Medicine
Where the buck stops
John Linklater
We hear that a ward in a Colchester hospital is to close due to shortage of nursing staff, that there is a temporary ban on psycho-geriatric admissions to another, nearby hospital for similar reasons, that there is a waiting list of 18,000 Essex patients who have not yet been able to obtain a specialist opinion, and that the Member for Colchester, Mr Antony Buck, has emphasised the, need for hotting up medical facilities in the area, whatever that may mean. The situation in Essex, however, is merely a reflection of a national problem and the aspects which make headline news are only the tip of an iceberg.
When a ward closes, the patients who.would have been treated in it do not simply disappear. They may cease to exist statistically, thus saving the nation some £20 per head per day, but they still have to be looked after at home by their relatives, by the grossly over-stretched district nursing staff and by their family doctor. Not only does the family doctor have to attend with greater frequency but he is also forced to spend more of his own time and money vainly chasing alternative hospital beds. So it is with the patients on waiting lists for a consultant opinion. These will continue to attend their own family doctor for interim and palliative treatment, for certificates and for general supportive help, while the family doctor finds himself coerced into doing more and more of the consultant's work for him.
In these circumstances, one is tempted to ask precisely what sort of "hotting up" Mr Buck has in mind, since every failure of the NHS hospital service is, and always has been, cushioned by being passed back to the general practitioner to sort out. When surgical or maternity wards become overcrowded, for example, patients are given an early discharge. The general practitioner is then inevitably faced with urgent calls to deal with postoperative chests, postpartum bleeding, stitch abscesses or deep leg vein thromboses, all of which would normally have declared themselves in the ward.
A typical, recent case is that of a hypertensive lady of seventy who lives alone. One evening she slipped and hurt her leg. Her general practitioner diagnosed a fractured tibia, sedated her mildly, stopped her drinking any more tea and sent her to the local casualty department with a letter explaining her domestic predicament. The letter may have been read but she was nevertheless sent back home on the same eveninewithout comment, still in great pain, in a. plaster of Paris cast in which she could not yet stand. The general practitioner thus had to attend her again forthwith for the relief of pain, to re-supply her with her hypotensive tablets which had somehow been removed and to organise neighbours to help: the social services could not be raised at such short notice, so late at night. He also treated her during her subsequent chest infection, which might not have developed had she remained in hospital with regular physiotherapy during her period of immobility.
Many such problems arise due to an increasing shortage of senior consultants and to the fact that consultants are nowadays forced to do so much of the routine, detailed, preparatory work themselves, because of the incompetence of their juniors, that they have little time left for their supervisory duties. The language problem also presents increasing difficulties for. the general practitioner who often finds it extremely difficult and time consuming to obtain a hospital admission, even for a seriously ill patient. Last week, for example, a general practitioner explained at length to a hospital house surgeon that he had just attended a fiftyeight year old man who was, at that moment writhing in the throes of an attack of acute, unexplained, abdominal pain, sweaty, pale and vomiting. "Well doctor", replied the house surgeon, "if he is comfortable now, perhaps you like to make appointment for our next clinic."
Quite apart from the ludicrously inappropriate solution suggested, the attitude of 'our clinic' demonstrates yet another subtle breakdown of the NHS which may not be apparent to the layman. When a general practitioner refers a patient for a consultant opinion, he does so because he needs the help of a senior specialist. He does not send a patient to hospital to be seen and treated only by a junior doctor. Yet the shortage of consultants is now such that the experienced family doctor may often be asked to rely upon the opinion of a less experienced doctor in one of these clinics. The patient's problem is often simply passed back again to the family doctor unless he appeals personally to the consultant, thus . taking up yet more of his time.
A different type of difficulty sometimes arises because of the close relationship between the family doctor and his patients, so that when it comes to the choice between giving less than the best treatment or sacrificing disproportionate time, he is inclined to abandon the failing NHS structure, and take this load also on his own shoulders. This is perfectly exemplified by the recent case of a highly intelligent, retired, senior businessman who was suffering from an acute, stress-induced, psychotic breakdown. The staff situation in the local mental hospital was such, added to problems of communication exacerbated by the psychosis, that the general practitioner concerned felt morally bound to treat the patient at home, remaining in attendances for several hours at a time until the anti-psychotic drugs took effect. Such are the real, underlying problems which result from wards closing, or when staff are inadequate.
An interesting new problem for the general practitioner is raised by the appearances of a so-called five-day hospital ward. This is a ward which closes at weekends due to shortage of nursing staff. A patient who recently entered such a ward for the investigation of dementia deteriorated so rapidly that the consultant in charge quite correctly decided that investigation would be pointless since no curative action was now possible. On Thursday, therefore, the relatives were told that they would have to take the patient home on the following day. When they protested that he could no longer possibly be nursed at home, the junior doctor to whom they spoke, agreed at once. "See your own doctor," he said. "He will find bed for you".
In vain did the family doctor waste a twenty minute trunk call protesting that it was ridiculous for a general practitioner to have to find another hospital bed for a patient who was already in hospital, and who would have to remain in a hospital bed. The ward was closing, and that was that. Meanwhile the relatives, 'justly aggrieved, are breathing hostilely down the family doctor's neck. They had, after all, been assured that he would find another bed.
Much of this type of problem could be relieved by an adequate psychiatric social service, but psychiatric social workers are no longer specialised in psychiatry and, apart from having no direct responsibility for treating the patient, they do not come under medical control. Most of the experienced social workers who should be dealing with patients sit in lavishly carpeted committee rooms instead, or spend the day writing each other voluminous minutes and reports; even these tend to end up on the family doctor's plate, for action.
It is clearly no longer a question of hotting up any regional facilities, but of attempting to put into reverse a number of cataclysmic, nationwide, policy decisions which have eroded the very basis of individual competence, responsibility and general excellence upon which the NHS depends. We lament a shortage of trained nursing 'staff while tempting many of our best and most devoted nurses to be isolated from patients and absorbed, like the social workers, in administrative duties, in the name of some theoretical advantage of career structure which allows a small proportion of nurses to rise to a seniority which they did not expect, while we still pay the remainder a totally inadequate wage. We lament the shortage of skilled doctors while paying such a wage for their skill, long hours and responsibility that when an advertisement appeared recently to go to Saudi Arabia, 400 British doctors answered it.
Indeed, the malaise probably goes deeper than the NHS and is related fundamentally to the egalitarian political myths of the Welfare State, based on a bland belief that there are unlimited funds to be disbursed for whatever crazy scheme may be thought up to curry political favour and win votes. They will pay. But it is we who are they, and we are running out of funds. We are spending More than we earn and it has to stop. The knowledge is nationwide, but it is the family doctor who has to keep on bailing the NHS out of its difficulty. We must take health out of the political arena, cut down on administrative spending and rethink the whole basis of NHS finance. The current problems in Essex are but a small example of a buck that has bee,n passed too often.
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