Nothing in this world comes for free?

If you find yourself up on a Sunday morning in Chico, grab a bike and hop on. Make your way into Bidwell Park and along its leafy paths making a special effort to avoid the young children and animals dotted along the way. Take a right at the cross roads and continue your journey down the narrow street with the perfect clapboard houses; watch out for the enthusiastic dog at number three. Round the corner past the pharmacy and cross the cash ‘n’ carry parking lot to a junction. Once there make a right again and you will find yourself at the Shalom Free clinic. Taking residence once weekly within a nondescript office building, this place won’t be what you expected to find.

I’m not exactly sure what I was expecting as I made that very journey for the first time, but I had an inkling it would be different to anything I’d experienced in the States so far…

The Shalom Free Clinic was founded in 2007 by a rather incredible lady who, having identified that accessing urgent but perhaps not emergency healthcare in her town was one of the biggest struggles, set out to find and form a solution. I was lucky enough to have the opportunity to speak to her one on one in the week following my first visit and record her story on film. Like many projects in the same vein, the clinic has been born out of her own experiences of witnessing and trying to help people in need. As she filled me in on a few of these occasions I came to understand that from the very beginning the clinic had been about more than delivering efficient healthcare in the traditional sense but more about providing a very rounded and holistic type of care that included not only medicines but also as many listening ears as were necessary, company and a hot meal for those that wanted it and general support to people who were struggling to find it elsewhere.

My own path to the clinic was a bit of a journey in itself. Keen to immerse myself in the community of Chico and also determined to listen to as many different perspectives as possible, I spent one Saturday morning at the local farmers’ market looking around and generally talking to anyone who would listen. A wonderful thing about the States: most people did. As I spoke about in an earlier blog, a chance meeting and introduction to the Butte County Health care coalition on that day kick started a roller-coaster of meetings and events that really broadened my experience and provided new insight into US healthcare in all walks of life.

It was my new market friend who introduced me to a GP she knew well. He, like her, believed and campaigned for a universal or ‘single-payer’ health service in California. Feeling that the current system let down those who were low in income or did not have insurance, he chose to work only with those groups. In being introduced to him, I was thrilled and incredibly fortunate to meet now a second Chico GP who believed in what I was doing and was determined to help me. He took it upon himself to find as many people as he could to speak to me... ‘Want to see something different?’ he asked me at one point, ‘Come to the free clinic’.

And there I found myself one October Sunday. I arrived to a gaggle of students; not really what I had been expecting, gathered around the small reception desk awaiting their instructions. The GP who had invited me explained that they were Pre-med students from the local university; they volunteered at the clinic and most came every week. He hoped the clinic, and the interactions with the public that it allowed, would stay with the students as they went into their medical careers.

The students are not the only volunteers; everyone who takes part in the clinic gives their time and skills freely. The clinic runs through donations, of both money and medication, in order that every person who walks through the door can access consultation and treatment without paying a cent.

The space was small and with one of the two consultation rooms given to me, very small. About an hour in, it was busy; the seating area was cramped and the general hubbub quite loud. As I’d seen in the Chico practice I was attached to, all patients were seen by a nurse or in this case medical student first. Their observations were taken and questions were asked about their general health. The space lacked the calm and peaceful surroundings of the other clinic and it was clear that confidentiality could not be fully maintained in the same way but I was impressed by the flow and how, at every point, thought was put into delivering the care that fitted with the clinic ethos. As I’d reflected on with the reception staff at the other practice, I spoke with the nurse and students about how vital their role of greeting people was; putting patients at ease and trying to identify early on any underlying concerns. The nurse present that day commented that many people did present with a physical complaint but on questioning would reveal something else going on. She noted that many really ‘needed to talk’ and that if that were the case they would simply ‘provide more and more ears until they were done’. Of course, everything has its limits; this was a busy and hectic clinic that could only deliver so much but, for me as an observer, the real feeling of the day was of making time.

It seems likely that this system only really functions without chaos because patients turn up expecting to wait. It has a ‘walk-in’ style for the most part and therefore there are no ‘appointment times’ as such. However, if you come at any point in the afternoon you will be seen.

