Continuous cruising and access to primary healthcare

As those of you who’ve read previous posts on this blog will no doubt be aware, I am a traveller. Specifically I am a live-aboard boater who continuous cruises. There are all sorts of problems with the continuous cruising guidelines, not least that CART are attempting to make my way of life if not illegal at least impossible. Like most younger continuous cruisers I (and my partner Skippy) have to work – if we’re lucky then we don’t have to work all the time or we can arrange to work in such a way as to allow our lifestyle to carry on regardless but, for both of us, working means staying around an area for a year or so while we work through our contract(s). What this means in reality is that we are tied to an area within two hours commute of our places of work for a year or so, then we move on. I’ve been doing this since 2006, Skippy joined me in February, in the time I’ve lived-aboard I’ve lived/worked in Reading, London and Bath with significant amounts of cruising in-between (if you’re following Miss Inexperience I will be taking the journey across to the west country fairly soon I promise).

Today, having been without a GP for the last three months I registered at my local practice. It just so happens that my local practice is near to my registered address. It’s a sad fact of life in the 21st Century that you are not really allowed to be a person “of no fixed abode” so an address on the land is essential as is pointed out in this RBOA quote from an article about living aboard – it seems to be under the impression that all itinerant live-aboard boaters are elderly, however this is not the case, Skippy and I use our parents addresses (as we always have done, they’re never going to get rid of us):

Once on board permanently, you will be a person of no fixed abode. This is not acceptable in today’s Britain where the first piece of information you are always asked is your postcode. To have a credit card, a bank account and a British Waterways licence you will need a permanent address on shore. This is why you have children. They’ve used your home as a convenience for years, it’s your turn now. (From RBOA article “Life as a Continuous Cruiser”).

My registered address is the one I use for the usual suspects (bank account, mobile phone contract) it puts me in an interesting position but most of the institutions I deal with are very tolerant of my itinerant lifestyle, as all of my interactions with them are online or over the phone it’s not really a big drag on my life. When I’m sure I’m going to be in an area for long enough (i.e. I’m looking for a job there) I arrange a Mail Boxes Etc account in the local area so our post can be forwarded to us and we can arrange for things to be delivered to a local address, and, of course we can register with a doctor.

The NHS guidelines regarding registering with a doctor state that the first thing you should do is:

Choose the GP surgery that you want to register with and check it covers the area where you live.

Well that’s all very well but the CART Guidance for Boaters Without a Home Mooring [PDF] state:

“Place”
The law requires that stops during such cruising should not be “in any one place for more than 14
days”.

“Place” in this context means a neighbourhood or locality, NOT simply a particular mooring site or
position.

Therefore to remain in the same neighbourhood for more than 14 days is not permitted. The
necessary movement from one neighbourhood to another can be done in one step or by short gradual
steps. What the law requires is that, if 14 days ago the boat was in neighbourhood A, by day 15 it
must be in neighbourhood B or further afield
. Thereafter, the next movement must be at least to
neighbourhood C
, and not back to neighbourhood A (with obvious exceptions such as reaching the
end of a terminal waterway or reversing the direction of travel in the course of a genuine cruise).

What constitutes a ‘neighbourhood’ will vary from area to area – on a rural waterway a village or
hamlet may be a neighbourhood and on an urban waterway a suburb or district within a town or city
may be a neighbourhood. A sensible and pragmatic judgement needs to be made.

It is not possible (nor appropriate) to specify distances that need to be travelled, since in densely
populated areas different neighbourhoods will adjoin each other and in sparsely populated areas they may be far apart (in which case uninhabited areas between neighbourhoods will in themselves usually
be a locality and also a “place”).

