A Duty Too Far

When I was studying for a Master of Laws degree, a term I became familiar with was that of ‘duty’. In terms of the law it is ‘a legal requirement to carry out or refrain from carrying out any act’. Healthcare professionals are familiar with their ‘duty of care’’; that is, the legal obligation to take reasonable care to avoid causing damage. If we fail, and that failure results in damage, then there has been a breach of duty and we can be found liable. For a professional to fail in his or her duty of care is therefore a powerful charge.

Imagine my surprise, confusion and abject distrust, when I read that the Government, that powerful body of august and learned individuals charged with making the laws of our land, has decided in its wisdom that henceforth a new statutory duty will be included within the NHS Constitution for GPs to ‘make every contact count’. By this, the Department of Health wishes to ensure that we are mandated to ensure that patients are leading healthy lifestyles on each and every occasion we meet.

GPs have been labouring away at this on an opportunistic basis for years without it being made a statutory duty. How many patients have not been nagged to reduce weight, stop smoking, drink less alcohol, eat healthier food, work fewer hours, and take more exercise? I bet the majority of my patients are surprised if I don’t say something about at least one of these issues every time they appear in my consulting room. It is what we do when trying to make people better.

However, making such activity a duty raises it to a whole new level. No longer will it be something we do as caring professionals. From now on, it will be a legal duty and to stray from that path means a breach of duty and the possibility of legal action.

So let us imagine a familiar scenario. Mr X, an office manager in his 50s, who smokes, is overweight, is stressed with running a workforce and meeting targets, has no time in the long working day for exercise, and winds down with an alcoholic drink or three, appears in the surgery for the first time in years, emotionally distraught because he has been made redundant. He is depressed and anxious because his family’s well-being is at stake, the mortgage cannot be paid and the house may be re-possessed. What he needs help with at that moment is coping with his emotional breakdown. What he does not need is a lecture on his errant lifestyle. That can come later. However, if he then goes on to have a heart attack, precipitated by the stress, but no doubt fuelled by his unhealthy habits, the doctor now becomes potentially liable in law for the harm that he has befallen.

Making it a professional standard of care is one thing; making such advice a statutory duty is open to abuse. Let us hope, for our collective sanity, that the courts see it as unreasonable and unenforceable.

(First published in the Scunthorpe Telegraph, Thursday, 28^th February 2013)

Community Needs

A couple of weeks ago I was left pondering the difference between a ‘neighbourhood’ and a ‘community’. It was a question posed during a meeting organised by the local Joint Health and Wellbeing Board (more of which a little later). My immediate response was to say that the term ‘neighbourhood’ invokes the geography of the area, whereas a ‘community’ reflects the people living within a neighbourhood. However, I was left feeling that my response was lacking and shallow, and the question has since been returning to me in the quiet hours of the night.

My discombobulation (such a wonderful word that simply rolls around the mouth) was partially assuaged by recourse to a dictionary. According to the latter, a neighbourhood is ‘a district within a town or city’; whereas a community is ‘a group of people living in one place’. So, I thought, a neighbourhood must contain a least one community (unless deserted), whilst a community could exist either within a neighbourhood, or be a distinct entity living on its own (for example, a small village or hamlet, or a remote tribe, etc.).

But for all the official gravitas of the aforementioned trusted lexicon, there was still some essence missing in that soulless definition of ‘community’. Where, for example, was the spirit of the place? Where was the sense of belonging that bonds people together in something more than the simple fact that they live in the same street or apartment block? Where was that sense of common attitudes and interests?

Ultimately, communities are about living people; people who breath and think; who interact with each other; who may work and play together, who love and fall out with each other, who may worship together; who care for each other in times of crisis, and who also care about the place where they live. That is what the term ‘community’ is really all about for me. A community is not just some sterile, amorphous entity.

