Speaking of Honest Matters

An early seventeenth century proverb informs us that, for practical as well as moral reasons, honesty is the best policy. Oliver Cromwell, when writing to the High Sheriff of Suffolk, Sir William Spring, in 1643, remarked that ‘a few honest men are better than numbers’. In 1814, Jane Austen recognised the difficulties of positions of power when she was writing her novel, Mansfield Park, remarking that ‘we do not look in great cities for our best morality’. Yet only with the pursuit of honesty in public life as well as in private, can one hope to achieve the safe haven spoken of by the Roman Emperor Marcus Aurelius when he said ‘nowhere can a man find a quieter or more untroubled retreat than in his own soul’. Today, the Oxford English Dictionary informs us that ‘honesty’ is being ‘free of deceit; truthful and sincere; simple and unpretentious; genuine and straightforward’.

Why is it then, with over two thousand years wherein leaders in a variety of fields have recognised that being honest is an imperative of life, do we find ourselves confronted by newspaper headlines informing us that honesty appears to be the last moral value adhered to within the NHS? In the past few weeks we have seen a number of these, not least those proclaiming ‘Rotten NHS culture led to cover-ups’, followed by discussions of ‘institutional secrecy’, ‘NHS scandals’ and regulators ‘suppressing evidence of failures’. The Secretary of State for Health, the Rt Hon Jeremy Hunt MP, was even moved to make a speech in which he demanded a ‘new culture of openness, transparency and accountability’, whilst also recognising that ‘the best motivated people do make mistakes’.

That latter comment is important, for the pursuit of honesty is not the same, and should never be the same, as the pursuit of litigation for negligence. In an honest workplace, with every person sincerely striving for the common good, negligence should be a rare beast that raises its head. Honesty underpins the act of doing the right thing at the right time and then being clear about what it was that was done; even if, with the value of  hindsight, matters could have been done in a better way.

In the same speech as that mentioned above, Jeremy Hunt went on to state that the success of a new culture of openness and transparency ‘will depend on the right incentives and consequences’, citing the need for greater powers for the regulatory bodies such as the Care Quality Commission (CQC). However, regulation and regulators are not the answer; they have never been the answer. Regulators are merely ‘the dust-carts that follow the Lord Mayor's Show of life’ as the NHS commentator Roy Lilley recently put it. They tell us what went wrong in the past; they do not give us reassurance that all is well in the present.

No; it is not more regulation that we need. What we need is for those working in the NHS (and politics, and any other facet of public life) to be honest. For only on the solid bedrock of honesty, do we have the capability of building the necessary facets of a valued and enduring society.

First published in the Scunthorpe Telegraph, 4 July 2013

© Copyright Robert M Jaggs-Fowler 2013

Fancy Doing Something for Nothing?

The American Psychological Association’s Psychology and Ageing Journal may not be the preferred bedtime reading for many people in North Lincolnshire. However, this month it contains an article that we all ought to be aware of. According to researchers at the Carnegie Mellon University (I know, but we won’t let the name distract us), the process of volunteering is helpful in bringing about a reduction in blood pressure.  Now, when was the last time you volunteered to do something for nothing? The employed might retort that they work for nothing for the first five months of the year (Tax Freedom Day being somewhere around the middle of May in the UK), but I am assuming that doesn’t count, otherwise we wouldn’t have such a high demand for blood pressure pills in this country.

High blood pressure is a major risk factor in heart disease, strokes and kidney disease, so it is worth taking seriously. The American research suggests that positive lifestyle factors such as volunteering can have a major impact on blood pressure through the chemical processes that bring about the ‘feel good factor’. To benefit, a person has to perform voluntary work for at least 200 hours per year.

Of course, one’s blood pressure isn’t the only thing to benefit from volunteering. Volunteering also helps to build a caring society, reduces social exclusion, makes an economic impact (adding £4.8 billion to the UK’s finances), opens up social networks, brings interesting and exciting new experiences, improves personal skills, enhances personal development, and improves employment and career prospects. From a medical perspective, stress levels are also often reduced, which may be part of the way in which volunteering reduces blood pressure. So, all in all, it is a good thing to do.

Meanwhile, in other areas of this week’s medical press, we learn that the Department of Health has decided that there is no evidence to support the concept that GPs are not capable of working in General Practice until their 68^th birthday. Ironically, the same report acknowledges that the same GPs may not be motivated to work that long. Motivation is a multifaceted beast, but it has a lot to do with job satisfaction, manageable workloads, and not feeling exhausted before getting to lunchtime (in itself a vague concept these days). Even more ironically, on the same day the above report was published, other reports highlighted (as though it wasn’t already clear) that General Practice is at breaking point and cannot be looked to in order to solve the country’s A&E crisis.

Nonetheless, that didn’t stop NHS England suggesting that GPs should provide 24/7 ‘decision support’ (whatever that means) to tackle the out of hours problems. Neither did a national lack of GPs stop the Care Quality Commission announcing that it would close GP practices that didn’t stay open long enough to satisfy patient demand. I may be losing the plot here, but will someone please explain to me how that solves the problem? Even as I write, I can feel my blood pressure rising. Perhaps a quick spot of voluntary work will help? Now, I wonder whether emptying the dishwasher and putting the rubbish out, before Mrs J-F tells me to do it, will count towards my 200 hours per year target?

First published in the Scunthorpe Telegraph, 27 June 2013

© Copyright Robert M Jaggs-Fowler 2013 

What do you want?

I recently had a go a cutting my throat. Needless to say, it wasn’t a clean sweep, otherwise I would not now be writing this column. Either that or I would be making a small post-mortem fortune in describing the true goings on from the ‘other side’. My wife immediately suspected that I had been listening to Mahler’s 5^th Symphony; for me, a wonderful work with an unfathomable depth of emotion to it. For my wife, it represents a morose person about to commit suicide. It is interesting how music affects people in different ways. However, the truth is that I was not listening to Mahler.

