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CHAPTER4 Social aspects of primary care
Multiculturalmedicine
Britain is a multicultural and multifaith society. It is important that healthcare
providers take into account the cultural and spiritual needs of their patients.
0 Table 4.1 is a rough guide to religious dierences that aect healthcare.
It is forcibly brief and cannot address all the many variations. Everyone is
an individual and there is a real danger of ‘pigeon- holing’ patients by religion or ethnic background and making incorrect assumptions as a result.
Always ask patients/ family about their own preferences.
Communication Eective communication is essential. Do not assume
English prociency; it is important to ascertain that you understand the patient and that the patient understands you.
• Ask the patient to let you know if he/ she does not understand;
consider using an interpreter
• Speak clearly and slowly and repeat important information; avoid jargon,
confusing phrases, double negatives, and rhetorical questions
• Ask patients to tell you what you have said to check comprehension
• Be wary of sounding condescending— English skills are not a reection
of a hearing disorder or level of intelligence
Respect beliefs and attitudes People have dierent reactions to-
wards illness, life, and death. Ask patients to provide you with information
about their own ideas, e.g. for newly arrived immigrants, ask: ‘Could you
tell me what would happen to you if you were in your country?’
Using interpreters Interpreters are an important resource in pro-
viding a voice for patients whose prociency in English is poor or insucient
for the situation. In general, anyone who has been in an English- speaking
country for <2y will need an interpreter. Sometimes a friend or another
family member can be used but if sensitive issues have to be discussed or it
is essential that the information is translated accurately, use a professional.
General tips:
• Anticipate an interpreter will be needed where possible, and pre- book
someone of the same gender who speaks the same language/ dialect
and will be ethnically acceptable to the patient
• Explain that the interpreter is bound to maintain condentiality
• Face and speak in the rst person directly to the patient, not the
interpreter; interpreters are solely there to convey information in a
language both patient and doctor can understand— not to analyse
information or decide what should or should not be conveyed
Useful contacts
Commercial interpreter services— local PCOs often have contracts with
interpreter services for GPs to use during consultations.
Ethnologue Information on languages of the world. M www.ethnologue.com
MedLine Plus US Government website providing free health information
for patients in a wide variety of languages. M www.medlineplus.gov/
languages
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Cremation preferred— no objections to
postmortem
Burial or cremation— no objections to
postmortem
not allowed
methods only
No objections No objections Strong preference to die at home. The body
should not be touched by non- Hindus. All
adults are cremated— no postmortems unless
legally required
All Muslims are buried. No postmortems
unless legally required
Variable— some Muslims
do not approve
Variable— some
Muslims may not
consent to transplant
MULTICULTURALMEDICINE
postmortem
Burial preferred. No postmortems unless
legally required
Children and adults are cremated
No objections Burial or cremation— no objections to
or organ transplant.
Dialysis is usually
permitted
No objections Some orthodox Jews
prohibit contraception.
Most Jewish boys are
circumcised 8d after birth
discussed
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Fasting involves
limiting type of
foods
are strict vegetarian
Religion Dietary restrictions Fasting Transfusion/ transplant Family planning Death
Buddhist Mainly vegetarian N/ A No objections No objections— abortion
Christian None N/ A No objections Some approve of natural
Table4.1 Religious dierences important inhealthcare
Hindu Most do not eat beef. Some
Fasting sunrise
l sunset during
Ramadan
N/ A No blood transfusion
have been killed in a special
manner (halal). Alcohol is
prohibited
No foods containing blood
Muslim No pork. Other meat must
Jehovah’s
Orthodox Jews
may fast for
or blood products. No
alcohol
Meat prepared in kosher
Witness
Jewish No pork, rabbit, or shellsh.
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Yom Kippur
N/ A No objections Allowed but not openly
fashion. Liberal Jews may not
adhere to dietary restrictions
Sikh No meat killed in ritualistic
fashion. Most are vegetarian.
Alcohol is forbidden
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CHAPTER4 Social aspects of primary care
Domestic violence:the GP’srole
Domestic violence (DV) Any incident or pattern of incidents of con-
trolling, coercive, or threatening behaviour, violence, or abuse between
those aged ≥16y who are/ have been intimate partners or family members
regardless of gender or sexuality. This encompasses, but is not limited to:
• Psychological abuse • Sexual abuse • Financial abuse
• Physical abuse • Emotional abuse
Controlling behaviour Acts designed to make people subordinate or dependent by isolating them from sources of support, exploiting their resources/ capacities for personal gain, depriving them of means needed for
independence, resistance ± escape, and regulating their everyday behaviour.