So, I can hear you ask, what does the above have to do with Health and Wellbeing Boards, and what are they in the first place?  The simplest answer is to quote the Department of Health. Established by the Health and Social Care Act 2012, Health and Wellbeing Boards act as ‘a forum where key leaders from the health and care system work together to improve the health and wellbeing of their local population and reduce health inequalities’. So they consist of people such as public health personnel, social workers, nurses and doctors, who are essentially charged with making life better for local communities.

The problem is we only have a partial idea as to what would make life better, because all communities are different. Ultimately, it is the people living within these communities who can really tell us what would make life better. So please tell us. Tell your local councillor, tell your social worker, tell your GP, write to the council and to this newspaper. Tell us what would really do it for you and your community. We cannot help you win the lottery, but often it is attention to the small matters that makes a big difference to our lives.

(First published in the Scunthorpe Telegraph, Thursday, 21^st February 2013)

The Question of Marriage

Despite the complex issues requiring this Government’s attention in respect to our struggling economy and NHS, our tumultuous relationship in Europe, Afghanistan, Argentina over the Falklands, and the clamour for Independence for Scotland, one matter has particularly exercised me recently. I speak of that ancient institution called marriage.

I thought I had a pretty shrewd concept as to what marriage is all about. Having sung as a chorister at countless weddings, the words of the religious ceremony are etched in perpetuity across my memory. I have even been known to have passed an audition and thus be appointed to one of the leading roles in such a ceremony; the sequel to which, I am pleased to say, is now in its seventeenth year and shows no sign of a diminishing plot. However, despite all of that, the Marriage (Same Sex Couples) Bill, recently put before the House of Commons for its second reading, forced me to analyse my ingrained learning and preconceived ideas as to what marriage means in both legal and philosophical terms.

I already knew the Bible’s standpoint on marriage, so I therefore turned to the Oxford English Dictionary, where I was predictably informed that marriage is ‘the formal union of a man and a woman by which they become husband and wife’. The definitions of the terms ‘husband’ and ‘wife’ were equally predictable and unhelpfully tautologous. A dictionary of law was slightly more helpful, stating that marriage is ‘a ceremony, civil or religious, that creates the legal status of husband and wife and the legal obligations arising from that status’. Nonetheless, many more questions spring from there; not least the problem of whether a man can be a ‘wife’ or a woman a ‘husband’ (the answer to the latter is ‘yes’ if you live in certain Sudanese tribes). The term ‘spouse’ makes life psychologically easier in this respect, being asexual in its implications.

Having got that far, I then considered the concept of marriage in respect to it being a ‘civil ceremony’. We have, of course, become accustomed to the concept of ‘civil unions’ or ‘civil partnerships’ for same-sex couples. So what, I asked myself, is the difference between a ‘civil union’ and a ‘marriage’ if we make the participants asexual by using the term ‘spouse’ to describe them? A Wikipedia article on marriage was particularly illuminating and I formed the opinion that there is little difference apart from certain legal rights; legal rights that should, in a 21^st century society, be available to everyone making a life-time commitment to another person regardless of their sex.

Ultimately, a relationship is all about shared values; values such as love, honesty, fidelity, trust, friendship, support and caring. A marriage or civil union gives society’s official recognition to a couple’s pledge to each other in respect to such values. If the values are the same, then the legal rights attached to the relationship should be the same. Let us therefore hope that our parliamentarians continue to consider the issue in depth and with unbiased wisdom.

 (First published in the Scunthorpe Telegraph, Thursday 14^th February 2013)

The Great Divide

I have a confession to make. Throughout my adult life I have voted for the Conservative Party on all but one occasion. That occasion was an episode in my teens in Kent when, in a rebellious streak, I voted for the local Liberal candidate. In retrospect, I suspect that was more because I had a soft spot for an old primary school friend, the Hon. Victoria Lubbock, (daughter of the former Liberal MP for Orpington, Eric Lubbock - now Lord Avebury) than the holding of any real political conviction. However, from thereon I politically turned from yellow to blue, and had seen no convincing reason to rekindle my chameleon activities until the past few years, when I became a sort of bland neutral in response to the growing conviction that nobody in Westminster really seems to know what they are doing with our country.

