Pessimism or Realism?

Amongst family and friends I am well-renowned for being an early riser, with a willingness to extol the virtues of making use of the time between 5am and 7am to an effect more rewarding than sleeping. However, this morning my newspaper colleague, the Honourable Columnist for ‘Strictly Speaking’, kept me in bed for an extra hour. Such is the stuff of rumour and gossip. However, before the editor makes room on the front page for a lurid exposé, let me explain that I simply awoke thinking about something my fellow correspondent recently wrote about the NHS. In his article on Thursday 27th October, Hugh Rogers expounded on why he felt confident about the future of the NHS, stating that in this respect ‘pessimism has no place’.

Whilst I am a person of strongly held views, I am always willing to consider the possibility that I have got something wrong. With this is mind, I lay awake pondering my recent proclamations within this column in respect to the current changes the NHS is being subjected to in the form of the Health and Social Care Bill 2011, asking myself whether I have been too pessimistic.

The answer can perhaps be drawn from a trawl of recent news articles regarding GPs (bearing in mind that the majority of medical care in the UK is carried out in general practice and not in hospital). According to a BMA survey, the majority of GPs believe the relationship of trust between them and their patients will be damaged by the NHS reforms. Commissioning will also bring a greater workload to GPs, who are already disenchanted trying to deal with an excessive workload and an administrative nightmare. Additionally, new work makes it harder to fit everything into a ten minute consultation slot, especially as a great deal of the work GPs now do used to be done in hospitals. One answer is to recruit more GPs. However, the evidence suggests that fewer young doctors are being attracted into general practice (this August there was an 11% fall in doctors accepted onto GP training courses compared to 2009); on top of which it takes ten years to train a GP from scratch, so increasing medical student training may help in a decade’s time, but doesn’t answer today’s problem. Then we have the suggestion that the government wants to do away with practice boundaries, so patients can see a doctor anywhere they wish. This may be handy for minor acute illnesses, but would be difficult and potentially dangerous for complex issues, apart from making it hard to predict demand for some popular practices.

What about the patients’ perspective? Well, I think everyone knows how hard it is to get an appointment with a GP at present. I am sorry to tell you that the forecast shows that it is going to get worse; a large percentage of GPs over the age of 50 years are actively looking at taking early retirement or going part-time. The reason is low morale, four years of seeing GP pay decrease year on year, government threats to the NHS pension, and a totally skewed work-life balance. Personal health budgets should also raise patients’ concerns. 50,000 people will get personal budgets over the next three years, with a view to rolling it out to more thereafter. These budgets will initially apply to patients with complex medical problems. So what happens when your personal budget runs out? After all, the changes are not just to make the NHS a more efficient service for patients; they are also to reduce the overall cost to the nation. This is further evidenced by the ‘care crisis’ induced by the one fifth cut (£1.3 billion) in government funding for nursing homes at a time when the elderly population is expanding.

I agree with Hugh Rogers that as a nation we tend to triumph at times of adversity. However, I don’t think I am being pessimistic in my expressed views. The evidence is out there and we are unwise to ignore it. Honesty and truth does not equate to pessimism; it is called being realistic.

(First published in the Scunthorpe Telegraph, Thursday, 4th November 2011)

First Amongst Equals - A Tribute to a Former Colleague

I like to think that it is a rare individual who cannot name one person who has influenced their life. Most of us can probably name a parent or teacher. However, just occasionally somebody comes along who is more than just influential; someone who is inspirational and whose memory lives on as a person against whom we measure our actions.

I have several such mentors; most of whom are oblivious to their role in shaping my personality and actions. The first in medical terms was a doctor who was my immediate senior when I was a houseman in a Devon hospital. His unfailing courtesy, diligence and attention to detail made him stand out from all other doctors I had come across during my training. His name was Dr Assad Al-Doori, and he was an Iraqi. Over subsequent years, I have often thought of Assad and hope that I have incorporated some small measure of him within my own practise of medicine.

Until recently, there have been few doctors who have measured up to Assad’s standards. Then I had the fortune to meet a doctor some twenty years my junior, who subsequently became an associate within my practice. Such was his dedication to his patients that one year ago we offered him a partnership, recognising that he would be a tremendous asset to our community. He embodied the very attributes I had recognised in Assad: unfailingly kind, gentle, polite, thoughtful, and dedicated to the art of medicine, the care of his patients and the teaching of young doctors. He was an untiringly hard worker who thought of himself last of all.

