Presidential Address given to the Glasgow Southern Medical Society on 24th October 2013. In her lecture, Dr Andrea Williamson discusses health inequalities and homelessness from the viewpoint of a general practitioner in Glasgow. Two videos are discussed during the meeting: The first is Isha and the Poverty Truth Commission: http://www.youtube.com/watch?v=CKGMok5s2Rs&noredirect=1 The second is Brian and the Housing First pilot in Glasgow: http://www.youtube.com/watch?v=iKyNhAaCsE0

1. Andrea Williamson
Southern Medical Society Presidential Address 2013

4.  Biomedical positivism: graphs,
gradients, life expectancy
 Qualitative interpretivism:
perspectives and explanations
 The experience of the
interpersonal and relationship

5.  Social determinants of health
“the conditions in which people are born,
grow, live, work and age…” (WHO)
 People risk markers: age, sex, ethnicity,
sexual orientation, education
 Place risk markers: geography,
community, workplace
 Meta-risk marker: SOCIO-ECONOMIC
POSITION
*All are interlocked and socially
patterned*

7.  Poverty truth commission video:
Isha from Govanhill

8.  “the conditions in which people
are born, grow, live, work and age,
including the health system”
(WHO)
“Health equity through action on the
social determinants of health”

10.  45,000 households applied as
homeless, Scotland, 2011-12





42% single men
22% single women
17%single parents (women)
7% single parent (men)
5% couples with children
(Source Shelter Scotland)

11.  Refused asylum seekers
 ‘no recourse to public funds’
 Numbers unknown, survey March 2012:
78/112
 Rough sleeping
 Sofa surfing
 Night shelter and voluntary sector
support
 Right to full NHS care if ever applied for
asylum
(Scottish Refugee
Council 2012, 2013)

12.  Your experience of working with a
person who is homeless?

13. All people are individuals and have their
own story
However many people have had the
following experiences:
 Disrupted family life (poverty, abuse,
into care)
 Poor educational attainment
 Poverty
 Experiences of violence
 Addictions
 Mental health problems
 On-going risky relationships
(Source National Mental
Development Unit 2010)
Health

14.  Mortality
 X6 risk of death than general
population
 1.4 times more likely to die than the
most deprived housed person
 Drug misuse
 Circulatory disease
 Respiratory disease
 Importance of psychiatric morbidity
(Neilson et al 2011,Morrison 2009)

15.  Housing First video: Brian

17.  Adult attachment
 Personality disorder
 Complex trauma

18.  Impact on
 Thinking
 Feeling
 Behaving
 Impulsiveness…self sabotaging…self harm…emotional
lability….dissociation...unexplained physical symptoms

19.  Listen to what your emotions tell
you when you interact with
patients: frustration, anger,
disgust, fear
 Accept your response is often a
reaction to patients psychological
function (not always)
 Encourage safety: physical,
emotional and social: for you and
patients
 Be very careful of verbal and non
verbal leakage (including
psychological environments)

20.  Patients respond, feel safe and
function better (so you might
actually get to addressing health
issues)
 Professional patient relationships
are key to an effective health
service
 You will waste less emotional
energy getting angry, frustrated,
upset

21.  life course approach
– attachment
– adverse life events
– Resilience
 Patient at the centre of care
 Involving wider health and social care
team
 Snap shot versus the long view
 Role of the therapeutic alliance
 Trust
 Boundaries
 Longitudinally over time

22.  “revolving door” patients in
general practice
 Serial missed appointments in the
NHS
 Evaluation of vulnerable women’s
addiction clinic in South Glasgow

24. [Barnett, Mercer, Norbury, Watt, Wyke, Guthrie, 2012]

25. T, mid 40s. She has chronic depression
with
multiple
previous
suicide
attempts. She suffers from angina and
has had an MI in the past. She lives in a
flat with her boyfriend. T has recently
been deemed fit for work, but is
appealing this decision. Money is
extremely tight, and she and her
boyfriend are currently surviving on his
benefits alone. T has suffered from
physical, sexual and emotional abuse
all her life and her current relationship
is no exception. T wants to visit her
daughter (whose young child has
recently been removed from her care),
but can’t afford the coach fare – her
partner (not the daughter’s father)
won’t pay, as he will not allow T to
leave him, even to see her own family.
T is waiting for her daughter to pay for
the coach ticket. The daughter in turn
is waiting for her own benefits to come
through.
Another
daughter
is
homeless.
[case study extract,
Deep End Austerity report 2012]

26.  Role of health care
 at its best where its needed most
 Arrangements and resources
reflecting the epidemiology of multimorbidity
 General practice as the natural hub
 Importance of serial encounters
 Time
 Relationships
 With patients
 With other professionals in
healthcare
 Outside health care (social
prescribing and advocacy)
 Connectedness of care

27.  Within the health system
 Relationship work in consultations
 Relationship work with other
professionals
 Social prescribing and community
engagement
 Influencing health policy (research,
teaching and Deep End work)
 Being an engaged citizen and
advocate for change

28. Andrea Williamson
Southern Medical Society Presidential Address 2013
andrea.williamson@glasgow.ac.uk