Every time you make a phone call to try and expedite an appointment for a patient and every time you write a letter to support a housing application or a letter to an employer on behalf of a patient, you are engaging in advocacy. These are everyday examples of advocacy that are familiar to us as GPs. Other examples include GPs involving themselves in advocating for groups of patients, eg. trying to improve services in their local area, or even advocating for changes to the larger systems that affect our patients.

Here, we define advocacy as any activity that supports or defends a health cause, or pleads on a patient’s or the public’s behalf. More simply, advocacy involves an entity with perceived power (a GP with education and status), speaking out on behalf of people or groups with lesser power, often for goals related to social justice.

In this article we will discuss why being an effective advocate is a vital skill for GPs and we will give some examples of advocacy in action. We will also discuss the results of a recent survey of GP trainees in Ireland that illustrates why we think consideration should be given to the inclusion of formal education on advocacy as part of GP training.

Advocacy in medicine

The role of advocacy in medicine has been highlighted on several occasions over the past year – being mentioned in both the new ICGP curriculum¹ and the 2016 Medical Council guide to professional conduct and ethics.² Indeed, it is considered a ‘key role’ for the profession in the World Congress of Family Medicine (WONCA) definition of general practice.³ The Medical Council advises: “You should act as an advocate for your patients... you should speak on behalf of individual patients, to help make sure they receive appropriate healthcare. In addition, you should support all patients by promoting the fair distribution of limited resources and fair access to care”.²

The ICGP recently published a new core curriculum for GP trainees where there are numerous references to advocacy throughout.¹ This curriculum describes being an advocate as campaigning for improvements in patient care both locally and nationally. It also refers to collaborating with colleagues to ensure the best care for patients. In discussion of different cases, the curriculum suggests advocating for marginalised groups, eg. advocating for housing for the homeless, for access to care at home for elderly patients or for access to supports for those with disabilities.

As GPs we are well placed to advocate on behalf of individual patients and on behalf of the community. We are at the coalface, the forefront of the healthcare service. We have the privilege of having a unique insight into patients’ lives and we bear witness to the effects of health policy and deficiencies in our health system on our patients. Advocacy can potentially help not just the individual patient in front of us, but can also try to effect change at a system or policy level. Patients place their trust in us as GPs to help them – not just by writing prescriptions or giving advice, but also to fight their corner on wider issues when we can.

No doctor, no village

A good example of system level advocacy in recent times was the ‘No doctor, no village’ campaign. This was a nationwide campaign led by rural patients and GPs to save and protect the GP service of rural communities, a service which has become increasingly vulnerable, leading to many isolated rural communities losing their permanent GP service. 

Of course, this is also part of a much wider neglect of rural Ireland generally, where second-class services in road, broadband, public transport to name but a few have become the norm. This campaign eventually led to Drs Michael Harty and Jerry Cowley standing for election under the ‘No Doctor No Village’ banner in the General Election 2016, with Michael Harty getting elected.

Another example of systems advocacy is the work currently being undertaken by the North Dublin City GP Scheme (NDCGP) on direct provision for asylum seekers in Ireland. Led by Drs Fiona O’Reilly and Rosanna O’Keeffe, the strategy aims to raise awareness around the direct negative health impacts from living in these settings. It also supports calls from various NGOs and activist groups to end the practice of leaving people in limbo in direct provision for many years. 

Asylum seekers are known to be a vulnerable population with higher rates of depression and post-traumatic stress disorder compared to the rest of the population.^4,5 Direct provision has been identified as a structure that leads to segregation, social isolation and enforced poverty.⁶ In developing the strategy, GP trainees first undertook a literature review and then looked at available working group, NGO and government reports on direct provision. A site visit to Balseskin Reception Centre was then arranged for trainees in order to gain an understanding of the health needs and health services available to asylum seekers on arrival to Ireland. Following this, trainees wrote an article which was published in the BMJ Blogs that outlined their concerns regarding this system that impacts negatively on people’s health and wellbeing.⁷

The next step was hosting an interactive talk for all members of the GP scheme where Lucky Kambhule (a spokesperson for the Movement of Asylum Seekers Ireland) gave a personal perspective on the impact of living in direct provision accommodation. Members of the media were invited to attend this event, with the aim of bringing the discussion on the health of those in direct provision to a wider audience. 

