Recently I took some second year medical students to see one on our oldest patients in a local nursing home. I had rather taken to her as she comes from the same part of the country Lincolnshire as my grandmother did and responded with a wry smile when I referred to her as a “Lincolnshire Yeller belly ” She also had that typical manner just like my grandmother that she was only going to tell you what she wanted but don’t ask too many questions!
*(referring to those from Lincolnshire and recognising the proud tradition of early 20th century soldiers of the Lincolnshire Regiment who wore yellow tunics at they inning of the 20th century)
She had a classical history of heart failure -a medical students dream but I wanted them to see her as a person and for her to tell them something about herself. She was delighted to tell them how she had been a kitchen maid since her early teens in the ‘big house’ owned by the dentist, but then wanted to leave and the only way out was to marry the footman ; the mistress of the house then told her to leave as she were surely be pregnant in no time!Oh said one of the students does this mean that ‘Downton Abbey was based on real life!”
Indeed she soon became pregnant and she knew that that when the time came she would be taken to the ‘workhouse’ to deliver and then have to stay on to scrub floors or do other tasks to pay for her stay. The pregnancy was not going well and she was developing late complications but mysteriously she found that she was being taken to a private hospital and safely delivered and to this day does not know who paid. As my grandmother would have said if anyone had asked ‘never you mind’
She then went on to describe the horrors of the workhouse and the huge inequality of health care and then the absolute joy when on July 5th 1948 health secretary Aneurin Bevan opened Park Hospital in Manchester, as the launch of a hugely ambitious plan to bring good healthcare to all. For the first time, hospitals, doctors, nurses, pharmacists, opticians and dentists were to be brought together under one umbrella organisation to provide services that would be free for all at the point of delivery.
The central principles were clear: the health service would be available to all and financed entirely from taxation, which meant that people would pay into it according to their means.
THE NHS WAS BORN
Much of the story of the NHS is about the interaction of the three main parties involved: those needing care, those who deliver skilled care and those whose task it is to raise the money and see it properly spent. The peculiarly difficult triangular relationship between these interested parties has to be satisfactory if the health service is to function to the benefit of society. The story goes on if you want read more a fascinating account turn to http://www.nhshistory.net/
I embarked on a medical career embracing this vision and trained in Cardiff and South Wales to be proud of a health service which offered this totally unprejudiced care. I worked with men who carved coal out of the bowels of the earth where machinery could not go and as part of my training was taken to the coal face to admire the sparkling diamond-like anthracite coal which man could only gets to on his belly. It took days for me to get clean !! I went the steel works and sweated profusely as I stood for minutes by the blast furnaces watching men that would be there for hours upon end and watch the glistening liquid steel pour out. It was only by seeing this could I fully appreciate the conditions these men worked but how we laughed as they told their tales and still tears come to my eyes when I hear the soulful singing of the Male Voice Choir sing with hywl and watching ‘the boys’ playing rugby with such devotion. Everything stopped, life was on hold literally only contacting the doctor, even with a heart attack when the match had finished. Where I worked Spina bifida had the highest incidence in the World, cystic fibrosis was not uncommon and of course the lung disease from working underground was rife along with cardiovascular disease.
It is not surprising it took a Welshman to fight for the a National Health Service and I have to say private medicine barely existed at that time. The miners built the hospital with a Maternity ward. The nurses were natural nurses: they were brought up to nurse as the majority of families housed at least one sick member.
What a valuable experience to work in this setting and why I feel so passionate about a national health for all and why it grieves me to see it being abused by ‘those same three parties which we always knew had a relationship which would be ‘a peculiarly difficult triangular relationship.
