Thursday, July 10, 2008

Happy Birthday (?)

"What's he doing down there?"

"Dunno. He's got a suit on, and a tie with big bold stripes on it... Looks like he thinks he's power dressing to me. Oh no, he's about to go off on one. He's got that didactic look about him, I've seen it on him before. He's about to have a moan."

"Oh. Right. Think I might skip this one then."

"Hold on. I'll join you...."

Ok now they're gone I'll get on. I'll be trying for levity again soon, but somehow today I just can't seem to manage it-- and no smirking up there at the back, you know that's not what I meant. What follows is drawn entirely from personal experience and my own hazy grasp on reality. It reflects the views of the author and is not intended to reflect the views of any other individual or organization. Neither is is intended to impugn the character, bona fides or intent of any named individual. It's sole intent is personal comment.

It can hardly have escaped anyone in Blighty that our dear old NHS has just turned sixty. In the midst of the somewhat muted celebrations we have seen the publication of Lord Darzi’s latest report intended to set out a bold new vision of service centered on the patient, with talk of “quality” and “compassion”. However it feels, at grass roots level, as though the decision has been already taken to pension the poor old NHS off and giver her job piecemeal to a gaggle of vested interests in the guise of modernization.

This might just be sour grapes of course, because the one vested interest that looks set to be excluded for submitting serious bids in the up coming NHS garage sale is yours truly. Well that is, yours truly and around 35,000 other small time, corner shop, un-entrepreneurial soi disant “entrepreneurs” out here in GP land.

From where I sit this is a bit of a pity. Looking back I realize my association with the NHS began with my very first summer holiday job almost exactly thirty years ago. (O.K. technically it began a lot earlier than that since I have been a patient of the service all my life—but you get what I am saying). It was a fabulous job, pulling X-rays that were over 10 years old and sending the plates for recycling (the silver in the old photographic plates could apparently be reclaimed at a cost that made the whole deal economic, as well as providing funds for the fledgling Doc J’s summer beer money fund).

And from that time to this it is hard to remember a year when the NHS hasn’t felt under threat from some quarter. In the late 70s and early 80s it was the class war and the flexing of union muscle (with a gaggle of us white coated medical students—in direct contravention of the diktat of “Hospital Management”-- brandishing placards on the picket lines in support* of our student nurse colleagues, we being on a grant or financed by mummy and daddy, they working stupid shifts for peanuts as they trained on the job).

In the late 80s we had the setting up of the “internal market” with the promise, still largely unfulfilled two decades on, that the money to pay for the treatment would “follow” the patient, allowing good and popular hospitals to increase their funding at the cost of the “poorer performers”.

The 90s saw tinkering with and eventually wholesale breakdown of the GP contract, with a shift to health promotion, away from out of hours care, into and then back out of fund-holding (where GPs held a “budget” for a tiny fraction of the care of their patients—pretty much just planned surgery and out patient clinic visits). The stated aim was to get the money to start following the patient, but the contractual framework for this was so hedged about with restrictions and caveats that it was very hard to realize, and with the arrival of NuLabour (sic) the whole concept was anathema anyway….

Through the latter half of the 90s and into the Noughties our colleagues in the hospitals have been battered with meaningless targets (along with many that were very worthwhile) and from 2004 on GPland has signed up to a contract that accepted a significant degree of similar targeting. Again much of this, it can be argued, has served to improve standards and give a more uniform quality of service, but it is increasingly ripping the soul out of the profession. And now Lord Darzi's report seems to imply we can re-engineer the entire NHS by chopping it into tiny bits and selling it off in the name of “quality” and “compassion” the two attributes that spring unbidden to mind whenever we think of private enterprise (not).

It really is too bad. To borrow a quote from an unexpected early supporter of a Nationalized Health Service, no less a man than Winston Churchill, the NHS for all its travails has proven to be “the worst form of Health Care provision, apart from all the others.”

I appreciate it sounds the utmost arrogance for any clinician to expect the political class to stump up a mere Hundred BILLION quid and then just step back and leave us to get on with the job, and in reality, as I believe the Darzi reports show, the very last people you want organizing health care provision are clinicians of any type. But I fear the next worst people to do it are the politicians themselves. Neither group can claim to be dispassionate, and nor should they be, it’s not in either one’s job description. But the running of a truly National Service demands the skills a dispassionate and pragmatic observer can bring. Sadly, as we look towards Lord Darzi’s professed vision of the future we are likely to get further fragmentation rather than increased co-ordination and unity of purpose.

Our NHS is sixty this year and yet I fear she will not be around in any meaningful form for her seventieth birthday.

*regrettably our motives might not entirely have been based in proletarian solidarity, but this was an unreconstructed age when Medical Students were predominantly still young men and student nurses were recruited as much for looks as for other aptitudes….

Wednesday, July 02, 2008

New tricks?

It’s a time of year when the burden of acute illness has dropped, excepting an especially vicious and protracted Hay Fever season. As a result normal surgeries have a little less pressure for appointments and the number of patients attending for routine medication reviews has increased, as they try to get in before the holidays, theirs or mine.

Bill was one such yesterday. He’s eighty years young. Six months ago he had a bit of a scare. He was on the bus, on his way in to town, when he went a bit “funny”. He came to in CCU with a temporary pacemaker making his ticker keep ticking. Shortly after this he was scheduled for the surgery to insert a permanent version. His nurse joked with him that they were going to put the temporary machine in. It’s a box the size and weight of a car battery with knobs and lights and such, and it needs a permanent mains electricity supply. Bill was a little perturbed. Then his surgeon came round and showed him the real one, a little miracle of miniaturization hand crafted in finest clockwork by gnomes in Zurich or somewhere similar. It has its own battery, good for at least five years before replacement. And fits snug and flat in the palm of one hand, with room to spare.

Bill described in detail the procedure of insertion, for which he remained awake, the whole thing being done under local anaesthetic.

“First they put the wires in and I got to watch them go into my heart on a t.v. screen. The the surgeon says “Right we’re going to put the thing in”, and they carved a lump of flesh out of my chest to make room.”

“ I’m glad they didn’t decide to use the bigger machine! After all I’d have looked silly with a wire hanging out of my chest!”

He looked down at the scar after the insertion. It looked surprisingly small given all the carving and excavation that had seemed to be going on. He was more impressed by the blood stained sheet left on the operating table.

A month after the procedure he was back in clinic to have his bionics checked. The pacemaker was working pretty well, but the voltage needed dialling up a bit to get Bill’s heart pounding as it ought. After a couple of electromagnetic tweaks the surgeon was happy.

“There you go Bill. Your heart’s as good as new. You can do anything you want now.”

From the back of the room Mrs Bill’s voice could be heard.

“Don’t even think about it Bill!”