Is There a Limit to Our Responsibility?

A few weeks ago, I was walking across the parking area of a motorway service station when I spotted a glass beer-bottle standing upright in the middle of a parking bay. I had two main options. I could walk past, ‘tut-tutting’ about someone’s carelessness and stupidity, or I could picked it up and deposit it in the nearest litter bin. (A third option of seeing how far I could kick it didn’t enter my mind at the time.) Conscious of the perceived danger to someone else’s car tyres, I chose the second of the options, and thus, just possibly, significantly altered the path of some unknown person’s journey later that day. Why did I act in the way that I did? Purely and simply because I felt that, having perceived a risk to someone else, I then had a social responsibility to do something about it. The act was a simple one; but not to have performed it would have been as socially irresponsible as the act of putting the bottle there in the first place.

I would have thought no more about that episode if it hadn’t been for a recent home visit in my capacity as a GP. My patient was an elderly lady who lives on her own. She had been unwell for a few days and a (much younger) female friend had called the surgery. The patient does not have any family living locally, so the friend stayed and tidied the house for her whilst waiting for me. I hadn’t met either of the two ladies before, but was impressed by the care being taken by the friend, who was able to give me a good history and presented me with various hospital paperwork and a list of medication.

Having examined my patient and diagnosed her problem, I wrote a prescription and handed it to her friend on the supposition that she would kindly collect the medicine. It was as I was leaving, feeling sure that the elderly lady was being well cared for, that her friend said something that has had me thinking ever since. ‘I’ll collect the medicine, but of course I’m just a good friend; she’s not really my responsibility’ were her words. It was the bit about ‘not really my responsibility’ which mentally stopped me in my tracks. Just what was the unwitting message behind that phrase? Clearly, she had no legal responsibility for the elderly lady; at least not in the same way as a parent or guardian has over a child, or a carer has over a resident of a residential home. Neither did she have the professional and legal ‘duty of care’ that I had as a doctor. Was the friend expressing the view that her ‘good friendship’ was conditional and only went so far; and when the going got rough, she didn’t really care that much?

Responsibility can be a legally imposed state. However, it is also about being morally accountable for one’s behaviour. In a society such as ours, surely we are all morally accountable for each other? Is there really a time when we can morally turn our back under the cover of the phrase ‘not really my responsibility’? W.B Yeats wrote ‘In dreams begins responsibility’. On humanitarian grounds, that responsibility never leaves us.

(First Published in the Scunthorpe Telegraph, Thursday, 1^st November 2012.)

We Are All In This Mess Together

October 2010 was an auspicious month. Amongst many other happenings, it was the month when I first voiced my concerns over the NHS reforms. One of those concerns was that there was (and still is) insufficient money to run the NHS in a way that pleases most patients and also satisfies the politicians who ultimately have to take account of public spending. Whilst many people lauded the Government’s concept of putting GPs in control of running the local services (whilst at the same time dismissing significant numbers of managerial staff who actually knew how to run the NHS), I voiced the concern that it would all end in tears. The money would continue to be insufficient, services would have to be reduced, hospitals would close, the public would be angry, and GPs, powerless to turn a pig’s ear into a silk purse, would get the blame from both patients and politicians. It was a poisoned chalice from the start.

Two years on, that moment of staring into a murky crystal ball is proving to be prescient. Nobody can doubt that the NHS is falling apart. Every day there are stories from across the country where patients are struggling to obtain an appointment to see their GPs, and clinics, wards and hospitals are closing. Most GP practices are inundated with work to a level where they simply cannot cope. Some have already had to close; others are hanging on whilst the doctors strive to maintain a resemblance of a credible service whilst seeing their personal income plummet. Meanwhile, the Government sits emulating the Emperor Nero, informing us all of how wonderful the reforms are, how necessary they are, and how the politicians are not to blame for the terrible mess they have created.

As an example, let us take one of the craziest tasks currently facing GPs. We must, we are told, reduce the number of A&E attendances. If we do not achieve this, we reduce the money coming into our practices. How, we all ask, are we to manage such a herculean task that is effectively out of our control? We may as well be asked to reduce the number of teenagers visiting the cinema on a Saturday night, for all the power we have over such a situation. People visit A&E for numerous reasons: genuine emergencies, convenience, lack of transport, inaccessible out-of-hours services and over-loaded day-time surgeries are just a few. The solutions for many of these issues do not sit within the grasp of most GPs. It is a multi-facetted, multi-organisational problem. It requires socio-economic changes out of reach of GPs. It also requires more money being spent to address it; not a reduction of finance to general practices.

No one group has the solution. However, you can start by helping us all out by not attending A&E for trivial reasons. The clue is in the title ‘Accident and Emergency’. If it is neither of these, please telephone NHS Direct for advice, visit an NHS walk-in centre, or wait until your local surgery is next open. If you do not, you are contributing to the financial waste and the subsequent decline in GP services. The truth is we are all in this mess together.

(First published in the Scunthorpe Telegraph, Thursday, 26^th October 2012.)

Don't Feel Helpless

Are you a fan of Doctor Who? If, like me, you watch every show with eager anticipation (even if it is from behind the sofa), you will no doubt be very familiar with the front door of the TARDIS. In particular, you will have seen numerous clips showing the distinctive black and white badge of the St John Ambulance on that very door (yes, even the Doctor travels everywhere with a first aid kit).

Well, the latest news is that the St John Ambulance, the country’s leading first aid organisation, has hitched a ride with Downton Abbey (another of my favourites), screening the first viewing of its new, hard-hitting campaign during the first episode of the latest season of Downton Abbey a few weeks ago. If you happened to miss it (the campaign, not Downton), do not worry as I will give you a web-link a little later.

The St John Ambulance film is called ‘Helpless’. It is a highly emotive drama, depicting the story of a young man who is diagnosed with cancer, is treated and survives; only to die of choking at a celebratory barbecue with his family. Why did he die? He died because nobody knew how to save him with simple first aid.

It is a worrying fact that so many people have not taken a first aid course because they do not see the point of doing so, or think it will take up too much time. However, there is a very good chance that everyone will get called upon to act as a first aider at some time in their lives. The tragedy is that some 140,000 people die needlessly each year, when simple first aid could have saved their lives. 140,000 deaths is equivalent to the number of people who die from cancer each year. Yet, despite these terrible statistics, 41% of people recently surveyed said that it would take something as severe as the death of a loved one to make them learn first aid. The obvious question is, why wait until then? Why not learn first aid now and be in a position to save your loved one from dying?

