The first word that comes to mind after a morning spent in the surgery of Glasgow GP David Blane is complexity.
The first patient of the day has mild learning difficulties and is struggling with pain in his arm and low mood. He has recently had a stroke. And now it has been suggested by a hospital consultant that he should be prescribed pregabalin. His consultation requires conversation about all of these issues and advice and guidance around this new, strong, treatment.
Our second patient is an Eastern European man with a history of heroin addiction and HIV in his 40s presenting with chest pain, abdomen pain and cirrhosis – he candidly describes this as ‘my fucked liver’.
Then Dr Blane ponders the case of a woman with type-one diabetes in her 30s who has depression, suicidal ideation and a host of adverse childhood experiences – and the means to take her own life with insulin. The local mental health team isn’t able to support her because their services are so stretched they struggle to deal with anything but the most catastrophic crisis.
Dr Blane also looks after an Iranian Christian forced to flee his home country owing to being at serious risk of persecution whose life has fallen apart after a marriage breakdown and a serious accident, a man from Pakistan who has had liver problems and also presented at the emergency department with chest pain, a three-year-old with croup and a mum desperate for help in the form of antibiotics, another patient with a street Valium addiction, and a woman in her 80s whose blood pressure plummets when she gets out of bed.
I can’t imagine how hard it must be to trust anyone given what my patients have been throughDr Blane
Finally, we see a young man who comes to Dr Blane with fears around what his likely diagnosis of Ehlers-Danlos syndrome might mean for his future life chances and who is also struggling to stay in employment owing to severe back and knee pain on top of major difficulties with anxiety, depression and suicidal ideation.
‘Even just observing for a morning can be quite tiring, can’t it?’ Dr Blane says when the first eight patients have been dealt with, reflecting on the dizzying array of need we have seen in the space of just an hour and a half.
Empathy
For Dr Blane, who is primarily a medical academic but works clinically one day a week here in the Pollokshaws medical centre, this is a quiet day. There is even time for a rare tea break. For a tired observer, this seems anything but quiet – and a 10-minute tea break hardly feels like presenting the headspace needed to cope with the scale of people’s need for help in this community. Is that sense of overwhelming need – and particularly the trauma that rests in the past and present of so many patients’ lives, often defining much of their future – something that rests heavily on Dr Blane?
‘I don’t feel like it affects me as such,’ he says. ‘I just sometimes think I cannot imagine what that would be like. I know I’m not personally impacted by the trauma but I feel for them. I can’t imagine how hard it must be to trust anyone given what they’ve been through. For me it’s a helpful lens to understand why people don’t necessarily behave the way I would in any given situation.
‘My parents got divorced, but they were decent people and good parents. They didn’t beat me up or sexually abuse me but there are many people here who can’t say that. And often it’s not spoken about. Lots of things are swept under the carpet and go unspoken because they can be deeply shameful or people internalise those things. It manifests at some point and often that will be with mental health or physical health symptoms.’
My parents didn’t beat me up or sexually abuse me but there are many people here who can’t say thatDr Blane
Dr Blane adds: ‘The things that maybe keep me awake at night are where I feel that there is real suicide risk, and there was one case that wasn’t a patient of mine but was at the practice and did kill herself. When that sort of thing happens it really sticks with you. You are always going to think, is there anything we could have done to prevent that?
‘For me, I think working clinically just one day a week is protective. I think that sets up automatic boundaries in terms of coping.’
The practice sits three or four miles south of the city centre on the Eastern flank of the massive Pollok country park. This – like so many parts of the UK’s most populous and significant cities – is a place of great contradiction. It is an area with pockets of striking, grand, Victorian housing, occupied by young professionals and affluent families on streets marked by independent bakeries and coffee shops. But there is also significant deprivation, poverty and need here – tower blocks and high-rise housing still loom large over local skylines. Here, the inequality and inequity rife across the UK is up close.
This deprivation and, particularly, the effect of economic and social policy on areas such as this are a huge driver of health need.
Dr Blane says: ‘The context for this practice and these patients is a decade-plus of austerity. If you look at the way services have been cut during this period it is the communities already struggling the most whose services have been cut the most. The notion that we were all carrying an equal burden on our shoulders was just fanciful. Food insecurity and fuel insecurity have increased. All these issues are more common.’
BLANE: Some patients are lost to or ignored by the system
Dr Blane adds that ‘missingness’ – patients just lost and ignored by the system – is a real problem in this area and has an interest in improving access to care. ‘We have patients who report that they very rarely leave the house,’ he says. ‘Levels of anxiety in particular are really high.’
It is working with patients of complexity – who most need general practice and anticipatory care – that inspired Dr Blane to follow the career path he has, working in one of the practices which serve Scotland’s 100 most deprived communities, and pursuing academic work in crucial areas such as food insecurity, social risk factors on health, access to healthcare and the organisation and delivery of care for people with multiple long-term conditions.
Skipping meals
Dr Blane is also the academic lead for the Scottish Deep End project, which sees GPs serving the most socio-economically deprived communities working together to advocate for greater resources where needed the most.
It is a project which advocates for general-practice hubs providing answers to healthcare challenges such as multimorbidity, fragmentation, increased pressure on emergency services and static (or worsening) inequalities in health. The project aims to improve the care of patients and make general practice an attractive career option to recruit and retain sufficient numbers to provide the services these communities need.
It is likely the difficulties faced by doctors and patients in communities such as these are only going to become more entrenched, with such a strong sense of economic and political perma-crisis engulfing domestic and international narratives – from the effects of Brexit and the pandemic to austerity, the cost-of-living crisis and war breaking out in Europe.
Levels of anxiety in particular are really highDr Blane
Last year, Deep End practices published a series of stories from the front line – outlining the effect of the cost-of-living crisis on patients’ lives every day. They tell of parents skipping meals so their children can eat but who still feel like they are failing, housing without basic washing facilities, people with diabetes swirling out of control and unable to eat nutritious food owing to relying on food-bank basics, lives blighted by panic attacks, two-year waiting lists for vital trauma psychotherapy and an overwhelming sense of hopelessness.
In 2022, Deep End GPs from across Scotland – alongside charities and community organisations – met, in a round-table meeting, to discuss the challenges of the cost-of-living crisis and how general practice can support patients experiencing financial hardship, with the link between poverty and poor health and widening health inequalities well established.
The context for this practice and these patients is a decade-plus of austerityDr Blane
Participants covered fuel poverty, inadequate housing, food insecurity and access to health and care services amid rising transport costs – discussing how to build teams and community hubs to challenge all these issues. But those present at the meeting also noted the effects working in these environments – with ever-increasing workloads amid so much trauma and suffering – was having on staff and agreed morale was ‘as low as it has ever been’.
In the face of all the evidence, the case for increased investment in, and focus on, general practice and anticipatory care in the most marginalised and disadvantaged communities is tough to ignore.
As former BMA president Sir Harry Burns once wrote: ‘What we need is a compassion that stands in awe at the burdens the poor have to carry, rather than stands in judgement at the way they carry it.’
Advocates such as Dr Blane will continue to make exactly that case.
(Images by Douglas Robertson)