Patients as People
By FRANCIS BOYD IT would be easy to become despondent about the future of the health service. Actions brought in the courts against hospital authorities have been regarded by some doctors as an omen of an era of litigation threatening the confidence of the profession. Parliament's handling of the service suggests that it will never be possible for the politicians to discuss its affairs with detachment. The controversy over the appointment of the Guillebaud committee to examine the cost of the service is the latest indication of that; and it is in the nature of the party battle that any change proposed by one side in a system devised by the other will be regarded as a political attack unless it can be proved beyond any doubt to be nothing of the sort.
Yet it is particularly desirable that the health service, above all other state enterprises, should be allowed to grow in con- ditions as favourable as those in which a new variety of plant is cultivated. The health service affects each one of us most Intimately. It is a vast undertaking. It brings doctor and patient face to face with a directness to which they have not been accustomed. The public, the users of the hospitals, are now responsible for their management, and the hospital staffs as well as the doctors have been placed in a new relation with their patients—and employers.
This situation is rather embarrassing to doctor and patient alike because it is so new and because its development is obscure. Can the patient (or the private individual on his behalf) take a more positive and articulate share in his treat- ment? Can the patient secure some recognition of the fact that he is less stupid than he has sometimeg-been made to feel in the past.? Can the doctor and the nurse increase their help to the patient by abandoning some of the mystery with which they have surrounded themselves for so long ? Can they be made to feel more a part of the community as a whole ? The answers to these and similar questions will settle the future of the, health service. It could be shattered in a ,quarrel based on profound misunderstanding: it could be at the start of a most fruitful partnership providing a new and powerful element of cohesion and pride throughout the nation.
Happily there are powers working towards partnership, and chief among them is the Central Health Services Council set up under the National Health Services Act of 1946. (Even in Parliament there is more co-operation than would appear in the formal attitudes of the two Front Benches.) The report of the work done in 1952 by the Council and by the statutory advisory committees which were set up at the same time is a most heartening document. It shows how layman and doctor Working together can agree upon far-reaching changes and can try to understand and solve those problems which arise When patient and doctor peer at each other rather apprehen- sively as individuals.
The value of advisory committees is of course no new thing. Successive Ministers responsible for housing have long known their worth. During the last war the Government and the country received great help from an advisory committee on nutrition, and the various state insurance schemes are con- stantly being examined by statutory committees. Nor is the Central Health Services Council incapable of improvement: its lay membership might include some people who are not administrators. But the Council has this peculiarity, that it considers and reports publicly upon a delicate human relation between the doctor, justly proud of his profession, jealous of his special knowledge, and anxious not to destroy the faith of his patient by too ready an admission of ignorance, and the patient, a little over-awed by the mystery of medicine, and inclined perhaps either to exaggerate the degree of his illness or to conceal the seriousness of his symptoms. The report of the Council leaves the impression that under the guidance of its chairman, Sir Fred Messer, the Labour Member for Tottenham, and of its vice-chairman, Sir Henry Cohen, the distinguished physician, who have worked together since 1948, the Council is devoting itself with a single mind to the creation of conditions in which doctor and patient can talk and work together on more friendly terms. In this task the contribution of those doctors, dentists, nurses and chemists who are members of the Council or of the committees is indispensable. Without the agreement of the professions no advance can be made: with it, advance may be rapid. It is most encouraging that the Council as a whole, with the approval of the Minister of Health, should have recommended an improvement in the reception and welfare of in-patients, that parents should be allowed to visit their children in hos- pital every day, and that there are no factors inherent in a hospital nurse's work that make living-in necessary. The Minister, Mr. Macleod, comments : "With their natural con- centration on the essential medical and nursing side of their work hospitals have not perhaps always paid enough conscious attention to the needs of their patients simply as people." The hospitals have in fact overlooked at times the therapeutic value of kindness.
The conditions in which doctors and nurses work have been changing rapidly. The iron discipline which Florence Nightin- gale imposed in her training school for nurses was designed as a barrier against Mrs. Gamp. Since then, not only has the public been made much more aware of the principles of hygiene, but Mrs. Gamp herself has disappeared from the world of caricature (except to the social historian) and now shines forth as a superb creature of fantasy. So, too, the increasing aid which the doctor gets from chemists and other scientists is threatening the mystery of medicine. The scientist is an expert, too, but in the doctor-patient relation he is on the side of the patient, for the rest of science has not shielded itself from the layman to the extent that medicine has done. The common indebtedness of doctor and patient to the scientist could be a means to greater friendliness.
There is much work for the Council still to do. We shall all of us have to be led forward gently. The patient cannot expect the doctor to surrender recklessly those proud traditions which protect not only his own status but sometimes the well.being of the patient against crippling fear. The Council, for example, has not yet decided how to persuade the public to seek early advice in the treatment of cancer "without caus- ing too much fear or too much hope." It will take time for hospitals to transmute " cases " into people. An elderly man who was recently a patient in hospital reported on his return to work that the nurses had been splendid, but that it had taken some time to break down the stiffness of the doctors. "I finally gave them a quotation or two from Milton," ha said, "and that led to an improvement." But kindness is needed perhaps even more by those patients who cannot invoke Milton to humble the mighty.
Of course, many doctors and patients are on the best of terms with each other. But the health service may confront each patient with more doctors than the one he is used to, and that is why it has become so important to raise the general standard of relations between doctor and patient. This is an aspect of the health service that the Council might well explore. A woman who becomes pregnant may pass from the care of her own doctor to that of the maternity service—many thousands do. The maternity service passes her on to the midwives who may, or may not, have their own doctors on call in case of difficulty. But these might be different doctors from those of the maternity clinic, and the family doctor need have no contact with any of them. Mr. Bevan, when he was moving the second reading of the Health Service Bill in 1946, mentioned fears of a " trichotomy " and dismissed them. The hub of the service was to be the health centre. As yet few patients can have all their ills treated in one health centre, and meanwhile liaison between the various branches of the service is loose if not defective.
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