Fewer than 1 in 5 of our population knows first aid. If you are one of those four people who doesn’t, please take a moment to watch the new St John Ambulance film ‘Helpless’ (http://www.sja.org.uk/sja/support-us/the-difference/helpless.aspx) and then ask yourself whether you would have known what to do. If the answer is ‘no’, then enrol now for a first aid course (http://www.sja.org.uk/sja/training-courses.aspx) or at least download a free first aid app for your mobile phone (http://www.sja.org.uk/sja/support-us/the-difference/helpless/mobile-phone-app.aspx) or request a free pocket-sized guide (https://www.sja.org.uk/sja/support-us/the-difference/get-a-free-first-aid-guide.aspx or text HELP to 80039). There is even an on-line game for the children (http://www.sja.org.uk/sja/support-us/the-difference/helpless/rescue-run.aspx); after all, it is often children who help the adults in times of emergencies.

Don’t feel helpless. Don’t wait for a loved one to die before you act. Learn first aid now and be the difference – the difference between a life lost and a life saved.

(First published in the Scunthorpe Telegraph, Thursday, 11^th October 2012.)

            

The Remembrance Day Parade

As he walked up to the rostrum

silence round him fell;

and, whilst he gazed upon the steadfast ranks,

emotive lines began to tell.

Too many lives were lost before today:

young men and women – yesterday’s youth.

They were the cheques we drew to pay

for the blinded search for fallacious truth.

You are the inspired; the fortunate few

who have lived through to this day;

the ones who now must tell the world

to find a better way.

It is the charge of those who live,

beyond vanquished dreams of many men,

to find the strength to forgive;

to learn and love as best you can.

And in so doing, let us ensure

a sense of remembrance, not of rage;

may this quietude beyond the war

turn pugnacious soldier into reflective sage.

Thus, he stood upon the rostrum as

the silence round him fell,

and gazed upon the steadfast ranks

of those returned from hell.

© Copyright Robert M Jaggs-Fowler 2008

Spirituality, Religion and Health

I wonder how many readers would find it strange if their GP was to ask them about the role of faith in their lives, or whether they consider themselves to be spiritual or practised a particular religion?

At the present time in the UK, the General Medical Council (GMC) may take a dim view of such a line of questioning. However, there is growing evidence to show how spirituality and religion can, and does, have a positive effect on many aspects of our health and longevity.

In a society that is becoming increasingly secular, those of us who profess a faith, pray, meditate, or attend a place of worship (regardless of whether it be the parish church, mosque or synagogue) are often, at best, misunderstood. Yet there are studies to show that we are most likely to make a successful recovery from illness, have lower incidence of some illnesses, and may live longer than those who are not spiritual or religious.

This column does not allow for a detailed analysis of the definitions of spirituality and religion. However, if we place to one side for the moment the precise meanings, and simply accept that the terms often overlap and encompass a wide range of beliefs and rituals, scientific studies indicate that people following such practices have lower suicide rates, less anxiety and depression, recover faster from depression, are less likely to abuse drugs and alcohol, have a greater sense of optimism and general well-being, consider their lives hold greater purpose and meaning, have higher levels of social support, and greater marital stability. They also have better immunity to infections, lower blood pressure and cholesterol levels, less heart disease, better recovery rates from heart disease, less sleep problems, lower death rates from cancer, are less likely to smoke and more likely to take regular exercise. Furthermore, regular religious attendance can add an extra seven years to one’s life; equivalent to the gain in longevity seen by non-smokers.

Armed with such important information, the question is how should health professionals make use of it? Being prepared to take a spiritual history may well be the first step. This is not as strange as it sounds, especially if we consider the role of doctors is to become familiar with any issues that may be affecting a person’s health, or may affect their acceptance of certain forms of treatment. The doctor does not have to be personally spiritual or religious, or be of a particular faith to understand the impact of such issues; just as a doctor is not expected to have heart disease to understand and assist someone with heart disease. The important factor is for the doctor to be in a position to assemble the resources required to assist a patient’s recovery; and that may involve calling upon the services of a chaplain, rabbi, imam or other members of a particular faith community. Furthermore, the evidence suggests that the positive role of spirituality and religion in people’s lives should even become an issue for Public Health services.

In 1869, when Charles Darwin wrote about the ‘survival of the fittest’, many thought he was blasphemous and anti-religion. The irony for Darwin and his followers (including contemporary writers such as Richard Dawkins) is that it is now known that the fittest are likely to be those who are religious.

(First published in the Scunthorpe Telegraph, Thursday 4^th October 2012.)

The Hard Game of Life

 ‘Hope springs eternal in the human breast.’

If only the 18^th century words of Alexander Pope were true for every person. Hope, that powerful emotion that, when present, so readily dispels its antithesis despair, is sadly lacking from many people’s lives. The result is a never ending spiral into an increasingly black hole at the bottom of which resides suicide; the thought of which curiously acted as a ‘great source of comfort’ to the German philosopher, Friedrich Nietzsche. Yet our true source of comfort ought not to be found in death, but in an optimistic outlook on life, fuelled by a game plan to bring our great expectations into fruition.

The statistics for suicide are a cause for great concern. The World Health Organisation calculates that every year some one million people worldwide die by suicide, corresponding to one death every 40 seconds. This is more than the annual loss through murder and war combined. Yet, the situation could be far worse as up to twenty times this number of people fail in their attempt at suicide. It is calculated that 5% of people attempt suicide at least once.

Often hidden by other events (such as road traffic accidents and cases of drowning), suicide is the leading cause of death amongst young people (100,000 adolescents per year). Those overwhelmed by stressful life events and emotional distress, in chronic pain, or suffering from a psychiatric disorder, alcoholism or drug addiction are most at risk. Overall, more men die by suicide, whilst more women attempt suicide. In terms of age, the suicide rate is high amongst middle aged men and highest in people over 75 years.

The costs to society from suicide are enormous, estimated to be equivalent to billions of US dollars per year. The psychological and social impact on families and communities is even greater. Yet, despite its frequency, suicide is often under-reported for fear of family stigma, religious concerns and negative social attitudes.