That was all before Andy Burnham’s speech to the influential King’s Fund last week. For those readers who are too politically fatigued to care anymore (and I don’t blame you), Andy Burnham MP is Labour’s shadow Health Secretary, and The King’s Fund is a renowned, apolitical, high quality ‘think tank’ for debating new ideas in healthcare delivery.

In his speech, delivered to a silent and intently listening audience, Mr Burnham outlined the contents of his Green Paper on how the Labour Party, if elected to Government in 2015, would rescue the remnants of our National Health Service from its current fragmented state on Death Row. What materialised was a breath of fresh air in political thinking in the way we need to tackle the growing crisis of care for an increasingly elderly population, and how to manage the shrinking financial pot with which to tackle that crisis. I say ‘political breath of fresh air’ as many of us outside of national politics but inside local health and social systems have long been convinced of the sensible way forward. That is, the abolition of the artificial divide between ‘health services’ and ‘social services’ in terms of funding, management and provision. The important word here is ‘integration’; an integrated system that can deal with a person’s entire health and social needs without recourse to cross-departmental or cross-organisational politics, policies and funding. Essentially, one organisation would take control of the lot, with specialist advisers (for example, doctors in respect to healthcare) to keep the system balanced. For once, ‘whole-person care’ will be the responsibility of one organisation. Just how sensible is that? 

As I listened to Andy Burnham from my beleaguered bunker as a GP in primary care, I began to sense another colour change materialising. For once, a political agenda was being proposed that I could warm to with heartfelt conviction. It was a policy that was actually saying ‘we understand and genuinely care for the plight of those with health and social needs in our society – and we want to provide a system that can comprehensively help them’. ‘Hallelujah’ was my response, as I psychologically crossed the floor of the House of Commons. Now, I wonder if my constituency Labour party needs an experienced doctor and health manager to stand as their candidate in 2015?

(First published in the Scunthorpe Telegraph, Thursday 7^th February 2013)

Is Anybody Listening?

In 1998, following the referendum in Northern Ireland in respect to the Good Friday Agreement, the politician Gerry Fitt said ‘The people have spoken and the politicians have had to listen.’ Seventeen years later, I wonder whether Whitehall has forgotten that lesson.

That thought commenced with the recent publication of figures from the Office for National Statistics. Evidently, some 3,599,000 people permanently left the UK in 2011. ‘So what?’ you may well ask; ‘aren’t we an overcrowded little island with insufficient housing stock, too few jobs and the incapacity to grow our own food requirement?’ The answer is, of course, in the affirmative. However, the worrying aspect is that two million of those leavers were young people (aged 25-44).

In a country where the older population is growing increasingly dependent on enough young people being around to work in order to provide economic growth, pay the tax to fund our pensions, and care for us in our aged ill-health and infirmity, we need to retain these people in their mother-country. Instead, we are seeing a repetition of the ‘brain drain’ of scientists, academics, doctors and executives seen during the post-war years and the seventies, when talented professionals fled these shores for the USA and Australia. In reality, lured by increased opportunities, better lifestyles and lower taxes, who can blame them? If I was ten-or-so years younger I would be seriously tempted to join them. Instead, I am nearer to joining the band of retired ex-patriots fleeing to warmer climes than throwing my lot in with the bright young things; and if the results of a recent survey of doctors are anything to go by, that departure could be a lot sooner than expected.

Regular readers of this column will know that I occasionally write about the decline of the embattled NHS. Oh, okay, I admit it; I frequently write about it. But it is a subject very close to my heart, and it is something that should be very close to yours as well, as you will miss it when it is no longer with us. Well, the latest news from war-torn General Practice is that, as a profession, we are at breaking point. The increased demands, very long working-days, and reduced investment are pushing many GPs nearer to the edge. In a large study of GPs from the South West of England, 96% responded that the workload had become more intense and complex, and the working day much longer over the past three years. What is more, 84% felt that their present high work load was unsustainable (with 48% saying that the workload was ‘dangerously unsustainable’), 66% have fears that their practices will not survive the contract changes that the Government seems set on imposing, and 50% are considering leaving the profession.