Neither was I contemplating whether to interview the young doctor who put in his curriculum vitae that his hobby was listening to ‘vintage rock’. It was the word ‘vintage’ that stopped me in my tracks (sorry; for those who still have LPs stored in the loft, I couldn’t resist that pun); as he then went on to explain that the term ‘vintage’ meant music from the 60s. As I was born in 1960, it was a new experience to be considered by implication as ‘vintage’.

No, the truth of the matter was that my razor head fell apart; giving the blade a new found freedom that heretofore it had only dreamt of. The result was a one inch gash a little too close to my left carotid artery for comfort. Fortunately, I survived the auto-mutilation and can now devote some time to contemplating how I wish to continue keeping well and live an independent life in North Lincolnshire. Which is all a very long-winded way of bringing me to the point of this week’s subject.

North Lincolnshire’s Clinical Commissioning Group (CCG) is, since April 2013, the organisation responsible for buying health services. The CCG is now keen to know your views; views that will help to inform how services are developed within our county. The question being asked is ‘what needs to happen so that you and yours feel confident about keeping well and living an independent life to the full?’ The CCG is keen for people of all ages to contribute to this learning process. What would make a difference for you and your family? How do we need to develop health and social services to help and support your aims and needs?

There are two ways in which you can become involved with this important survey. The first is to simply go on-line and complete a survey here, giving us the opportunity to see how you see life. The second is to attend a public meeting on Thursday 27 June 2013 between 9.30 – 14.30 at the Wortley House Hotel, Rowland Road, Scunthorpe, North Lincolnshire DN16 1SU. The organisers say that the event will be ‘fun, inspiring and you will learn a lot’.

Finally, if you want to learn more about public health inequalities and what people die of in your area, enter your postcode into the Longer Lives website and see how we compare to other areas: http://longerlives.phe.org.uk/. Fortunately, self-beheadings do not seem to feature for my street, so I may be okay for a while longer.

First published in the Scunthorpe Telegraph, 20 June 2013

© Copyright Robert M Jaggs-Fowler 2013       

Gallantry and the Ungallant

My faith in human nature has been partially restored this past fortnight by the myriad of telephone calls by worried patients wishing to express their concern that we live in such an uncaring world that a GP could be left stranded by the roadside whilst half his local community simply drove past without bothering to enquire as to his well-being. Many have gone to great lengths to reassure me that they did not pass me by on that fateful day; and furthermore, to emphasise that, if they had seen me, they would most certainly have stopped to give assistance. Such an outpouring of goodwill is gratefully received; so much so that, contrary to data protection laws, I have made a note of your contact details and will ensure that you all receive a daily printout of my future travel plans.

Not that I am likely to need you, thanks to an enterprising local business couple who have devised the ultimate emergency aid for doctors. Kindly presenting me with the prototype at the start of a recent consultation, the aid consists of a protective cardboard storage tube in which is housed a rolled-up warning sign. On green paper (green for medical and no doubt also fluorescent in headlights – clever people these entrepreneurs), the sign boldly proclaims ‘STOP! THE DOCTOR’S CAR IS NOT WELL!’ Thank you. I shall most certainly display it next time I breakdown; if only to assist my aforementioned telephone rescue brigade in finding me.

Sadly, the same gushing sentiments cannot be written about my declining faith in the medico-political world. If the incessant public bashing of doctors in particular and healthcare professionals in general was not sufficient, a Conservative health minister has now got to the nub of the problem. The difficulties of the NHS have nothing to do with decades of political interference and mismanagement, underfunding, inadequately resourced training, mindless bureaucratic targets, and burnt-out GPs. No, the problem has been staring us in the face all the time. It is the fault of women; or to be more precise, female GPs. At least it is according to Ms Anna Soubry MP. Why? Because women want to mix a working life with caring for their families, and thus wish to work part-time; thereby putting a strain on the NHS. Her outdated and derogatory comments understandably caused outrage amongst the medical profession and feminist movements alike, and did nothing to bolster the failing reputation of politicians. With women making up over 55% of today’s medical students, the future of general practice is as a female profession. In itself, that is not necessarily a bad thing; after all, are we not told by anthropologists that women are biologically geared to be more caring in nature than men? If that is the case, I know which sex I would wish to be sorting out my multiple pathologies of old age. No, Ms Soubry, the problem is not the women, but the failure of Westminster to recognise the changing face of the world’s working patterns, and to ensure that more doctors are trained in order to facilitate part-time working, flexible-working, and job-sharing. Paraphrasing the words of Henry II, who will rid me of these turbulent politicians? Perhaps my new-found band of ‘community vigilantes’ could help?

First published in the Scunthorpe Telegraph, 13 June 2013

© Copyright Robert M Jaggs-Fowler 2013

A Pilgrimage on Life's Odyssey

If life is the greatest journey of all, then last week I went on one small pilgrimage within my life’s odyssey. Of course, a pilgrimage is usually thought of as a religious undertaking; the process of travelling for religious reasons to somewhere held to be sacred. My pilgrimage was not truly a religious one, but more spiritual in nature; meaning the seeking of something or somewhere that elevates my sense of well-being.

There are several such places I can rely on for spiritual sustenance. One of these is nearer to home; being the entire North Yorkshire Dales. I have often joked that, during the week, my body can be found working in North Lincolnshire whilst my soul is freely roaming around the Yorkshire Dales. When time allows, I don walking boots and a back pack and stride into the dales where, with a sigh of pleasure and a great sense of freedom, my soul re-joins my body and I am once again as one with the world around me.