The good news is that suicide can be prevented. It was with this simple fact in mind that September 10^th marked the 10^th anniversary of the World Suicide Prevention Day. The latter exists to raise public awareness of risk factors, improve efforts to strengthen society’s protection of the vulnerable, and to teach people where they can seek help. The focus is on public awareness campaigns, increasing supportive networks for young people, increasing training for healthcare professionals, improving mental health resources and reducing the barriers to accessing these.

That said, even at present, there are various readily accessible support groups outside of the normal health services. For example, the Samaritans, founded by the Reverend Chad Varah (who was born in Barton upon Humber), provides a 24 hour support line on 08457 90 90 90 (www.samaritans.org). There is also Nightline; a student-focused support line, whose Hull number is 01482 466272 (www.nightline.ac.uk).

Life was never promised to us as something that is easy; but neither, contrary to the lyrics of the theme song to the television programme MASH, is suicide painless. Somebody, somewhere, always gets hurt to an unfathomable extent. Working together, society can reduce that pain.

(First published in the Scunthorpe Telegraph, Thursday, 20^th September 2012)

Thought for the Day

'I believe in Christianity as I believe that the Sun has risen - not only because I see it, but by it, I see everything else.'

C. S. Lewis (1898 - 1963)

Out of the Frying Pan into the Fire

Stagecoaches were the main means of long-distance travel before the advent of the railways. Drawn by horses, each journey required regular stops to change the tired horses for fresh ones. Travelling at slow speeds (4-7 mph), a lot of effort was involved just to cover short distances. Indeed, it could take an entire day’s journey to travel from Barton upon Humber to Boston; a long, arduous journey without any meaningful change of scenery.

Last week saw the Prime Minister change many of his horses in a mid-term re-shuffle of the Cabinet. Amongst the ministers put out to grass was the former Secretary of State for Health, the Rt Hon Andrew Lansley. Vaunted as the architect of the Health & Social Care Act 2012, many would prefer to see him cast as a demolition man rather than a designer; in this case, the destruction of the National Health Service. Having spent almost nine years holding a health portfolio (the first six in Opposition), it is astonishing that he so spectacularly failed to understand that the National Health Service works better as a functioning whole rather than as fragmented bits. After all, who in their right mind buys a jig-saw puzzle ready made up, dismantles it into 1,000 pieces, and then stands back to admire the result?

That, however, is what Andrew Lansley has managed to bring about after nine years of studying the NHS. Albeit rickety and demanding high-maintenance, what was once a functioning and coherent service is now lying in broken chunks scattered over the landscape. The irony is that Aristotle understood the principle as far back as the 3^rd century BC, commenting that ‘The whole is better than the sum of its parts’. Integrated health care is something clinicians have desired for many years. Yet, the concept of co-ordinated, comprehensive and seamless care has been laid to waste by a Secretary of State who was deluded into thinking he understood the complexities of life at the forefront of health care. For someone who holds a degree in politics, it is astonishing that he was unable to assimilate the lessons of the past, and in particular the Porritt Report of 1962 which stated ‘We have concluded that in future one administrative unit should become the focal point for all the medical services of an appropriate area’. That was what the now terminally-ill Primary Care Trusts were for.

The Prime Minister’s change of horses has produced Jeremy Hunt as the new Secretary of State for Health. Hunt is on record as holding controversial views on health care, which do not exactly encompass Aneurin Bevan’s vision of free-at-the-point-of-use medical care for everyone. A failed exporter of marmalade, Hunt is clearly the right person to pull the NHS on to its final stage of destruction.

The only real hope of rescue is a change of government with the next election when, as one senior NHS executive said to me recently, another major reform will be needed to stitch the NHS back together again. Perhaps the French novelist, Jean-Baptiste Karr had it right when he wrote ‘Plus ça change, plus c'est la même chose’; the more it changes, the more it is the same thing. After all, even after a long arduous journey, the Wash still looks a bit like the Humber.

(First published in the Scunthorpe Telegraph, Thursday 13^th September 2012)

Thought for the Day

'Faith need not be unacceptable to contemporary culture, and contemporary culture need not be unacceptable to faith'

Paul Tillich (1886-1965)

Thought for the Day

'To study theology is to set out on a voyage of discovery that is at times enriching, at times challenging, but always profoundly interesting.'

Alister E McGrath (2011)
From the Preface to Christian Theology - An Introduction

In a Motivational Mood

Continuing with my theme of the Olympics and Paralympics serving as motivators to those who for some reason psychologically feel unable to achieve something with their lives, I watched with interest as Professor Stephen Hawking opened the Paralympics with an opening ceremony designed to ‘celebrate the possibilities that lie within us all’, as the brief for the artistic directors was phrased. 

Tapping those inner possibilities is not something we are always good at; either as individuals or as adults with a responsibility to do precisely that in respect to our younger members of society. I still remember the moment my headmaster informed me that, in his opinion, I would never become a doctor. I could so easily have been discouraged at that first hurdle, spent my time at university reading the Classics and be running a bookshop by now. I could also have been dissuaded of my heart’s desire when, in the 4^th year at medical school, a general surgeon pompously informed me that I was wasting my time by wanting to enter General Practice. Fortunately, my well-polished rebellious streak came to the fore on both occasions and I ploughed my own furrow with a focused determination.

However, not everyone can be so self-motivated. It is then that such reservations need to be overcome by those who recognise the untapped potential. It was with those thoughts in mind that I recently listened to BBC Radio 4’s programme ‘Lewis’s Return Home’. Based on the life of the writer Ted Lewis (author of the book behind the famous film, Get Carter), it told the story of how, when a pupil at the Grammar School in Barton upon Humber, Lewis was taken under the wing of his schoolmaster, Henry Treece. Treece, in his own right a celebrated poet and author, recognised the artistic talent within Lewis and persuaded both him and his parents that the Hull Art College was the place for Ted to go. From there, Ted Lewis began a writing career and, as the saying goes, the rest is history.

