open space

Health authorities are falling down in their statutory duty to ensure that everyone has access to a GP, argues Steve Ainsworth

Many of the 'rights' that patients were presented with in the Patient's Charter amount to nothing more than reasonable expectations, one of which is the right to be registered with a GP.

Everyone is entitled to receive treatment by a general medical practitioner either as a permanent or temporarily registered patient. The relevant current legislation is regulation 4 of the NHS (choice of medical practitioner) Regulations 1998, headed 'Assignment of persons to doctors'. Where someone has been refused acceptance by a GP for inclusion on their list they may apply to the local health authority which is required to assign them to a GP. Paragraph 4 of GPs' terms of service in the NHS (general medical services) Regulations 1992 requires all GPs to provide treatment in an emergency, and immediately necessary care for up to 14 days to anyone who has need of it.

How disappointing, then, to read the Big Issue's study of primary care for its vendors in the north.1

According to the study, which covered 212 Big Issue vendors in Manchester, Liverpool and Leeds, 29 per cent (and 37 per cent in Liverpool) were not registered with a GP. This is comparable to a figure published by homeless people's charity Shelter, which estimates that 28 per cent of homeless people are not registered, compared with 3 per cent of the general population.

Vendors of the Big Issue provided several reasons for this. Nineteen per cent in Leeds, 38 per cent in Liverpool and 44 per cent in Manchester referred to 'difficulty in registering' or having been removed from their GP's list. Almost a third - 31 per cent - could not be bothered or had not had time to register with a GP. And a further 3 per cent reported not knowing how to register.

Overall, 41 per cent found it 'difficult' or 'very difficult' to gain access to a GP. Why this should be so is not made clear. But of those vendors who did visit a GP in the previous 12 months, 49 per cent had done so for drug-related problems and 27 per cent for depression or mental illness - not the kind of conditions most favoured by GPs. While most GPs no doubt meet the terms of their contract and their ethical responsibilities, it is reasonable to conclude that a large minority are resistant to accepting patients they perceive as undesirable.

The alternatives to registration include treatment by GPs specially appointed to treat homeless people and attendance at accident and emergency units. How much homeless people's use of A&E is inappropriate is debatable.

Each year, an average of 13 per cent of the population as a whole attends A&E. But half the vendors in the Big Issue went to A&E. A 1998 study by Shelter concluded that 57 per cent of A&E visits made by homeless people were inappropriate.2 But that outcome was contradicted by Nat Wright, a GP for homeless people in Leeds, whose own study, conducted in the city over 18 months concluded that only 10 per cent of attendances by homeless people at A&E were not for valid reasons.3 The most significant health difficulty complained of by Big Issue vendors was that of registering with a GP.

Although most HAs appear to meet the Patient's Charter standard of making assignments within two working days, this disguises the truth. Many HAs operate an informal policy of preventing applications for assignment until the applicant has first attempted to register with more than the statutory one GP.

In January I telephoned the three HAs covering the area of the Big Issue study, saying my daughter had been turned down by one GP and needed to be assigned. Manchester HA encouraged me to try a few more GPs. Leeds HA instructed me to try 'all or most' of the GPs in the locality before applying in writing for assignment. Liverpool told me to try a minimum of three GPs before I could be assigned.

I believe that the response of these HAs was not exceptional. Assigning unwelcome patients to often unwilling doctors is a thankless task, and not infrequently results in the officers concerned being subjected to verbal complaints by unhappy GPs. But HAs' responsibility is to apply statutory powers actively for the benefit of patients. HAs should be taking proactive steps to ensure that everyone receives the services they are entitled to through registration with a GP. At present, many - perhaps most - HAs, are failing to meet their charter standard and to perform their legal duties. They are also, in the process, failing homeless people.

REFERENCES

1 A Primary Health Care Study of Vendors of the Big Issue in the North, 1998.

2 Homelessness and Health Factsheet. Shelter, 1998.

3 Wright N. HSJ 1999; 109 (5637): 18 (letter).