Q Exchange
Making primary care accessible to women with experience of trauma
- Winning idea
- 2020
Meet the team
Also:
- Six women who've experienced trauma
- Sarah Moore & Kathryn McGregor, GP trainees
- Helen McGeown, GP
- Maria Carvalho & Kate Lemon - One 25 charity
- Chris Mills - Bristol, North Somerset & Gloucestershire Clinical Commissioning Group
- Natalia Lewis - researcher trauma-informed care
- Jeremy Horwood, Associate Professor (supervisor to Lucy and Michelle)
- Gene Feder, Professor (supervisor to Lucy)
What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?
Women with complex needs (e.g. addiction, mental ill-health) often have experienced extensive trauma such as sexual violence and exploitation, domestic abuse, homelessness and children-taken-into-care. Services are often ill-equipped to meet these extensive needs, worsening already severe health inequalities.
Bridging Gaps is a collaboration between women with lived experience, GPs, University of Bristol researchers, the local CCG and One25, a charity serving some of Bristol’s most marginalised women. Women have shared stories of stigma, discrimination and re-traumatisation when accessing healthcare services; these are key reasons for disengaging.
During COVID-19:
1. Bridging Gaps women received trauma-informed care training and enriched this with lived experience to co-design training and quality improvement projects (QIPs) for Bristol GP practices.
2. Bridging Gaps supported a local surgery to develop a specialised clinic; the surgery is now seeing patients with complex needs who have not consulted for years.
We now want to develop this work further.
What does your project aim to achieve?
Our overall aim is to improve access to primary care for people with complex needs, ensuring that services are more trauma-informed. COVID-19 is sharpening health inequalities. Primary care has rapidly increased remote consultations, but some clinicians are concerned about their implications on health inequalities. We want to improve access for people with complex needs and will use this project to understand:
1. What components are needed in a collaborative service improvement intervention between women with complex needs, an organisation that supports them and general practice?
2. What outcomes matter to people with complex needs, general practice and commissioners when trying to improve access to trauma-informed primary care?
How will the project be delivered?
This collaboration is steeped in co-production principles, with Bridging Gaps women making key decisions at every juncture. We have blended the knowledge of lived experience from the women, service delivery from GPs and latest research from academics to create trauma-informed training materials. We plan to:
1. Deliver trauma informed care training sessions with GP practices. These will be delivered by our team of clinicians and women with lived experience, supported by researchers.
2. Collaborate further with up to 3 of the surgeries who we have relationships with to co-design other aspects of the service improvement package. These co-design meetings will take the form of collaborative meetings between the Bridging Gaps team and 2 clinicians (or one clinician and one manager) from the GP surgery. The surgeries we collaborate with may be able to pilot some of these changes. We will be meeting regularly as a team to develop our ideas and plans.
How is your project going to share learning?
This award-winning Bristol-based collaboration has been running for 18 months. Learning includes how to successfully engage marginalised groups (and busy GP practices!); combine the knowledge of marginalised groups, GP practices, charities and researchers; and co-produce trauma-informed training and quality improvements. Through our work together Bridging Gaps has learnt many lessons about how to co-produce work together in a more trauma-informed way, working to support service improvements whilst at the same time supporting people’s own personal development.
Several Q community SIGs may be particularly interested in Bridging Gaps including primary care, co-production, measures for improvement, women’s health, mental health and developing improvers. Through these networks, we will share learning. With the Q community we want to further refine the intervention so we can understand which components of it help to enable changes and improve access to primary care, and help expand our work.
How you can contribute
- Sharing strategies and best practice to improve access to primary care for people who face health inequalities and have experienced trauma.
- How to engage with primary care services and create service improvement work when they have multiple demands placed on them - even more so now with the COVID-19 pandemic and vaccination work.
- Any experience/ guidance on what and how to measure improving access to trauma-informed primary care for people with complex needs.
- Thinking through how to potentially scale up the project
- Website design and social media support
Plan timeline
| 1 Jun 2021 | Start delivering GP practice training sessions |
|---|---|
| 1 Sep 2021 | Collaborate with GP practices to develop service improvements |
| 1 Oct 2021 | Start developing website & wider communications strategy |
| 30 Apr 2022 | Finish all training delivery to primary care practices |
| 31 May 2022 | Finish co-creating communications and scaling up strategy |
| 30 Jun 2022 | Q Exchange project concludes |
Project updates
1 Oct 2021
What have you learned so far, either from the successes you have had or from where things haven’t gone to plan?
We have received additional funding through our Clinical Commissioning Group to be able conduct some evaluation and research on our approach and are currently writing up our learning about how co-production methods need to be more trauma-informed, to be able to support the involvement of people who’ve experienced complex trauma in service improvements and health research.