The story was far different for Nicholas McCarthy. McCarthy only has one hand; he was born without his right hand. At school, his head teacher told him that ‘having one hand would always hold him back and it was better not to waste his and other people's time’. The comment was made in respect to McCarthy’s desire to learn the piano. Not to be daunted, McCarthy taught himself to play the keyboard. Last month he graduated from London’s prestigious Royal College of Music. Last week, he played as part of the paraorchestra, Britain’s first disabled orchestra. Next month he embarks on a tour as a concert pianist, starting with the Fairfield Halls in Croydon. (McCarthy’s remarkable story and the opportunity to watch and listen to him play can be found at www.bbc.co.uk/news/uk-england-surrey-19179499).

Teachers such as the headmasters both I and Nicholas McCarthy were exposed to have no place in the lives of children. Demotivation is the last thing young people need. Every child should have a Henry Treece at their elbow, seeing the hidden potential and driving them forward to achieve what is in their hearts and minds, regardless of the hurdles they might face along the way. ‘Celebrating the possibilities that lie within us all’ is what the London Paralympics was focused upon. It should become everyone’s mantra for life.

(First published in the Scunthorpe Telegraph, Thursday, 6^th September 2012)

The Frustrating Field of Human Endeavour

As a doctor, I have realised that people broadly fall into three categories when it comes to illness and disability. The first consists of those who are so severely ill or disabled that they require assistance with all activities of daily living. They are unable to perform even the most minor task. They need and deserve all the assistance that medicine, social services and society as a whole can provide to ease their misfortune.

Then there are those who, regardless of how severe their diagnosis is, shoulder the burden and carry it with aplomb, determined that they will continue to live as actively as they possibly can. They overcome psychological and physical burdens, as well as social prejudices and discrimination, to make their lives fulfilling. They are largely uncomplaining, being appreciative of everything done to lighten their load. They strive to meet everyday challenges, including working for as many hours or days they can manage. They do not expect to be totally kept by the nation on benefits, and instead earn money and pay their tax as well as any able-bodied person. They are a credit to themselves and to humankind.

Finally, there is the opposite group to the aforementioned. They usually have some genuine illness or disability (although some do fabricate their condition), but they magnify their symptoms and wear their suffering like a badge for all to see. Regardless of how capable they remain, they consider themselves to be totally incapable of work for even a reduced number of hours per week.  These are people who are quick to blame others, including the medical profession, for their misfortune in life. They also believe that society owes them something and that it is their right to live on state benefits. The fact that they still have a functioning brain, or the use of their arms, or can sit even if they cannot stand for long (and so on) is immaterial to how they see themselves and their ability. In their eyes they are totally disabled and incapable of contributing to their own care or to society as a whole.

It is this third group that I admit to professionally finding the most frustrating. With such people, there is a part of me that wants to confiscate their unnecessary walking stick or crutches, shake them by the shoulders and tell them to get a life. As a reader, you will know someone like that. You may even recognise yourself as one of this group.  To such people let me say that I know you are often in pain, or have difficulty with your heart, lungs, bowel, bladder, or a limb or two, and that life is not always easy; but it is not impossible. Life is also precious; a once-only gift and you are wasting yours.

Dr Ludwig Guttmann shared the same professional exasperation when he was put in charge of a spinal unit at Stoke Mandeville Hospital in 1943. Refusing to allow his colleagues or his patients to see people with disability as totally incapable, he strove to make patients focus on what they could do rather than what they could not. As a result, the Paralympics was born. This week we will watch with awe, pride and fascination as men and women show how they have overcome enormous difficulties and suffering to excel and make something of their lives. As you watch, ask yourself one question. If they can do it, what is stopping you from achieving more than you currently imagine you are capable of doing? 

(First published in the Scunthorpe Telegraph, Thursday, 30^th August 2012)

Thought for the Day

'We must...resist the doctrines of progress and emancipation that undervalue the task of helping one another to live well and truthfully with situations when, frequently, there are no cues or answers. This is the task of the pastor which early Christians termed 'sustaining'...'

Elaine Graham (1999), 'Pastoral Theology: therapy, mission and liberation?'
Scottish Journal of Theology, p. 448.

Thought for the Day

'In nothing do men more nearly approach the gods than in giving health to men.'

Cicero.

The Dawn of a New Renaissance

Within the past week an avid reader of this column kindly let it be known that her husband calls me ‘Renaissance Man’. For someone whose internet blog describes himself as ‘an aspirant polymath’, such an accolade was very flattering indeed. For a few hours I basked in the delusion that I had finally joined the ranks of Leonardo da Vinci, Frances Bacon, Galileo and other erstwhile figures, until my wife recognised the danger symptoms and rescued me by the simple reminder that I still hadn’t accomplished the task of getting the flat battery out of her MG, and had yet to remove a radiator from the wall without the need to call an emergency plumber.

With my feet firmly back on the ground and putting my practical failings to one side, I attribute my interest in so many areas of life to my time spent at one of the country’s foremost grammar schools (St Olave’s in Kent). An Ofsted inspector recently described the school as having ‘a focus on scholarship and cultural enrichment with a vibrant approach to intellectual curiosity’; another said ‘it is a school which aims at success and succeeds’.

A major aspect of life at St Olave’s was the sense of competition. Competition ran through every activity of the school as much as ‘Brighton’ runs through Brighton Rock. If you were not competing to ensure that your ‘House’ won the most points in that academic year, you were striving to be in the 1^st rugby team, squash team, tennis or fives team. In between the omnipresent sports fixtures, you polished up your musical scales in order to secure your place in the school orchestra, brass band, wind ensemble, jazz band, barbershop quartet, choir or whichever musical group was performing in the near future; and amidst all of that, you aimed to ensure that your academic grades would secure you a place at one or other of the country’s top universities. Quite simply, you aimed to be the best…at everything. What is more, it was always understood that you had either ‘succeeded’ or you ‘hadn’t succeeded yet’. Failure was not recognised. Everything was possible.

The 2012 London Olympics has profoundly demonstrated the sense of endeavour portrayed by an enormous number of people; men and women who, day in and day out, have pushed themselves to the limit to excel at their sport; to be the best. Often, during the long hours of training, the only driving competition has come from the inner strength and desire to beat their personal best; to excel for the shear unadulterated joy of achieving something worthwhile.

If we think we have already witnessed drive and enthusiasm, the London Paralympics is sure to make us think again. I have no doubt that in one week’s time we will witness human endeavour beyond the personal comprehension of many. If the Olympics have been inspiring, let the drive and enthusiasm of the Paralympics teach or remind each one of us that success is all about competing with, and overcoming, our own personal limitations; whatever they may be.