Exact precision is not required or expected – what is required is that the boat is used for a genuine
cruise. [emphasis mine]

Even ignoring issues regarding the exact wording of the British Waterways Act which merely states:

the applicant for the relevant consent satisfies the Board that the vessel to which the application relates will be used bona fide for navigation throughout the period for which the consent is valid without remaining continuously in any one place for more than 14 days or such longer period as is reasonable in the circumstances.[British Waterways Act 1995 Section 17.3.c.ii]

without any guidance as to what constitutes a “journey” (although I personally would argue that moving backwards and forwards between neighbourhood A and neighbourhood B as I know some so called continuous moorers do, does not in fact constitute a journey, except perhaps, in the sense that one might take a journey to and from work/school/university). That aside, the requirement to remain in one place for “14 days or such longer period as is reasonable in the circumstances” is well known amongst the live-aboard community if not well respected. According to CART

Circumstances where it is reasonable to stay in one neighbourhood or locality for longer than 14 days
are where further movement is prevented by causes outside the reasonable control of the boater.
Examples include temporary mechanical breakdown preventing cruising until repairs are complete,
emergency navigation stoppage, impassable ice or serious illness (for which medical evidence may
be required).

Such reasons should be made known immediately to local Trust enforcement staff with a request to
authorise a longer stay at the mooring site or nearby. The circumstances will be reviewed regularly
and reasonable steps (where possible) must be taken to remedy the cause of the longer stay – eg
repairs put in hand where breakdown is the cause.

Where difficulties persist and the boater is unable to continue the cruise, the Trust reserves the right
to charge mooring fees and to require the boat to be moved away from popular temporary or visitor
moorings until the cruise can recommence.

Unacceptable reasons for staying longer than 14 days in a neighbourhood or locality are a need to
stay within commuting distance of a place of work or of study (e.g. a school or college).

This document was significantly changed in 2011 following the judgement [pdf] in BW vs Davies and has been subsequently amended during the BW/CART handover to make the definition of both place and journey clearer.

So what is the relevance of this to my attempting to register with a GP? Well, not a lot if I don’t tell the GP that I live on a boat however it’s quite hard to avoid doing this as it permeates every aspect of my life. If you’re lucky, as I have been on several occasions it’s possible to get yourself registered with a GP who realises that live-aboard boaters without a home mooring are unlikely to ever be within the catchment area of the surgery for more than 14 days at a time (given that catchment areas for GP’s surgeries and neighbourhoods tend to be of a similar size). Since requiring an individual to register with a new GP every two weeks is ridiculous as a proposition there tend to be surgeries in areas near the canal who will take on continuous cruisers without issue, aware that their situation is not comparable to that of the static community. In fact, for those of us who try to cruise within the spirit of the legislation and keep ourselves moving over large distances for large proportions of the time our situation is closer to that of the Roadsiders in the land-based travelling community who

have great difficulty accessing primary health care and it is almost impossible for people to access secondary care without a referral from a GP. Many Roadsiders will only access health care at the point of crisis as homeless services are heavily over-subscribed and waiting times can be extremely long. This results in an overdependence on A&E Departments with many people opting to use these instead of crowded and sometimes culturally inappropriate Walk in Health Centres. At A&E departments people know that they will not have to explain their housing situation, will be guaranteed to be seen that day or at least within a few hours and will generally receive a good level of care. It must be stressed however that this is not an “easy option” for many Gypsies and Travellers, but one taken by many because they feel they have no other choice. [1]

I don’t have the cultural barriers to healthcare access and, as a middle class, university educated woman with an RP accent (when I try anyway) I’m good at getting access to the services I am entitled to use even given my itinerant lifestyle. The problem here is not in fact my ability to find a surgery who will be reasonable about my lifestyle and will give me the assistance I need but that not everyone has access to that. In theory it doesn’t matter where you live you should be able to walk in to any GP’s surgery and make an appointment if you need it. The problem is, that if you don’t have an address you can’t get registered at that first point. This situation has lead to me being without a GP for nearly 6 months, it doesn’t massively matter to me, I’m not on any regular medications (other than contraceptives, and there are ways round picking those up) but itinerant lifestyles are not just for the young and healthy, in fact most true continuous cruisers are in their later years and as a result are more likely to need regular access to primary and secondary healthcare. It’s time the NHS stepped up and did something about this terrible state of affairs, no one should be told as I was earlier today that there was basically no point in my registering as I’m going to be moving my boat soon and therefore will be moving out of the catchment area of the surgery, and will no longer be allowed to use their services. Of course if I move far enough away for it to be impractical to go back to my surgery for an appointment I will move my GP, of course I will, but in the mean time I should be allowed access to primary healthcare without being made to feel like a freak for not wanting to live in a house or a marina (which tbh is the “respectable” way to live-aboard).