During the 2021 winter lockdown months we had to pause our co-production meetings as community centres were shut and not everyone had a safe space to access online meetings. We re-started meetings in April when community centres re-opened but the impacts of lockdown had been harsh on people, and so we had a smaller group of women to begin with. We have developed a new recruitment process for new members with lived experience to get involved.
Because of the lockdown and the fact that GPs were busy vaccinating everyone, we had to cancel the training that had been planned up to April 2021. Since April we’ve been consistently meeting every fortnight and have reviewed the training and our offer to GPs. We have developed a plan for a series of meetings with GP practices to support them in reviewing and improving their access to trauma-informed care for people with complex needs. From our previous work, we have learnt that one-off training events don’t always enable an interactive process, and that we need to work with GPs in the longer term to be able to implement changes on the ground. We have also reflected that previous training materials put an emphasis on women with lived experience sharing their own encounters with primary care. This had the potential to retrigger trauma when discussing difficult experiences with strangers in a professional setting. Going forward, future discussions will have more of a collaborative style, focusing on working alongside practices to come up with practical solutions to barriers to providing trauma-informed care.
What could others learn from your experience of working with a range of stakeholders and collaborating across boundaries (geographical, professional, sector) – including what is working well and any challenges you have faced?
As a team we comprise researchers with expertise in coproduction, GPs, women with lived experience of trauma and women working with those with trauma backgrounds in the third sector. Combining our experiences enables us to provide practical advice that is directly applicable to primary care. We have successfully collaborated with representatives from the local Clinical Commissioning Group to enable us to provide funding streams for practices engaging with our work. At the regional level, we are working with various stakeholders across the Integrated Care System to influence plans for delivery of trauma-informed health and social care across Bristol, North Somerset and South Gloucestershire. Ensuring collaboration with those in charge of policy decision-making will enable our work to be incorporated within broader plans for the region. This will avoid duplication of effort and hopefully enable our interventions to be developed in such a way as they can be delivered at scale in the region. Most importantly this ensures that the voices of those with lived experience will be represented ‘at the table’ where decisions are being made.
There have been many challenges for GP practices during the pandemic, including the roll-out of vaccinations and demand on services so it has been really helpful to work with academic GPs and trainee GPs who both have particular time set aside to be able to get involved in this project and have an understanding of the current climate in Primary Care and what might be feasible. We have learnt the importance of a flexible approach and have used technology to support this. Whilst some women have found online meetings helpful, for others they have been impossible to attend safely. Online meetings also present challenges in terms of fostering positive relationships, forming bonds and understanding how people are feeling. As a result of our learnings we have moved back to face to face meetings but with the option of joining online for anyone who feels more comfortable to do so (and can do so safely in a confidential setting).
What are the next steps for your project over the coming months?
In addition to our work at the regional level within the local Integrated Care System, we are working closely with some practices individually. Our goal is to collaboratively develop trauma-informed service improvements/ interventions for people who have complex needs, offering a specific tailored approach needed for different GP practices and their populations. We will use learning from our collaborations with one practice in which a new ‘Open Doors’ clinic set-up has been trialled. Key questions which we will address include:
- How to identify people on the register who may have complex needs and who are not accessing primary care
- Understanding clinical encounters- are they trauma-informed? How to optimise this
- What training/expertise do clinicians /reception need?
- How to improve the interface between clinician and social prescriber/ support worker
- Pathways and communication into and out of primary care e.g. referral pathways, links between agencies, drop-in availability/ fast track appointments
How can the community get involved in your project?
We hope to link in with the Q community co-production special interest group to share our learning on how co-production can be more trauma-informed. We would also like to share our learning with the primary care special interest group after we have done some more in-depth work with individual GP practices. If others involved in primary care, women’s health, and mental health are interested in developing work on trauma-informed care then please get in contact and we can share learning.
Comments
Julia Carr 26 Sep 2021
Do you know of anything like this in Kent? Services in Thanet seem to be particularly inaccessible to women who've experienced trauma. From both personal and professional experience there's almost a culture of causing harm 'on purpose' provoking, tormenting, ridiculing patients who can't cope with procedures that many would find so straight forward, using care plans to identify vulnerabilities and using this knowledge for harm.
Helen McGeown 1 Oct 2021
Hi Julia,
I am so sorry to hear this. If you have had a specific negative experience with a local practice and feel able to, it is worth writing down your experience and sending a letter to the practice manager in the first instance. If , as your comment suggests, you feel there is a more systemic issue then the local CCG is a good port of call- https://www.kentandmedwayccg.nhs.uk/. I note there is a meeting coming up in November. Another potential port of call is the Care Quality Commission (https://www.cqc.org.uk/).