As one commentator reflected, the Olympic Games have shown that there is nothing we (the British) cannot do well if we set our hearts and minds to it. The re-introduction of a sense of competition to school life is an important component of future adult success; whether it is on a national or international level, or simply for personal satisfaction. Ultimately, we can all be 21^st century Renaissance people if we wish to. Now, wouldn’t that tell the world a thing or two about the British?

(First published in the Scunthorpe Telegraph, Thursday 23^rd August 2012)

Art for Heart and Mind's Sake

‘When I was a child I spoke as a child, I understood as a child, I thought as a child; but when I became a man, I put away childish things.’

So wrote St Paul in his letter to the Corinthians. For the majority of us, such is the case with most aspects of our child and adult lives. However, in my case there was a flaw in the process and it is called ‘art’; or to be more precise, the ability to draw and paint. Words were never a problem; neither was music; but as a child I was lost with a pencil or a paint brush. Throughout my adult life, I have found it difficult to break away from the childish representation of a tree or house that I learned to draw when I was about three years old. It may have worked for L S Lowry, but I am not even sure that I can reach his standard of depiction. 

It was therefore a great honour and an eye-opener to spend twelve days recently in the company of five of the world’s greatest living artists; to study their work, listen to them speak about their styles, watch them at work, and to receive the occasional tuition from them. In no particular order, they were Viktor Shvaiko, Bill Mack, Michael Godard, Gary Welton and Adam Scott Rote. If you are not already familiar with their work, I recommend spending some time looking at their official websites in order to gain a deeper perspective on what I am writing about. What you will see is that they all have very different and distinctive styles. Some of them have additionally had very difficult and troubled pasts (as reflected in the books, ‘Journey to the West’ by Shvaiko, and ‘Don’t Drink and Draw’ by Godard).

Watching them work, they make it all looks so easy. However, all five men are masters of their art and have spent decades at perfecting their styles. Nonetheless, there is much to be learned from them, and the greatest lesson I brought away with me is just how cathartic the process of producing a piece of art can be. It doesn’t matter whether it is a simple pencil sketch, an abstract colour-filled vision, or a moulded lump of clay; it is the process of producing the end-product that is of immense personal value.

Art Therapy has long been an unsung hero in the world of medicine. Funding for such treatment is often very limited, and the ability to access formal courses is frequently restricted to a few places through psychotherapy departments. That aside, it forms a valuable resource for the treatment of many different types of disorders, from depression and post-traumatic stress disorder, to autism and other complex communication disorders. Artists may be interested in the website of the British Association of Art Therapists (www.baat.org); alternatively, Wikipedia provides an article of general interest on the subject (www.en.wikipedia.org/wiki/Art_therapy).

For me, fine art will no doubt prove to be an elusive skill. However, after my time recently in the company of the aforementioned five men, my eyes have been opened to the benefits art in general has to offer for even the most juvenile of artists. As the Swiss painter, Paul Klee (1879- 1940) said ‘Art does not reproduce the visible; rather, it makes visible’. As a doctor, and from a psychological perspective, I can only concur.

(First published in the Scunthorpe Telegraph, Thursday 9^th August 2012.)

The Rise and Fall of the Silly Season

August has long been known as the silly season in terms of newspapers publishing low-key or humorous stories to fill the otherwise empty news columns. This year, possibly owing to global warming, the season started early, with the publication of articles at the end of July trumpeting research promoting the Polypill.

The Polypill was first postulated in 2003, so the story is not exactly new.  The pill contains three drugs to lower blood pressure and a statin to lower cholesterol (amlodipine, losartan, hydrochlorothiazide and simvastatin for those who are interested). The concept is to make the Polypill available without prescription, at a cost of 50p per day, encourage everyone to buy it and thus halve the number of people who die of cardiovascular disease.

Now, that sounds like a meritorious aim; a magical pill to halve 200,000 deaths per year in the UK. So where are the flaws in this argument? Well, to start with, to gain that saving effect everyone, I repeat, everyone in the UK would have to take the Polypill; all 56.1 million of us according to the 2001 census. That is 56.1 million annual monthly sales to save 0.1 million lives. Making the assumption that some sensible person out there has patented this latest version of the Polypill, then that is a lot of profit for the pharmaceutical industry.

Then, of course, there are the side effects of the medication. Anyone who has been prescribed some of the constituent medicines will know that side effects are common. I grant you that most are minor, but nonetheless, many are inconvenient and sometimes very troublesome. Swollen ankles, gastric upset, urinary frequency, impotence, muscle pain and weakness, rashes, confusion and memory loss are just a few of the unwanted features. It is therefore bad enough trying to comply when your doctor believes that you need to consider such therapy; does anyone truly think that those who have not identified themselves as unwell or at risk will put up with such effects? I suspect not.

And what about lifestyle? Where does the enthusiasm for five portions of fruit and veg per day, low fat and low calorie foods, reduced meat consumption, reduced alcohol consumption, stopping smoking, exercises at least three times per week, and reducing weight to sub-obesity levels fit in? All of them are no longer necessary, or so it would seem. Forget the healthy lifestyle and simply pop a pill every day to compensate. A late 16^th Century proverb declared that ‘the age of miracles is past’. Apparently, the declaration was premature.

In 1995, Ivan Illich published a book called Limits to Medicine. It was subtitled ‘Medical Nemesis: The Expropriation of Health’. In his book, Illich declared that ‘the medical establishment has become a major threat to health’. He was concerned that ‘the disabling impact of professional control over medicine has reached the proportions of an epidemic’. He was prescient to say the least. With the advent of the Polypill, we all become patients at the stroke of a medicine licence.

Not convinced that my cynical approach is the correct one? Then let me ask you a question. Would you subscribe to the idea of underpinning every house in the country in order to stop a few subsiding? I suspect not, and with that I rest my case.

Hopefully, autumn will come and the silliness will be forgotten for another few years. Meanwhile, I am off for a good walk in the fresh air, followed by a healthy fish dinner and, just perhaps, a small glass of red wine.

