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“Blaming disadvantaged patients has no place in care”

Most nurses provide a high level of care to most patients - but not all. It appears acceptable not to offer some groups of people compassionate care and for health services to discriminate against them.

Winter, hard-to-reach, health

There has been a lot of discussion around Compassion in Practice, which sets out the 6Cs - a set of values and behaviours that aim collectively to improve nursing at every level. It has probably generated much informal debate between nurses nationwide; some will welcome it but others will view it less positively, seeing it almost as an insult to them and the profession, maybe thinking: “If this needs to be taught, are we training and employing the right people?”

As a community matron in the health inclusion team, I work with some of the most discriminated-against groups, namely homeless people, sex workers, substance misusers and ex-offenders. These people experience multiple and enduring disadvantages and are cut off from the opportunities most of us take for granted. As a result, they are doubly disadvantaged by experiencing difficulty in accessing health services in general, and primary care in particular.

One explanation for this is stigma, which, in my experience, is common. I often hear comments about our clients - “dirty”, “smelly” or “it’s their own fault because they drink” - from my colleagues. Refusing to operate on patients who are obese has resulted in public outrage as this is viewed as discriminating against overweight people; this refusal, however, is based on sound scientific evidence that obesity is a risk factor for surgery. I am convinced no one would consider being disrespectful to a patient in the terminal stages of lung cancer through smoking. Yet it remains acceptable to use the “self-inflicted” label for people who experience cellulitis through drug use or frequent falls when under the influence of alcohol.

There is a high did-not-attend rate for these clients, which can lead to their gaining a reputation as “time wasters”. When a person is hearing or visually impaired, legislation demands the NHS takes specific measures to help them access healthcare, yet there is no such consideration for those with no permanent address who cannot be sent an appointment letter. Access could be improved for these patient groups by considering how their lifestyle affects their likelihood to attend, such as timing an appointment for a person with an addiction issue for when they are neither too heavily under the influence nor experiencing withdrawal.

Many users of the health inclusion service have mental health issues and often resort to drug or alcohol use as a form of self-medication. We may be quick to judge, but how many of us self-medicate, for example, by having a glass of wine at the end of a hard week?

During winter, many hard-to-reach groups experience significant emotional, mental and physical hardship. Surely a true test of compassion would be to consider their needs and ensure they are met? NT

Jane Morton is community matron for the homeless, Shelton Primary Care Centre, Stoke on Trent

Readers' comments (10)

  • Jane the world is a better place with you around.
    I saw on the news recently where homeless shelter to close because that council wants to save money.
    It is sad when to save money the first place is to look is at the poor and disadvantage to take a little bit more from them.

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  • See how easy it is to blame?
    I know someone who cannot eat in front of other people. I always think all this are the symptoms of other hidden problems. Could be self-worth or lack of confidence.

    I cannot understand why we should judge all these people, after all it may be you there

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  • Great piece Jane. The population I look after are a group that don't engage with healthcare very often I thought your comment "I am convinced no one would consider being disrespectful to a patient in the terminal stages of lung cancer through smoking" was interesting. As someone who has worked in lung cancer for a long time I have sadly seen how judgemental and disrespectful people can be. Maybe its a matter of scale?

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  • I agree with the main thrust of your article, however, I would disagree with some of your assertions.

    With regard to " Refusing to operate on patients who are obese has resulted in public outrage...". I think you'll find that the opposite is more likely to be true. I also recognise the experience of Anonymous | 6-Dec-2013 7:43 pm.
    It is sad but I think that in these times of 'austerity', we are experiencing less tolerance of others. People have become much more concerned with looking after themselves. We live in a time where people are classed as scroungers if they receive benefits; where, if they come from abroad to contribute to our economy, they are accused of being 'health tourists' and stealing our jobs and resources; where, if they are disadvantaged in any way, it must be their entirely their own fault.
    Tackling health inequalities is increasingly difficult in an intolerant society.

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  • A lot of the prejudice against disadvantaged groups can come from the admin/reception team who are in the front line of contact for disadvantaged groups.