Patients were asked if they would be willing to speak to me after they had had their observations checked. Some seemed keen to talk and surprised to be asked, some were happy to offload their frustrations and others were simply pleased to escape the crowded waiting room for ten minutes.

The biggest surprise of the day came in the sheer variety of stories I heard that afternoon as I had definitely made an assumption before visiting the clinic. I had expected to see a predominantly homeless and unemployed population living without health insurance and it’s true, I certainly did see and speak to people in that situation. However, I’d say the majority of patients I came into contact with were middle-class workers, some from the nearby university and local schools, who for whatever reason did not have health insurance or could not afford to use it. This might be because they worked part-time meaning they weren’t entitled to health benefits or because their wage did not meet the level in which an employer provides insurance. Those with private policies often spoke of incredibly high monthly payments and deductibles they simply couldn’t afford and earning an income meant that many of them would not fit the criteria for the welfare insurance plan.

Many of the patients I interviewed were fairly new to the clinic and had found their way there after experiencing difficulties in accessing doctors or medications elsewhere. It was, therefore, easy to get lost in the reams of ‘horror stories’ that were presented to me. As much as I was interested in listening to everything, I tried to guide people back to their relationship with their doctor and it was in doing so that some of the most powerful points were made. For many of the patients I spoke to, the concept of a close and therapeutic relationship with a doctor was a luxury that they had never experienced. Although most spoke very highly of their recent interactions at the free clinic, the years up until then had been littered with Emergency room visits and urgent care appointments where they’d experienced little personal attention and had been simply ‘patched up’ and sent away. These conversations reminded me of another Californian friend’s comment that ‘in the ED, they take care of you physically but not emotionally’.

Whilst I empathised with all of these view points, I couldn’t help but relate to the idea that in ‘emergency care’ the idea is to ‘patch you up’. Of course, every doctor should have the desire and capacity to a certain extent to see a patient as a whole person with a variety of needs but realistically in a busy emergency room or A&E department, there has to be priorities. This clinic population, it would seem, had just been struggling to find a place where their emotional or psychological needs were a priority.

I could say the same thing; I don’t have a close relationship with my GP. However, that is largely due to the fact that, thankfully, I have not needed to see them for over two years and I am lucky enough to be supported by other people in my life and that was certainly the case for some patients visiting the free clinic; those who had called in for a quick course of antihistamines or to have that bad knee finally looked at. But for some, many with chronic illnesses such as diabetes or heart disease, having a stable relationship with a doctor they trusted was something they were clearly lacking and something that would have been of real benefit.

I don’t mean to paint a gloomy picture, only a fair one. In contrast to what I’ve documented above, on interviewing patients at the other clinic, I’d say nearly every one talked about the relationship with their GP unprompted and how this positively impacted their care. The conversations I had at the free clinic didn’t illustrate a lack of continuity or personal care everywhere in the States, for me they just revealed the huge discrepancies in care received and the variance in patient experience as a consequence.

It was becoming apparent to me that in the States, if you had comprehensive insurance, you really could receive the best care available and this very much included a personal and patient-centred approach from your doctor(depending on the clinician of course). However, if you were not quite in that position, the regular access to a doctor with whom you could build a rapport with and perhaps turn to for emotional support, would likely be one of the first things to go. It would be inaccurate to suggest that these cuts and choices are made only in the States; it is a situation that we are seeing more and more in the UK and there is logic to this reasoning; if any one of us were to go into cardiac arrest I think we’d all agree we’d prefer a defibrillator to a nice conversation. However, I would argue that the emotional needs of our patients have never been and are especially now not insignificant and I’m not sure how long we can continue to not make them a priority.

But even on that serious note, it is thankfully very possible to end this one on a high. Part of this project is to explore globally the ways in which healthcare professionals are showing resilience and coping with challenging healthcare contexts in order to deliver the best care possible to their patients. That is exactly what I saw that October Sunday; a small group of people giving their time for free and striving towards a model which prioritises treating patients as people within a larger system that sometimes does not hold the same values.

I’d better leave it there before I run out of paper…but please tune in next time when I’ll delve deeper into the workings of the free clinic and the side that cares specifically for peoples’ mental health…

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