Looking after patients in a GP setting affords a unique opportunity to care for them as people, where their illness is seen within the rich complexity of their lives. Despite the increasing technical skills of modern medicine, or maybe because of them, there is a powerful movement from patients and professionals alike to safeguard and develop this personcentred, holistic patient care.
But what does it mean to help patients recognise they have 'existential' or 'spiritual' characteristics which are profoundly important to them as people, and may be relevant to how they handle disease and suffering?
I have worked as a GP in a large partnership in central Birmingham, covering areas of high deprivation, for nearly 20 years. Our practice has aimed at whole person healthcare delivered by a large primary health care team. Having seen the team develop to include practice and district nurses, health visitors, counsellors, family therapists, and a physiotherapist, chiropodist and dietician, there was some sense of reaching this goal. However, we were aware that patients were still presenting with issues we were not adequately addressing.
There existed in their lives a wide spectrum of needs, sometimes hard to define, including loneliness, loss of connection with any meaningful community, low self worth, and absence of a sense of purpose. Only sometimes would patients volunteer they were looking for some spiritual answer to life's complexity, but often they felt estranged from any previous religious community. Although some of these issues could be dismissed as 'social problems', they were clearly relevant to the patient's health and we found it helpful to use the term 'spiritual needs'. These included a need to be loved, a need to feel worthwhile, and a need for meaning and purpose.
The then primary health care team could not fully address these needs and we thought we might be doing patients a disservice by raising awareness without possessing resources to respond appropriately. So in 1996 the concept of extending the primary health care team to include a chaplain came into being.
Some years on - what is the reality?
Health service managers support but don't fund
There is clear evidence favouring professionals seeking to be holistic, and the NHS has committed itself to addressing spiritual needs of patients and staff, so there are no grounds for resisting expanding a primary health care team to include a chaplain. However, NHS funding will always be in short supply. Initially we funded the post through fundholding savings, later through efficiency savings, and currently there is no funding stream.
The community has benefited
The chaplain initially formed a group of local clergy who wanted to work together to address unmet needs. They established a registered charity, which has worked with the elderly, asylum seekers and families with young children. It formed a partnership with numerous community organisations allowing the birth of a Sure Start programme, where it was lead body for several years. The chaplain remains closely involved with the charity and together they hold regular lunchtime meetings for Christian workers to meet and pray together.
The primary care team and counsellors value it
All sections of the team refer patients, and there is close liaison between counsellors and chaplain, who sometimes refer patients to each other. Patients understand that the chaplain is not there to counsel, but is able to give time to listen, reflect and offer support for as long as is appropriate.
Patients appreciate it
The most important criterion of 'success' has to be the experience of the individuals who have risked revealing their personal and often painful experiences to someone they may not have expected to find at the doctor's surgery!
Ross Bryson is a GP at the Karis Medical Centre in Birmingham
My job description states my purpose is to 'provide the pastoral and spiritual care of patients and staff'. Who is referred? Anyone, regardless of faith! The patients I see often come from the GPs, some from the nurses or counsellors, and about 25 percent are self-referrals. The reasons vary. Working with the bereaved and dying is important and significant, and I see people coming to terms with change, illness, trauma, loss, or difficult decisions.
Some patients come with 'spiritual' issues – guilt, forgiveness, wanting to find God, or looking for meaning. Patients of different faiths, who already have a faith structure, are often open to receiving strength from God in different ways.
What can the chaplain offer?
Henri Nouwen describes listening as 'the highest form of hospitality of the sort that does not set out to change people but to offer them space where change can take place'. Many patients do not have a social network where they can be listened to and understood. I can offer a place of safety to be listened to without being judged or hurried.
Discerning the signs of life
Many come with feelings of depression, anxiety and low self worth. I encourage some patients to 'review the day' – to look back over it and pick out one small moment of pleasure. Initially some report that nothing in their grey lives brought any glimmer of joy. Yet over a period, they may describe walking in the park, listening to music, or cooking a meal made them aware of stirrings of life for which they could begin to give thanks.
Recognising the signs of life emerging out of despondent situations, and giving thanks, is an important key to health and points to the Giver and Creator.
It is challenging to sit with people when there are no easy answers or quick fixes. Some patients can only understand God as cruel or, at best, disinterested. He is a God who allowed their child to die or who did not protect them from being raped. I must stand with each of them in their 'Easter Saturday', a time that seems helpless and hopeless, for as long as it takes. Yet I do not do this without hope, for I believe in resurrection and new life.
Over time, I have seen patients take small yet courageous steps out of despair towards healing and forgiveness. A nun commented to me once: 'God can take the s**t of our lives and turn it into manure!' I quoted this to a patient who had suffered bitter betrayal. She said, 'You mean the roses can grow again!' They did.
Ritual is important as a means of acting out and making sense of events. One Ugandan asylum seeker had not been able to attend the funeral of her two children. I held a short service in which she said her goodbyes and this enabled her to move on in her grief.
Another man, a Muslim consumed with guilt after adultery, found making his confession enabled him to move on. I encourage some to write a letter expressing their anguish to someone who has wronged them, and then to burn it. Patients describe this symbol of letting go as a significant turning point.
I always ask permission to pray, explaining what I mean. Only one patient out of hundreds has declined, and she asked if I would pray for her in her absence. I pray with the 'laying on of hands', and explain this is a sign that, although we cannot see him, God is close to us and embraces us as we are.
In prayer I declare each patient's value and worth to God. So many carry negative beliefs about themselves and it is important for them to hear the truth spoken. I often observe tears spring to their eyes at this point. I then bring their requests before God. These may be for comfort in sorrow, peace in anxiety, light in darkness, or healing in their situation. Some patients ask, when they come for a further appointment, 'You will pray at the end again?'
I have found practice chaplaincy challenging, demanding and immensely rewarding. I hope there will be many more such appointments in other practices.
Anne Hughes is lay chaplain at Karis Medical Centre in Birmingham