    Whilst there are nurses out there who pre-judge, there are probably more unqualified staff who are causing a barrier. I have worked in many walk in centres and GP surgeries, on temp contracts and agency, and some of the attitudes displayed by reception staff never fail to depress me.

    "Waste of space" "another waste of taxes" "services wasted on these people" "just have to help themselves" .........are all comments I have heard in the last month.

    This week, one homeless man who pushes his meagre belongings around in a shopping trolley was told to leave it outside as it smelt. He did not want to leave it unattended (quilt/pillow/extra overcoat and a shopping bag with change of underwear and shaving gear) so sat outside in the cold, and when was able to be seen did not come in as he was terrified of it going missing. I went outside and brought him into my consulting room, with his trolley, and had to refer him to hospital due to heart failure. He was unable to get there, so had to call an ambulance.

    They took his belongings which I managed to get some bin bags for, but not his shopping trolley. The ambulance crew treated him well, which is more than I can say for the reception staff, who turned their noses up at him and gave sideways glances and complained that he smelt.

    What small, privileged worlds some people live in.

    The growing amount of young and middle aged men who have broken down and cried because of the situation they find themselves in through circumstances they have no control over gives me sleepless nights. Redundancy, zero hours contracts, impossibly high standard of living and keeping a home and family together is getting harder and harder.

    The horrible media who blame unemployed people for being made redundant, blame the poor for claiming what they are entitled to, and practically blame them for existing in the first place, lack of housing, food banks, hungry children at school, the miserable list goes on and on.

    Roll on the next election. Things were not this bad under the last lot, despite the continual harping on about the "deficit" which is wearing a bit thin now. At least the poor had more protection and were not going hungry.

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  • some admin and reception staff do not seem to have adequate training in people skills which is an extremely important part of their job as they often give the service user the first impression of the organisation charged with providing their care.

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  • Yes a lot of admin and reception staff need to have compassion.
    Some are just so rude.
    Only recently I had poor reception experience from the GP surgery when I asked for a nurse appointment.
    They wanted more details than I care to give them, then was not at all helpful, I asked to speak to the manager, spoke to the reception supervisor who was just going to stand by this unprofessional receptionist and even lied about appointments times.

    It is true our society is getting very uncaring and selfish toward people right here around us.
    One does not have to shave their hair off or climb the highest mountain so every one can see how good we are, just give a little care when it is needed.

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  • My colleague had a homeless man in with a nasty festering wound a few weeks ago, which he needed anti-biotics for, but he had absolutely no money for a prescription. She said if there was a cupboard that she could have just taken them from, she would have given them to him. During the consultation she asked him about his circumstances. He was ex services, with 2 tours of Afghanistan under his belt. His girlfriend and daughter left the matrimonial home whilst he was away and when he returned it was going through re-possession, too far to reverse. So he was made homeless. He spiralled downwards. And now he cant even obtain anti-biotics for his cellulitis.

    Whatever the spiral downwards involved, whether drinking or taking drugs to alleviate his miserable position, does not need to be judged so harshly by some.

    The receptionist cleaned after him, when he stood up to go into the consulting room, she cleaned the chair in front of everyone waiting. And even sprayed the room! She never said goodbye as she did to all the other well heeled clean people, just turned her nose up.

    Its odd that the nurse concerned could have been brought before the NMC for taking medication out of a cupboard for the best of reasons; yet this odious receptionist escapes scott free for her selfish and inhuman behaviour.

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  • Anonymous | 9-Dec-2013 12:03 pm: well said.

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  • michael stone

    'It appears acceptable not to offer some groups of people compassionate care and for health services to discriminate against them.'

    It isn't acceptable to me - this Goverment seems to be quite strong on things like 'the deserving and undeserving poor' and perhaps on 'the underserving ill' - well, that is where the hideous Nazi policies, and the infamous US syphilis study, came from, isn't it ?!

    'Sticks' have got no place in a humane health care system - 'carrots' and advice, fine, and even some 'rationing' of [types of] care might be necessary, but despite some medics supporting this 'the undeserving ill' stuff, I find it lacks all humanity !

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