How Useful is the Establishment of a Duty of Care for our Armed Forces?

Much has been written in recent months regarding the ‘duty of care’ this country has to its armed forces. Such a duty does not have to be enshrined in statute law and the establishment of such a duty is often left to the common law to determine in respect to individual cases. However, it is a welcomed fact that the duty is being enshrined within the Armed Forces Bill currently moving its way through parliament.

That said, whilst many people were, through the media of press and television, publically rejoicing at the Government’s decision, I was led to consider what such inclusion might mean in reality, and whether it was just a statement of the existing situation rather than a positive move towards establishing that which most people really want; that is, practical care of our serving forces personnel and their families, along with appropriate after-care when they leave the forces (and especially so if they are injured). The best way I can describe my concerns is to consider the duty of care which exists in respect to the role of healthcare personnel to our patients.

The Oxford Dictionary of Law defines ‘duty of care as ‘The legal obligation to take reasonable care to avoid causing damage’. Clearly, that is an understandable duty in respect to the actions of a doctor, for example. However, the same concept does not translate very well to a soldier serving in the front line of a war zone. In medicine, it is a duty which has been established in common law and is enshrined within the General Medical Council’s Code of Practice for doctors. From a patient’s perspective, the purpose of establishing a duty of care is to ensure that the patient is treated well. The flip side is, of course, that a patient might seek legal remedy should there be the perception that something has gone wrong in the process of that duty being performed. Therein often resides the difficulty, for establishing negligence (and thus being eligible for compensation) is a tortuous path to tread.

To establish negligence a patient must first show that there existed a duty of care; that done, the next step is to prove that there was a failure on the part of the doctor to fulfil that duty. Finally, it has to be shown that the failure directly led to the injury for which the patient seeks compensation. If there is no injury sustained, or the causal link between the three factors cannot be proven, then there is no remedy in law as negligence has not been established.

In medicine, the whole process is often confounded at the second hurdle, as what constitutes good or appropriate care is not always clear-cut within a profession that is only partially based on science. The Bolam test is often quoted, being a judgement stemming from a 1957 court case (Bolam v. Friern Hospital Management Committee), when it was established that ‘a doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art’. So, if it is as difficult as that within the realm of healthcare, what hope does the family of an injured soldier have, where the boundaries are even less clear? I fear that the current inclusion may be a good start, but the victory may still prove to be very hollow in a practical sense.

First Published in the Scunthorpe Telegraph, Monday 30th May 2011

To be or not to be (a doctor)

'If you had your time again, would you still have become a doctor?'

    The latter was a question to me a few weeks ago, not long after my article regarding the current NHS political changes. It was an interesting question, and one I have asked myself over many years. Careful consideration always produces the same honest, emphatically positive response. It is true that I can think of other paths I would have liked to travel; other subjects I would have enjoyed reading at university; other areas of the country (or even the world) where I would have enjoyed living. Then again, which of us (regardless of the nature of our upbringing, social status, occupation or interests) hasn't had similar thoughts? Is that not simply a case of 'the other man's grass is always greener'? Ultimately, we have to settle for something which will provide the backbone to our lives. Thirty one years after I first walked into a London medical school, I have no hesitation in saying that I would still chose to become a doctor.

    Of course, 'becoming a doctor' is not quite the same thing as receiving a Bachelor's degree in medicine. There are many years following the five or six spent as a medical student before a doctor can feel that he or she has arrived at the long-sought destination, during which time a junior doctor jumps the various postgraduate hurdles of training posts and postgraduate examinations. Even then, there is the need for life-long dedication to continuing professional development.

    So you may ask why I would do it all again; why, when the training is arduously prolonged, the workload overwhelming, and the political interference with the NHS so frustrating? The answer is because a medical degree can be one of life's most valuable passports. I am sure other professionals would claim similar attributes for their own qualifications. Nonetheless, the intimate involvement in people's lives that the practise of medicine requires can be both spiritually rewarding and tremendously humbling; bringing with it a tremendous sense of worth and satisfaction that few other occupations can easily trump. There is also the chance of a decent standard of living; although not necessarily a fortune to be made. However, the qualification is far more valuable than that. With imagination and determination, a medical degree can open so many opportunities in life that it is difficult to say where the boundaries are. In my view, those opportunities are far more valuable experiences than the acquisition of wealth.

This column is not a place for me to blow my personal trumpet. It is suffice to say that, suitably armed in educational terms, I have ventured into numerous occupational realms that, as a child, I never dreamt I would access. I have also had the pleasure of travelling the world, participating in grand society events and meeting people from all walks of life. For me, a medical degree has been the passport to life's sweet shop, enabling me to fulfil Rudyard Kipling's maxim of filling 'the unforgiving minute' in a kaleidoscope of ways.

