When Steve (1), a gay man in his late 60s, discussed his GP practice with me, he described almost every member of staff in the practice. Nicola, the healthcare assistant, was the best at doing blood tests; Dr Hall was very thorough but never smiled; nurse Debbie was the ‘old hand’, having been at the practice for years. His overall favourite was “his” doctor, Dr Manral, and he booked to see her whenever possible. In contrast, Ralph, another gay man of a similar age to Steve, didn’t name any member of staff at his large, urban GP practice, or offer an individual description of any of them. In interview, Ralph commented: “I think every time I’ve been there I’ve seen a different doctor and when I’ve been to see a nurse for something I’ve seen a different nurse.” In line with recent changes to GP contractual requirements, Ralph had now been assigned a named doctor, which had been done on the basis of his month of birth. He couldn’t remember the name of the doctor but thought he probably had met him at some point.
Advice on the NHS Choices website encourages LGBT people to come out to their GP. However, surveys by campaigning organisations such as Stonewall, and The LGBT Foundation have highlighted that many LGB people are not ‘out’ to their GP. There has been less work which specifically relates to trans people, but it seems likely that they also experience difficulties talking about their needs in healthcare. The percentage of people who are reported as not being ‘out’ to their GP can vary quite significantly between different surveys, and may differ according gender, location within the country, and age. A sense of embarrassment, concerns about prejudice, or feelings that questions of identity are not relevant to healthcare have been suggested as possible factors in decisions about coming out in general practice.
However, the survey format may not be able to capture the very different relationships individual patients have with their GPs. When conducting interviews with 36 LGBT people over 60 about their experiences of GP services, I was struck by just how diverse these relationships with general practice and with general practice staff were. Steve and Ralph are not the only examples of contrasting experience within the interviews I conducted. Anne had been with the same individual GP for 25 years; Julie had met her new GP for the first time a couple of weeks before the interview. Helen had been scolded by her former doctor for bringing too many issues to one appointment, but Eleanor’s GP was always happy to fit in extra time for a chat if she needed emotional support. Zenobia was actively encouraged by her practice to book with the same doctor every time, Chris found it almost impossible to do so.
With such diversity in older LGBT patients’ relationships with practitioners, it is scarcely surprising that it also has an effect on patients’ decisions to talk about personal details of their life and identity. Neither Ralph nor Steve expressed concerns that their practice would be homophobic. Neither suggested that they felt embarrassed or worried about coming out in healthcare. But Ralph wasn’t sure whether his practice wanted to know that he was gay, or what they would do with that information if they had it. Since he rarely saw the same person twice, it was unclear whether any personal information he did provide would be remembered in subsequent appointments. Ralph suggested that the practice could do more to make it clear whether they wanted to know about his sexuality: “I would have thought that it would make sense to have some sort of wording [on the practice website] that says: ‘if you’re gay or lesbian or whatever, y’know, however you want to do it, uhm it would help us to know’.”
In contrast, Steve had first come out to one of the practice doctors years ago, and thought most of the practice staff knew he was gay. He sometimes joked about it with the nurses. Similarly, Frankie, a non-binary person, remarked on the friendly atmosphere in their general practice, and the fact that staff knew them and their partner as a couple: “It’s quite like a family, you know. If [my partner] and I go in they’ll say: ‘Oh hello you two, are you all right?’ ‘No we’re not, that’s why we’re here’ or ‘We’ve just come to drop off a prescription request’ or whatever.”
Length of time at the practice was not the only factor in deciding to come out to a GP. Julie had recently moved house, and had come out to her new GP. One factor in this was the open atmosphere created by the new doctor, which Julie contrasted to her experience with a previous doctor: “[The new GP’s] approach to me was extremely, uhm, relaxing and friendly and, uhm, and as I say, I felt I could say what I wanted to say, and, and it was just pleasing that, that I knew she would support me in whatever way. Whereas, like, my previous GP was a little bit more, uhm, efficient. [….] She’s very efficient. Very good, very efficient, but uhm, but very, uhm, very keen to say you’ve got your ten minutes starting now.”
For Oscar, not feeling able to be open about being gay had put him off accessing local services, such as a diabetes support group. He was reluctant to hide the fact he had a male partner, but was concerned about how other people would react if he came out: “You see I’d like to go to a diabetic, because they do, like, meetings [for] diabetes, you know when you get round and I don’t know how I would be treated if I came out. And I’m not prepared to lie any more, and say: ‘Uh, uh I live with my partner’, you know? I live with a man, don’t I, and I have done for thirty bloody years, for Christ’s sake, you know. Uhm, so rather than participate you withdraw.” (Oscar)
There are many pressures on general practice. The Royal College of GPs has reported an urgent need to recruit more GPs. At the same time, GPs are being encouraged to do more by offering extended hours, diverting more patients from acute care, and co-ordinating care for older patients. The British Medical Association has highlighted the fact that at present, GPs are often expected to offer a high number of short consultations, and has called for longer appointment times and a limit on the number of consultations in the day. Continuity of care and an individual relationship between patient and professional may well become difficult to offer with increasing resource and time pressures.
Yet many of the most pressing issues facing later life healthcare are multi-factored and closely related to the context of day-to-day life. It is difficult to address problems such as depression, caring responsibilities and chronic illness without knowledge of an individual’s life beyond general practice. That includes information about relationships and social networks: who does a patient live with, who would they call on in an emergency, how are their relationships with others affecting their well-being? These conversations may be harder to have in a service which is structured to short consultations and where one medical professional is assumed to be entirely interchangeable for another. Not only do patients have to recite their medical history to every new practitioner they meet, they also have to repeat information about their life and their personal circumstances. That may be particularly difficult for those whose circumstances require more explanation, and for those who are worried about the possibility of prejudice.
Healthcare has done a lot to improve its inclusivity to minority groups, through equality policies, action plans, training, and measures to eliminate prejudice. But if we really want primary care to be more LGBT-inclusive – and indeed, more inclusive for everyone – we also need to take into account the relationships between patients and practitioners, and how those relationships affect conversations about individual needs. My research project is finding that patients value the opportunity to talk to their doctors about their personal lives, and that includes feeling able to discuss aspects of their sexuality and gender identity.
(1) All names used are pseudonyms
Michael Toze is a PhD researcher at the University of Lincoln, currently completing his research on older LGBT people’s experiences of GP services. He has previously worked in local government, and volunteered for a variety of LGBT support organisations.