Those needing the care would gradually take less and less responsibility for their own health and their family’s health. So that when George Bernard Shaw wrote in his preface of ‘The Doctor’s Dilemma’ 100 years ago when he despaired of the private health care it is ironic that the same despair for different reasons but also aimed at doctors should apply today after 65years of a National Health Service
“If you cannot have what you believe in,you must believe in what you have. When your child is ill or your wife dying,” when you are confronted by “the spectacle of a fellow creature in pain or peril, what you want is comfort, reassurance, something to clutch at, were it but a straw. This the doctor brings you. You have a wildly urgent feeling that something must be done; and the doctor does something. Sometimes what he does kills the patient.” The philosophy of the placebo effect.
Last Bank holiday weekend a gentleman brought his child to the out of hours clinic in the evening with a non complicated chickenpox. He wanted me to admit the child as he didn’t want anyone else to catch the disease especially as the extended family with their children had arrived from Leicester and were staying for the weekend. When I tried to explain that this was not necessary as the condition was not serious and it would be totally inappropriate as there are children in hospital seriously ill (perhaps leukemia ) and contact with them could be be seriously detrimental and even cause death to which he retorted ” couldn’t you put her in a side room? ‘ he persisted trying to make me give in but I stood my ground and as he left very annoyed as I had wasted his evening and it had cost him a lot in petrol. When I shared this with my colleagues they proceeded to relate similar stories. Constantly, we see streams of minor medical or social problems which we deal with patiently day after day and then try not to get caught out when the ‘real patient’ arrives. To make matters worse our reputation of unconditional healthcare has spread throughout the world and people use it as a stop off place to get free medical care and don’t appreciate the boundaries.
Nevertheless, many patients use the service with respect and maintain a good working relationship with health professionals and benefit greatly from all the amazing advances in medicine and the service provided. But sadly this does not make news.
Those skilled workers, doctors,nurses and other health care workers as part of this service dedicated their lives to providing health care to all. nursing sisters slept in a room on the ward, ruled their ward with pride and a rod of iron. when I was first qualified if I entered a ward I would have report to the sister who would then look me up and down to see if I was suitably dressed and my white coat was clean before allowing me near a patient. At the same time there was a mutual respect and the sisters and nurses shared their wealth of knowledge and knew the patients well and guided many doctors through those terrifying months of being a newly qualified doctor and rescuing them when they were unsure and had to be answerable to the consultant. Ask Mary our practice nurse, she will tell of the many junior doctors she has had to offer guidance and sometimes with great authority and they have obviously benefited as some now hold reputable positions as specialist consultants. But now there is a more liberal approach and there is more antagonism. We have all become preoccupied with status,targets, cost effectiveness, evidence based medicine and losing sight of the fact we are dealing with individual characters who have lives and stories to tell and how the same illness can effect different people in different ways.
However, when I talk to doctors in all sorts of situations albeit in hospital, A&E , in practice or in between lectures I am always reassured that for the most part they are ‘nice’ people wanting to provide and care for their patients in the best possible way and this keeps me reassured that for the most part values have not changed.also our medical schools are working hard to reinforce these ideals. But these health professionals are also people and deserve to have a family life and enjoy other aspects of life and I would not advocate bringing back those obscene long hours. Indeed, the modern doctor had taught me a lot about looking beyond the consultation room and I feel it keeps me much more in touch with my patients.
Those whose task it is to raise money and see it wisely spent have used health as a commodity to be bargained with and failed to take into account the services that cannot be measured the hours doctors pass dealing with patients mental health a rising malady which is predicted to be the major cause of illness in the next 5-10 years. Unlike blood pressure it can’t be measured or monitored in the same way and when I hear a mere suggestion that patients are to be limited how many consultations they can have each year my hackles bristle at the thought. I used to dread seeing a patient who was depressed and hopeless I instantly adopted the same feeling and then after more experience of life and all that it throws at you I began to feel more confident to support and guide people through a crisis. Moreover, following the advent of safer medication with faster action and less side effects I began to see patients emerge from that black hole and restore their lives which in turn encouraged me to recognise mental illness management as a important part of the treating patients.
However, when I see how our local musculoskeletal service run by GP’s and physiotherapists has grown from strength to strength and now provides an excellent exemplary service which is totally due to doctors working in partnership with patients and managers. By working together to effectively manage the service, using local resources, spending wisely it can work and the patients undoubtedly benefit.