If that seems a trifle odd, you may then find it hard to believe that a small portion of my soul also lives in the remote and deserted mountain village of Vouni in Cyprus. With a chequered history that includes being a centre for EOKA (the National Organisation of Cypriot Fighters, who fought a campaign for the end of British rule of Cyprus) the village was down to a population of about 136 in 2001. Most of the old stone houses are now empty, abandoned and crumbling; with the cobbled streets echoing to little more than the occasional footsteps of the inquisitive traveller.

However, despite its past, there is one stone house that held my attention when I first stumbled across it a few years ago. Tucked away in a narrow side street, it stands as a detached sentinel, waiting. Lizards have been its only inhabitants for some years; the paint on its shutters is peeling, and the doors are held fast by rusty bolts. A balcony adorns the first floor at the front, appearing to stay in place more by an act of levitation than any means of construction; whilst a rambling bougainvillea entwines the whole in its rose-red petals. It is a potential haven just waiting for a writer or artist; its empty rooms echoing to the sound of chatter and untold stories amidst filtered beams of sunlight. I was smitten at first sight; so much so that a small portion of my soul was left there, recumbent in the shade of its courtyard.

We all need places of retreat, where we can recharge our batteries. However, we do not need to own them to experience their life-enhancing power. Neither do we always need to travel far; it may be somewhere very close to home that works for you. For the sake of physical and mental health, it is important to find that place, or those places in your life, and to tap into their revitalising power from time to time.

First published in the Scunthorpe Telegraph, 30 May 2013

© Copyright Robert M Jaggs-Fowler 2013

Who is my Neighbour?

Last week I related the experience of having dropped my Smart car into a pothole, only to find that, when it re-emerged, it didn’t work anymore. I likened the process of contacting the RAC and the subsequent service received, along with the aftercare by the local council, to that of a patient seeking medical assistance. What I didn’t describe was the distinct lack of Good Samaritans on the B1218 at 1pm on a sunny Tuesday afternoon.

For those who are not regular readers, my moribund car had drifted to a halt on the Barton to Brigg road, just before the B1206 turn-off for Barrow and the A15 intersection. It is a fast road and not the sort of place a sane person would normally park. However, over the course of three hours, despite the fact that over one hundred assorted cars, vans, lorries and tractors passed by, not one person paused to find out if I was okay, or offer assistance.

Now, it is true that many did look in my direction, and several had to stop behind me before being able to pass by, so it is not the case that they didn’t see me. It is also true to say that many will have recognised me; I certainly recognised them as local people. No doubt they all had their reasons for not stopping (perhaps some used it as retribution for not being able to get an appointment at the surgery). However, one thing is for certain, they couldn’t have concluded that seeing a local GP sitting on a crash-barrier in the middle of nowhere, with his car at a strange angle and partially obstructing the road, was a normal activity in the early afternoon, midweek. Unless they thought I was merely taking the opportunity of the sunshine and topping up my vitamin D level; though I can think of safer ways.

The episode raised an interesting question for me in respect to how we see each other in the 21^st century. The Catechism in the Book of Common Prayer reminds me that ‘My duty towards my Neighbour is to love him as myself, and do to all men, as I would they should do unto me.’ It is a direct reflection of both the Bible’s Old Testament (Leviticus 19:18) and the New Testament (St Matthew 22:38). My question is, if we cannot extend such exhortations to those within our own community, what chance is there for our neighbours in today’s so called ‘global village’? The Good Samaritan helped a stranger because he saw his need. If we cannot help someone who is not a stranger but well known to us, how can we counter the vast needs we see in other parts of our country and the wider world?

Maybe those who passed me by perceived the truth that I was essentially okay. However, I suspect that many were too busy, too distracted, or just too indifferent to even think about asking. What, then, does my breakdown tell us about our true ability to meaningfully respond to our neighbours in the wider world?

First published in the Scunthorpe Telegraph, 23 May 2013

© Copyright Robert M Jaggs-Fowler 2013

Feeling the Bumps

I had to call upon one of the emergency services last week to assist me. They were very helpful and, within an hour, I had professional assistance by my side. He made sure the situation was safe before greeting me politely and taking a quick history. He then proceeded to examine the problem, made a preliminary diagnosis, and tried treating the condition. Sadly, relapse occurred after a short distance of mobility and, despite two more attempts at treatment, we finally agreed to call a halt. There was nothing for it but to call for transport and whisk me off to hospital. Well, at least my Smart car was whisked off to a car hospital. I had an afternoon’s work to do.

I have to say that the RAC provided a first class service. They answered the telephone quickly, were caring in their approach, had assistance to me as quickly as possible and, before that, kept me informed throughout by regular telephone updates. The patrolman was incredibly attentive and went out of his way to be of help, with a ‘nothing is too much trouble’ attitude (even to the point of running me home to collect another car whilst we waited for the transporter to arrive.)  The driver of the car ‘ambulance’ from Gallows Wood Services was equally caring and soon had my car delivered to the garage, where it has since been operated on.

As a postscript, the aftercare has also been good. Even the local council sprang to life with the rapid mobilisation of community care in the guise of the Mayor of Barton upon Humber, Councillor Paul Vickers. Within 24 hours, he ensured that his office staff had been informed of the whereabouts of the offending pothole and, the last I knew, he was seen striding up the B1218 armed with a can of yellow spray paint.

Likewise, Smart cars are usually wonderful things; small, nippy, easy to park and very economical. At least that is how they are until one hits a pothole or two in the road. Once that happens life has the propensity to come to an abrupt halt, with the prospect of helplessly sitting staring at a ploughed field, or the equivalent, for several hours. At least it was a sunny day and the birds were singing.

