A Doctor's Journal
Cogs in the NHS Machine
By MILES HOWARD
ONE aspect of the NHS that frets many people is the possibility that family doctors may one day become mere cogs in a civil service machine. The advent of health centres, the suggestion of a salaried service and the many contractual obligations doctors now have under the State, such as sickness certificates under the National Health Insurance—all these are food for serious thought.
The other day a doctor who practises in a health centre wrote on what he called unjustified claims by his patients upon the NHL The paper threw little light on certification, or why people cannot go to work, but it did reveal something of the doctor who certifies. He said, 'Because I practise in a health centre and in almost ideal conditions, my sickness certification is probably stricter than that of some practitioners,' and, later on, `. . . if a woman complains of feeling tired, I will always issue her with a sick certificate for a week or two; but if after that time she still shows no symptoms or signs of disease, then I regard her as probably unjustified in prolonging her claims.' There's the rub. Change your family doctor into a health centre official, and he can afford to be 'strict' to his heart's content and will only let you off if you can produce the symptoms and signs of the illnesses laid down in the Ministry textbooks.
It is hardly the doctor's task to be either 'strict' or 'lenient,' or to hand out certificates with an ill grace for a week or two because the patient feels tired. His real task is to find out why his patient is ill and do something about it, if he can. The working woman who comes to the doctor and complains of tiredness and inability to work, and has no signs of 'organic' disease, may (and indeed probably does) suffer from that very real and all too common illness, depression. The man suspected of malingering, and refused a sick note, may well respond to the lash of the whip and go back to work. But will that solve anybody's problems? I believe that frank and conscious malingering is pretty rare. Unconscious utilisation of illness is uncommon, but it always has a mean- ing: it is a solution, however unsatisfactory, for some problem of life. Brute force will not take us much farther in the exploration of that para- mount question : why do people fall ill?
It would be a pity if the doctor, whose pro- fessed aim is to relieve suffering, became preoccupied in counting up the money which he thinks patients have unjustifiably drawn from the State. In the paper I refer to the author had worked out that £410 of benefit had been claimed 'unjustly,' and £7,468 of it was justified. This is a moral judgment and, while as a tax- payer I can understand how the doctor feels, I wonder whether judgments of that kind have any place in our dealings with patients.
There are several important principles here: one is the influence upon his patients of a doctor's own ethical system. Suppose a man goes to his doctor and says he is tempted to commit adultery; he asks for advice and tries to get the doctor into the position of telling him what to do. How is the doctor to act? Does he try to remain neutral? Or does he come in on one side or other of the battle inside the patient?
Another question is that of the doctor's emo- tional attitude to the patient. How much insight has he? And how far are his feelings for the patient affected by forces in him that are outside conscious awareness? There is a huge field here for investigation and, except for the work of Michael Balint and a few like-minded men, not
much is being done. The place to begin the in- quiry, I think, is the progressive medical school, and the time to begin is when the student makes his first contact with patients as people and not as diagrams in a book. There are some signs that the students and their teachers are awakening to a realisation of the tasks which confront them if the doctor-in-training is to be prepared for the handling of a human being sick in body and mind, as most patients are.
How will it all look to an observer in 2050? What will he the next steps, which will occupY the rest of this century and make the established medicine of AD 2000, and the educational system appropriate to it? It will not simply be the elaboration of laboratory methods: that is the triumph of yesterday. Compare what was in" wresting the most advanced minds of 1855 0 1865 with what premonitions of a new departure are perceptible today: does it look as though the understanding and control of the mind and of the mental aspects of all diseases is what mos, closely corresponds to the rising material in' terest of the post-Darwinian era?
This is from the last paragraph of the last chap ter of a recent book on medical education by Dr. Charles Newman, who is Dean of the Post' graduate Medical School of London, where doe" tors who have already qualified can go for further training. The author has been able to stand back from the contemporary medical scene and take' a detached look at it; and this is all the more striking, for the Postgraduate School is the seal, of some of the most high-powered research and experimentation in the physical sphere—labora- tory methods, in fact. He is thus an exception to the general rule that consultants (and especially postgraduate teachers) are slower to see the way medicine 0 moving than the GP. Present-day views about stress and disease have more reality to the praC' titioner, who lives in the thick of it. As Geoffrey Barber once said, 'The GP is a naturalist, Or' suing his quarry and studying its habits in the jungle, the specialist only the specimens in the zoo.' But the intelligent and thinking layman 15, ahead of both of them. When the 'Stress of Life articles appeared in the Sunday Times last spring. I heard several non-medical friends comment 0n them, 'What's all the fuss about? We know this already.'
Too little attention has been paid to the effect of the hospital community on the individual patient. Even less has any serious attempt been made to use the hospital community as an active force in treatment. . . . We have tried to build up a therapeutic community where each member of the staff has a clear concept of his or her role. By frequent (daily) meetings, these roles have been, elaborated and clarified, and the inter-personal relationships developed by discussion and by resolutions of tensions where possible.'—Social
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Psychiatry. By Maxwell Jones. (Tavistock cations, 1952.)
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