A dermatologist checks for skin cancer. Photo: Joe Raedle/Getty Images
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Worried about your moles? GPs are here to help – except they’re not allowed

A deluge of mole-owners have put pressure on health services.

A letter arrived this past week from our local dermatology department, telling us that it is closed to new patients. Actually, that’s not quite true: the department will still see suspected cases of the two most serious forms of skin cancer, but everyone else will have to go elsewhere. Except that there isn’t anywhere else to go. GPs manage the vast bulk of skin problems but there is a range of conditions that need consultant input. For the time being, that service is not available.

There are a few factors behind this, not least the government’s 18-week referral-to-treatment target. If a hospital isn’t able to see patients within that timescale then it gets a big slap on the wrist. The immediate solution for a department facing imminent breaches is to stop taking referrals, giving itself breathing space in which to deal with the backlog.

Where has the backlog come from? The dermatologists believe it’s a direct result of the Be Clear on Cancer campaign, the skin cancer component of which was piloted in our area last year, advising people to get moles checked if they’d noticed any change in them. The problem is that a) virtually everyone has moles, and b) invariably over time they change. Most often they are harmless. The problem with cancer campaigns is they push these issues to the forefront of people’s minds, so when a small change occurs it becomes disproportionately worrying. This has led to a surge in the numbers of people consulting their GPs with pigmented skin lesions. While dermatology would like to blame the cancer awareness campaign for its present woes, it has, as a specialty, made its own contributions to the crisis.

The problem for GPs is that, although it is usually possible to be sure a mole is harmless, sometimes there is an element of doubt. In the early years of my career, we would solve this dilemma by making a simple excision under local anaesthetic at the surgery and sending the specimen to the lab to ensure it was definitely benign. On rare occasions, the biopsy would show it was an unsuspected melanoma (the most aggressive form of skin cancer), which would require that the patient be referred for wider excision of the problem area, and possibly further cancer treatment.

Over the past decade, however, this practice has come to be frowned upon, largely because dermatologists are mistrustful of GPs doing an adequate job of the primary excision. In fact, most GPs carrying out minor surgery are more than competent – but the dermatologists’ response was to turn the assessment of pigmented lesions into a secondary-care-only service. Any GP these days who performs an excision biopsy of a pigmented lesion that turns out to be an unsuspected melanoma will face an investigation and severe sanction for having dared to deviate from “best practice”.

This same process of the specialisation of skin surgery has extended to encompass even the most indolent form of skin cancer, called basal cell carcinoma. This rarely spreads, and most types are readily treatable in primary care. This was also standard practice in my early years as a GP but again it has now become a specialist-only pursuit. GP minor surgery has gone from being something performed at virtually every practice to something only a minority maintains skills in.

The resultant flow of work to hospitals has been rather good for dermatologists, ensuring a steady expansion of consultant numbers and the general building of empires. Now, however, the chickens are coming home to roost. We are a society increasingly fearful of disease, bombarded on all sides by “Watch Out!” messages.

The recent tidal wave of worried mole-owners could have been managed in primary care but for the deskilling and dismantling of GP minor surgery. We need to restate our confidence in competent GPs being allowed to manage most of these cases without referral. Then dermatologists may again find that they have the capacity to do what only they can properly do. 

This article first appeared in the 13 February 2015 issue of the New Statesman, Assad vs Isis

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Gender pay gap: women do not choose to be paid less than men

Care work isn’t going anywhere – and it’s about time we recognised which half of the population is doing it, unpaid.

Is it just me, or does Mansplain The Pay Gap Day get earlier every year? It’s not even November and already men up and down the land are hard at work responding to the latest so-called “research” suggesting that women suffer discrimination when it comes to promotions and pay. 

Poor men. It must be a thankless task, having to do this year in, year out, while women continue to feel hard done to on the basis of entirely misleading statistics. Yes, women may earn an average of 18 per cent less than men. Yes, male managers may be 40 per cent more likely than female managers to be promoted. Yes, the difference in earnings between men and women may balloon once children are born. But let’s be honest, this isn’t about discrimination. It’s all about choice.