However, the analogy between my car hitting a pothole and the subsequent care received from those coming to my assistance, made me think about our journeys through life and how unexpected events have the ability to bring us to an abrupt halt. I also recognised an analogy between the services provided to me by the RAC and Gallows Wood Services with that experienced by patients in the NHS. Our hopes and expectations would be very similar: swift, expert and compassionate care interlaced throughout with good communication; followed through with focused community support after the event. It is what we all want at times of crisis, and I don’t think it is too much to ask for, is it?  

First published in the Scunthorpe Telegraph, 16 May 2013

© Copyright Robert M Jaggs-Fowler 2013

Putting Lie to the Myth

I recently had the audacity (according to some patients) to take ten days off and go on holiday with my wife. Astonishingly, when I arrived back in the UK, I found that my aeroplane had become a time machine. I had not simply switched time zones, but was greeted by newspaper headlines proclaiming that GPs were to be tasked with providing 24-hour care, and that the concept of the ‘family doctor’ was going to be revived. I had gone back not just ten years or so, but a few generations, for there was even mention of Dr Finlay.

For the youngest of my readers, Dr Finlay was the leading character in a BBC television series from the 1960s. The stories were based on A J Cronin’s novella called Country Doctor; itself based on fictitious tales of medical practice in a small Scottish town in the 1920s. So, Dr Finlay was a mythological character, and one whose style of practice is a century out of date. A myth is, of course, a traditional story concerning a widely held false belief, a fictitious person or thing. The poet, W B Yeats, wrote of the folly of believing in such stories in his poem ‘A Coat’: ‘I made my song a coat/Covered with embroideries/Out of old mythologies/From heel to throat;/But the fools caught it/Wore it in the world’s eye/As though they’d wrought it./Song, let them take it,/For there’s more enterprise/In walking naked.’

Well, the present Secretary of State for Health, Mr Jeremy Hunt, appears to have a new coat. It may look fine in many people’s eyes, but I predict it will leave him looking foolish when the truth is realised and reality is seen for what it is. Somebody needs to tell Mr Hunt that Dr Finlay is not only dead, his real-life counterparts practised medicine at a time of home visits on horse-back, when medicines were tinctures of coloured water, and the sun shone from May to September.

Now, I am sure that I speak on behalf of all my colleagues when I say that we strongly believe that everyone deserves good out-of-hours medical care. Nobody wishes to deny anyone that service, and it is what we need to strive for. However, it cannot be provided by a GP who has already worked a 12-hour day; therein lays danger for everyone. So the first myth to go is that of the ‘family doctor’. Even if GPs were to provide the care, it would still be a miracle if you saw your ‘own’ doctor.

Training more doctors to become GPs is a good start, and that must be supported by increased funding to allow them to be sensibly employed within a 24-hour service. Sadly, such an influx will be many years off. So, Mr Hunt, let us start talking sensibly about the problem; which means dropping the myth-speak, and not simply dumping the problem onto General Practice without giving us the tools to do the job properly. Our patients, your constituents, deserve more than fables and buck-passing.

First published in the Scunthorpe Telegraph, 12 June 2013

© Copyright Robert M Jaggs-Fowler 2013

A Collective Accolade

A few weeks ago, I received an e-mail via this newspaper’s office. It came from a local resident who knew me from many years ago when we were both serving Queen and Country. (Well, ok, I admit that much of that was whilst also enjoying a weekend or two under green canvas out in the English countryside, or suffering the rigours of postings to far-flung places like Gibraltar. Nonetheless, our spirit was in it.)

Anyway, this old acquaintance of mine had taken the kindly trouble to write with his own reflections regarding the National Health Service and the selfless dedication of those who enter the caring professions; this being sparked by his own knowledge of a young person set upon entering the medical profession. As someone whose retirement is sitting on the horizon, it is reassuring to me to know that enthusiastic young people are likely to be qualifying as doctors just at the time when I might need them in my dotage. However, in true Ronnie-Corbett-style, I digress. The point is that the e-mail ended with the following comment: ‘I'd be grateful if you could give a firm and well-deserved pat on the back to all serving "medics" in your excellent column’. Humbly forgoing the reference to my column, I therefore hereby thank you for your gracious words, kind Sir, on behalf of all my Northern Lincolnshire medical and nursing colleagues.

The reason I have chosen to include my reader-correspondent’s comment this week is that it times well with the publication of the findings of a review by the Commonwealth Fund International Surveys, called ‘How Does the UK Perform? Improving the Quality of Primary Care: An International Perspective’. This presents a very different picture of Primary Care (General Practice) to that constantly being put about by politicians hell-bent on undermining the morale of health professionals in general, and GPs in particular. The findings make for interesting reading and should offer some reassurance to our community that we (the doctors and nurses) really are trying our best on your behalf.

Whilst noting that the NHS is not particularly good when it comes to easy communication across the various sites of the NHS, or in respect to the time available to spend with patients, it did have the following positive comments:

Compared to other countries, the NHS has the second lowest health spending per capita; the lowest ‘cost related access problems’ to primary care; the joint best same or next day access to general practitioners; the least difficulty in accessing out of hours care without needing to attend A&E; the best access to out of hours care (with noticeable improvement in recent years); the highest access to online repeats and appointments; the least hassle in getting patients needed medications or treatment; the highest scores for management of chronic diseases; is joint second in use of information technology; and is highest in reviewing patient data and outcomes. The review concluded in stating that the UK stands out and performs at the top (or near the top) of the range for many of the above aspects of care.