So, the answer to the original question is an emphatic 'yes'; I would still become a doctor and, placing medical politics aside, I would encourage others to do so. More importantly, to any young person considering reading medicine, I would exhort you not to consider your degree as the 'be all and end all' of your aspirations. There is a whole world out there; with effort, determination, and imagination it is all yours to sample.

First published in the Scunthorpe Telegraph, Wednesday 11^th May 2011

The Encouraged Optimist

Sign seen on the bar of a pub ('The Dog') in Whalley, Lancashire:

'I'm going to live forever.

So far, so good.'

Extra, Extra, Read all about it!

Blessed with such wonderful weather, the Easter weekend was a great opportunity to clock up some time exercising in the great British outdoors; which is precisely what I had the fortune to be doing in that land known as God's own country, the Yorkshire Dales. However, with a few days away from the turmoil of the surgery, it was also an excellent time to catch up on some serious reading of an ever-growing backlog of medical journals.

Keeping up to date with medical developments is a task that doctors endeavour to perform on a regular and life-long basis. It is almost an impossible task, and we can only try to do some justice to the postbags of journals and medical newspapers that fall through our letterboxes on a weekly basis. However, most of us will select and concentrate on a few favourites and then scan the remainder for particularly eye-catching articles which the others may not have covered. For me, the British Medical Journal and the Journal of the
Royal College of General Practitioners are the main players, topped up with a couple of medical news magazines called GP and Pulse.

This particular weekend was of considerable interest, and I was able to update my knowledge of how vitamins pills may be bad for you by increasing the desire for fast foods (reported in the journal Psychological Science). I also took notice of various public health articles on the smog alert affecting Britain; found that the Archives of Disease in Childhood contained research linking excessively crying babies with the later development of behavioural problems; learned that the journal Arteriosclerosis, Thrombosis and Vascular Biology was reporting on the link between the time children watch television and the development of heart disease and high blood pressure; discovered that the General Medical Council is considering holding misconduct hearings for GPs behind closed doors; and that peat moss was once used for dressings for battle wounds during the First World War. Further reading included an article on euthanasia, and how elderly people in Holland are now carrying cards to ensure that doctors do not over-enthusiastically end their lives. There were also papers with evidence that playing a musical instrument may help protect against Alzheimer's Disease (reported in the journal Neuropsychology); reports on how air pollution raises the risk of breast cancer (reported by the American Association for Cancer Research), and finally, that the Boston University Medical School had discovered that the 'older' types of contraceptive pill may be safer than newer versions.

All of the above made for fascinating reading. However, the truth is, none of the articles were actually from the journals I earlier reported reading on a regular basis. In fact, they were all to be found in the nation's daily newspapers. I cannot imagine for one moment that any GP actually receives half of the journals mentioned above, let alone gets to read them. So, despite our best of efforts, we cannot possibly keep on top of every single development in medical science; I am not even certain that retirement would allow sufficient time to do achieve such a herculean task.

One often hears the phrase 'if in doubt, consult your GP'. However, a gentle plea on behalf of all my GP colleagues: whilst we do our best to keep our knowledge fresh, the next time you come to the surgery to discuss an article in this week's news, please bear in mind that journalists will often trawl through esoteric science journals to find eye-catching headlines which the jobbing GP will never read at first hand. If we sit their nodding wisely and saying nothing, it is probably because we are totally bemused and wishing we had paid more attention to the weekend's newspapers.

First Published in the Scunthorpe Telegraph, Monday 2^nd May 2011

A Columnist’s Life

'Political language is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.'

    Thus wrote George Orwell in his 1946 book, Why I Write. His words will no doubt find support and understanding amongst many readers and writers alike. It might be construed that one raison d'être of newspapers in general is to see through such political rhetoric and bring to the public's attention the hidden aspects and undertones of a news story. That was certainly the reason behind my recent column on the subject of the current reforms to the National Health Service (Scunthorpe Telegraph, Friday 1^st April 2011). The article may have appeared on April Fools' Day, but readers of this newspaper are not foolish. Recognising the truth when they read it, the feedback from you in response to that particular article has been considerable.

    All of which leads me to the question as to why I write a column in the first place. Many questions abound in the minds of columnists (at least they do in the brain of this particular one): What purpose does the column serve? Does anyone (apart from my mother) actually read the articles? What should I write about? Do people care what I write about? Are there particular issues that interest people more than others? Those are just some of the thoughts which pass through my brain on a weekly basis as I sit in my cold and draughty garret tapping away at the keyboard.

