Sunday, 10 August 2008

Living for the city

Don't know quite what I'm doing up at this uncivilised hour on a Sunday morning. Can't sleep. Anyway...

Have been doing a few interesting things this week. On Friday I met GPs from Charlotte Keel Health Centre, who are concerned about the Government's plans for extended opening hours and the PCT's plans for another GP service at Eastville Health Centre. The thrust of what they were saying 'though, is that the Government's primary health care agenda doesn't take into account the differences between running 'normal' GP practices and inner-city ones.

First issue is about funding. They are paid according to the number of patients on their books; they have 17,000. But, they say, whereas a GP service in Westbury-on-Trym might have a similar number of patients, the amount of attention they require is vastly different. In Westbury, an average patient might pop in to see their doctor once a year, if that. They are pretty good at managing their own conditions. At Charlotte Keel, it's a different picture. Many patients have a multitude of problems, from chronic illnesses to mental health problems to what could be termed lifestyle issues (drug addictions, obesity, poor housing conditions). A very high proportion are from BME communities; many have English as a second language or don't speak it at all. A fair proportion are asylum seekers, or failed asylum seekers. So even the process for registering a new patient takes a lot longer, and then there's the need for interpreters, longer appointments, etc. But it doesn't matter whether a patient comes in once a year, or twice a month; whether they take 2 minutes to ask for a repeat prescription, or 20 minutes to explain with the aid of an interpreter what exactly is wrong with them. The funding is the same. (I've had similar representations made to me by the advice services sector - running a CAB in central Bristol is a different kettle of fish to running one in Tunbridge Wells, but they get funded on the same 'average case' basis.)

The second point was about choice. Their argument was - to summarise very crudely, possibly at the risk of misrepresenting them slightly - that choice is a middle-class issue. Their patients don't need extended opening hours (mostly because they don't work, or could take time off or don't like going out after dark) and shouldn't be using walk-in centres because GPs there wouldn't have experience of dealing with people from BME/ deprived communities and they wouldn't be able to explain their conditions to a GP who didn't know their full medical history. (Although some of this could of course be addressed by a shared database). I wasn't convinced by their arguments on these points, but I did appreciate their unhappiness that GPs tend to be portrayed in the media as overpaid fatcats who want to knock off early so they can go and play golf, whereas the reality for an inner-city GP is very different. (Same with solicitors - being a Legal Aid lawyer and a corporate lawyer are completely different jobs - and I speak as someone who's done both - but they get lumped together (although in defence of the latter, they do work incredibly long hours for their hefty pay packets). And a big difference between being an inner-city MP and Sir Somebody-or-Other who represents a leafy constituency in Surrey or Hampshire. But I never seem to get anywhere when I make that point, so let's leave it at that). I'm going to do a constituents survey on GP opening hours soon, and this has served as a reminder that I ought to make sure some of those surveyed live in the inner-city wards.

One of the interesting minor points the GPs mentioned was Vitamin D deficiency. They said it affects a huge number of people on their books, particularly within those BME communities who tend not to expose their skin to sunlight, or, indeed, to go outdoors as much. It can be easily treated with vitamin drops but, the GPs said, it would be far better if these were distributed to people as a matter of course, e.g. given to everyone in inner-city schools, or available for cheap over-the-counter purchase. That would be far more effective than requiring GPs to diagnose a deficiency and then prescribe treatment. I'm going to look into where we are on that issue; I know it's not the first time it's been raised.

1 comment:

Anonymous said...

I appreciate that this is a report of a meeting and that what was said may have been far more nuanced but there are some issues here:

1. The issue of interpretation/translation.

In my experience of working in the inner city there's virtually an inverse relationship between the amount public sector professionals push this as an issue and demand significant amounts of scarce and valuable resources for it and the actual take-up and demand for it.

I'm willing to bet this is an issue that affects barely one per cent of patients in the practice.

This begs the question: why skew resources towards it at the direct expense of the majority?

Surely the key word here is General Practice? If people have specialist problems around language shouldn't there be a centrally-based and centrally funded (by all GP surgeries) Specialist Practice?

Quite why the poorest communities should be left to pick up the tag for specialist services like these while the richer communities get to feel all smug about the wonders of a multicultural society is a mystery to me.

2. "Choice is a middle-class issue."

I don't know a great deal about the whole choice agenda and it may well be a bad thing but to criticise it as being middle class seems a little weak.

Have they got any evidence for this? Or is it the same kind of lazy assumption that says it's only the middle classes that compete for school places while the working classes don't care and treat education as free childcare?

I also find it slightly disconcerting when £100k a year public sector professionals start deciding on our behalf what we do and don't want without bothering to ask us.

As a former user of the practice I don't recall ever being asked my views on the future of health care provision. Presumably they've formed my opinion for me then?

3. Their patients don't need extended opening hours (mostly because they don't work, or could take time off or don't like going out after dark).

I'd like to see the evidence base for this one. Statistically I bet most of their patients do work. Perhaps they just tend to see the ones that don't?

As for this claim that people are able to take time off easily. This displays a total ignorance of the labour market that many of their patients are in.

Having worked extensively in temporary and unstable jobs in factories, warehousing, call centres, light engineering and much else for many years I can tell you that taking time off is simply not that easy, regardless of what the law might say.