1. Friends, Families and Travellers, Fair Access for All? Gypsies and Travellers in Sussex, GP Surgeries and Barriers to Primary Healthcare [pdf]

12 thoughts on “Continuous cruising and access to primary healthcare”

  1. To be honest there’s no good reason for it to be too complicated. GP’s need to control their workload, and to control the area that they’re responsible for. There’s nothing inherently wrong with this, and, I agree, the use of a post code is a highly convenient way of sorting through this and clearing the red tape. However there are ways to use the system as it stands. The purpose of having 1 GP who provides continuity of care is definitely useful in many circumstances, but there is an existing system of temporary residence in the system where all consultations will make their way back to a central source, where you hold some form of identification, just as you have an address for all the other things you mention.

    Personally I’d have no problem having a patient with a connection to my area who travelled around so long as they, at some point, intended to continue to return to my area and would make some effort to answer requests posted to them. If they see other GP’s in other areas in between, that’s fine.

    1. Robert: I understand the need for GP’s to control their workload and that controlling the area their responsible for is one relatively simple way of doing that. Having been cc’ing for a long time I’m aware of the ability to use walk-in centres near where I’m moored and “temporary residence” at a GP’s surgery, I have used both over the years. However, the problem with this system tends not to be the GP who originally let you register (if you manage to get to talk to a GP rather than getting told by the receptionist or nurse that you are not eligible to join their practice) but rather (for ongoing treatment) the GP you’re visiting in another area who can be quite scathing of the fact that you are visiting them, quite legitimately, for a repeat prescription rather than your actual GP.

      In this instance however, I am registered with a GP in Bath (where I have no intention of returning) and therefore needed to move my main GP registration to somewhere at least vaguely near my current location (I have been putting it off for 6 months, and it had finally come to a head). It was at this point that I discovered that the GPs surgery in my area were under the impression that I was only eligible for treatment while I was physically in their catchment area – which is ridiculous.

  2. A GP surgery has the ability to accept patients at their own discretion without seeking details and information like address/ immigration status… at last years GP conference this was something emphasised time and time again as a way that as GPs we can be a good first port of call for the most vulnerable in society, including those of NFA. However, that being said, not all GP surgeries are actively aware of this and look at this as a positive of working in primary care, and certainly I would imagine that not many receptionists at surgeries are aware & empathic in this way.

    As regards the pragmatics, the easiest way is to have one place where you are registered as NFA and then if requiring help in other areas, to regsiter as a temporary resident for those pruposes.

    1. My GP is in Swindon, I will consider staying with them, or getting a new one in manchester.

      I gave up citalapram because they made it danm near imposible for me to get an appointment outside 9-5 mon – fri.

      1. Also, plenty of places will do phone consultations with GPs, which for medication reviews of an existing medicine (like citalopram) are ideal.

    2. Davina: I’m extremely pleased to hear that the GP’s conference felt that the issue of access to primary healthcare for the most vulnerable in society including those of NFA is a pressing one however as you rightly surmise not all GP surgeries are actively aware of it and it is certainly not trickling down to the reception staff even in those that are.

      I have actively decided not to register with a “boater friendly” surgery in the past because of the attitude held by the reception staff which was bordering on irrational distate. (I have since met some of the GP’s and the practice nurse at the surgery and they’re lovely).

      As you say it is simpler to register as NFA in one particular area, and use the services that are provided on an ad-hoc basis as and when required. However one of the things I am likely to require is a repeat prescription of the pill, as I hadn’t kept the box and did not have an actual repeat (my GP for some reason hadn’t put me on one) I was almost turned away from the walk-in centre in Swindon without – I’m sure contraception is supposed to be one of the easiest things to get hold of, as the reception staff wouldn’t give me a GP appointment and they addressed the nurse in such a tone of voice that it was inevitable she would deny me. As it was a GP who happened to walk into reception in the middle of this argument agreed to prescribe it. As I said, generally not the GP’s that cause the problems, it’s getting past reception and their attitudes to travellers.

      1. I think it’s the management of continuing healthcare that is least well organised for NFA people of all kinds. I think this is partly inherant to the situation, as identification of people becomes more tricky, affecting prescribing safety.