There can be no doubt that the ‘people are speaking’, and our politicians would do well to remember the maxim of the American physician and poet, Oliver Wendell Holmes, who said ‘it is the province of knowledge to speak and it is the privilege of wisdom to listen’. Are you listening in Whitehall?

(First published in the Scunthorpe Telegraph, Thursday 31^st January 2013)

Dying with Dignity

Every so often a piece of investigative journalism hits the national press and causes a storm of sensational outpourings because of its emotive content. Sometimes such reporting has much to commend it, bringing important issues into the open and exposing flaws and wrong-doings in our national systems. However, there are also times when unintended consequences occur, with readers being given an inaccurate picture resulting in confusion and unnecessary concern. Over the past few months we have seen such an occurrence in respect to the topic of the Liverpool Care Pathway.

Whilst it is likely that most readers of this paper will be familiar with the name of the pathway, it is possible that the details are hazy or unknown. I will therefore briefly explain what the pathway is before discussing the current controversy.

As the name implies, the pathway was developed in Liverpool in the late 1990s as a joint activity between the Royal Liverpool University Hospital and the Marie Curie Hospice in Liverpool. It was initially designed to aid the appropriate care of patients who were dying from cancer. However, since its origin, the care value of the pathway has been recognised and as a result, it has become more widely used in the care of many patients dying from other conditions.

The aim of the pathway is to ensure that dying patients are given appropriate treatment to ensure that they die with dignity and in peace, with any potentially distressing symptoms suppressed or controlled. No doubt this is something we would all want for ourselves and for our loved ones when the inevitable outcome to life catches up with us. Sadly, prior to the pathway being formulated, such control was not always the case, and many families no doubt have sad stories to relate about the less than dignified passing of a relative or friend. In recognition of the value of the pathway in terms of patient care, the government introduced a financial incentive to hospital trusts, so that they are rewarded for the use of the pathway. Incentives for good care are not new and are used throughout the health service in order to drive up care standards.

The problems that have recently been uncovered stem from occasions when the Liverpool Care Pathway may have been less than efficiently utilised, resulting in accusations of professional mismanagement, lack of communication with relatives and the patient, and even charges of its inappropriate use for the purpose of financial gain by the hospital trust. Understandably, this has caused outrage in some quarters, and certainly widespread national concern that people are being put on the pathway when more can be done to treat their condition and possibly allow them to live a little longer.

Whether the above is true or not, I cannot judge. However, there is nothing inherently wrong with the Liverpool Care Pathway when used appropriately by experienced professionals. It is also appropriate that tax-payers’ money is used to improve standards of care. As always, the secret is in communication. If a patient is deemed to be dying, and a multidisciplinary team is in agreement that nothing more can sensibly be done to treat their condition, then the patient (whenever possible) and family members need to be included in the conversation, so that everyone understands what is being done and why.

With understanding comes acceptance and freedom from fear, anxiety and anger. With the Liverpool Care Pathway comes a dignified death. Both aspects should be part of the same package.

(First published in the Scunthorpe Telegraph, Thursday, 24^th January 2013)

And the Challenge Continues

Now that 2013 is well and truly here and the partying is over, what can we expect from the NHS? Well, one thing is for sure, there isn’t going to be any new money in a hurry. The economy is failing to bounce back as the Chancellor had hoped, the top earners in the country are being plucked to a state of baldness and thus leaving these shores in droves to escape being skinned into the bargain, and the queues at the Food Banks are becoming longer; as is the waiting list for Tribunals to hear people’s appeals against the withdrawal of their state benefits.