 (First published in the Scunthorpe Telegraph, Thursday, 2^nd August 2012)

Style Matters

For William of Wykeham, the 14^th Century Bishop of Winchester and Chancellor of England, the proverb ‘Manners Maketh Man’ became his motto. Later, in the early 15^th Century, another proverb developed to the effect of ‘Clothes make the man’. Moving forward to the 20^th Century, the English novelist, Angela Carter, writing in Nothing Sacred (1982), said ‘Clothes are our weapons, our challenges, our visible insults’.

What then, would any of the subscribers to these historic notions make of the appearance of many of our professional men and women in the 21^st Century? In particular, what does the dress of today’s doctors say about them and their attitudes to life, medicine and their patients?

Here, I must declare not only an interest, but a strong prejudice which, to those who know me, hopefully speaks for itself. Archaic notion though it may be, I subscribe to the idea that appearances matter. The 18^th Century provides us with another proverb to illustrate the case: ‘First impressions are the most lasting’, the saying goes.

As a younger person, a doctor for me (and I speak of male doctors in the main here), was somebody who at the very least wore a jacket and tie. Suits were once de rigeuer for daytime wear for hospital consultants and Harley Street GPs; with tweed suits and jackets the domain of particularly the rural GP. Evenings and weekends on call required, at the very least, that other scarce item in today’s young man’s wardrobe, a sports jacket.

However, my view is rapidly becoming an anachronistic one. Hospital doctors have witnessed their crisp white coats resigned to the recycling bin, as uninformed policies have blamed long sleeves for hospital-acquired infections, and ‘bare below the elbows’ has been become the enforced rule. Ties now dare not show their face in the hospital clinical setting, as though these and cuffed shirts were the enemy rather than the failure by administrators to ensure that their hospitals were regularly cleaned, and staff  remembered the simple expedient of washing their hands between patients.

So, how do you see your GP? Does it matter to you that he or she is in faded jeans, a slogan-bearing tea-shirt and training shoes; with straggling hair and, for the men at least, a couple of days growth on their chins? With allowances made for cultural differences (though the fact that such consideration should change our perception is witness to our fickleness), does it matter that your male doctor has a studded nose and ears, your doctor of either sex sports a lip ring, or medics of either sexes are happy to bare their strange and often indecipherable tattoos?

Laying my cards on the table, I think that it does matter. Standards of dress are slipping and, in my view, with that landslide of slippage goes a major chunk of professionalism. Doctors need to inspire confidence; wining the patient across at the very start is a major step towards assisting them with their complaint. The way a doctor dresses says a lot about their standards, attitudes and, in turn, how thy might apply those same principles to the care of their patient.

The early 20^th Century proverb states that ‘you can’t judge a book by its cover’. However, next time you are confronted by a scruffy looking doctor, you might wish to remind them that style does matter, and patients shouldn’t be made to feel insulted by the appearance of their physician. After all, if book covers really don’t matter, would publishing houses spend so much time, effort and money making them look so good?

(First published in the Scunthorpe Telegraph, Thursday 26^th July 2012)

The Dying Keats (Book Review)

Author: Brian Livesley. Published by Matador, 2009

ISBN 978-1848761-711

The Dying Keats was written for the 20^th Biennial Keats’ Memorial Lecture in 2009. With 50 years of experience of caring for the elderly and the dying, its author, Professor Brian Livesley, has successfully researched and crafted a succinct argument for improved medical care for the dying; drawing on the distressing death of the 19^th century poet and apothecary, John Keats, in order to illustrate how doctors so often fail their dying patients.

Keats died at a young age from tuberculosis. Denied drugs such as opium to ease his terminal suffering, he experienced distressing symptoms up to his death; causing him to describe his final days as ‘this posthumous life of mine’. Livesley describes this as the ‘Keatsian Experience’ and compares it to euthanasia in the truest sense of its meaning; that being ‘a good and comfortable death’.

As the author points out, it is astonishing that today’s care of the terminally ill is often little better than that experienced by Keats; believing this to be due to the reluctance of doctors to consider death as a diagnosis that requires treatment, and reminding us that ‘dying should be a humane experience for us all’. A thought-provoking read for all clinicians.

(First published in Pulse Today, July 2012

http://www.pulsetoday.co.uk/main-content/-/article_display_list/14263504/book-review-the-dying-keats-a-case-for-euthanasia-by-brian-livesley)

So much for the Money; what about the Care?

The Government recently published the latest Social Care White Paper; which starts to address the problem of financing the care of elderly people. In outline, there will be a scheme whereby those receiving care will not be forced to sale their homes to pay for that care. Instead, they will be eligible for a council loan, repayable from their estate after death. With implementation postponed until 2014, the detail has yet to be revealed. However, if the recent Health & Social Care Act is an illustration, the ultimate Act stemming from this White Paper will be a hotchpotch of compromise, inadequately thought-through process and a few nasty surprises, which will fall short of appropriately addressing the real issues.

One of the real issues for me is not so much the money, but the quality of care. Having to sell one’s home to pay for care in a residential home may be emotive, but ultimately someone has to pay. After all, money is only a tool to obtain what we desire. When we are elderly and infirm, what we truly need is the security of knowing someone is properly looking after us. Sadly, for many people, that quest is an impossible one; particularly the closer we get to dying.

The physician and author, Dr Brian Livesley, addresses this issue in his book ‘The Dying Keats – A Case for Euthanasia?’. Livesley uses his 50 years of medical experience of caring for the elderly and combines it with a well-researched thesis about the circumstances of the death of the poet John Keats.

Keats, also a doctor, died in 1821 from tuberculosis at the age of 26. Well-aware of the availability of drugs such as opium, it is therefore an irony that he was deprived of medicines to relieve the distress of his final days. So distressing were his symptoms that Keats described the concluding period of his life as ‘this posthumous life of mine’; something Livesley describes as the Keatsian Experience.

Sadly, the Keatsian Experience is still endured. In 2008, 54% of the complaints about hospitals were related to the lack of care at the time of someone’s death. As Livesley states, dying should be a humane experience for us all. That the reality for many is so different is a sad indictment of the so-called ‘caring professions’. At the heart of the matter is the failure to treat dying as a clinical diagnosis requiring action.

The term ‘euthanasia’ is today frequently used as a synonym for assisted-suicide. However, the origin of the word is very different and means ‘a good and comfortable death’.  Keats lacked carers skilled in providing him with a good and comfortable death. Without those skilled carers, all the money in the world is meaningless to those in their twilight days if they are not being appropriately looked after.

