Friday, 20 May 2011

Everyone's talking about love (or the parable of Lennie and the puppy)


Just like David Cameron, I love the NHS. I love the way that whenever I deal with a patient, we can talk about what we are able to do to help with their medical problem, rather than what they are able to afford. I love the way the NHS evens out the peaks of affluence and the troughs of poverty.

But I don’t really want to play a game of who loves the NHS the most - that really doesn’t get us anywhere. What helps is to examine how well the NHS serves its patients, and what it can do to serve patients better.

I used to think that because the people who tend to use the NHS the most are the people who contribute the least (poverty is associated with poorer health) they should feel lucky to get the service they do, and they should accept the level of service on offer. This view was in part driven by the misery of being an A and E SHO, where the relentless, thankless toil of being at the sharp end of emergency services can really test one’s resolve. Objectivity suffers under those circumstances.

My views are different now, partly through maturity, partly through better insight into what it is like to be a patient, and partly through having the time and space to really reflect on what is important in healthcare. One of the conclusions I have come to is that as doctors, while we are expected to be technical experts in managing disease, we should also try to be experts in managing patients through the often frightening experience of being poorly. While very few of us actually know what it is like to suffer the conditions that we treat everyday, we have the ability to help patients and their relatives know what they can expect. For many, it is the uncertainty of illness that is often the hardest to bear, and the uncertainty of what the diagnosis means. Often my patients don’t know whether they have experienced good medicine or bad, but they do know whether they have been treated with dignity, courtesy and candour.

But where am I going with this? Well, a couple of days ago, during a discussion at a Geriatric SpR training day, I remarked to one of our speakers that I often found that when I was  discussing a patient’s clinical care with other doctors, particularly in other specialties, the conversation was not always driven by the clinical needs of the patient, but rather it felt as if it was being influenced by any number of other interpersonal factors; my point was that as doctors we need to be honest enough with ourselves and each other to acknowledge that the way we do things isn’t always driven by the priorities of patient care, and that we often bring a lot of ourselves into our interactions with work. I think I closed with some remark that medicine is a customer focused industry, and we need to remember this sometimes.

This standpoint was later contested by one of the registrars in the room, who argued that users of the service had an obligation to use it properly, for example by remembering that on weekends there is only a skeleton staff, and the same level of cover cannot be offered. Her point revolved around the viewpoint I outlined at the start of this piece - that the health service provides a level of cover that patients are lucky to have, we all pay taxes that support it, that we work jolly hard in providing it, and that it cannot always be organised around the convenience of the patient.

Now this is a complex field and I am not planning to iron all of this out today. But it did remind me of the many occasions I have heard doctors complain about patients presenting to A and E rather than going to see their GP. Sometimes (particularly as an A and E SHO) I have real sympathy about this. But the health service is a complicated beast, and navigating one’s way around it can be very hard. It doesn’t matter what community initiatives, or GP consortia or out of hours services there are in your borough, the one constant of the health service is that A and E is always there, and it is always open, so it is no wonder that when something happens to someone that is subjectively important to them (but not objectively serious to us as doctors) that their decision making brings them to A and E.

And this is my point today - we love the NHS, and when someone tries to change it, it can feel like the essence of the thing we love is being questioned. But just like Lennie and the puppy in Mice and Men, our love is not always helpful, particularly when it blinds us to the things that the health service could do better: it could be easier for patients to know where to get the right help, it could be better at arranging services around the convenience of patients, and we could all be better at being experts in managing patients through the experience of ill health.

1 comment:

  1. Sickness doesn't work to a calendar. If I get a bad kidney infection on Saturday morning, I can't wait until Monday morning for a GP appointment (not with PKD as it might lodge in a cyst and I have suffered from one of those before). GPs are also not good at understanding certain conditions. A&E is often only place to go.

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