The queue outside my surgery at 7.45am is not much better, either. We still cannot meet the burgeoning demand for appointments; the Department of Health is imposing even greater impossible targets onto us, and patients still book valuable GP appointments and then fail to keep them. GPs, overwhelmed by the aforementioned pressures, coupled with ultimatums from the Care Quality Commission, the requirement for revalidation with the General Medical Council, the expectation that we will balance the failing NHS budget through our work in the Clinical Commissioning Group, and the growing assault on NHS pensions, will continue to retire early or look for alternative employment. In the terms of Charles Dickens, the NHS is indeed a very bleak house.

Some months ago, I mentioned the Nicholson Challenge; essentially the challenge to find the difference between NHS funding and spending. Now, as any self-respecting housewife or businessman (oh, alright, any house-husband or business-woman) will tell you, there are only so many cost-savings that can be made before ‘cutbacks’ and ‘rationing’ come into play. With no extra funding, and costs rising by 4% minimum year-on-year, the problem is more than just a challenge, Nicholson or not; before long it will become impossible without some fundamental changes.

Cue crystal ball and zoom forward to 2015 and beyond. What is happening in the world of NHS General Practice? Well, for a start, I cannot see many small practices around; having either closed under the financial and quality-improvement pressures, or amalgamated with larger practices. There are also fewer older GPs working, having seen the sense of early retirement against ‘early-death-through-exhaustion’. Some practices have been taken over by private companies, staffed by a steady flow of changing faces; young, inexperienced doctors, many of whom are set on bigger goals. In more affluent areas, private GP surgeries are beginning to appear, where for a fee of £50 or so, you can see a GP for half-an hour in state-of-the-art premises. Those patients still dependent on the NHS are still in queues for just about everything; except that now, just like prescription charges, there is a ‘token fee’ for all sorts of things including blood tests, x-ray and scans, contraception, maternity care and A&E attendances. Hospitals still provide care, but families supply the food and bed-linen.

You think I am joking? Well, come and look at the finance books and tell me how it is not going to happen. The golden days of the NHS are fast becoming a memory.

(First published in the Scunthorpe Telegraph, Thursday, 10^th January2013)

Writing for Health

A question I am frequently asked is in respect to how I find time to write as well as run a busy medical practice. Well, I could claim that it is an illness. After all, the Roman satirist, Juvenal, once proclaimed that ‘many suffer from the incurable disease of writing, and it becomes chronic in their sick minds’.

However, the answer is that for me writing is not an illness, but is therapeutic. I am not alone in that sentiment, as many other writers will tell you something similar. Writing is a good way to wake up the brain in the mornings, and is a relaxing way to unwind at the end of a busy day or week. Henri Stendhal, a French novelist, once declared that ‘for those who have tasted the profound activity of writing, reading is no more than a secondary pleasure’; so I apologise to all those readers who are presently not having as much fun reading this column as I had writing it. You are, nonetheless, in good company. Winnie-the-Pooh’s friend, Eeyore, might have agreed with you, stating ‘this writing business – pencils and what-not; over-rated, if you ask me. Silly stuff. Nothing in it.’

There is, however, a serious message behind today’s column. Research has shown that writing can indeed be therapeutic in many different conditions, especially when stress is an underlying cause of the illness. The precise mechanism of action is unknown; though there is a lot to be said for just ‘getting it off your chest’ (my recurrent reflections on the state of the National Health Service spring to mind). However, it is likely that there is a much deeper-seated action, triggered from within the brain, which has a longer lasting positive effect on health. 

That said, the therapeutic effects of writing are not restricted to emotional issues. There is good clinical research to show how writing can improve the symptoms of irritable bowel syndrome, reduce resting blood pressure, improve walking speeds in patients with rheumatoid arthritis, quicken recovery from post-traumatic stress disorder, produce an enhanced sense of mental and physical well-being in patients with bowel, breast or prostate cancer, and reduce the symptoms of some adults with asthma.