Listen, for instance, to Mark Littlewood, director general of the Institute of Economic Affairs:

“When people make the decision to go part time, either for familial reasons or to gain a better work-life balance, this can impact further career opportunities but it is a choice made by the individual - men and women alike.”

Women can hardly expect to be earning the same as men if we’re not putting in the same number of hours, can we? As Tory MP Philip Davies has said: “feminist zealots really do want women to have their cake and eat it.” Since we’re far more likely than men to work part-time and/or to take time off to care for others, it makes perfect sense for us to be earning less.

After all, it’s not as though the decisions we make are influenced by anything other than innate individual preferences, arising from deep within our pink, fluffy brains. And it’s not as though the tasks we are doing outside of the traditional workplace have any broader social, cultural or economic value whatsoever.

To listen to the likes of Littlewood and Davies, you’d think that the feminist argument regarding equal pay started and ended with “horrible men are paying us less to do the same jobs because they’re mean”. I mean, I think it’s clear that many of them are doing exactly that, but as others have been saying, repeatedly, it’s a bit more complicated than that. The thing our poor mansplainers tend to miss is that there is a problem in how we are defining work that is economically valuable in the first place. Women will never gain equal pay as long as value is ascribed in accordance with a view of the world which sees men as the default humans.

As Katrine Marçal puts it in Who Cooked Adam Smith’s Dinner?, “in the same way that there is a ‘second sex’, there is a ‘second economy’”:

“The work that is traditionally carried out by men is what counts. It defines the economic world view. Women’s work is ‘the other’. Everything that he doesn’t do but that he is dependent on so he can do what he does.”

By which Marçal means cooking, cleaning, nursing, caring – the domestic tasks which used to be referred to as “housework” before we decided that was sexist. Terms such as “housework” belong to an era when women were forced to do all the domestic tasks by evil men who told them it was their principal role in life. It’s not like that now, at least not as far as our mansplaining economists are concerned. Nowadays when women do all the domestic tasks it’s because they’ve chosen “to gain a better work-life balance.” Honestly. We can’t get enough of those unpaid hours spent in immaculate homes with smiling, clean, obedient children and healthy, Werther’s Original-style elderly relatives. It’s not as though we’re up to our elbows in the same old shit as before. Thanks to the great gods Empowerment and Choice, those turds have been polished out of existence. And it’s not as though reproductive coercion, male violence, class, geographic location, social conditioning or cultural pressures continue to influence our empowered choices in any way whatsoever. We make all our decisions in a vacuum (a Dyson, naturally).

Sadly, I think this is what many men genuinely believe. It’s what they must tell themselves, after all, in order to avoid feeling horribly ashamed at the way in which half the world’s population continues to exploit the bodies and labour of the other half. The gender pay gap is seen as something which has evolved naturally because – as Marçal writes – “the job market is still largely defined by the idea that humans are bodiless, sexless, profit-seeking individuals without family or context”. If women “choose” to behave as though this is not the case, well, that’s their look-out (that the economy as a whole benefits from such behaviour since it means workers/consumers continue to be born and kept alive is just a happy coincidence).

I am not for one moment suggesting that women should therefore be “liberated” to make the same choices as men do. Rather, men should face the same restrictions and be expected to meet the same obligations as women. Care work isn’t going anywhere. There will always be people who are too young, too old or too sick to take care of themselves. Rebranding  this work the “life” side of the great “work-life balance” isn’t fooling anyone.

So I’m sorry, men. Your valiant efforts in mansplaining the gender pay gap have been noted. What a tough job it must be. But next time, why not change a few nappies, wash a few dishes and mop up a few pools of vomit instead? Go on, live a little. You’ve earned it. 

Glosswitch is a feminist mother of three who works in publishing.