Coercive behaviour Act/ pattern of acts of assault, threats, humiliation, and
intimidation or other abuse used to harm, punish, or frighten victims.
Prevalence Although men may be the victims of DV, ~80% of reported DV
is against women by male partners. DV aects ~1 in 4 women and is the
most common form of interpersonal crime:60%— current partner; 21%—
former partner. Half suer >1 attack; 1 in 3 have been attacked repeatedly.
Eects High incidence of psychiatric disorders, particularly depression, and
self- damaging behaviours, e.g. drug/ alcohol abuse, suicide/ parasuicide.
Factors preventing thevictim leaving theabusivesituation
• Loss of self- esteem makes victims think they are to blame
• Disruption of the family and children’s relationship with partner or
other key family members (e.g. grandparents, uncles, aunts, cousins)
• Loss of intimate relationship with partner
• Fear of partner • Risk of homelessness
• d in income • Fear of the unknown
Presentation General practice is often the rst place that victims seek help, but
only 1 in 4 actually reveals the true nature of the problem. Without appropriate intervention, violence continues and may i in frequency and severity.
By the time injuries are visible, violence may be a long- established pattern. On
average, victims are assaulted 35 times before reporting DV to police.
Guidelines for care 0 Emphasize condentiality.
• Consider the possibility of domestic violence— ask directly
• Document the patient’s story and any injuries— accurate, clear
documentation, over time at successive consultations may provide
cumulative evidence of abuse and is essential for use as evidence in
court, should the need arise
• Assess the present situation— gather as much information as possible
• Provide information; oer help to make contact with other agencies
• Devise a safety plan, e.g. give the phone number of local women’s
refuge; advise to keep some money and important nancial and legal
documents hidden in a safe place in case of emergency; help plan an
escape route in case of emergency
0 Do not pressurize the victim into any course of action. If the patient decides to return to the violent situation, in time your information and support
might provide the condence needed to break out of the situation.
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DOMESTIC VIOLENCE:THE GP’ROLE
• If children are likely to be at risk, inform social services or the police—
preferably with the patient’s consent.
Elder abuse Single or repeated act, or lack of appropriate action,
occurring within any relationship where there is an expectation of trust,
which causes harm or distress to an older person. Prevalence is ~4%
(iwith age; ♀:♂ 82:1). Older people may report abuse but often do not.
Dierent forms of abuse can be taking place simultaneously (Table 4.2).
Management Talk through the situation with the patient, carer, and other
services involved in care. Assess the level of risk. Consider admission to a
place of safety— contact social services and/ or police as necessary; seek
advice from Action on Elder Abuse.
Deprivation of Liberty Safeguards (DoLS) E p. 1106
Assault E p. 88 Adult safeguarding E p. 197
Non- accidental injury in children E p. 902
Table4.2 Elder abuse:what tolook for
Type of abuse Symptoms and signs to look for
General Patient states he/ she has been abused; inconsistent story from
Physical abuse Cuts, bruises, unexplained fractures, burns
Psychological
abuse
Financial abuse Unexplained/ unjustied removal of funds by family members,
Sexual abuse Vaginal or anal bleeding, genital infections
Neglect Malnutrition, deh ydration, squalor, poor personal hygiene, late
Institutional
abuse
patient and carer; inconsistencies on examination; fear shown by
the older person in the presence of a carer; frequent attendance
at A&E; frequent requests for GP visits; carer avoiding the GP
Unusual behaviour, unexplained fear, appears helpless or
withdrawn
carers, or others; new will in favour of an unexpected recipient
requests for medical attention
In a residential care environment, care of the individual is
compromised by the rules and routines of the organization, e.g.
no food if not hungry when lunch is served
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Further information
DH Domestic abuse:a resource for health professionals. M https:// www.gov.uk/ government/ publications/
domestic- abuse- a- resource- for- health- professionals
Useful contacts
Action on Elder Abuse F 0808 808 8141 M www.elderabuse.org.uk
Men’s Advice Line F 0808 801 0327 M www.mensadviceline.org.uk
Police, and local authority social services/ housing departments
Womens’ Aid and National DV Helpline F 0808 2000 247 M www.
womensaid.org.uk
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CHAPTER4 Social aspects of primary care
Victims ofcrime
Victims of any crime need treatment of injuries and emotional support.