Writing is also a useful adjunct to counselling, being a means by which a patient can express concerns, fears and unpleasant memories in a controlled way. Often performed whilst in the comfort and privacy of their own home, the patient can take time to say what they really want to say, without the distress of speaking directly to a stranger. The counsellor can then subsequently use what has been written as a means of conducting the therapeutic session. In many ways, writing therapy can mirror the process of art therapy, the value of which is already well-recognised.

Whatever writing may be to you, I personally subscribe to the view of the Japanese diarist, Sei Shonagon, who proclaimed that ‘if writing did not exist, what terrible depressions we should suffer from’. On that thought, perhaps everyone should adopt writing as a resolution. Happy New Year to you all.

(First published in the Scunthorpe Telegraph, Thursday, 27^th December 2012)

Numbering our Days

In 2005, I arrived at the Chamberlain’s Court at the Guildhall in the City of London, where I was greeted by a gentleman dressed in a frock coat and top hat. Introducing himself as the Beadle, he conducted me to the Court Room and announced me to the Clerk of the Court as a ‘Citizen and Apothecary of London’. Having read the Declaration of a Freeman, I was then invited to sign the Freeman’s Declaration Book, and was presented with a parchment copy of ‘The Freedom’, declaring my new found status as a Freeman of the City of London, with the right and privilege to trade within its walls.

The ceremony itself was simple. However, like many matters in life that initially appear to be modest, the Freedom of the City of London is steeped in history and is supported by a wealth of wisdom and expectation.

Dating back to Medieval times, the first Freedom was presented in 1237. The ceremony was once an essential requisite for anyone who wished to conduct business in the City, to own property, and to be unencumbered by subservience to a feudal lord. Today, it is a quaint, symbolic recognition of our rich heritage, and one in which I am a proud participant.

I had cause to reflect on the ceremony when I recently picked up a small, plain red book presented to me at the time of the Freedom Ceremony. With only 43 pages, it is an unpretentious tome apart from the gold embossed title on its front cover, declaring that it contains ‘Rules for the Conduct of Life’. In size, it presents a sharp contrast against another book on my desk that might be said to hold the original ‘rules for life’; I mean the 1,165 pages of the Bible. However, the brevity of the former defies the depth of wisdom contained therein.

Rule I requires the reader to ensure that ‘whatever you intend to do…be sure that it be always really good, or at least innocent.’ Rule II beseeches one to act lawfully; whilst Rule III warns against idle speculation, and exhorts us to put our ideals into practice.

Of the remaining thirty one rules, Rule IV particularly attracted my attention on this occasion. It starts by reflecting on the transitory nature of life; a life ‘short and uncertain’, where ‘the pleasures of it are always intermixt with doubts, fears, and sorrows, of one kind or other’. The rule then requires us to look beyond ‘the joys, pleasures, or prosperity of this transitory world as the ultimate end’. It is indeed a rule of wisdom, and one many of us so easily forget as we travel life’s journey. Yet it is a rule which not only keeps our feet on the ground, but assists us in finding happiness in that which really matters in life.

Psalm 15 says ‘So teach us to number our days, that we may apply our hearts unto wisdom’. Perhaps finding such wisdom brings with it the most significant freedom of all in life.

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

Children in Need

On the 16^th November, the BBC held its 32^nd annual appeal known as ‘BBC Children in Need’. A successful evening was had, as the total raised during the televised event was just short of £27 million. By the time the appeal closes for the year, the amount raised is likely to have been doubled.

However, for me, the success of BBC Children in Need is overshadowed by the very name (and I am not alluding to the bad press the BBC has experienced this year). The words ‘children in need’ are the key issue. The very fact that we, as a so-called civilised society, even need to have a public fund-raising event for children’s well-being, the aim of which is to enable every child to have a childhood that is ‘safe, happy and secure’ and ‘allows children the chance to reach their potential’, is in itself a terrible indictment of our society.