So, ‘serving medics’, there is your public pat on the back as requested from my correspondent. Well done. Now get off your laurels and go back to work…

First published in the Scunthorpe Telegraph, 9 May 2013

© Copyright Robert M Jaggs-Fowler 2013

A Cauldron of Emotions

As someone who was very content with a portable black and white television until I was thirty-two (well, the news is the same in any colour), I never thought that I would someday find myself reviewing a television programme. However, one recent series had me captured for all eight of its weekly episodes; not just because it was a slow burning ‘whodunit’ type of mystery story, but even more so because of the magnifying glass it held over the emotions of a small community deeply affected by the death of one of its children. I refer, of course, to Broadchurch.

The writer of Broadchurch, Chris Chibnall (who has also written several episodes of Dr Who), has stated that he never intended it to be a murder-mystery suspense story, but had wanted to look closely at how the murder of a child has the capacity to stir up the whole spectrum of human emotions within a close-knit community. Well, my own take on the situation is that he managed the feat of pulling off both aspects with considerable acclaim.

Repeating the plot here is superfluous for anyone who saw the series, and I have no intention of spoiling it for anyone who did not and may wish to find out what they have been missing by other means. What I will comment on is how the story started with the anguish of a child’s death, and went on to evoke scenes of grief, numbness, shock, bewilderment, panic, anxiety, suspicion, envy, passion, anger, depression, doubt, compassion, betrayal, resentment, hatred, ambivalence, confusion, indecision, trust, mistrust, rage, bitterness, pity and forgiveness. The whole gamut of human emotions was entwined throughout the plot, as they weaved their way from character to character like the threads of an invisible spider, until everyone was captured within its sticky web of sentiment and sensation. The 19^th century English novelist Thomas Hardy would have been proud. Set against the backdrop of his native Dorset, Broadchurch was a 21^st century mix of all the human passions stirred up by Hardy’s books such as Jude the Obscure and the Woodlanders.

However, for all of that, the one emotion standing out from all of the others was, for me, the ability for anguish to turn to forgiveness. We saw several examples when individual characters, once thrown upon the helter-skelter of distress, spun for a while in uncontrolled frenzy, only to be rescued by the soft landing of an overwhelming sense of forgiveness. Even the anger of the dead boy’s father turned to pity when finally confronted with the confused, emotional wreck that was the person responsible for the death of his son.

Forgiveness is a layered reaction and is given in degrees. In essence, ‘to forgive’ is to stop feeling angry or resentful towards someone for an offence or mistake. It is not synonymous with a state of unconditional love and trust; such feelings are entirely different. Forgiveness is more a state of neutrality and acceptance. As the 20^th century psychiatrist, Thomas Szasz wrote, ‘The stupid neither forgive nor forget; the naïve forgive and forget; the wise forgive but do not forget’. Broadchurch held a mirror up to us all, and in so doing, reminded us that it is best to be wise.

First published in the Scunthorpe Telegraph, 2 May 2013

© Copyright Robert M Jaggs-Fowler 2013 

A Fortnight of U-Turns

As the Nation settles again following the funeral of the late Baroness Thatcher, one of the many remembrances of her long political life is her famous statement about ‘this lady is not for turning’. The same, fortunately, cannot be said of a significant sector of the country she once led. The measles epidemic in Wales has seen to that.

Measles is a highly infectious, very unpleasant disease that can lead to serious complications such as blindness and death. Fortunately, the incidence of measles in this country has been kept low owing to our vaccination programme. However, the value of a vaccination programme is best when what is called the ‘herd immunity’ is high. Essentially it means that, if the majority of the population are immune, then those who are not immune (for example, they are too young to have the vaccine) are protected as they are unlikely to come into contact with someone with measles. Sadly, there was a drop in vaccination rates in 1998 owing to misleading reports connecting the MMR (measles, mumps and rubella) vaccine with autism. The result has been a fall in our herd immunity, with the sad and concerning result now being seen in Wales.

The good news is that it is never too late to catch up with the vaccinations, and that is now what a considerable portion of the population is doing. The sudden harsh reality of the importance of vaccination is bringing worried parents into surgeries with the request that their children are vaccinated. This is one of the best forms of U-turns I can think of. At present, there are no plans in North Lincolnshire to vaccinate children any earlier than the usual age of 13 months. However, if your child is over 13 months and has never been vaccinated, or has only had one MMR injection and missed having the second (usually given between 3-5 years), then please do discuss the situation with your doctor. The likelihood is that you will be encouraged to bring your child’s vaccinations up to date.

In respect to adults, the Health Protection Agency is currently offering the following advice: ‘Anyone born between 1980 and 1990 may not have received a mumps vaccine, and anyone born between 1970 and 1979 may have only had a measles vaccine. If you fall into one of these groups ask your GP for the MMR vaccination. Anyone who is travelling to an area that is known to have had outbreaks of measles, mumps or rubella should ensure that they are fully immunised.’ For adults, the two injections can be given one month apart.

The second U-turn of the past fortnight has been the weather. The sudden change from cold and snow has already brought sightings of shorts and t-shirts. However, whilst exposing bodies to the sun is good for topping up vitamin D levels, don’t forget to protect your skin. Even spring sunshine can be powerful and, although I am yet to see a swallow this year, I have already seen my first case of sunburn. As Baroness Thatcher also said, ‘It’s a funny old world.’

First published in the Scunthorpe Telegraph, 25 April 2013

© Copyright Robert M Jaggs-Fowler 2013

Lost Identities

Have you noticed how certain medical conditions are attached to people like labels to a parcel? Once attached, they become irremovable, regardless of how well the person is at a particular moment in time. The label becomes the person, and the personality that was once the person becomes obscured and ultimately lost behind that label. The condition may contribute to that process. However, there is often an unwitting desire to speed the process along; emphasising the negative aspects until the last semblance of the original character is buried beneath an inundation of symptoms and signs.

