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'My time has been split between district nursing and prison healthcare'

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Communications and engagement manager Martin Machray reflects on his experiences during two very different placements, as well as on the future of clinical practice in primary care.

Over the past four months, as I’ve studiously undertaken my return to practice course, I’ve been fortunate enough to work in two excellent but very different clinical placements. As I come to the conclusion of the course I have an opportunity to say thank you to everyone who has put up with me in both of my placements and to reflect on my experiences as I think about my future. At the same time I can also reflect on the future of the profession as I see it, particularly in primary care.

My clinical time has been squeezed in between the demands of a full-time job and split between a placement with a district nurse and a prison healthcare team. The differences between the two settings are both stark and glaringly obvious. To begin with, the demographics of each client group is markedly different. On one side of a literally very high divide, I work almost exclusively with young men. On the other side, my patients are mainly elderly and predominantly female.

Their healthcare needs are also very different. Most of the prisoners I meet don’t “need” healthcare at all. They are often fit and healthy but when they do need support the majority of their needs are linked with mental health issues. There are of course a range of other things with sexual health and concerns around cross infection (Hepatitis, TB, HIV/AIDs etc) all presenting significant challenges.

Things are very different in the wider community. Most of the patients I see have long-term physical conditions exacerbated by old age. Memory loss, physical decrepitude and frailty all contribute to intractability of otherwise treatable conditions.

Perhaps the most obvious differences between the two client groups is the environment in which care takes place, although it would be an accurate description to say that in both cases care is delivered in the “home environment”.  However, when working “on the district”, home often means small front rooms of compact flats, sometimes alongside the welcome offer of a cup of tea on arrival. Not that there is ever time for that and in some houses you look at the state of the kitchen and you’re glad you’re too busy to accept!

Very unlike the prison environment, particularly as the majority of primary care is delivered “on the wings” and not in the slightly more clinically familiar environment of the healthcare wing.  Victorian cells are converted into consulting rooms but there is no disguising that they remain Victorian prison cells.

It is the environment in which one can start to see some all too close similarities as well as differences. How often have my elderly community patients told me they feel like prisoners in their own homes? Their age and health, stairs and broken lifts all acting as warders and bars, keys and chains, preventing their longed-for release. This imprisonment is as real and seemingly unchallengeable as it is to my other, younger clients. Working in people’s homes brings challenges to the delivery of any health service. My ability to do the very best for patients is somewhat restricted by the two environments, neither of which were originally designed for caring. At least in this regard the prison has the slight advantage of always having hot water and soap available – something that is not always seen as a pre-requisite of some community clients.

Given the isolation people experience in both settings, it seems common for my patients to look to either the nurse or the volunteer to fill the void where once there may have been human contact, warmth and affection.  Loneliness and fear are perhaps the most common emotions I have witnessed in my patients. As a profession our biggest impact is not necessarily therefore the application of our clinical skills but the emotional support we invariably provide. Long ago as a student nurse I was told that the patients on my ward would look to me to confide in and seek support from rather than the senior staff or medics. I now know that was the case, although I’m not sure I really understood it at the time. On my return, I was all too aware that the emotional and social needs remain and patients need us more than ever.

So as I look to the new year in a world of cuts and austerity, I worry that it will be increasingly difficult for society, and our profession to continue to meet the needs of our patients and clients. The prison population grows in synch it seems with increasing social isolation more generally and that provides a challenge for me and our profession in 2011.

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Readers' comments (1)

  • George Kuchanny

    Nice article Martin,
    All too often we are blinded by 'scientific remedies' when in fact the placebo effect of caring is vastly underestimated. Before 1935 this was effectively the most powerful general remedy available to doctors and nurses. There has not been a Big Pharma remedy as effective as antibiotics coming out of research for at least the last decade.
    The problem here is that complex social issues (for instance the decline of the extended family who keep an eye on granny and the social isolation of your young men) are not really amenable to the rather expensive 'medicalisation' of the problem in the long term.
    So what to do? When we have an answer, I have none by the way, there may be light at the end of our particular tunnel.

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