The next steps for the GP trainees will be a research project and the development of an education session on direct provision for medical students and doctors. The aim of this work is to ultimately support and strengthen the calls to end long-term institutionalisation in direct provision settings. 

Advocacy as part of formal training

Given that advocacy is so central to the role of the GP, we feel that it should be a formal part of training. Research conducted internationally has found that doctors and trainees believe advocacy to be a significant part of their role as a doctor. A qualitative study of family medicine residents in Canada found that healthcare advocacy was seen by them as an important and worthwhile activity. These residents felt it would be beneficial to create time for advocacy in the curriculum. Their suggestions included having health advocacy-based electives or undertaking advocacy-oriented research.⁸ Apart from lack of training, research suggests other barriers to engaging in advocacy including insufficient time, rest and work-related stress.⁹

Online survey of GP trainees

Recently we distributed an online survey to GP trainees in Ireland to attempt to understand their perceptions and experiences of advocacy in the course of their training and work. There was a mere 5% response rate (14 out of 280) from trainees we emailed. This consisted of 10 females and the age range was 20-39 years. Seven of the respondents were in year three of GP training. This low response rate may signify ‘survey fatigue’ among GP trainees, but there is a possibility it may indicate a lack of knowledge or indifference to the subject matter in question. The survey found that 12 of the respondents were willing to advocate for patients, but only two had ever received formal advocacy training; all of the respondents felt advocacy training should be offered to GP trainees. 

Everyday advocacy skills

What would a training programme in health advocacy for GP trainees look like? It could deal with the everyday advocacy skills such as writing an effective letter, or knowing how to access particular services for your patient. It could also train doctors to look at the bigger picture and consider how they can help to improve the health of their local community or how they can best help to use the limited resources we have. It would help to empower the GPs of the future to engage in advocacy and, indeed, to see it as core to their working lives. Our online survey, while small in numbers, provides a basis for further research to be undertaken. Future research could look at the experience of established GPs in Ireland as well as trainees. It should seek to establish more detail about what advocacy activities GPs are participating in and what areas training should focus on. 

Those in medicine who have brought about the greatest change have often been those who have had a comprehensive vision involving not just pathology but also social medicine, politics and anthropology. It is this vision we hope to instil in the GPs of the future, enabling them to be great advocates and architects of change, particularly with regard to the most vulnerable in society. 

Authors: Melissa O’Neill is a GP registrar in Blackpool, Cork, Rosanna O’Keeffe is a GP trainee with the North Dublin City GP Training Scheme, Liam Glynn is a senior lecturer in general practice, NUI Galway; and Patrick O’Donnell is clinical fellow in social inclusion with the Graduate Entry Medical School, University of Limerick 

References

1. Irish College of General Practitioners. Curriculum for GP Training in Ireland. 2016. Available online at: www.icgp.ie/go/library/catalogue
2. Medical Council of Ireland. Guide to Professional Conduct and Ethics for Registered Medical Practitioners. 2016. Available online at: www.medicalcouncil.ie/News-and-Publications
3. WONCA Europe. The European definition of general practice/family medicine. 2011. Available at: www.woncaeurope.org
4. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees re-settled in western countries: a systematic review. Lancet. 2005;365:1309-1314
5. Burnett A, Peel M. Health needs of asylum seekers and refugees. BMJ. 2001; 322: 544-546
6. Arnold S. State Sanctioned Child Poverty and Exclusion: The case of children in state accommodation for asylum seekers. Irish Refugee Council. 2012. Available online at: www.irishrefugeecouncil.ie/wp-content/uploads/2012/09/State-sanctioned-child-poverty-and-exclusion.pdf 
7. O’Keeffe R. Direct Provision: Is this really the best we can do for those seeking asylum? BMJ. 2016. http://blogs.bmj.com/bmj/2016/10/19/direct-provision-is-this-really-the-best-we-can-do-for-those-seeking-asylum/ 
8. Mu L, Shroff F, Dharamsi S. Inspiring Health Advocacy in Family Medicine: A Qualitative Study. Education for Health. 2011; 24(1): 534
9. Stafford S, Sedlak T, Fok MC, Wong RY. Evaluation of resident attitudes and self-reported competencies in health advocacy. BMC Medical Education. 2010; 10(1): 82