Dementia is like that. How often have you heard an introduction along the lines of ‘this is my husband; he has dementia’, a statement made as though the spousal position is somehow irrefutably entwined with the condition of dementia. You don’t tend to hear the phrase ‘this is my husband; he has osteoarthritic knees’, or ‘this is my wife; she has irritable bowel syndrome’. So why do we do it with conditions such as dementia?

The answer may reside in the fact that dementia affects the person’s mind, and that, of course, is where we assign the residence of a person’s character. Mental illness often has a similar fate; in particular schizophrenia or bipolar disorder (manic depression). Despite the fact that both of these conditions can have long periods of remission, with no symptoms of ill-health being exhibited by the patient (is someone still a patient if they are actually well?), once applied, the label remains; the person has become dehumanised and has metamorphosed into the condition. Kafka would be proud.

It was the realisation of how unfair this is on the person concerned that made me start this article. Like many conditions of the mind, dementia is not in itself a diagnosis, but a term describing a collection of symptoms (confusion, memory loss, loss of identity, the inability to recognise other people, disorientation in time and place, disinhibition and so forth). There are many causes of dementia (just as there are many causes of a painful knee, for example), and not every type of dementia travels the same path, or takes that path at the same speed. Equally, there can be periods of great lucidity, where the mind of the person clears and conversation is relevant and accurate.

The theologian, John Swinton, has written a book on this subject. Called ‘Dementia: Living in the Memories of God’, it is an insightful attempt to readdress the current imbalance in the way many of us view dementia. He argues for a resetting of our perspective and for the need to see beyond or behind the condition in an effort to preserve the spirit of the person captured behind the illness. He maintains that the person’s identity is not irredeemably lost, but struggling to exhibit itself. The task of the relative or friend is to preserve the personhood of the person affected, and not strip him or her of the last vestige of that which makes us human. ‘This is my husband’, is all we need to know as an introduction. Ignore the distracting label, but please do tell us about the identity of the person who, beyond all else, remains your husband and a human being. As one might offer an arm to support a person with arthritis, let us also give a voice to the identity of our relative or friend with dementia. Let their identity live on, safe in the hands of a loved one.

First published in the Scunthorpe Telegraph, 18 April 2013

© Copyright Robert M Jaggs-Fowler 2013

To Whinge or not to Whinge?

As I have previously stated, it is always good to receive constructive feedback on the contents of this column. So I was intrigued last week when a Scunthorpe Telegraph reader took the time and trouble to put pen to paper and shared her reflections on the NHS. The lady started by telling me that she always reads my piece, but immediately went on to say ‘But, oh dear, you do whinge a little’. However, she then addressed the reasons why she felt that the NHS is not what it once was, and why it does not satisfactorily serve her requirements, nor those of her husband. Those reasons covered another three pages of the letter.

It was the difference between the opening statement of the lady’s letter and the contents of the main body that caused my intrigue; as here was someone who was castigating me for the opinions I express in this column, but then had a whole host of issues which trouble her about the NHS.

Now, always one to try and work with facts rather than hearsay or supposition, you might have guessed by now that my first recourse was to check the definition of the word ‘whinge’, especially as I have never previously been told that I do that. According to my well-worn copy of the Oxford Dictionary, to ‘whinge’ means to ‘complain persistently and peevishly’. The ‘persistently’ bit I accept without any hesitation; I am nothing if not dedicated to the task of trying to improve the lot of my fellow man and woman, and I will not cease in trying to influence those issues that are so obviously wrong in life. However, I am a little less certain about the ‘peevishly’ bit. Once again, the Oxford Dictionary rescued me. ‘Peevish’ means ‘irritable’; the implication being that I upset or irritate some of my readers by what I write.

Oh dear! What have I written so laboriously about so as to start upsetting people? Well, there has been quite a lot about how the new structure of the NHS is tearing the organisation apart, depriving GPs of funds to do the job properly, undermining the morale of healthcare staff, pushing the NHS into private hands, fragmenting care, increasing waiting times, reducing services, increasing the number of doctors retiring early or seeking employment elsewhere, and reducing the attraction of medicine in general, and general practice in particular, to newly qualified doctors. So, I guess I have been quite persistent about all of that over the past year or so.

The question is, does any of the aforementioned matter to my readers? Well, the same lady went on to lament the decline of a 24-hour GP service provided by her own doctor, the difficulty in booking appointments, the lack of continuity through not being able to see the same doctor on successive occasions, the reduction in home visits, and the changing standards of the old-fashioned ‘bedside manner’. Dear reader, I couldn’t agree more with you. General Practice is not what it used to be, and will become even worse if we cannot rescue the disintegration of the NHS. If bringing these issues into the open causes you irritation, then I am so very sorry; but I can at least claim to be trying hard to fight your cause.

First published in the Scunthorpe Telegraph, 11 April 2013

© Copyright Robert M Jaggs-Fowler 2013

By the Left

I don’t know about you, but I find it quite fascinating to learn what other people think about things; in this case, especially if the ‘thing’ in question is me. Side stepping the immediate and predictable accusations of narcissism, I am specifically referring to readers’ views on the content of this column. As my primary aim is to try and shed light on some of the hidden truths of the Machiavellian world we know as the NHS, as well as to offer an occasional foray into some diverse and more esoteric subjects that fascinate me and thus make me want to share the same with you, having feedback as to how such issues are being received is always of value; even if you disagree with my views.