• Note the date, time, and place of the event
• Record injuries in detail (physical and psychological)— including
measuring the size of lacerations and bruises. Record all information
carefully as it may be needed for legal cases
• Arrange for photographs to be taken, if appropriate
• Encourage reporting of the incident to the police— the patient will not be
eligible for criminal injury compensation if the incident is not reported
• Give patient details of local victim support groups
• If the patient’s safety is an issue, contact the duty social worker for a
place of safety to be provided
Rape and indecent assault If a patient reports rape or indecent as-
sault and is willing to report the matter to the police, do not perform an
examination. The case against the assailant could be won or lost on the
basis of evidence gained by examination of an alleged victim, so it is best
done by a doctor trained and experienced in such work.
If thepatient will not report thematter tothepolice
• Take a full history of the event. Note:LMP, contraception, sexual history
• Suggest the patient attends a Sexual Assault Referral Centre (SARC) for
forensic/ medical examination and specialist advice and support
If there is no SARC or thepatient is unwilling toattend
• Make a note of any injuries and take photographs if possible and
appropriate. Do not insist on examination if the patient is unwilling.
Ensure a chaperone is present if any examination is attempted
• Discuss the need for emergency contraception, prophylactic antibiotics
(e.g. azithromycin 1g po stat), blood tests at 3mo to exclude transmission
of syphilis and at 3– 6mo for exclusion of seroconversion for HIV
• If at high risk for HIV transmission, refer to A&E for consideration of
prophylaxis (E p. 720)
• Discuss the need for counselling, and inform the patient about the victim
support scheme and SARCs
• Arrange follow- up in 2– 3wk
Domestic violence E p. 86 Elder abuse E p. 87
Non- accidental injury in children E p. 902
Modern slavery The Home Oce estimates that there are 13,000 victims
and survivors of modern slavery in the UK; 55% are ♀ and 35% of all victims
are tracked for sexual exploitation. People are in slavery if they are:
• Forced to work— through coercion, or mental or physical threat. Work
may include anything from hard physical work to commercial sexual
exploitation or drug tracking
• Owned or controlled by an ‘employer’, through mental or physical
abuse or the threat of abuse
• Dehumanized, treated as a commodity, or bought and sold as ‘property’
• Physically constrained or have restrictions placed on their freedom of
movement, e.g. by removing passports
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VICTIMS OFCRIME
Common types ofmodern slavery intheUK
• Debt bondage Most widespread form of slavery in the UK. People
borrow money they cannot repay to come to the UK, and are then
required to work to pay o the debt, losing control over the conditions
of both their employment and the debt
• Human tracking Involves transporting, recruiting, or harbouring
people for the purpose of exploitation, using violence or coercion
• Forced marriage When someone is married against their will and cannot
leave the marriage
The role of the GP People trapped in modern slavery may come into contact
with medical services, particularly in primary care. It is important to be alert
to this possibility. In these situations, patients are often not in a position to
discuss what is happening to them. As modern slavery is a serious crime,
GPs have a duty to report the matter, even if this involves breaking patient
condentiality. Gather as much evidence as you can from your encounter(s)
with the patient and consider discussing the issue with your local safeguarding lead and/ or the police. There is a national reporting helpline (F
0800 0121 700) or modern slavery can be reported online (M https://
www.modernslaveryhelpline.org/ report).
Prevent Part of the UK’s Counter Terrorism Strategy known as
CONTEST. Aims to stop individuals from getting involved/ supporting terrorism or extremist activity. All healthcare sta must undergo training to
recognize signs of radicalization and refer to the police if suspected.
Criminal injuries compensation For victims of violent crimes—
even if the attacker is not identied. Compensation is paid for the injury,
loss of earnings, and expenses. Claim online or by telephone. F 0300 003
3601 (option 8)M www.gov.uk/ claim- compensation- criminal- injury
Post- traumatic stress disorder (PTSD) 23% of assault victims
and 80% of rape victims develop PTSD. ♂:♀ 82:1. Dened as signicant
symptoms 1mo after the event— i.e. ashbacks, nightmares, survivor guilt,
mood changes, detachment, poor concentration, insomnia, anxiety, and
depression. Alcohol abuse, work, and relationship problems are common.
Symptoms may last years. See E p. 976.
