Working as a GP with vulnerable people

Two years ago Dr Peter Gough left the semi-rural practice in Royston, Hertfordshire where he had been a partner for 29 years. Since then he has done a mix of teaching and locum work and volunteering once a week or fortnight with the charity Doctors of the World UK in its clinics in east London.

The clinics aim to help vulnerable people who would otherwise be unable to access healthcare, including refugees and undocumented migrants, some of whom may have been trafficked or victims of torture, sex workers and people with no fixed address.

‘I’ve always had a desire to help vulnerable people – it is after all why I did medicine in the first place, and I spent some time in India with a charity which I helped set up around 16 years ago,’ Dr Gough explains. ‘I’m now in a very fortunate position, because I am still doing NHS clinical work, in that 10-minute-appointment world, but it’s the volunteering work that really keeps me engaged.’

Excluded people

Dr Gough works principally in Doctors of the World’s Bethnal Green clinic, which sees people from all over the world. The clinic aims to provide excluded people with access to a GP by advocating on their behalf and it also provides direct medical care when necessary.

Often the patients who attend the clinic do so because they are worried about the expense of care, fear being reported to the authorities or cannot register with a GP because they don’t have identification or proof of address.

‘It’s a tiny little place; we have two clinicians, and a half dozen or so support workers,’ Dr Gough explains. ‘A lot of our patients are the opposite of "health tourists"; they don’t realise they can access primary health care or they have been living under the radar for one reason or another.

‘Others have tried to register with GP practices but have been turned away because the practices don’t realise they can register people with no fixed address.’

The clinic provides one-off appointments with GPs, meanwhile volunteer support workers also meet patients and help to advocate on their behalf, including directing them to organisations that can offer counselling and/or provide advice and help to deal with hospital bills.

If a patient requires immediate care the volunteer GPs can prescribe medication (using a local pharmacy that bills Doctors of the World) and write letters to and liaise with primary and, if necessary, secondary care to help patients get the treatment or ongoing primary care they need.

‘As a GP, I think it is important that I can give a practice the information my other GP colleagues need to take that patient on,’ Dr Gough says.

The usual, at extremes

As with any other day in general practice Dr Gough says he has absolutely no idea who will come through the door. The clinics operate on a ‘first come first served basis’, with access to interpreters through a three-way telephone line.

‘A lot of what we see is the usual conditions, in a very unusual context and at a far later stage,’ Dr Gough says.

‘For example, people with diabetes, or underactive thyroid or breast cancer, who’ve never had treatment or who have run out of treatment; and a lot of people with acute stress. Some come in from being tortured overseas; others come in after being beaten or attacked here.

‘Recently, a Middle Eastern man came in with a very swollen arm. He’d had no medical care for the three years he had been in the UK, and spoke no English – he brought his 11-year-old daughter with him to interpret. I explained to him, through her, about lymphodoema and wrote a letter to take to a GP surgery to register there.

‘Then there was a young man who’d been in the country for a few years. He’s had a limb tumour for at least three years now. It’s not life-threatening but it is giving him huge pain and a lot of problems. His mother has leave to remain in the country but he has been refused permission to stay even though he has nobody back home, so it took a lot for him to approach us in the first place.

‘He took himself off the list for treatment when he was told he’d have to pay, so for three years it’s been growing and getting worse. I think I was the first doctor he’d seen in some years. I examined him and rang the practice where he was originally registered and spoke to a very helpful GP colleague and we decided that we’d try again to make a case for the hospital to treat him.

'Once it’s treated he should be fine, but there will probably be life-long effects, because it has got to this point first.’

Remembering why I did medicine

Dr Gough is now applying to do an MSc in medical education, but plans to continue with Doctors of the World, helping with new initiatives in east London and supporting the care of newly-arrived Syrian refugees.

‘I think the essence of general practice is to think in a wider context,’ he concludes. ‘Working in this way re-energises you, and keeps you motivated; it also makes you appreciate what the NHS can offer.

‘What these people really need is primary care so that they can feel safe and get the right treatment. I go away remembering why I did medicine in the first place. If we weren’t there, they wouldn’t get a service. You do the best job you can as an NHS GP, but these people would get absolutely nothing.’