One of my professional roles is as the Named Doctor for Safeguarding Children for NHS North Lincolnshire. It is a role from which I dearly wish I could be made redundant. However, every month or two, I attend a committee which exists purely to perform ‘serious case reviews’; each review being about one or more North Lincolnshire children who have been neglected or abused in various ways. Sadly, it is never necessary to cancel a meeting for the want of agenda items.

Elizabeth Barrett Browning, in her 1844 poem, ‘The Cry of the Children’, wrote ‘Do you hear the children weeping, O my brothers/ere the sorrow comes with years’. That there is ever a need for children to weep is a burden we all share as members of a society which turns a blind eye to abuse when it is to the betterment of other motives. Yet we continue to assuage the guilt of that betrayal by donating large sums of money once per year, as though that makes good our society’s shameful negligence in securing and ensuring every child’s safety. Our aim should not be to raise even more money so as to beat the previous year’s total. Our constant focus should be to eradicate the dangers to children within our society, by everyone adopting a higher level of awareness and a zero-tolerance approach to every type of abuse.

Children, those symbols of the miracle of new human life, are intensely vulnerable. Too many of them are carrying painful burdens, when they should be experiencing the innocence and happiness of childhood. ‘The place is very well and quiet and the children only scream in a low voice’, wrote Lord Byron in 1813, when communicating with Lady Melbourne. In 2012, we should be ashamed to even contemplate the writing of such sentiment, let alone hold the knowledge that there are children doing precisely what Byron described for fear of further abuse if heard. As the Chief Rabbi, Lord Sacks, said in a recent Radio 4 Thought for the Day, ‘Never let us be deaf to the cry of a child.’

(First published in the Scunthorpe Telegraph, Thursday, 29^th November 2012)

Do We Really Value the NHS?

According to one opinion poll after another, one of the things that we British say we value most about living in the United Kingdom is the National Health Service. When defining the word ‘value’, the Oxford English Dictionary speaks of ‘the regard something is held to deserve’, and continues on about an object’s ‘importance’ or ‘worth’. However, therein lays a strange conundrum.

Every year, so many appointments are missed by patients that the cost of the lost time amounts to a staggering £162 million. At the best of times, that is an appalling waste of money; within a harsh economic climate it is nothing short of madness. If a government department was identified as wasting that level of hard-working tax-payers’ money there would be a national outcry, with newspaper headlines baying for blood (think BBC executives’ pay, MPs’ expenses and so on); and yet here we are individually contributing to the monumental wastage of something we steadfastly maintain that we ‘value’.

Separating those appointments out between general practices and hospitals, it is apparent that approximately 1 in 20 GP appointments are lost. In my own practice, around 100 GP appointments are lost every month, and last month an appalling 200 nursing appointments were lost. Like many practices across the country, we are overloaded with work and stretched to the limits in trying to meet the demands thrust upon us. We limit advanced-booking, as it is well known that the more appointments booked in advance, the greater the quantity that is wasted. Yet we are castigated for trying to reduce those wasted appointments by applying such a policy.

The value of each lost GP appointment in the NHS is worth in the region of £20. Now, if you saw a £20 note on the pavement, would you pick it up and consider yourself lucky, or would you walk by and ignore it? I know what I would do. I cannot ignore 1p or 2p pieces, let alone a £20 note, and I suspect that you would do the exactly the same; at least when it comes to the note. So why are we so dismissive of the issue of lost appointments? Is it that we have been lulled into the false sense that the NHS is ‘free’, when it is anything but free?

Items given away are often seen as holding little value. If we lose them or break them, it doesn’t really matter to us as they were free in the first place. It seems that to value something, many of us need to understand the cost. Even more so, that cost needs to be seen as being paid by us. So, how about the introduction of a fine of £20 for every missed GP appointment? Last month my practice alone would have brought in enough money in fines to pay for another full-time GP or a couple of practice nurses to ease the workload. Perhaps fines would start to make us truly value the NHS and reduce the shameful wastage currently taking place.

(First published in the Scunthorpe Telegraph, Thursday 22^nd November 2012)