So the message to the Government should be that the Keatsian Experience has no place in our time. Of course the problem of funding the provision of care in our final years needs to be sorted. However, the quality of care also needs to be considered. Getting the quality right from the moment we first need care will help ensure our closing days are also right. Without that, the Social Care Act will be yet another 21^st century political failing, and one we will all potentially suffer from as a consequence.

(First published in the Scunthorpe Telegraph, Thursday, 19^th July 2012.)

Be Careful What You Wish For

I do not normally consider myself to be a pessimist; although readers of this column may think otherwise, bearing in mind the inches of concern I have expressed over the past year in respect to the future of the NHS; I call the latter realism.

No, I am for all that, an optimist. I rejoice as each day dawns, regardless of the weather, the day of the week, or the latest damage the Department of Health might bring forth. I search for that hidden moment, event or experience that will bring a frisson of pleasure and make that day all the more worthwhile than the simple delight of being alive.

However, on three separate occasions recently, I have felt concern when others have felt joy. All three occasions have revolved around scientific ‘breakthroughs’; events which, as a scientist, I should be hailing with enthusiastic delight rather than guarded pleasure.

The first concerned the report that researchers have successfully predicted the entire genetic code of a baby. The process was fairly simple, and involved nothing more invasive than a saliva swab from the father and a blood test from the pregnant mother. ‘Magic!’ as a performing magician might say.

Being able to predict a baby’s genetic code means that it is now theoretically possible to screen unborn babies for some 3,500 disorders; which then raises the next question of what to do once we know that there is a problem. The morals and ethics of such investigations, along with the expected increase in the number of abortions, are far too complex for a short newspaper column. However, the vision of a future of designer babies does make me uneasy.

The second ‘breakthrough’ was the knowledge that it is now scientifically possible for women to store a small sample of ovarian tissue, and then have small pieces re-implanted over time in order to maintain their fertility beyond the age currently dictated by nature. Of course, the same process also delays the effects of the menopause. The latter may be welcomed by many women, and I do not blame them. However, does society really want or need childbearing by mothers in their 60s and 70s, or beyond? I will leave you to ponder your answer to that question.

Finally, quantum physicists have been rejoicing in the discovery of the long-postulated Higgs Boson, or ‘God-particle’ as it has been popularly known. This elusive particle apparently explains the force that holds the Universe together and enables stars and planets to exist. The discovery has evidently clarified one of the great mysteries of science and the world. It is one which will undoubtedly lead to other great advances in science, although exactly what is presently uncertain. Nonetheless, I feel that we should temper our excitement with a degree of caution, for mankind has not always been good at putting great scientific discoveries to the best of use.

If designer babies and fecund octogenarians do not as yet ring any alarm bells for you, then the Higgs Boson should. If you ask me why, I am not sure that I can presently give an erudite answer. However, I experienced the same pang of pessimism when reading about all three of these discoveries. The 18^th century clergyman-writer, Charles Caleb Colton, wrote ‘the greatest fool may ask more than the wisest man can answer’. In this context, I am not certain whether I am the wisest man or the greatest fool. However, I have no doubt that we should be very careful as to what it is we wish for.

(First published in the Scunthorpe Telegraph, Thursday, 12^th July 2012.)

The Delusional Art of Statistics

 ‘There are three kinds of lies: lies, damned lies and statistics.’

The quote is attributed to the 19^th century British Prime Minister, Benjamin Disraeli. What, I wonder, would he therefore make of the new iPhone app called ‘GP Ratings’, or indeed the expansion of statistical data now available on the Department of Health’s website, NHS Choices (www.nhs.uk)?

Statistics are only helpful if they compare like with like, compare data that is meaningful, and are sourced from unbiased data. Sadly, the aforementioned App and website fall down on all three counts, being drawn from a fundamentally flawed annual review called the GP Patient Survey. As a result, practices are now given a score out of ten based on patient experiences.

Now, speaking as a GP and from a personal basis, I have nothing I wish to hide from my patients or my peers. I strive to be the best GP I can. However, I am not, and can never be, perfect. That I frequently fall short of perfection is down to many different factors; an increasing number of which are totally outside of my control (lack of funding for the NHS, inflated Governmental and patient expectations, the number of hours in the day, imperfect therapies, and the mysteries of health and life that are yet to be answered by science, to mention a few). I therefore do not mind my work being compared to another GP, as long as the comparisons are fair and meaningful. Sadly, there is very little of that within the Government’s new ratings system.

Many writers in the medical press have condemned the new scores as simplistic, lacking detail and running the risk of overwhelming patients with unhelpful information. They are quite right. In many important areas, such as how well a doctor manages chronic or life-threatening illness, the information provided does not allow for meaningful judgements. Instead, the main comparisons are on factors such as how easy it is to obtain an appointment at a convenient time and how long one waits in the waiting room.

Not for one moment am I saying that these issues do not matter; of course they do. However, I would rather wait for an hour to see a doctor who is going to take my problem seriously, diagnose me accurately, treat me appropriately, explain the details to me in language I can understand, and, somewhere amongst all of that, show me a little compassion, than be whisked in and out on time, but left feeling that my issues have not been properly addressed.

Unfortunately, many of the issues the Department of Health measures doctors against are ones which are easily managed if one works in a well-resourced private institution, but will always be wishful thinking for large, underfunded, overloaded, NHS practices whose staff are trying to juggle the complex demands of patient care with training medical students and new GPs, commission local NHS hospital services, balance the NHS budget, and contribute to numerous other demands from the world of medical politics. Read the data by all means, but treat it for the crude information that it is. If it is of little use to me, in my capacity as the medical director for a Primary Care Trust, then I seriously question what real use is it to you as patients.

As Albert Einstein once said, ‘Not everything that can be counted counts, and not everything that counts can be counted.’

(First published in the Scunthorpe Telegraph, Thursday, 5^th July 2012)

The Importance of Good Communication

Communication, according to the Oxford English Dictionary, is the action of sharing or exchanging information or ideas. What the dictionary does not say is whether communication includes the concept of understanding the message the informant intended to relay. Without adequate understanding the message being communicated is lost or misconstrued, sometimes with unintended consequences.