        In regards to the GP workload situation, I think it’s a mixed blessing under the current system. Under the system of areas which GPs are responsible for (& therefore also able to home visit should the need arise… hence the questions about where you live, and whether that comes within a practice boundary) the plus side is that there’s very little power for GPs to refuse to see someone because they just don’t like them.

        At same GP conference this was raised as one (of many mnay) concerns about the new health bill as the abolition of boundaries had been suggested, but with little clear guidance on how this new system would avoid ‘cherry picking’ of patients.

        I think both situations kind of illustrate the big plus/minus of general practice as a whole: there’s a lot of variability in the focus and style of GP surgeries, the plus hopefully being that there’s somewhere to fit everyone.

  3. You guys have been ‘CCing’ a long time. The rules then were simple. It said something like ‘CCing is not for people who have jobs, children at school or other reasons for spending long periods in one place.’

    Now I saw you here at Thrupp a few weeks ago and you seemed to me like a couple of reasonable, well educated young people. What happened?

    I am not saying you shouldn’t CC, but what is the point in highlighting the problems you have because you are pushing the rules. These problems do not exist for GCCers, (Grey CCers)

    In reality the law was changed in 1995 because many retired people (not rich people) used to travel the system ‘continuously’ and never got to see the marina berth for which they paid good money, as required by law prior to the 1995 act. The sad thing is the CC life style has been high-jacked and is slowly being erroded by people for whom the law was never meant to cater for (I am not saying you are wrong. I know you both make a valiant effort to abide by the rules). But you have stepped into the grey world, a world for which the law was changed to benefit the main protagonists who are retired and on a pension. The point about that being is that they do not need to stay in one place for a job they do not need to not need to stay for childrens schooling. The Act never was designed for people having jobs and having children at school. I myself do work, but from my boat most of the time, as do many people, young and old. Bridge hopping is not CCing.

    One thing about CCing is that you are ‘off the radar’ so to speak. If that is why someone is a CCer then they simply have to accept that it can be tough at times.

    As an addendum I have never had problems finding a doctor or getting hospital treatment and believe me I have needed it.

    1. My problem is not really with the rules as they are currently applied. I like the fact that there is no requirement to have a home mooring for your boat and that it is still (just about) possible, even as a younger person who needs to work to cc. My problem here is not with the rules for continuous cruising – if I want to stay in one place for a significant length of time and I do not have a reason outside my control (as defined in the guidance) then I can always pay for a marina mooring for a short term. My issue here is actually with some elements in the NHS who make it difficult for you to sign up with a doctor even though, as highlighted by the two GP’s who have commented above, it is perfectly possible to do so and is in fact at the doctors discretion. Here again the problem is one of communication – there are guidelines designed to assist those of us who continuous cruise get medical treatment but they are not well known (particularly in the more rural practices) and there is limited trickle down of this knowledge.

      I actually saw a GP at the practice which prompted this blog post earlier on today and she was quite happy with the situation. I appreciate that this might not be the best way to address the issues of medical treatment for boaters (I know of several who have had problems accessing primary care due to anti-traveller prejudice – remember we’re the “acceptable” end of the traveller community, if it’s bad for us what must it be like for roadsiders?) but if we don’t talk about the issues then how are they going to be addressed?

      As to the issue of cruising ranges “Bridge Hopping” – we view an approximately 60 mile radius of our places of work an acceptable range (that’s roughly an hour and a half to two hour maximum commute, dependent on the quality of the roads) and will venture out of that when possible, on a linear canal this gives us a 120 mile cruising range. In Manchester or Birmingham (both places we’re contemplating for the next few years work) the area covered will be larger due to the density of canals in the area. As you pointed out I’ve been playing this game a long time, I rarely stay more than about two years in any one area (area here means 120 miles) and I regularly take winter moorings. I’d like to take a CART mooring for a year or two in the area I wish to stay in, but sadly that isn’t an option – that’s also a discussion for a new blog post I suspect. Might do that one tomorrow.

  4. It is possible to sign a waiver at your registered surgery stating that you understand and agree to forego home visits are not made outside the catchment area. You can then remain registered with one Surgery despite moving about.

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