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At the heart of general practice since 1960

Caring for those who fall through the cracks

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She hobbled in on crutches, her face contorting with every step. Her brow shimmered with sweat as she sat down, looking up at the GP with wide, hopeful eyes.

They both looked at the door. After a long pause, Amelia shuffled in and perched awkwardly on the edge of a seat next to her mum, staring at the floor.  

The appointment was for her. She was a young carer for her mum, who had multiple sclerosis. A few weeks ago, she had started to self-harm. Amelia was 13.

It had started with a GP, who saw the disconnect between what her patients needed and what the system offered

Her mum left, blinking back tears and pleading with Amelia to open up. For a while it seemed she would refuse; the words like stones, held just under her tongue that she wouldn’t release. 

And then she started to tell her story. She was sick with worry. She lay awake at night thinking about their future, her fear amplified by the drunken yells from revellers next door punctuating the silence. The mould in their tiny studio flat was making her asthma play up. She was bright - she harboured a secret dream to be a lawyer. But she couldn’t concentrate at school.

I hated to admit it, but Amelia was one of those ‘heart-sink’ patients I dreaded. Every strand of her life woven together in such a way that stifled her potential. I felt helpless, backed up against a wall in a tiny patch of our labyrinthine system. Child and adolescent mental health services (CAMHS) services were full to the rafters, counselling would take months to materialise, and even contemplating her housing issue left me with a guilty sense of dread.

But I escaped that internal ‘head-banging’ that afternoon, because she wasn’t my patient. She was Dr Stephanie Lamb’s, a GP at The Well Centre in Streatham, which I was visiting.

That mental turmoil I described had frustrated Dr Lamb for too long. Five years ago, she decided to do something about it. She first sketched out the idea in a pub one evening with John Poyton, the director of a local youth-work charity called Redthread. After many late nights around the kitchen table, The Well Centre was born. Their vision was to create a holistic service for the neglected group that fall between paediatric and adult services, pushed from one silo to another at a time when seeking help is hard enough. 

It hadn’t been easy. With some funding from an NHS innovation award and Guys and St Thomas’s Charity, they ploughed on. They had no idea where the money might come from the following year. A group of local teenagers helped them to refurbish a mouldy, graffiti-ridden annexe. Youth workers, counsellors, and GPs were brought together under one roof; a one-stop shop wrapped around the needs of the young person at the centre.

It felt a world away from my usual experience of adolescent care: watching a whole person, with layers of issues replete with nuance and ambiguity, be collapsed into scraps of paper and flung into streams of a disjointed system. We’ve all seen it.

That afternoon I found myself watching care being delivered in a way I would want it to be, if Amelia was my daughter.

Dr Lamb had the help she wanted at her fingertips. She reviewed her inhalers, arranged for her to see a counsellor, and connected her with a young carers service. Amelia looked hopeful. I could see how she might begin to trust Stephanie, and take comfort from coming to the same, safe place.

She wasn’t the only one; 17-year-old Hayley came in next. Her 18th birthday was looming, and she had nothing to celebrate. She was about to be kicked out of foster care and into her own place. Her scrawny frame barely occupied half of the chair, as she repeated her monosyllabic mantra that she would be fine. But the fear in her eyes was palpable. Somehow, reaching that milestone signalled to the world that she was ready to go out on her own, and take whatever it threw at her.

Hayley had first heard about the centre from word of mouth, like 70% of their patients, and had drifted in and out for years. Stephanie had built a relationship with her over that time, and made regular appointments for the coming weeks with herself and the youth worker.

My memories from my psychiatry rotation were still fresh: the inpatients who rode the revolving door of the ward, grappling with depression and anxiety, staring into a future so bleak that it perpetuated their problems. Three-quarters of all lifetime mental health issues show before the age of 25. What difference could it have made to my patients if, 20 years ago, they had access to a service like this?

It had started with a GP, who saw the disconnect between what her patients needed and what the system offered, and channelled that into change. The potential to alter the trajectories of many young lives is hard to put into words.

As one young girl wrote, in an unprompted letter to the staff: 'I want you to know how much you mean to me and also to tell you to keep doing what you’re doing, the world is a better place with people like you on it, and I really hope that you can reach out and pull others out of the dark place, the same way you did to me.'

Dr Nishma Manek is a GP trainee in London. You can follow her on Twitter @nishmanek

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