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If prescribing demands are high in an affluent practice, how are deprived practices faring?

A beautiful, tanned and rounded woman proudly presented her snotty and impetiginised three-year-old.

‘She put the appointment down for Chambrel but it’s for all four of them,’ she said as the rest of the family trooped in.

They were followed by the young Dad. He had the most amazing hair art: shaven back and sides topped with tight cherubic curls, reflected hair-for-hair in his accompanying son (who did not need or want an appointment, but would be seen anyway).

With the enthusiasm of the new boy, I blitzed through the family’s combined tonsillitis, herpes labialis, coryza and impetigo, and deluged them with topical and systemic antibiotics, and even provided an unguent for the asymptomatic son.

With time to spare for health promotion in this single appointment, I complimented Ma on her tan, hoping to prompt the spray-tan defence - it is, after all, the coldest, bleakest Spring on record. She admitted, however, that it was actually a sun-bed tan. I didn’t have the energy to educate as they bounced out with their sheaf of scrips.

Later, a barely 20-year-old with waist-length strawberry blonde hair gently teetered in on dramatic heels, jeans which had been sprayed on and a psychedelic cyan top proclaiming LOVE over two lines.

She was just visiting family and, she explained, as a traveller she was probably registered with a practice on the other side of the country but would it be okay if she got a repeat of her “————”, a particularly potent antipsychotic?

When prompted for a diagnosis we got as far as bipolar, but she knew it was preceded with another important diagnosis whose name escaped her.

Her temporary resident record screen was unhelpful except to confirm that “———” had been issued intermittently over the years.

Concerned about the long term effects of such medication we explored side effects, such as tardive dyskinesia, but the joint reading of a patient information leaflet was turned down - ‘I’m not good with me words,’ she said.

We compromised on a spell of permanent registration to give the opportunity at least to review the original psychiatric diagnosis delivered in her teens - if her original medical record has not been lost in the ether of multiple changes of address from camp to site and back, that is.

There then followed a series of bizarre but at least recognisable medication encounters - requests for day-time hypnotics (does anyone else think z-drugs are the modern day equivalent of Ativan?) and multiple short-acting opiates, which could not be described pharmacologically as anything other than recreational.

Somewhat wearied by these consultations I reflected on my former lives both as a rural GP and a CCG commissioner, the latter of course now responsible for improving the quality of general practice.

That role put me up close and personal with all the contemporary prescribing habits in this fair city. Here, the single most important factor driving clinical behaviour here is the degree of deprivation of a practice’s population - a continuous gradient along  the indices of multiple deprivation.

What scares me, dear reader, is I am now in the practice looking after the most affluent population. Perhaps moving from rural to urban practice, the genuine health inequalities gap has widened, rather than shrunk. What’s your view?

Dr Peter Weaving is a GP in Brampton, as well as the commissioning locality lead for NHS Cumbria. He has been writing the Diary series for Practical Commissioning magazine since 2007. You can read the archive of his posts here and send him a tweet via @PeterWeaving.