why? The brain is physical, mental illness is about the brain and chemicals … and yet in our thinking we consider them differently. Someone with a mental health problem is still seen as somehow responsible in some way for their illness. And yet every illness has both physical and psychological components. When as a GP I talk to patients about a psychological component to their symptoms they rush to the view that I am saying it is somehow less valid ,less real, their fault. Our belief system leads us to believe mental health issues are based somehow in weakness, a flaw in our constitution and yet those with mental illness are some of the strongest and bravest people I have ever known.


We talk freely about our family members struck down by cancer but we are less willing to talk about those with depression, psychosis or substance misuse. On some level that remains private, uncomfortable.


There is a strong history of mental illness in my family. So I have watched people I love struggle to survive and witnessed how we as a society respond. Gemma was young when she developed severe depression. Her school was, it seemed, a caring and supportive place. At the same time there was another pupil who developed cancer. The contrast in the way the school handled their response to both pupils was illustrative of the deeply held values that are part of our culture. Both were very ill. Both had life threatening illnesses. Both had long periods in hospitals 50 miles away. Both missed many months of school. One had a computer bought for her, work sent to her, regular visits made to her, cards sent to her, regular updates of her progress in her form and support to her siblings and extended family. The other had nothing. This I believe was not because the school was uncaring or unkind. It just didn’t occur to those in charge. They treated these two poorly girls completely differently, one was “ill” the other “troubled”.
WE as a society raise money for cancer sufferers, run for them, swim for them, build beautiful new shiny buildings full of state of the art equipment for them, but we don’t do the same for those people with mental illness, many of whom still languish in old poorly equipped facilities. They remain on the “edge” of our health services and the “edge” of our generosity as a society. Within the NHS doctors and nurses still draw lines around mental and physical illness rather than seeing people as individuals with complex problems, we as clinicians still perpetuate the belief system that underpins the prejudice.


I read today that more ex-service men have taken their own lives than died in Afghanistan. I am not surprised. But are we outraged as a society about that? WE should be.


Parity of esteem is a grand ambition. WE can do our best as a CCG to make sure we do that. We can write it into our plans, benchmark our investments, include it in our specifications. But for things to change we must all be prepared to do everything differently. To challenge long held beliefs and social norms. Gemma’s family accepted mutely the response of the school, the neighbourhood, the extended family. We must all fight individually to expose the unconscious prejudice that is still as strong now as it was 15 years ago when Gemma was at school. What happened to Gemma? Well finally she found a psychiatrist who cared enough to discover what was important to her, who didn’t tell her as others had that she must have modest ambitions for herself because she was somehow permanently damaged by her illness. He allowed her to believe she could succeed and she has. She went to Cambridge, got 3 degrees and is deputy head of department in a large sixth form college in London after 3 years of teaching and is planning a Phd. More importantly she is well and happy. The health service is a lottery and no more so than in mental health. The struggle to find good care took 8 years.


One day I hope Gemma will write her own story. It will be heart breaking to read. For now she is getting on with her life. The scars are there though, forever in her life, made worse because the journey was so hard, the support so thin. I sent this blog to her to ask her permission to publish it, she commented “ I’ve found it much easier to come out to people about my sexuality than tell them about my depression”. That I think says it all. We, as an NHS and a society, continue to fail so many. We need to start by being honest and open about mental health, to have parity of esteem in every conversation, every interaction with staff, colleagues, friends. We need to challenge every unconsciously unkind thoughtless comment or decision. Small steps yes, but without change in the way we think as a society nothing will really change.... The NHS can lead but it cannot go it alone….

Conflicts and confusion....

All CCGs are considering co-commissioning primary care and some are keen to do it all.. budgets and all… We are more cautious. Co commissioning has 2 major flaws it seems to me, conflicts and capacity. We are living the issues that will inevitably arise when people start to do these things in earnest. We are re-procuring our community and out of hours services through a competitive dialogue. We want something new, innovative, joined up. Something that will bring together services and reduce duplication and waste. Our GP federation is probably going to bid. All the practices bar one single hander are in our federation therefore every GP on the governing body is conflicted.
Not everyone gets the problem. Many of my GP colleagues who manage confidentiality and potential conflicts of loyalty, information, role every day think it should be easy to sort and what is the fuss all about? But these issues are important.

We are a very open organisation we don’t really do secrets and huddles. From now on we will have to be careful who is in what conversation, who overhears what, what conversations are okay at lunch. WE eat lunch together each day.. or at least anyone who is in the building congregates in the kitchen. It is fun, social. We learn about each other as people with lives, families, interests. The chat is about all sorts but sometimes strays back to work. WE will just need to be careful we don’t talk about “some things” within the earshot of our GPs. It is important we can’t compromise them. Our weekly Strategic Management Team meeting is now divided into 2 with separate notes and minutes. The big stuff- Governing Body meetings etc. are easy enough it is the day to day that presents the challenge. AS we assess the PQQs we can’t use our usual clinical resource so will bus some GPS in who have very kindly agreed to help, from the north…This is a single project… when we commission primary care as a CCG which no doubt in the fullness of time we will all be doing it will be harder still.

Yet it is important. The public are rightly concerned about GPs making decisions about their own work and pay. Practices are concerned about in- crowds and outsiders…Everyone is concerned about fairness. Yes, CCGS understand primary care the best probably but are they best placed to make tough decisions about the services that are delivered by their friends and colleagues?

The second issue is do we have the skills and the time to do this well?...IT is a massive job. WE are doing good things but I worry that there comes a tipping point where if you take on too much you stop being able to be creative, productive and proactive and simply do nothing but fight the fires that have ignited when you were too busy to notice. And you end up running from one fire to another- exhausted, directionless. I have been there before.


Is this the right direction for primary care commissioning? I think the issues the services faces are huge and very complex. I am normally fairly good at coming up with solutions to problems…. But I struggle to even begin to find a model that will develop and invigorate primary care whilst safeguarding the pivotal role it delivers in the NHS within the structures we have today. National contracts, privately own premises, independent contractor status, financial pressures, scary workforce predictions around both recruitment and retirement, lack of leadership capability… all these conspire together to create an impending catastrophe for primary care and yet we are all sitting around watching feeling powerless to change things. Will co-commissioning be the answer? Definitely not in my view… but what will be?