Starting work in a refugee clinic in London

Six months ago, I decided that I wanted to improve my French. I learnt it at school and I had spent three months in Paris before starting GP training so I wasn’t bad at it but, like all skills, if you don’t use it, you lose it. Rather than opting for classes which I knew would never last, I decided to skills-swap. I cold-called the Notre Dame Refugee Centre in London six months ago on the off-change they needed a doctor and lo and behold they had a vacancy! The centre, located in Leicester Square, was set up for the francophone population but has an open door policy so half the clients are English-speaking. They mainly do advocacy work for housing and immigration but they also have a cafe where local restaurants donate food and they offer also classes in IT, English, yoga and all sorts run by volunteers.

My role is more as a health advisor rather than a GP but being a GP definitely helps! The mainstay of my work is non-clinical and my indemnity staying the same reflects that. I have a telephone and a laptop that is so slow that it makes the NHS look good and I sit behind a partition board in a shared room – not great for patient confidentiality – but actually we don’t talk much about personal things. I give the only private room in the building to Barbara, the counsellor as I’m sure her patient need privacy more than mine.

The background stories of my patients are harsh and so far removed from my middle-class life of first world problems. I don’t get to go much into why they fled their countries (and not all my patients are asylum seekers or refugees) but I certainly get an insight into their lives now. I have ladies who couch-surf and get body aches and pains because they sleep on a different sofa every night who are on neuropathic drugs for chronic back pain. I’ve got men who sleep in mosques or walk an hour-and-a-half a day to find a new bed in a shelter for the night who don’t take their regular medications because they’d rather eat. Having the time to understand their background makes me realise only how little I can achieve overall as a doctor without the necessary infrastructure and support for my patients. However, I make myself feel better by knowing that I am that friendly voice helping them navigate the system. The dynamic between myself and the patients at the centre is different to my NHS work. Perhaps it’s because of the safe space it creates or that they know that we’re all volunteers but there’s less of an us vs them mentality and the consultations are more collaborative even though I feel more free to be frank with them here.

The vague feelings that were thrown up by my time at this clinic was crystallised by a chat that I had recently with my medical student friend (who is so smart that I forget that he’s 14 years younger than me) about his systematic review (I know!) on the gradual move at policy level to create patient choice. I am all for patient empowerment but reading his review highlighted the question of “are we introducing inequity by introducing choice?”. Being able to choose your services and your appointments may inadvertently favour the educated and leave the vulnerable at risk and this is so apparent at my volunteer clinic.

One of my patients turned up and handed me three cancellation letters which he had received in the post and there was nothing to indicate which of his two referrals, that had been made by his regular GP, was being cancelled. In my daily practice, I feel that patients booking their own appointments is genius and totally advocate this (and still do). Any problems they would have I would signpost to the practice secretary but, here, with the benefits of time, I decided to call the numbers up to find out what had happened. The eRS advisor gave me two dates and the hospital gave me two different dates. I am a native English speaker and I am a GP and I was confused! We decided that he was better off attending the dates given by the hospital as they were closer in time but what a mind-f*ck?! How was he to know that you could call the hospital directly and how was he to figure out which of the million options he was supposed to choose on the phone? This could have easily turned into a DNA.

Another patient, with no GP, no fixed abode and spoke very little English, had a systolic blood pressure 170 (I allow myself a BP machine for triage purposes). The charity had allowed him to use their address as permanent address so I walked him over to the local GP practice in Covent Garden to register him. With my ropey French we managed to get through the registration form (FYI it felt really unsavoury asking him about whether he considered himself sedentary or active and whether he thought his diet was good or bad). It really gave me flashbacks of the time that I was sitting in a town hall in Japan trying to register for a resident’s form in 2016 which I had never done before. I just remember the sheer frustration, nay humiliation, because I didn’t know the system and the staff looking really troubled because they didn’t comprehend why I didn’t understand. Or that time I lived in Paris when the girl at the mobile store shouted at me in French because I hadn’t realised my phone wasn’t unlocked. I would have given up in both cases if it hadn’t been essential for me to complete my task for my day-to-day living but that feeling of shame of not knowing what was expected of me is still burnt in my memory. The heart-breaking part was that the patient and I parted  because he had to set off on his hour-and-a-half walk to Portobello road (with all his belongings) to see if he could get into a shelter there. I could see why he hadn’t registered with a GP yet when he had bigger fish to fry.

One of my other patients is on a waiting list for a nerve block and, through patient choice, was being seen by a pain clinic on the other side of London to where he lives. He arrived with several forms in his hands and had come to see me because he wasn’t sure what they were. They were his pre-op forms which needed completing before attendance. “Do you have any medical problems?” “Allergies?” “Do you smoke or drink?” We got to the bit about who was going to pick him up. No friends, no family, no one. So I called the hospital and they said that a taxi was ok if there was no one to pick him up – but we both knew it would be too expensive. He said that he would get the bus and thus comedic altercation with patient ensued. I could just imagine that he would arrive and be denied his nerve block because no one could pick him up or that the post-op nurses would get cross with him when he tries to leave. It did make me think that one night in hospital probably wouldn’t have hurt but when services are so stretched, it’s so challenging to meet these social needs. I’ll find out in a couple of weeks hopefully what happened.

The things that I love about this clinic is that I know that I am making a change, however small, to one person’s life and giving a helping hand in what feels like a hostile environment. It almost bypassed me but the NHS surcharge is doubling to £400. That’s £400 on top of your visa application and the taxes that you pay if you are a migrant outside the EU. Is this what the UK considers as universal health coverage? If you believe that access is important, it’s worth checking out the DOTW safe surgeries initiative to make sure that your surgery is compliant. And if you’re an ST3, I hear that they are developing a template for a QIP on whether your practice is  in line with NHS guidelines.

DOTW BMJ article on dehumanising migrants

DOTW toolkits on safe surgeries

I am also going to interject here to say that I am looking for someone to cover me at my clinic whilst I am away for three months from March so please email me on chairjic@rcgp.org.uk if you’re interested. It’s a couple of hours on a Thursday afternoon, French is desirable but not essential, and and I’m happy to answer any questions before you commit!

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