Ghettoes medicine

Many of us as GPs are feeling the battering of constant changes, and a growing instability of British NHS primary care. I’m regularly concerned for its recipient - the patient. 

Two things come to mind. One is my traveling scholarship which I received upon qualifying from med school. It enabled me to study the provision of primary care paediatric services from within the tertiary setting of the Albert Einstein College of Medicine in the ghettoes of South Bronx, NY.  Secondly there’s Molly, a delightful 82-year-old spinster who has changed practices to join our GP team here in Nottingham recently.
 
Back in 1981 in the South Bronx, it was considered innovative to begin providing primary care, including basic immunisations and feeding advice to young mothers from the base of a high-powered, obviously expensive tertiary referral center such as the Albert Einstein College Hospital.
 
I understood the need to do so when I stayed in the ghettoes, experiencing, and witnessing the breakdown of communities, and services there. As a med student, I had seen British GPs with Health visitors, and Community Paediatricians in Nottingham taking care of these basics, and even much more complex needs of patients in their communities close to home- and so much less expensively!
 
Sadly there are many pockets in Nottingham today where there is evident community breakdown, and a struggle to maintain core medical services. More sadly and ironically where there are stable communities and providers of care with well intentioned and established primary care services, there are threatening and sinister forces bringing much destabilization to both providers, and recipients of basic, and time proven, cost effective health care.
 
Having had significant experiences of life in Uganda, and India, and having gone to the Bronx from my medical studies in Nottingham, I felt then, and continue to feel today, that the well trained and supported British GP in primary care provides unbeatable value - which brings me to Molly!
 
Molly though an octogenarian herself has been fit enough to care for Arthur, her 88 year old widowed brother-in-law with dementia.  Arthur is happily oblivious of his condition and needs supervision for his activities of daily living.
 
Molly cooks, cleans, shops for him - and lovingly cares for him, reminding him constantly of the mindful connections we all need to proceed with the most basics of daily life. It was through coming with Arthur that Molly decided to change to our practice. This time she had come on her own. She said she did not wish to take much of my time, but could I please repeat a prescription that the nurse at her previous practice had been prescribing for her bottom. She handed me a piece of cut out card – the back of a cornflakes packet on which she had neatly written Xyloproct.
 
I had to prise Molly’s history out of her, as she was very embarrassed. She had put up with painful defaecation for a ‘long’ time and admitted to feeling as though there was ‘something there’ she needed to ‘push past’. Unfortunately at the tip of my examining finger was a hard cauliflower-like cancer in her rectum.

Prising out a history, and the ability to get such a patient's trust and agreement for a rectal examination is a skill that GPs develop over time. 

It's a delicate balance, but  we need a system where GPs aren't completely disengaged from patients who  on the surface may seem to need mainly the 'softer' caring skills - Molly's cancer may have been picked up sooner if she had seen a GP.

One key person holding the patient's hand throughout remains invaluable - and only takes 10 - 15 minutes of consulting time if this person is a GP.  We shouldn't allow this to become extinct.