Who gets care? Decisions about access

Good Medical Practice is the core guidance to doctors and describes what is expected of those registered with the GMC.

The current guidance makes clear that all doctors must treat patients with respect whatever their life choices and beliefs and give priority to the investigation and treatment of patients on the basis of clinical need (see paragraphs 7-10 of the guidance).

This month you can read James Taylor's (Health Officer, Stonewall) opinion on decisions about access to care, find out what we say, what happens elsewhere and watch a video where we ask whether patients' lifestyle should affect their care.

After you have explored this content, don't forget to stay in touch with the review.

James Taylor

James Taylor is a Health Officer at Stonewall - the lesbian, gay and bisexual charity. Who gets care? The answer to 'who gets care?' should be simple, everyone who needs it. Yet, there are populations of society which suffer discrimination and harassment preventing them from getting the care they need. At Stonewall we regularly hear of lesbian, gay and bisexual people who have been discriminated against, and in some cases denied access, by their GP, nurse or other healthcare practitioner to services they need, despite it being illegal since 2007. Our own research into the health needs of lesbian and bisexual women Prescription for Change, found that 50% have had a negative experience of healthcare in the past year, 70% reported inappropriate comments when they came out to their GP and, 90% felt their partner was not welcome during consultation. Similarly, our ground breaking research into lesbian, gay and bisexual people in later life, published last month, found that 17% have experienced discrimination because of their sexual orientation when using GP services and, many have not accessed GP services they felt they needed for fear of discrimination or hostility. So what impact does this have? Our own research highlights the higher prevalence of common mental health conditions such as depression and anxiety in the lesbian, gay and bisexual population but also, worryingly, higher prevalence of suicide attempts and self-harm. The poor experiences that lesbian, gay and bisexual people report can impact on their health and lead some to stop seeking treatment or services altogether. In the 21st Century there is no place for denying people services, or providing people with a poorer service than others, because of their sexual orientation. Thankfully, we now have a single simplified piece of legislation, the Equality Act, which places a duty on public bodies - including GP surgeries, to promote equality of opportunity and eliminate discrimination. Yet, as I have discussed, there are challenges that must be overcome. There are some simple steps that doctors can take to begin to tackle these, ranging from avoiding making assumptions about a person's identity, ensuring patient areas are inclusive and, monitoring patients across equality strands. Activities like these will help ensure that people who need care can access that care, without fear of discrimination, hostility or poor treatment.

What we say

Fairness and equity in accessing medical care are key principles in Good Medical Practice. The current edition says that all patients are entitled to access care and treatment to meet their clinical needs and that doctors must not allow their views about the patient - for example, their age, lifestyle or ethnicity - to adversely affect the care they provide or arrange.

As a principle this is difficult to argue with; but challenges arise when it is put into practice. For example, should patients be able to access care when in doing so they place the healthcare professionals providing that care at risk of serious harm? This could arise where a patient has a condition such as SARS, or their mental or physical condition makes them prone to violence.

Doctors have rights too - and could reasonably expect to work in a safe environment. And while they have duties to their patients, they may have other duties and responsibilities too, for example to their children or wider families. Is the duty to treat patients according to their clinical needs - in extreme cases - asking doctors to put their patients before their families and their own safety and ability to provide care for patients in the future.

This view in itself raises new problems - are the lives of people with dependants to be valued more highly than those without? And if all doctors have the same rights to avoid risk of serious harm, is there a danger of creating groups of patients who must simply be contained - prevented from harming others - rather than treated.

The question in drafting guidance is where the balance between the needs and rights of doctors and patients should lie; and where pragmatism must sensibly override principle.

What we currently say in GMP is that doctors cannot refuse to treat a patient simply because their medical condition may place them at risk. However, we do recognise that doctors must take the appropriate steps to minimise any risk before providing treatment or making other suitable alternative arrangements for their patients'.

Is this the right balance?

What happens elsewhere

The American Medical Association, Opinion 9.067, says:

• 'Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health or life. The physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with ability to care for patients in the future.'

The Medical Council of New Zealand, Good Medical Practice, says:

• 'All patients are entitled to care and treatment that meets their clinical needs. If a patient poses a risk to your own health and safety, you should take all possible steps to minimise the risk before providing treatment or making suitable arrangements for treatment.'

The World Medical Association, Statement on HIV/AIDS and the Medical Profession, says:

• 'All persons infected or affected by HIV/AIDS are entitled to adequate prevention, support, treatment and care with compassion and respect for human dignity… A physician may not ethically refuse to treat a patient whose condition is within his or her current realm of competence, solely because the patient is seropositive.'

What do you think? Are there any circumstances where a doctor can refuse to treat a patient? Email us at GMP2012@gmc-uk.org

Should patients lifestyle affect care?

The GMP Review team spent some time recently asking members of the public what they thought about a range of questions relevant to the review.

This month, we asked a range of people on the street:

• 'Should a patients' lifestyle affect their care?'

Watch the video below and visit our Youtube channel to explore more video content.