Confessions of a GP

Class

After I call out my patient’s name on the tannoy, it takes approximately 30 seconds for them to walk from the waiting room to my consulting room. In these 30 seconds I usually have a look at the patient’s address and before they have even knocked on my door, I have already made many sweeping judgements about their health. I’m not proud of this as these assumptions are based purely on the street they live on. I know the local area well and, as with most towns, there are some streets with nice posh houses and others with small impoverished council flats. Class shouldn’t play a part in how I treat my patients but it has such an effect on how people look after their own health, I can’t help but consider it. This might simply sound like my middle-class prejudice but I promise you it isn’t. Life expectancy for people in the lower social classes is significantly shorter than for those in the higher social classes and, in fact, even when you take out the risk factors of smoking, poor diet and obesity, simply being from a lower socioeconomic class independently increases the risk of having a heart attack.

From a personal perspective, I have worked in hugely different environments, from surgeries in inner city council estates to a surgery deep within the wealthy country lanes of the Home Counties. The difference in the sort of health problems seen is extraordinary. Issues such as smoking, teenage pregnancy and obesity are three of the biggest health problems that the UK faces today, but although they get a lot of publicity, it is very seldom pointed out that they are principally conditions of the lower social classes. Of course, there are a few posh people who are overweight and smoke and even the odd rebellious private-school girl who gets pregnant, but ultimately these medical burdens are more related to a person’s social environment than anything else. The onus is being put on to the NHS to solve these problems and, yes, we have a role to play, but ultimately if we could improve housing, education, attitudes and expectations, I think health would improve all on its own.

In most areas of our society, class is still extremely divisive. Our social class decides where we live, socialise, go on holiday and even where we buy our groceries. In many countries, private medicine ensures that class remains a divisive measure when it comes to the accessibility of healthcare. The NHS, however, means that the GP surgery is a bit of a melting pot for everyone. My waiting room can contain the posh ladies who lunch, sitting next to the homeless drug addicts who do crack. In theory, they should all get ten minutes of my time and have equal access to the NHS services available, but, of course, the reality is very different. Obviously, having private healthcare helps to oil the path to seeing the best doctors quickly, but even without paying, middle-class educated patients get a better deal. They ask more questions, are more demanding and are better able to access services available on the NHS. This has to go down as a failing on our part as doctors because we should be empowering our less-demanding and less-privileged patients with the information they need to get the best care available.

There are some wonderful GP surgeries in very poor parts of the country and they do a fantastic job; however, some of the surgeries in poorer areas are run down and unloved, with unmotivated and unhappy staff. The surgery on a council estate I know of is an example of this. It is very busy because there are a lot of social problems on the estate and, as I’ve mentioned, social deprivation breeds medical problems. The staff have been threatened and the surgery keeps getting broken into, which doesn’t help morale. Also there is the issue of money. I’ve talked previously about how GPs make money by hitting targets. This is a generalisation, but middle-class patients tend to be more active in managing and maintaining their own health than more socially deprived patients. This means that they are more compliant with medication and keeping appointments. Motivated healthy patients make it much easier for the GP to hit targets and, hence, earn money. The patients on council estates often have quite difficult, chaotic lives. If they miss their asthma review appointments or don’t take their blood pressure medication, then this directly influences how much the doctors earn.

The reduced earnings of the council estate practice and low morale mean that it can’t attract enthusiastic, dedicated new doctors. There is no shortage of GPs locally but the surgery on the council estate is currently being run by a series of locums. This is because one of the permanent doctors is on long-term sick leave with stress-related problems and, despite advertising, they can’t find a GP to fill the other vacant post. The locum doctors never get to know the patients and as a result are generally fairly apathetic and disinterested. It is the patients who lose out. Middleclass patients would often demand improvements or move to a new surgery, but the patients on the estate often don’t have the means to do this so put up with a poor service. It is yet another example of a two-tier health service. Nye Bevin must be turning in his grave.