    The answers to my many and varied questions are less readily accessible than the original queries. It is certainly the case that my editor cares about the subjects I choose; otherwise I would have my copies returned to sender with a red reject stamp accompanied by a large redundancy cheque (do I hear my editor saying 'dream on'?). Ostensibly, my column is supposed to be health-orientated; which on most occasions it succeeds in being, even if it does take a few detours through the world of poetry and literature. However, there, as Shakespeare's Hamlet would say, lies the rub. Whilst many people throughout Northern Lincolnshire have taken the trouble to write or speak to me in person in order to express their views on the column's subject matter, their desires in respect to the future content of the column seems to be quite varied. Some would like to see more on medical politics; others appreciate my occasional attempt at humour, whilst a further group wish I would write more about poetry and literature, even to the extent of requesting that I publish my own poems in the column. Ultimately, my editor has the final say in such matters, and unless I am commissioned to write on a different subject matter, the column has to continue (in respect to my own commission) to be health-orientated. However, I do promise to try and take the occasional meander into other, more erudite pastures to try and satisfy everyone. After all, you, the readers, are the final arbitrators over whether the column is worthwhile and meeting your needs. So, please do keep the feedback coming in and, in turn, I promise to continue burning the midnight oil for you. Meanwhile, a Happy Easter to you all.

First published in the Scunthorpe Telegraph, Easter 2011

Second Thought for the Day

Interviewed by Lucey Jarrett in the ALCS News (Spring 2011), Russell T Davies remarked:

'... gradually I came into contact with writers, and realised they were ordinary people. This was before I realised that they are all, in fact, mad.'

Thought for the Day

A marvellous quote in the ALCS News (Spring 2011):

'The freelance writer is a person who is paid per piece, or per word, or perhaps.'

                        Robert Benchley (1889 – 1945)

Snap a Quill

Whilst in recent conversation with Penny Grubb (www.pennygrubb.com) , crime-writing author and Chair of the Authors Licensing and Collecting Society, I remarked that there ought to be a literary equivalent to the acting world's 'break a leg' salutation when wishing a writer good luck in a forthcoming venture.

The suggestion from Penny was 'snap a quill', which seems wonderfully appropriate.

So, over to the rest of the writing world – who knows, it may be a phrase carried on into the literary centuries to come!

Happy Talk

'What is this life if, full of care, we have no time to stand and stare?'

So begins the famous poem by the Welsh poet, William Davies. There can be no doubt that the lives of many of us are under pressure; not only because of the current economic climate and the (often difficult) changes thereby necessitated at home and within our workplaces, but also through a predilection for the tendency of those living in a western society to squeeze more and more into each day and week, until the months and years become but a passing blur - so much for the 1970s concept that computers (for example) would make life easier for us all, and allow for greater leisure time.

    Holidays are a time when many of us realise the undesirable qualities and true nature of our working lives. It was the topic of leisure that was on William Davies's mind when he penned his 1911 poem. It was also something he took very seriously, living his early adult years as a tramp (I recommend to you the Wikipedia website for a fascinating account of his life). Leisure was also the topic on my mind when I pensively sat overlooking the terraced farm land and distant slopes of the Troodos Mountains in Cyprus last week, where life in the hillside village of Pissouri is still conducted in the slow lane of time. Whilst there, I pondered on the various blessings of my life, some of them immediately tangible; others less so, such as the privileges of being a Freeman of the City of London (it is such a great comfort to know that, should I ever be hanged for treason, it will be by means of a silk-rope: so much easier on a delicate neck).

    Of course, as individuals we have a myriad of ways of finding happiness, and it doesn't need a trip abroad or the quasi-benefits of an archaic preferment to discover happiness within our lives. Being happy and feeling free of stress are often two overlapping concepts. It was therefore interesting to learn about a new campaign recently launched by the likes of the Buddhist leader, the Dalai Lama, and our own poet laureate, Carol Ann Duffy. Called the Action for Happiness Campaign (http://www.actionforhappiness.org), and drawing on research by the London School of Economics, the campaign aims to encourage and assist the British to rediscover the pleasures to be found in even the most simplest of lives.

    We all know that stress is, in its extreme, bad for our health. However, how many of us make the time within a busy week to sit still for even a short while and reflect on the pleasant aspects of life? Perhaps we should all take a leaf out of the Quaker practice of sitting quietly still for at least one hour per week? For, as William Davies ended by saying: 'A poor life this, if full of care, we have no time to stand and stare'.

