“Hello. Bromley by Bow Health Centre. How may I help you?”
“Hello. Bromley by Bow Health Centre. How may I help you?” Thus begin my mornings at the Bromley by Bow Health Centre. From 8am to 8.45am each morning the phones ring incessantly. With, on average, only three Patient Assistants working the phones, two of whom are also at the front desk dealing with patients coming in, there is hardly time to catch your breath, let alone get in that vital morning cup of tea, without which I am unable to function…!
This year I’m taking part in a ten-month social enterprise/innovation fellowship programme called Year Here. For those of you who don’t know it, Year Here is a graduate course that provides young people with the opportunity to get to grips with some of the most problematic societal issues Britain faces. Divided into four broad categories (Youth Inequality, Homelessness, Community Resilience, and Health and Wellness), Year Here places each Fellow into a frontline service provider for a period of five months to gain experience of how organisations currently address the stark inequality present in British society. The experiences we gain working in a frontline role inform the development of innovation ideas that we embed over the course of the placement. Following the frontline placement, we add consulting skills to our repertoire by taking part in a two-month public sector consultancy project led by Bain & Co. The course concludes with a three-month project, during which we draw on what we have learnt over the past seven months to create a social enterprise prototype which we pitch for funding at a crowdfunding event in December.
I am placed at the Bromley by Bow Health Centre (BBBHC), a primary care provider based in Tower Hamlets, one of the most deprived areas of London. The deprivation of the area has a poor impact on the health of the patient community resulting in above average rates of morbidity and mortality (Tower Hamlets has the lowest male life expectancy of any London borough (77.5 years). In 2014, Tower Hamlets had the second highest unemployment (8.8%) rate across the London boroughs and 42% of children in Tower Hamlets were living in poverty, the highest child poverty rate in the UK and more than double the national average. To address the negative impact of these social conditions, BBBHC developed a method of ‘social prescribing’ that recognises that when people come to the clinic with symptoms such as a headache or a low mood, the cause may be social, such as issues around debt, housing, immigration status or employment. Instead of a biomedical intervention, doctors ‘prescribe’ a social response such as a visit to the welfare advice worker, the employment team or volunteering opportunities.
Year Here, by placing us into a role on the frontline, upholds a key tenet of its programme: experiential learning. In other words, throw the fellows into some of the most deprived areas of London, let them get stuck in and learn on the job. The only information I received about the role was an eight-page pack briefly telling me about BBBHC, the objectives, and my duties. Needless to say, I wasn’t really sure what I had let myself in for.
I arrived on the first day of my placement filled with a mixture of trepidation and excitement, half an hour early (so anxious was I about being on time that I had set three alarms, at 6.15am, 6.16am, and 6.17am respectively), and grasping my Year Here pack, which by this point was dog-eared, having been read and re-read in the hope of gleaning every possible nugget of information I could from between the pages.
I was particularly conscious of the fact that I had no experience of working in a GP Practice and nor was I particularly aware of the issues surrounding Health and Wellness, save the multiple issues facing the NHS and the Junior Doctors strikes that have dominated our news outlets for the past year. Rather, my previous experiences had been grounded in education, supporting refugees in Jordan whilst on my year abroad and, post-graduation, working for Red Balloon, an educational charity that recovers severely bullied young people who have self-excluded from mainstream education. I couldn’t help but think of Polly Toynbee’s words on starting a new job, when she very aptly describes it as “the worst part (…): arriving, knowing nothing and feeling a useless fool”.
Thankfully my lack of experience hasn’t seemed to matter as I have been taken under the collective wing of the Patient Assistants (BBHC’s term for a receptionist) who have let me shadow them and bombard them with questions, all the while continuing to support me and remind me not to be so hard on myself when I make a mistake — it is only week three, after all!
It’s funny how my perceptions of frontline work have changed over the short period of time I have been working at BBBHC. Prior to my placement, my understanding of ‘frontline work’ revolved around the direct provision of a service to the beneficiary, for example a teacher engaging directly with the student to provide tuition. The Patient Assistant role, however, inhabits that liminal space whereby they aren’t directly responsible for providing the service (that’s the role of the doctor) but they are still the face and voice of the practice, dealing with the patients to organise their appointments, order their prescriptions, answer their queries etc. Without this team, the GP practice would come to a grinding halt. If we take the analogy of a steam engine, the Patient Assistants are the pistons, keeping the train going by regulating the admission of patients and ensuring that both the patients’ and doctors’ demands are met.
The Patient Assistants in GP clinics, and indeed receptionists across all sectors, are the most exposed. As the intermediary, they engage directly with the patients and the doctors and face admonishment from both ends if things don’t go to plan. Although patients on the whole are understanding, there are always those who are able to reduce you to the size of an ant by a look of contempt or a sharp comment about your ineptitude (I experienced this last week when I was unable to respond straight away to a query from a patient and the woman on the phone requested to speak to someone who was not ‘clearly new’ — Toynbee’s ‘useless fool’ comment felt particularly pertinent at this moment).
Of course there is no room within the remit of the Patient Assistant for a response befitting such impatience. Instead, you have to be incredibly apologetic — “I’m terribly sorry. Yes I am new. Of course you may. Roz, would you mind coming and speaking with this patient?” — the ‘customer’ is always right after all. However, difficult patients can cause trouble for all Patient Assistants, not just tyros like me. It is these stresses and strains, and the constant juggling of tasks that I believe are often overlooked and taken for granted, especially in the stereotypically transactional relationship between the patient and the receptionist.
It is the ‘transactional’ element of the patient/Patient Assistant relationship that I am examining as a Year Here Fellow. To what extent can this transactional interaction be transformed into a more holistic relationship, rather than being purely a supply and demand scenario? Is it possible for the Patient Assistant team through more holistic conversations to help patients identify non-biomedical solutions to their issues so that they can engage in social prescribing and self-refer to the relevant provision in the Community Centre, to which the practice is adjoined? As is presented in the Marmot Review: Fair Society, Healthy Lives, and visually portrayed in Dahlgren and Whitehead’s 1992 representation of the wider determinants of health, the notion that health is driven by social factors is integral to BBBHC’s approach to primary care. In other words, the more we can do to facilitate a patient accessing social prescription to address poor social conditions, the more likely they are to be healthier in the long term.
However, it is early days yet and my journey to address these issues has only just begun. In the meantime I’m focussing on perfecting my telephone manner, increasing my efficiency in responding to patients’ requests, and gaining as much insight into BBBHC and the Health and Wellness sector as possible. *Brrrr Brrrr. Brrrr Brrrr.* “Hello. Bromley by Bow Health Centre. How may I help you?”
Alex Peter, Spring Year Here Fellow 2017