It was therefore intriguing to hear one reader, who is also a patient and a fellow-employee of the NHS, proclaim that I am ‘becoming a lefty’ and that he expects to see me wearing sandals and a beard any day now. Apart from a recent suggestion that I had psychologically crossed the political floor from blue to red (the turmoil of the NHS does things like that to you), I had previously considered myself to lean slightly to the right of centre (although I do admit to being present on the occasional CND march in London during the seventies, and I did grow a rudimentary beard in my teens when I was trying to emulate the singer, Kris Kristofferson).

Of course, being a former military man, I should be used to the concept of stepping off with the left foot; so perhaps it is more ingrained in me than I realise. Whatever the reason for my current posture, I strongly believe in transparency and honesty. We all deserve to know the truth about matters affecting our lives, but those truths must be reflected fairly and with the desire that, by sharing the truth, we can together influence change for the better. That is my constant hope. Information brings understanding; understanding brings about the wisdom to influence change; and the knowledge that we all have the power to bring about change means that we can rejoice in having hope.

By sharing with you my hopes and fears for the future of the NHS, I hope that I may encourage some of you to take up the baton and conduct your own movements to improve a vital part of our society. Working together is essential; we are all part of the problems, and we are equally all part of the potential solutions. As St Peter wrote, ‘always be prepared to give an answer to everyone who asks you to give the reason for the hope that you have. But do this with gentleness and respect’ (1 Peter 3:15). If becoming a ‘lefty’ means respecting those in whose community I live, and whose lives are so intricately entwined with my own, then pass me a ‘social equality’ banner and let us march on in step…by the left, of course; but I do draw a line at the sandals.

First published in the Scunthorpe Telegraph, 4 April 2013

© Copyright Robert M Jaggs-Fowler 2013

A Tale of Morality

Have you noticed how morals and morality have been sliding into politics recently? At least, that is the case in word if not also within deed. Listening to politicians speak when being interviewed by the media, and additionally whilst strutting their stuff within that pantomime arena known as the House of Commons, a stranger to our world might be struck at how high they place the ethics of their idealistic pontificating.

Of course, it all started with the world of banking. With banks blamed for precipitating, fuelling and maintaining the current economic crisis, politicians were very quick to harness their high principles to the bandwagon of corporate flagellation; conveniently ignoring the fact that years of political mismanagement, overspending from the public purse, and misguided interference into systems (such as the NHS) where they understood very little about the work at the coalface, were all part of the same fiasco. Bankers’ bonuses were the first to be targeted in the name of the public good and as a means to shift discredit from Westminster towards the City of London. The words ‘morally wrong’ and ‘immoral’ were heard issuing from the lips of politicians as though they were experimenting with a new-found toy and took delight in the sound it made. Such words of high standing started to join the lexicon of the political interviewee along with ‘active’, ‘best’ and ‘capable’; all designed to make the smallest of statements sound impressive and reliable.

Other large corporations followed the bankers down the path of political castigation, with the manufacturers of faulty silicone breast implants and metal hip joint replacements being urged to ‘act morally’ and ‘fulfil their responsibilities’ to their customers. Corporations are not, of course, the same as people. In law, a corporation has an identity of its own; a living beast that has to pay its tax and can be fined for wrong-doing, but which has no humanistic features like a brain or heart and doesn’t breath, eat or sleep. So it is not the corporations that need to be behaving responsibly and showing observance towards moral tendencies, but the people employed to run those institutions.

Like the National Health Service, for instance. However much as individuals we try to blame the parent organisation, the organisation is in effect the sum of our individual parts. Our collective actions contribute to the identity of the whole. Ultimately, our own individual morality, when compounded with that of our colleagues, has an effect on the entire establishment. Are you listening Sir David Nicholson?

So when politicians speak of morals, they need to understand that it starts at home; like admitting to speeding and not committing perjury, for example. Morality should not, as The Devil’s Dictionary puts it, ‘have the quality of general expediency’. But then again, the same dictionary does describe politicians as ‘eels in the fundamental mud upon which the superstructure of organised society is reared’; continuing to state that ‘as compared with the statesman, he (the politician) suffers the disadvantage of being alive.’ Perhaps I am expecting too much from our leaders.

First published in the Scunthorpe Telegraph, 28^th March 2013

© Copyright Robert M Jaggs-Fowler 2013

The Winds of Change

It is very hard not to be despondent about life in general practice these days. Readers of this column may at times dismiss my negative proclamations as the weary ranting of a burnt-out public servant and look for the next bright young thing with a spring in his or her step to inform everyone that all is well with the world of primary care. Sadly, the bright young things are not flocking into general practice, and fortunately (for me at least) I am yet to reach such depths of exhaustion to warrant the epithet of being burnt-out. However, as the 19^th century German philosopher and writer, Friedrich Nietzsche, wrote ‘if you gaze for long into an abyss, the abyss gazes also into you’.

To paraphrase the words of a former British Prime Minister, Harold Macmillan, the wind of change is blowing through primary care, and general practitioners are becoming increasingly fearful of the approaching storm. The latest squall blowing our way is the Government’s imposition of yet more contract reforms. These reforms, on top of all that has been brought about by a depressed economy and the on-going reform of the NHS in general by virtue of the ill-thought through Health and Social Care Act, may well become the final nail in the coffin for many practices.

The British Medical Association recently polled 8,000 GPs in England. The results do not make for comfortable reading. Accordingly to the poll, 13% of GPs (i.e. approximately 1 in 8) are planning to quit the NHS. Of these, some 63% are planning to bring forward their retirement and leave earlier than originally planned; many others are looking to move into different careers or seek work abroad. The reduced financial flow to general practices is also forcing many to consider making staff redundant; this in a business where spare capacity amongst the workforce is not to be found. The staff being laid off includes clinicians (i.e. salaried doctors and nursing staff). The survey also showed the true extent of GP morale across the country: 91% feel unable to manage the increasing workload, 97% believe general practice is becoming more stressful, 89% are less enthusiastic about a career in general practice and 87% said that they were less likely to encourage young doctors to become GPs.

