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:

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

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

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]