Of course, there are those who would claim that the opposite is also of value. Some might argue that misleading communication is an art well exercised by politicians to meet their own ends. As the American author Lionel Trilling said, ‘where misunderstanding serves others as an advantage, one is helpless to make oneself understood’. Examples of that were certainly seen last week during the battle over NHS pension arrangements.

However, the language used to communicate a message is equally important as the ideas being expressed. A favourite expression of mine is ‘words mean what words say’. Naturally, it is a paramount prerequisite for good communication that both the communicator and the listener understand the meaning of the words being used. I assume that Tim Loughton MP, was not being deliberately misleading last week when he said ‘I shall be speaking about it more fulsomely later.’ Referring to a report on missing children, he probably meant to give the impression that he would speak ‘in detail’ or ‘at greater length’, and that is possibly what most people took to be his meaning. However, the word ‘fulsomely’ is ambiguous. Properly interpreted as ‘lavishly’ or ‘extravagantly’, it can also convey ‘insincerity’ to the point of being insulting. To some listeners, his message would therefore have been received in a completely different manner to that which he probably intended.

Doctors need to be good communicators if patients are going to understand the health issues being discussed. For the majority of patients, there is no point in the doctor hiding behind erudite phrases, words in Greek or Latin, or medical jargon full of acronyms, if it is hoped that the message will be understood. According to recent studies, 43% of Americans have a literacy standard below that necessary to understand health issues (see www.nchealthliteracy.org for more details). In the United Kingdom, the figure is thought to be around 12%; although these figures assume that the message is being conveyed in a language suitable in respect to its origin, dialect, complexity and accuracy as befits the recipient. The phrase ‘health literacy’ is increasingly being used in reference to such matters.

‘LSD? Nothing much happened, but I did get the distinct impression that some birds were trying to communicate with me.’ The poet, W H Auden, was clearly speaking of his experience of using an hallucinogenic drug when it said that. Nonetheless, for many people, even the most caring of doctors can leave them feeling confused and uncertain. For them, a trip to see their GP or specialist may be as equally puzzling as Auden’s encounter with his feathered friends.

The problem is not just about whether someone can read and write, or whether they speak the same ethnic language as the doctor; our population is increasingly an aged one, and even very intelligent people start to lose cognitive ability as they get older. Defined by the World Health Organisation as ‘the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions’, health literacy must be taken into consideration and appropriately addressed if we are to achieve the desired health outcomes for our communities. Doctors must remember that patients will not always say that they do not understand; for their part, patients must not be ashamed or intimidated, and must tell the doctor if they do not understand what is being said. Getting the health communication wrong can be costly to the individual and society, in terms of deteriorating medical conditions, more expensive medical treatment, prolonged hospital stays, and increased risk of death.

That said, the French poet Charles Baudelaire once declared that ‘It is by universal misunderstanding that all agree. For if, by ill luck, people understood each other, they would never agree.’ Perhaps that is an apt statement for tautologous political circles, but not one for an effective health service. Unlike Sofia Coppola’s film, health messages should never be lost in translation.

(First published in the Scunthorpe Telegraph, Thursday, 28^th June 2012)

Standing up for more than a Principle

The medical profession is not usually considered to be a militant organisation. Frequently  coming high on the list of those members of society who the public holds to be honest, reliable and worthy of respect, doctors are generally considered to have a learned and caring vocation, whose voice is willing listened to with politeness and interest, even if only out of curiosity. In turn, the profession usually recognises and appreciates this esteemed status and, through the General Medical Council’s code of conduct, does much to ensure that the public trust is not undermined.  

That today, the 21^st June 2012, has been declared a day of industrial action by doctors is therefore of great significance. Of course, ‘industrial action’ is not necessarily the same as a ‘strike’; but the mere fact that it is happening at all is of great importance, with all the implications that it has to threaten the aforementioned public good-will.

The official reason given for the industrial action is the Government’s recent action in respect to the NHS pension scheme; action which effectively renegades on negotiations and an agreement in 2008 which was supposed to ensure the future viability of the pension scheme. Be that as it may, there is much more behind the situation than is immediately apparent. However, before I expand on the unwitting testimony, it is worth clarifying a few misconceptions that the Government is keen to promulgate.

First, the NHS pension scheme is not funded by the tax payer. The scheme is supported by its members; the doctors, nurses, ancillary staff and administrators who make the NHS work. The ultimate pension is in effect deferred pay, and has historically been on decent terms in recognition of the lower pay and substantial good-will of health workers; many of whom spend years of arduous training and contribute many unpaid hours to the good of society.

Second, is the fact that the NHS pension scheme currently returns a surplus of around £2billion per year to the Government; money that the Government then happily puts into the general coffers. Despite this, the Government argues that the situation is not sustainable and that, with the rising number of retired members, the scheme will not be able to support itself in future. However, that is what the negotiations of 2008 were all about. At that time, the medical profession, along with most healthcare workers, willing worked with the Government to bring about changes which would secure the inherent viability of the scheme and avoid it becoming a drain on the tax-payer. Nothing has changed since then to undermine those calculations; not even the change in the economy. Instead, the Government is set on unashamedly fleecing the NHS pension scheme whilst hiding behind flawed arguments and shameless lies, and that is what has angered the medical profession.           

Nonetheless, the institutionalised theft of people’s pensions is only the final straw of the unbearable load that has broken this particular camel’s back. As a body, doctors are tired of successive Governments meddling with the NHS, introducing badly thought-through policies, ignoring the profession’s opinion, increasing the workload to unsustainable levels whilst inappropriately raising public expectation of what should be achievable, and then publicly blaming the doctors for when it all goes horribly wrong. The profession is exhausted by inflated demands, frustrated by the focus on irrelevant outcome measures, weary of being the scapegoat, and demoralised by the determined destruction of the NHS. The theft of people’s hard-earned pensions is just a small part of this Government-built mountain of unrest.  

Today, for the first time in almost 40 years, some doctors will stop doing routine work for 24 hours. Urgent patient care will continue, and no patient should suffer as a consequence. That said, many of us will carry on as normal, strongly supportive of the need for action, but unable to put our own well-being ahead of those we have trained to help and serve. No doubt the Government will again ignore us and the popular press will vilify us. However, the population as a whole should take note. When a venerable profession is moved to such extremes, there is something very wrong with our world in general and its politicians in particular.

(First published in the Scunthorpe Telegraph, Thursday, 21^st June 2012.)