Sunday, 15 April 2012

Not so Much Care in the Community as Care in a Cubicle

Well I enjoyed my holiday at home week. Although the weather wasn’t always kind, some much need TLC was lavished on the gardens, the long list of outstanding household jobs has been reduced to a very short list, pub lunches were consumed, books read, Cello had his hair cut, friends and family visited, first ducklings of the year seen at high Rid and all the Easter Eggs finished off. There was also no excuse for me to not catch up on attending to neglected health issues. Of course I admit to contributing to the evidence base that shows men, in general, are 20% less likely to visit their GP than women. In fact ‘50 something’ men are the worse culprits. But if my experience this week is anything to go by, it is not surprising that men maybe reluctant to seek help.

My appointment, made on line some 18 days before, was for precisely 10.10am. And although my reasons for the appointment were not life threatening, just an irritating flare up of a form of eczema, caused by a chronic and longstanding circulatory problem in my legs, at 10.40am I was still waiting to be called in. The man sitting next to me had been waiting for 60 minutes (but in fairness he didn’t own a computer and didn’t realise that these days an appointment was required). He was still sitting patiently when 6.5 minutes later I left the practice clutching my 2 prescriptions.

In that 6.5 minutes my GP told me I couldn’t have the treatment I wanted as (1) it wasn’t advocated in the best evidence to date, (2) the NHS was running low on funds and we all had to do our bit. So much for consumer and patient choice, especially so when I thought of what I had done to help prepare a generation of doctors to treat such a condition.

Some 33 years ago I had been stood on a table in a room full of medical students, my legs covered with felt tip pen tracks that traced my veins. For the next 40 minutes I endured the medical students taking turns to inject my varicose veins before each leg was tightly bound with compression bandages. I can recall not being able to take a bath for weeks and having to walk 5 miles each day until the bandages came off. These days the preferred approach is steroid cream for the eczema, and compression stockings to be worn daily. And unless the legs become infected that’s all my GP would do. So I dutifully took my prescriptions to Tesco’s to get both filled. The steroid cream was no problem, but the stockings had to be ordered.

The pharmacist was apologetic on 2 counts – that she had to order the stockings and that I would have to pay for each item (1 pair of stocking do not 1 item make). The current prescription charge is £7.65 (but this equates to £15.30 for a pair of elastic hosiery). As my GP had helpfully prescribed 2 pairs of stockings (presumably so I would always be able to wear a pair even when a pair was in the wash) the total bill came to £38.25. However, included in this price was a private consultation and personal measuring session in a made to measure state of the art health care cubicle. I was impressed.

During the week I had read a PhD thesis on 'compliance and coercion in mental health care', and my experience did make me think of the impact on treatment compliance of such a high total prescription bill. England is the only one of the 4 countries in the UK to make such a charge. The Department of Health says that scrapping the charge in England would result in a shortfall of some £460 million a year (I can see where my GP was coming from now with his cunning approach to prescribing). In 2011 prices this money would buy nearly 18,000 nurses, or 15,000 midwives, or over 3,500 hospital consultants. I don't know how many Tesco employed pharmacists the money might also buy.

And these numbers, more so than the cost of my prescription, made me think of what the potential loss of that number of health care personnel might mean in terms of health promoting opportunities. Those working in the health sector (which increasingly has to include supermarket provided health care) have an unique access to the general population. According to the Institute of Health Equity (who last week launched a consultation on the role of the health care workforce can take in positively influencing the social determinants of health and tackle health inequalities) the NHS deals with 1 million patients every 36 hours. That’s 463 people a minute or almost 8 a second.

Each week, 700,000 people will visit an NHS dentist, 3,000 people will have a heart operation, and each of the 40,000 GPs employed by the NHS will see an average of 140 patients a week. There are some 1.4 million people working directly for the NHS. Additionally there has been a 60% increase in supermarket pharmacies in the last 12 months, and 20% of all prescriptions are filled at supermarkets. Such supermarket provided services offer an increasingly diverse range range of health care advice and services.

Like the Institute of Health Equity, it seems to me there is huge potential to influence health inequalities through the contact health care professionals have in both their direct patient contact at key points across the full life course (before, during and after birth and at times of illness). Despite Shipman, and Allitt, most health professionals are highly trusted and every encounter is an opportunity to promote good health and well being and take action on addressing the cause of cause of health equalities.

And I haven’t always been a '50 something' male statistic, health promoting health care professionals is a cause dear to my heart and if you want to know more see:

Holt M., and Warne T., 2007 Pushing at an open or closed door: Training Pre Registration Student Nurses as future Health Promoters. Nurse Education in Practice 7 373 – 380

Carlson G., and Warne T., 2007 Do healthier nurses make better health promoters? A review of the literature. Nurse Education Today. 27 506-513

Warne T., and McAndrew S., Health promotion and the role and function of the nurse. In: D. Whitehead & F. Irvine (eds) 2009 Health Promotion and Health Education in Nursing: A Framework for Practice. Palgrave MacMillan, London
And I am sure, like me you will all start to see BOGOF ‘care in the cubicle’ offers at a supermarket near you soon.