The concerns are not just being expressed by dispirited GPs. The leading health lawyers, Hempsons, have predicted that general practices with less than 15,000 patients on their list will not survive the politically-induced changes. Whilst that may ultimately bring improvements in service provision for some areas, it is worrying to think that there are only two or three practices of that size throughout North Lincolnshire; the implications are immense, and will result in many amalgamations and practice closures.

If we think we have it bad in England, Welsh GPs believe that the entire system of general practice in Wales is at risk of collapsing. Conspiracy theorists would say that is what the Government is hoping for in England as well. I am beginning to subscribe to the same theory.

First published in the Scunthorpe Telegraph 27 March 2013

© Copyright Robert M Jaggs-Fowler 2013

A Question of Healing

During this past week I was left contemplating the meaning of the word ‘healing’ after a patient thanked me for ‘healing her’. Fortunately, the expression of a few words of gratitude is not an uncommon phenomenon amongst patients who feel that they have been helped. However, on this occasion it was the choice of the word ‘healing’ that left me pondering. It is not a word that is used that often by either doctors or patients. Doctors speak of broken bones healing, or a wound healing; both in terms of two sides of a break or cut joining together. Nonetheless, it is rare that the word is used in a more generalised context. Instead, we tend to prefer the words ‘curing’ or ‘treating’. The choice of the word ‘healing’ by my patient sounded strange and somewhat antiquated.

As is always the case when I am puzzling over words, my instinct is to reach for a dictionary so as to acquire a baseline for my thoughts. The Oxford English Dictionary thus informed me that the word ‘heal’ means ‘make or become sound or healthy again’. The dictionary did not expand on the word ‘healer’, other than to label it a noun; thus leaving me in the rather unsatisfactory situation of understanding that a healer is someone who makes something sound or healthy again. The problem with words is that the deeper you dig into them, the more complex the question becomes.

For example, if the two ends of a broken bone knit together, we would class that as healing. However, if the limb containing that bone is left misshapened and the patient has a resulting limp, can they truly be said to be ‘healed’, ‘sound’ or ‘healthy’? Furthermore, what does being ‘healthy’ mean? Can an eighty year old with nothing more than mild arthritis, consider himself as ‘healthy’?

I believe that the answer to the last question is ‘yes’; just as I have come to the conclusion that being ‘healed’ means far more than being rid of one’s disease. Indeed, I have started to consider the possibility that a person can be healed despite the continuing existence of what most people would consider as ill-health.

Faith-healers have probably thought this all along. Often considered as charlatans or quacks, faith-healers use their skills to make people feel better. The operative word here is ‘feel’. The eighty year old with an arthritic knee feels healthy because he has come to terms with the reality of living with a worn joint; he has come to consider that his disease is a normal part of him and thus, in his mind, he is healthy. Each year millions of people flock to Lourdes for precisely the same aim. Very few people leave Lourdes without their disease; indeed the Roman Catholic Church has only officially recognised six such miracles. Nonetheless, many more people return home feeling better for their experience.

Perhaps healing is something we, as doctors and nurses, should be attempting more often in medicine, rather than trying to cure or just treat. We can only cure patients some of the time; but we can probably heal people on many more occasions.

First published in the Scunthorpe Telegraph 14 March 2013

© Copyright Robert M Jaggs-Fowler 2013

A Matter of English

Writing in his book Leviathan in 1651, Thomas Hobbes said that a man that seeks precise truth has a need to remember what every name he uses stands for, and to use it in its rightful place; for failure to do so will leave him impossibly entangled. For that is the power of the language we call English. It is a language built up over more than 1,500 years, from its start as a Germanic dialect spoken by little more than 150,000 people to an international language understood by some two thousand million people. It is estimated that the English language currently has 171,476 words in use, with another 47,156 words listed by the Oxford English Dictionary as being obsolete.

That is a lot of complexity to become entangled in. It is a language that represents, as Melvyn Bragg puts it in his The Adventure of English, ‘the collective work of millions of people throughout the ages’. Yet, for all that inherited richness, it is a language that is still growing, as new words are added every year. Dr Samuel Johnston, the author of the first English Dictionary, would not recognise the distance his dictionary has travelled in terms of development. For example, he would certainly no longer be able to write that ‘there are no words in the English language beginning with the letter X’.

People born in the United Kingdom tend to take for granted the concept that the English language will be spoken wherever one travels in the world. However, despite its popularity, it is not the case that someone speaking the language can also instantly make themself understood; the nuances within the language can cause the greatest to stumble. This is an important concept when considering the case of people coming from abroad with the intention of working in the United Kingdom.

In England, we are fortunate to have many doctors working within the National Health Service whose country of origin is elsewhere. Without the knowledge, skills, hard work and caring dedication of these doctors, the NHS would struggle to survive at all. The majority of these doctors have excellent language skills, and would put my own linguistic ability to shame when you consider my inability to speak any other language beyond a rudimentary ‘schoolboy level’. Occasionally, however, we meet someone who can get by in English, but who lacks the finer depth of knowledge to ensure that they are understood when trying to explain difficult medical concepts to patients.

From April 1^st, all doctors coming to England will need to demonstrate that they have a good command of the English language before they can start work. This is something that has long applied to doctors from outside the European Union, but will now apply to those from the EU as well. Hopefully, patients will no longer be left thinking ‘I heard every word, but what did he say?’ It should enable us all to benefit from the skills of overseas doctors, and is thus a welcomed step by the Government.

First Published in the Scunthorpe Telegraph 7 March 2013

© Copyright Robert M Jaggs-Fowler 2013