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The vital importance of seeing the patient in context

It was 2 o’clock on a winter’s morning. It sounded like the woman at the end of the phone was calling from a party. There was loud music. I barely heard what she was saying.

My three year old son has a fever, he seems to have a rash and he doesn’t like the light. He also has a sore ear. We have no way of getting to you doctor.

I couldn’t be sure what was going on so I agreed to make a house call. In those days home visits were an accepted part of UK NHS general practice. When I got to the house, 25 miles away the 3 year old greeted me at the open door. He had a mild fever and a runny nose. Mum and dad were in the lounge drinking, a neighbour was in the room and they had recently consumed a take-away meal. The air was thick with tobacco smoke. It became clear that the child had been unwell since lunchtime the previous day and after midnight when he complained more bitterly about a sore ear mum decided it was time to get the doctor. There was no paracetamol in the house.

In 2013 Mullainathan and Shafir wrote the book ‘Scarcity’. With reference to experiments in psychology they postulate that people who are labouring under some sort of lack cannot be expected to behave ‘rationally’. Not if rationally is defined as doing what professionals might consider prudent. And yet such people are perfectly rational in the sense that they behave in ways that are consistent with having to live with ‘scarcity’. This is perceived as any lack which poses an imminent threat. For the people then curled up on a sofa with wine and cigarettes the evening must have panned out in such a way that their child’s brewing respiratory tract infection had been considered secondary to whatever else was going on. I noted the sticky carpet, the wet sofa, the remains of a take away meal, the child’s filthy thread bare clothes, the baby sleeping on the couch, the dog now sniffing at my heels and the bare bulb glowing dimly over the scene while a new TV in the corner screened a quiz show.

These people could have made different decisions on so many fronts. It was obvious they had very little money but there was no reason to believe they couldn’t clean or call for help earlier. And yet looking back although it seemed that they were the authors of their own misfortune the whole scene could have been framed very differently. The young mother had been abused as a child and left home pregnant at sixteen. Her older partner was violent especially when drunk. They lived on a meagre income supplemented by social security payments. They had debts because they borrowed money (hence the new TV) and most of the income was gone even before the weekend. I couldn’t see the ‘final’ notices, the violence, the bullying employer, the menial job, the threats from money lenders, the demands from authorities- all of which reduced bandwidth in their attempts to be good parents in the small hours of that morning.

It can be frustrating when the answer to people’s problems are ‘obvious’. And yet, to those who serve them in whatever capacity they seem incapable of making the ‘right’ choice. Such frustration can be experienced most in so-called deprived areas- where the need to be proactive may be greatest and yet there is the least possibility of acting on ‘professional’ advice.

Both individual and neighbourhood deprivation increased the risk of poor general and mental health. Stafford and Marmot

The result in those communities can be a steady stream of healthcare professionals who move on having themselves experienced ‘scarcity’ in serving people with complex social problems.

A higher propensity of GP burnout was found among GPs with a high share of deprived patients on their lists compared to GPs with a low share of deprived patients. This applied in particular to patients on social benefits. This indicates that beside lower supply of GPs in deprived areas, people in these areas may also be served by GPs who are in higher risk of burnout and not performing optimally. Pedersen and Vedsted

If we are to serve people who most need creative ways to improve outcomes we have to frame their needs in the context of scarcity.  It is almost impossible to ‘motivate’ people to do the right thing when there are competing demands on their meagre resources. What is required is a new paradigm in healthcare reaffirming that those who live like this are not unintelligent or unwilling but caught in a spiral of scarcity. We need to vaccinate healthcare professionals against the danger that their skills and commitment will be eroded in such an environment. We cannot fix societal ills but better healthcare starts with recognising our response to its challenges. ‘Scarcity‘ should be required reading.

Picture by *sax