His name was Dr Imran Arfeen. He was from Pakistan and he was a devout Muslim. It was his Islamic faith which strongly guided his principles and actions and, alone in his consulting room, he would snatch moments of his busy day to incorporate his ritual of prayer. To observe Ramadan, he worked non-stop throughout the day in order to overcome his hunger. Imran was inspirational and influential; holding long conversations with me regarding the comparative values of Islam and Christianity, the Koran and the Bible. I discovered from Imran far more about how the two religions overlap than I had previously discovered. Imran also quietly and gently reminded me on numerous occasions of the reason why we practise medicine – to serve the poor and sick. My colleagues now tell me that I was not alone in benefitting from his wisdom and humility.

I write of Imran in the past tense as, shortly after being offered a partnership, he was diagnosed with a terminal illness. He died two week ago. Throughout his illness, his courage and fortitude remained inspirational. Taking strength from his faith, he never lost hope and fought an heroic battle. Insisting that work was best for him, few of his patients knew that he was receiving chemotherapy, and was in effect more gravely ill than many of those he was treating.

Ironically, on the day he died, the practice received a letter addressed to Imran from a patient who is a retired Church of England priest. The letter is an outstanding testimonial to Imran’s attitude, beliefs and character; extolling his work as a doctor. It was meant as a private letter, but sadly not one Imran was to read. If he had, I am sure that we would never have known about it; such was his self-effacement.

No parent should ever suffer the grief of losing a child. It is equally true that no doctor should see a younger colleague succumb to a fatal illness. However, Imran was a devout Muslim amongst Christians, the most Christian of Muslims, and medically the first amongst equals. He taught us all something of value and his humanitarian legacy will live on as we endeavour to serve our masters the poor and sick.

(First published in the Scunthorpe Telegraph, Thursday, 3rd November 2011)

Thought for the Day

Nothing in life is to be feared - it is only to be understood.

Marie Curie (1867-1934)
Physicist & chemist

Crossing the Line (Part 2)

Last week I wrote about the need for doctors to adopt a holistic approach to caring for patients, reflected on the General Medical Council (GMC) guidance on religion, and finished with the historic connection between priests and doctors.

Last month a Kent GP was accused of ‘crossing the line’ when he asked a patient whether he had ‘considered Christianity’ as a means of psychological support. The patient was apparently willing to listen (BBC News, 22 Sept), but later told his mother that the GP had said that he ‘just needed Jesus’. The mother reported the GP to the GMC. Following a disciplinary hearing the GP was given a formal warning, which he has appealed against and the case will now go to a public hearing. The appeal is yet to be heard. However, it does raise many important issues; not least the manner in which patients interpret what is said within consultations. We all know of patients with incurable problems who, after the GP has gone through the long-term management plans of (say) pain relief, physiotherapy, occupational therapy, home adaptations, diet and exercise, tells his family that ‘nothing can be done’; which is not quite the message the GP had in mind.

However, there is also the issue of whether a GP is wrong to raise the subject of religion. The GMC stated that the Kent GP ‘crossed the line’, meaning the GP moved from acceptable to unacceptable practise. So what happened to the holistic approach to caring for a patient? This is where I believe that the medical profession is confused and acting illogically. On one hand, the GMC has announced that it is ‘tightening up’ the guidance on religion in practice (Pulse Today, 5 Oct), by making it a duty for GPs to consider patients’ ‘religious, spiritual and cultural history’, whilst simultaneously castigating a GP for having that very discussion. Unless a GP can openly explore a patient’s views, how are the requirements of the new GMC duty to be met? The conundrum is added to by a recent Health Foundation study, which states that doctors should adopt the role once taken by a ‘local priest’. I cannot see the GMC warming to that report.

So what of other views? The Department of Health issued guidance earlier this year warning against ‘proselytising’, stating that it is the role of the NHS Chaplaincy Service to meet patients’ spiritual needs. Fine, but when did you last see an NHS Chaplain in your surgery? Many doctors have told the British Medical Association that they want the right to pray with their patients without fear of being suspended; whilst the co-director of Patient Concern has stated that patients often welcome the offer of a prayer as a ‘warm and kind thought’. Understandably, the National Secular Society has the counter view that health and religion should not mix.