Michelle Farr 1 Oct 2021
Hi Julia
I'm really sorry to hear this, that sounds like a very difficult situation. I'm not aware of any particular work going on around trauma-informed care in Thanet or Kent but will let you know if I hear anything. The Scottish Government have published lots of guidance and support on how to implement trauma-informed care which might be useful to look through: https://www.gov.scot/publications/trauma-informed-practice-toolkit-scotland/
If it's helpful to get in contact with me individually, please email me m.farr@bristol.ac.uk
Emma Gibbard 19 Oct 2020
This looks like an excellent project which has already, and will continue to make, a difference to women with complex needs. Thank you for the additional information in the links, really useful to see the impact that the co-produced intervention has already had including the increased engagement in mainstream services and empowering women with complex needs to act as champions in their community. It will be brilliant to scale this up and share! The project looks really well planned, good luck!
Lucy Potter 19 Oct 2020
I can honestly say this has been such a great project to be part of. As a GP I've been frustrated with unsatisfactory clinical encounters with women with complex needs (10 minutes not enough, you're already running late in clinic then the patient walks in and you can see they've got really wound up in the waiting room, you don't know them, they don't know you and you have to ask them difficult questions with little time, you can see they're suspicious- have they been hurt by authority figures previously? You don't know how to get them to trust you, and you don't know how on earth you're going to be able to help with only a few minutes, and funnily enough it doesn't go well! Will they come back or have you made it worse? What if they never come back now?)- You get the picture.
It's so refreshing to take a step back and have real conversations with women with lived experience and clinicians to build relationships and work out how this can be done differently and more effectively.
Please support us!
Rammya Mathew 12 Oct 2020
This looks like a really interesting and ambitious project. I think QI projects often overlook these hard-to-reach groups, because it's not 'easy work'. It's often difficult for practices to find this cohort as primary care coding is poor for areas of work/ practice populations that don't attract incentive payments. The required interventions are complex, and it's not straightforward to measure impact. But this doesn't make the need any less, so I'm glad that your team have taken this on and already have a cross sector partnership in place to try and ensure its success. Good luck, I look forward to finding out more.
Michelle Farr 13 Oct 2020
Many thanks Rammya. I agree that more QI projects need to be working with people who face health inequalities and was really glad to see your Q Exchange project also working towards this in a different way. Lots to learn from each other here. You make a really interesting point about incentive payments, these need to align better so that health inequalities can be tackled and changed. One of our GP practices who we are working with have got some funding from the local CCG to run an Open Doors clinic, this is now successfully engaging with people who have previously faced barriers to accessing primary care.
Josephine Ocloo 9 Oct 2020
This project was very interesting to read and would seem to meet needs with groups on issues that are seldom tasked about.and discussed. It is important for these types of initiatives to be developed
Michelle Farr 13 Oct 2020
Thanks Josephine. I was really pleased to see your Q Exchange project also working on inclusivity within the area of health inequalities. As another comment on our project has said, we definitely need more QI projects to be working with a much greater diversity of people in quality improvement projects.
Oliver Watson 9 Oct 2020
Hello, this looks like a really well-designed project that will address a crucial issue for our services. We have some complementary work in our Drug and Alcohol and Adverse Childhood Experiences Health Integration Teams that it would be good to talk about. Thanks and good luck!
Michelle Farr 12 Oct 2020
Thanks Olly, that's really helpful. It would be really great to have a conversation sometime about how we can link in with the Drug and Alcohol, and Adverse Childhood Experiences Health Integration Teams. I'll send you an email to set up a time to catch up in the next few weeks.
Emma Adams 5 Oct 2020
Hi Michelle. Really great project that already looks like it is making a difference. I'm working with the Health Foundation to encourage opportunities for collaboration during this Q exchange round. I know you've mentioned the project being of possible interest to members of SIGs, but I think it might be helpful to post in the groups or contact the SIG leads to get your idea out. Also, there is a West of England Q community group that might link you in with some local Qs for support. Good luck with the project, Emma
Michelle Farr 8 Oct 2020
Hi Emma
Many thanks for this, that's really helpful. I will post in the SIG groups and contact SIG leads to get our ideas out there so we can connect with more Q members.
Michelle Farr 28 Sep 2020
I'm finding hyperlinks challenging! So...
For more on the background of Bridging Gaps, please see https://www.bristol.ac.uk/research/impact/impact-story-complex-needs-womens-healthcare/.
For more on the charity One25, please see www.one25.org.uk.
For more on trauma-informed research informing this project, please see https://www.bristolbrc.nihr.ac.uk/our-research/mental-health/experimental-medicine/trauma-informed-approaches-in-primary-care-and-community-mental-health-care-tap-care-study/.
For more on the awards already won by this project, please see https://www.goldenkeybristol.org.uk/news/identity-bristol%E2%80%99s-system-change-heroes-revealed.
Thank you!
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