If only those patients who work so positively with us in partnership and those caring doctors maintain their dedication and good care and the managers can spend wisely and manage effectively we could reconnect using that peculiarly difficult triangle to restore a NHS for the 21st century.
George Bernard Shaw 100 years ago lambasted the medical profession when he wrote in the preface of his play ‘The Doctors Dilemma’ “Until this body of men and women were trained and paid by the country to keep the country in health it will remain what it is at present: a conspiracy to exploit popular credulity and human suffering”.
After reading many statements from Jeremy Hunt accusing doctors particularly GP ‘s of causing the chaos in A&E and reading the Editorial of this months BMJ “Let the patient revolution begin” I felt I wanted to write a blog reflecting on my experience of working in the NHS for > 40 years.
The article refers to George Bernard Shaw in his claim of the medical profession having a conspiratory against the laity likening it today where disease and doctor centric health systems that are costly, wasteful, fragmented, and too often uncaring are provoking similar ire.
It goes on to say
“Clinicians and patients need to work in partnership if we are to improve healthcare and challenge deeply ingrained practices and behaviours. Doing this won’t be easy for either side after eons of paternalism, and many patients will prefer to maintain the status quo.”
Although I think we need to maintain the original principles we need to exercise it to be relevant today.
Many members of the population need to be educated into knowing how to cope with everyday health problems and how to improve their lifestyle to prevent illness. This was voiced by our patient participation group but again they favoured electronic information as well talks by clinicians. Many patients want to know more about their illnesses and take an active role in making a choice about treatment. No longer can we dictate how to treat a patient but we need to work together .many years ago I remember prescribing antidepressants which took 3 weeks to work when the patient returned after 10 days feeling no better I (and many other doctors did the same) would say which end of the capsule did you put in your moth first and the tell the patient to turn it around and come back in 10 days. ( it makes me shudder as I write this) In the article they quoted American examples of progress but I think we are making changes in our practice which are more relevant today such as the MSK clinics which are GP led and allow patients be seen much quicker than hospital and treated or only referred to specialist consultants. This has saved considerable amounts of money, expanded and most of all has had huge patient satisfaction. During the last year several Integrated care groups have been set up whereby the GP has an extended consultation with a patient with complicated medical/social problems and often are frequent attenders at A&E or outpatients. Together the GP identifies patient goals and clinician goals and both work together to achieve these and review after a set time. If some of the problems are proving difficult to address the case is taken incognito to a Multidisciplinary meeting which consists of specialist consultants, mental health and social service professionals and any other appropriate professionals and representatives of a group of practices. These meetings are held every month and during the last year. We have been discussing patients >75years and diabetics. During these meeting we have shared our problems of management, poor control of symptoms and control of diseases as well as identifying educational needs for all those attending. Lessons learnt in these meetings can also be used in similar cases.
Believe or not getting social services, hospital staff including psychiatrists and GP’s around the same table has been revolutionary.
We now need to educate our patient population. Medical students I teach in their 4th year have to do a project looking at health promotion. The students have looked at smoking cessation, healthy eating in schools, exercise in the elderly an even how providing socks for the homeless and how this can prevent cellulitis of the legs. We are holding more public health meetings and Sarah Jarvis not only appears on the radio but is up to date with her blogs on current medical concerns http://www.patient.co.uk/blogs/sarah-says
This website is a mine of information and also has an App I do recommend it if you haven’t found it already. There is a plethora of websites and Apps but it is important to keep to recommended sites which I attempting to do on these blogs. We have a long way to go but positive things are happening. I remain cautiously optimistic I trust this caution will get lessen as in time this peculiarly difficult triangle work together.
Watch out for more blogs on this subject!
The article referred in The BMJ
Editorials: Let the patient revolution begin
The article referred in The BMJ
Editorials: Let the patient revolution begin
Written by Dr Jacqueline Bayer