Further information
Modern slavery M www.gov.uk/ government/ collections/ modern- slavery
Prevent Training and Competencies Framework
Mwww.england.nhs.uk/ wp- content/ uploads/ 2017/ 10/
prevent- training- competencies- framework- v3.pdf
Patient information and support
Rape Crisis England and Wales Provides support, information and a list
of SARCs and local Rape Crisis Centres. F 0808 802 9999 M www.
rapecrisis.org.uk
Rape Crisis Scotland F 0808 801 0302 M www.rapecrisisscotland.org.uk
Survivors UK Provides resources for men who have experienced any form
of sexual violence. M www.survivorsuk.org
Victim Support F 0808 1689 111 M www.victimsupport.org
Victim Support Scotland F 0345 603 9213 M www.victimsupportsco.org.uk
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CHAPTER4 Social aspects of primary care
Occupationalillness
If a patient develops an occupational disease, a doctor is obliged to notify
the employer in writing, with the patient’s consent. The doctor does not
need to make a judgement about whether the disease is, in that particular
case, caused by the occupation.
Employers must then inform the Reporting of Injuries, Diseases and
Dangerous Occurrences Regulations (RIDDOR) incident contact centre
(F 0345 300 9923 M www.hse.gov.uk/ riddor). Self- employed patients
must contact RIDDOR themselves.
Patients who do not give consent for the doctor to notify their employer
may allow the doctor to inform the employer’s occupational health department or RIDDOR directly instead.
Industrial injury Injured employees should always report details of any
accident to their employer and record them in the accident book as soon as
possible— however trivial the injury. Employers must inform RIDDOR of:
• Dangerous incidents— even if no one was hurt
• Incidents where death or serious injury occurs
• Incidents resulting in injury requiring >3d absence from work
• Incidents involving gas
Prescribed industrial disease Disease for which benet is paid if the
applicant worked in a job for which that disease is ‘prescribed’ and it is
likely the employment caused the disease. Claims may be made at any time
with the exceptions of occupational deafness (claim <5y after leaving employment) and occupational asthma (claim <10y after leaving employment).
Notiable industrial diseases 0 This is not a complete list:
• Poisoning by industrial agents,
e.g. lead, arsenic, mercury
• Bursitis, e.g. housemaid’s knee
• Occupational asthma
• Folliculitis and acne (associated
with work with tar, pitch, or oils)
• Occupational infection, e.g.
hepatitis B in healthcare
workers, anthrax in farmers
• Chrome ulceration
• Irritant dermatitis, e.g.
hair- dressers’ dermatitis
• Vibration white nger
• Repetitive strain injury
• Tenosynovitis, e.g. as a result of
repeated movements of the hand/
wrist
• Pneumoconiosis
• Extrinsic allergic alveolitis
• Occupational deafness
• Occupational cancers, e.g.
nasopharyngeal cancer in
woodworkers, bladder cancer in
plastic workers, cancers as a result
of ionizing radiation, mesothelioma
due to asbestos exposure
The list of prescribed diseases is similar to, but not the same as, the list of
notiable diseases.
Making claims Through local Industrial Injuries Disablement Benets of-
ces. Afull list of prescribed industrial diseases is also available from these
oces. Some claims can be made online. For further information contact
F0800 121 8379 M www.gov.uk.
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OCCUPATIONALILLNESS
Industrial benets that may bepayable
Industrial Injuries Disablement Benet Available to employed earners for
injuries resulting from accidents or certain (prescribed) illness arising as a
result of employment, even if the employee was either part or wholly to
blame. ‘Industrial’ covers virtually all forms of work. For accidents, claims
can be made at any time after the event but benet is paid only if there are
still eects of the injury after the 91st day.
Payable if the person was a paid employee at the time of the accident or
when he/ she contracted the disease; and disability is assessed at ≥14% (exceptions:occupational deafness >20%; dust- related lung disease— no level).
If a patient claims benet for >1 industrial accident or disease, assessments
may be added together and benet awarded on the total.
Reduced Earnings Allowance Payable if the accident occurred or disease was
contracted prior to 1 October 1990, the disability is assessed at ≥1%, and
the individual is
• Unable to work, or
• Unable to do his/ her normal job or another job with equivalent pay, or
• Working less hours at his/ her normal job
Retirement Allowance Reduced earnings allowance becomes retirement allowance at statutory age of retirement. It is paid at 25% the rate of reduced
earnings allowance when a claimant stopped work.