First published in the Scunthorpe Telegraph, Friday 15^th April 2011

The Coffin

I this week discovered that a poem from my first collection was used at a recent funeral.

It is always a momentous occasion to send a piece of work out into the world for public consumption, as one never quite knows how it will be received. It is therefore rewarding to know that some poems subsequently take on a life of their own.

The poem in question is The Coffin, taken from the collection A Journey with Time (ISBN 978-1-4092-2847-9), first published in 2008.

The Coffin

A lifetime encased:

your boundless intellect and

energy, swathed in

a vast cloak of achievement,

simply borne by two trestles.

©Copyright Robert M Jaggs-Fowler 2008

Looking into the tea-leaves

Anyone who has opened a box of Twinings tea will be familiar with the quotations on the inside lid. One is from George Gissing (a 19^th century English novelist), who is reputed to have said 'The mere chink of cups and saucers tunes the mind to happy repose'. It is in the spirit of trying to induce even a mild state of euphoria that I am now drinking a large cup of Breakfast Tea whilst writing this article. However, the conversion is proving to be a challenge, and I will explain why.

My medical career began in 1980, when I entered a London medical school with tremendous enthusiasm and the single focus of qualifying and practising medicine. Even then, I knew I wanted to be a GP, despite various professors trying to sway me in other directions. I was one of the lucky ones, having previously gained a place in one of the country's top grammar schools, and then, with the aid of a decent student grant, topped up by a small scholarship award. I was, as the saying goes, upwardly mobile.

    After several years of working a long and arduous passage through a variety of junior hospital jobs (120 hour weeks were the norm), I landed in North Lincolnshire and had the great fortune of being offered a medical partnership. For the major part of the past twenty-one years I have tried to offer a decent quality of service to my patients; many of whom, by virtue of living within a small community, I would now call friends. The long working days and pressured demands have been compensated for by the firm belief that I have been helping others in need and putting something back into society.

    Now, in 2011, the present NHS reforms have overturned my enthusiasm and ideology. Whilst it is true to say that I still enjoy the individual patient-doctor relationships of everyday general practice, the pathway the NHS is now being forced down makes me increasingly look for alternative ways of spending the next decade of my working life. Such a statement comes as a surprise to many who have known me for a long time. However, the truth is, I (and many others on a national basis) fear for the future of general practice in particular and for the future of the NHS in general. Along with a large proportion of my GP colleagues, I can see through the political rhetoric of 'giving GPs the power to run the NHS'. Whilst it is true that we are to be given the responsibility of keeping within restricted budgets (not a bad thing when dealing with tax-payers' money), the exhortations of the Secretary of State for Health that the reforms are going to 'free up GPs to spend more time with patients', 'empower clinicians to make the decisions', 'liberate the NHS', and that 'the majority of doctors support the reforms' are, many of us believe, far from the reality.

    It is true that there are a few doctors who are enthusiastic about the changes. There are slightly more who are pragmatically getting on and trying to make something decent out of the reforms. However, the majority of GPs are disquieted and fearful; certain that the changes will see greater privatisation of NHS services and hospitals, a loss of experienced managers, greater demands on GPs' time in respect to running the service rather than treating patients, increasing pressures to achieve unreachable targets, insufficient money to provide a decent service, closure of some hospitals and surgeries, and ultimately a dismantling of primary care as we know it. Of course, GPs will get the blame when it all goes wrong (nothing new there), whilst those presently in Government, who should carry the responsibility for the wholesale destruction of our national health service, will have moved on to pastures new. In the meantime, it is you, the patients, who will suffer.

If you think I write as a burnt-out fifty-year old GP who can no longer stand the pace, you are quite wrong. However, I am angry, demoralised, and reflectively surprised that I should find myself seriously considering a career change after years of enthusiasm for life in medical practice. I strongly believe that the nation needs to wake up to what is happening before it is too late. Don't swallow the political rhetoric without reading the label; there are some serious side-effects to these present reforms, and many of them are yet to become apparent. Use your wits and start asking questions of your MPs and doctors. Seek out the truth and then decide whether you personally wish to influence the changes before it is too late.

There, I have said my piece. As I drain my cup, I am mindful that Noel Coward once asked 'Wouldn't it be dreadful to live in a country where they didn't drink tea?' I quite agree, although I find myself wishing I hadn't used a tea-bag; a few tea-leaves may have helped decipher the future. As it is, looking at the bottom of my cup, there is nothing there. Then again, perhaps that is also the future of the NHS as we know it...

First published by in the Scunthorpe Telegraph, Friday 1^st April 2011