Holistic care means precisely what it says. The key point amidst all of this is for a doctor to be sensitive to a patient’s views, regardless of what they may be. Patients need doctors to be human beings and to consider them likewise; for some this occasionally means the need to include spiritual matters within a consultation. However, until the GMC, RCGP and BMA agree how doctors can approach such matters, doctors will find themselves between Scylla and Charybdis; damned if they do and damned if they don’t consider patients’ religion. One thing is certain: extracting the spiritual component from medical care produces a large hole in ‘holistic’.

(First published in the Scunthorpe Telegraph, Thursday 27th October 2011)

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 2011

Crossing the Line (Part 1)

Being a doctor, and particularly being a GP, is a complex process. It is not enough to simply spend five or six years at medical school, followed by four years or more in hospitals and general practice as a junior doctor. Neither is it enough to have a list of qualifications, or to have worked in your own practice for decades. Nor is it sufficient to hold a licence to practise, read all the recent research, apply all the latest guidelines, pass an annual peer-conducted appraisal, or be revalidated by the General Medical Council (GMC) every five years.

According to the Royal College of General Practitioners’ guidance ‘medicine…is based on a set of shared beliefs and values, and is an intrinsic part of the wider culture’ (Being a General Practitioner, 2010). For centuries, doctors have been exhorted to consider the ‘physical, psychological and social’ aspects of their patients’ health needs. This is called taking a holistic approach and, according to the RCGP guidance, requires caring for the person in the context of their ‘personal values, family beliefs, family system, and culture in the larger community’. This, of course, is the ‘art’ of medicine, rather than the science. The RCGP guidance acknowledges that ‘the holistic approach…admits that people have inner experiences that are subjective, mystical (and, for some, religious), which may affect their health and health beliefs’.

The GMC ethical guidance is equally of interest. In the booklet Good Medical Practice, the GMC states that patients' ‘personal beliefs may be fundamental to their sense of well-being and could help them to cope with pain or other negative aspects of illness’. It also recognises that ‘all doctors have personal beliefs which affect their day-to-day practice’, and advises a doctor that ‘if carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs…you must explain this to the patient and tell them they have the right to see another doctor’. The GMC guidance also states that a doctor ‘must not express…personal beliefs, including political, religious or moral beliefs, in ways that exploit (a patient’s) vulnerability or that are likely to cause them distress’. What the GMC does not state is that a doctor is barred from expressing personal beliefs in any way or at any time during consultations, or indeed at any other time.

The holistic approach is not new. Throughout my career I have often expressed the view that modern GPs are ‘part physician, part priest and part social worker’. The second aspect of that statement is in recognition of the diminishing impact of the parish priest within local communities. (I accept and respect the fact that communities with a faith system based on something other than Christianity may still have a stronger daily role for their religious leaders). However, in communities where the population would once have been regular church attenders, many of the problems now brought to a GP are issues where a person may once have sought advice from the parish priest. That acknowledgement brought me very close to becoming a non-stipendiary priest some twenty years ago; a move which would have seen me officially wear the combined mantles of ‘white coat and dog-collar’. Such a move is not new; before Hippocrates, priests were also the physicians of the day, and prior to the advent of scientific medicine, laws regarding health and the practice of healing rituals were largely laid down within religious texts (the Bible’s Book of Leviticus being a prime example).

Next week I will explain how all of the above is topical, why I think the medical profession is confused and acting illogically, and why I believe such muddled and contradictory thinking is not good for doctors or patients.

(First published in the Scunthorpe Telegraph, Thursday, 20th October 2011)

A Spiritual Uprising

Only on Halloween in the UK could The Telegraph have made such a wonderful typographical error.

In their article published on the 31st October 2011 regarding the resignation of the Dean of St Paul's Cathedral, Richard Alleyne, Victoria Ward and Martin Beckford wrote as follows:

'The Dead of St Paul's had pushed hard for the church hierarchy to back legal action by the Corporation of London to remove the 200 or so tents from St Paul’s churchyard.'

(http://www.telegraph.co.uk/news/religion/8861089/St-Pauls-branded-laughing-stock-as-Dean-Graeme-Knowles-resigns.html)