Constant Attendance Allowance For people who need daily care and attention and who are getting industrial injuries disablement benet for disability
assessed at 100% or 80% war disablement pension. Four rates of benet
depending on the level of care required.
Exceptionally Severe Disablement Allowance For people who get constant attendance allowance at ‘exceptional’ or ‘intermediate’ rate and where need
for attendance is likely to be permanent.
0 People who suer from industrial diseases or have suered disability as a
result of an industrial accident are also eligible to apply for benets available
for any disabled individual (E p. 108).
Benets for service veterans E p. 106
Further information
Citizens Advice M www.adviceguide.org.uk
RIDDOR Incident Contact Centre. F 0345 300 9923 M www.hse.gov.
uk/ riddor
Trade Unions
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CHAPTER4 Social aspects of primary care
Time owork
In the UK, 31.2million working days were lost due to work- related ill health
and workplace injuries in 2016/ 17. Average time o work was 17d. The
most common reasons were:
• Stress, depression, and/ or anxiety (12.5million days lost)
• Musculoskeletal problems (8.9million days lost)
Facts andgures
• Sickness absence i with age; ♀ have higher rates than ♂
• There has been a d in amount of sick leave over the past 20y
• 16% of sick leave is for >20d, but this accounts for 32% of lost time
• The longer someone is not working, the less likely that person is to
return to work; someone who has been o sick for ≥6mo has an 80%
chance of being o work for 5y
Benets of returning to work Going back to work promotes re-
covery, i physical/ mental health and well- being, and d social exclusion/
poverty. In contrast, long periods out of work can cause/ contribute to:
• i consultation, medication consumption, and hospital admission rates
• 2– 3× i risk of poor general health and mental health problems
• 20% excess mortality
The role of the GP When someone of working age presents with a
problem that aects ability to work, record a brief occupational history:
• Address the underlying health problem and any personal, psychological,
organizational, or social factors preventing return to work
• Wherever possible, suggest work adjustments where appropriate to
enable a patient to return to work (e.g. graduated work or transitional
arrangements) or instead of signing the patient o work; do this through
the ‘remarks’ section of the ‘Statement of Fitness to Work’— E p. 95
• Involve occupational health professionals if possible
Certication of time o work E p. 95
Postoperative time o work Table 4.3
Time o work for emergencies In many cases, patients have the legal
right to take time o work to deal with an emergency involving someone
who depends on them. They may only be absent for as long as it takes to deal
with the immediate emergency; employers do not have to pay for their time.
Dependants Include spouse or partner, children, parents, or anyone living
with the patient as part of their family. Others who rely wholly on the patient for help in an emergency may also qualify.
Emergencies Include situations in which a dependant:
• Is ill and needs help • Goes into labour
• Is involved in an accident or assaulted
• Needs the patient to deal with an unexpected disruption or breakdown
in care, such as a childminder or nurse failing to turn up
• Dies and the patient must make arrangements/ attend the funeral
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TIME OFFWORK
Table4.3 Expected postoperative time owork forcommon surgical
procedures
Surgical procedure Time o work (wk)
Minimum
Angiography/ angioplasty <1 4
Appendectomy 1 3
Arthroscopy (knee) 1 4
Cataract surgery <1 2
CABG or valve surgery 6 12
Cholecystectomy 2 (laparoscopic) 12 (open)
Colposcopy ± cautery <1 <1
Cystoscopy <1 <1
ERPC or surgical TOP <1 <1
Femoro- popliteal grafts 4 12
Haemorrhoid banding <1 <1
Haemorrhoidectomy 2 4
Hysterectomy 2 (laparoscopic) 8 (open)
Inguinal or femoral hernia repair 1 (laparoscopic) 6 (open)
Laparoscopy ± sterilization <1 <1
Laparotomy (open) 6 12
Mastectomy 2 12
Pacemaker insertion
Pilonidal sinus
Retinal detachment <1 Avoid heavy work life- long
Total hip/ knee replacement 6 26
TURP 2 8
Vasectomy <1 2
a
Driving rules following pacemaker insertion E p. 243
b
If time o work is allowed for dressings
a
b
<1 <1
2 8
Maximum for
uncomplicated procedures
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0 These are not hard and fast rules— alter them to t individual circumstances (e.g. laparoscopic procedures often entail less time o than open
procedures; patients performing hard manual jobs may require more time
o work).
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