Tag Archives: NHS

Saving the NHS – the struggle to manage increasing anxiety

Peter Aird

Peter Aird

Peter is a GP in Bridgwater, Somerset.
Peter Aird

Photo by hotblack at Morguefile.com

On the eve of the 1997 election, the year I became a GP partner, Tony Blair declared that the nation had ’24 hours to save the NHS.’ Twenty years on, like those who advised the emperor who paraded about town in his nonexistent new clothes, some politicians pretend they cannot see that the NHS is in the altogether perilous state of near collapse. One wonders if they have completed a DNAR form for the NHS without the agreement of those who love it most.

One wonders if they have completed a DNAR form for the NHS without the agreement of those who love it most.

Be that as it may, what is certainly true is that the NHS cannot do all that it is being increasingly asked of with each successive year. This is for at least two reasons. Firstly, as science advances, more things become theoretically possible. But as Isaac Asimov once said ‘The saddest aspect of life right now is that science gathers knowledge faster than society gathers wisdom’. This is still true – not all that can be done should be done. The second reason, I think, is more fundamental. We live in an increasingly anxiety ridden society. Henry Thoreau wrote: “The mass of men lead lives of quiet desperation, and go to the grave with the song still in them.”

Undoubtedly some of our patients are, indeed desperate. Lacking the fulfilment that they desire, but don’t quite know how to realise, they are desperately anxious not to miss out on whatever it is that would give them satisfaction. Idolising absolute health, anxiety rises as their desire for the elimination of every problem, big or small, real or imagined, cannot be met. The constant endeavouring to solve every problem is exhausting and counterproductive, for both those with the problem and those trying to do the solving. As Leonard Cohen sang: ‘There is a lullaby for suffering and a paradox to blame’. Facing our weaknesses and accepting our suffering can be, I believe, paradoxically, comforting.

However this is a difficult philosophy to convey and one that is harder still to convince people of. So anxiety persists, together with its lonely companion, its accomplished accomplice, depression. Anxiety in all its forms is now so pervasive that I think it easily represents the most common problem presented to me at work.

Put these all together and it seems that almost every consultation has an agenda, hidden or otherwise, driven by anxiety.

Firstly there are those patients who present with frank anxiety- by which I do not mean to suggest they have an irrational fear of Frank’s be that Sinatra, Zappa or D. Roosevelt. Rather I mean those patients that present with up front anxiety symptoms – panic attacks and the like. Then there are those patients who present with symptoms that they are anxious represent serious underlying disease. They are often hard to reassure, so twitched are they by the twitches that they experience. And then there are the patients whose symptoms generate anxiety in us – the doctors. We can be left concerned that we are missing something serious and fear what that might mean both for the patient and also for our own reputations – reputations that we cherish, perhaps, more highly than we ought. Put these all together and it seems that almost every consultation has an agenda, hidden or otherwise, driven by anxiety.

I wonder how much of this is tied up with the current postmodern notion of relative truth and its recent spawned offspring ‘alternative facts’. Many have remarked that 2016 was a particularly bad year and perhaps, with all the terrorist outrages, natural disasters and political upheaval the year brought, not to mention all those celebrity deaths, we do all have good reason to be uneasy. But also concerning, perhaps more so, is the fact that the Oxford English Dictionary made ‘post-truth’ its word of the year – a decision that reflects that public policy is being decided based on appeals to personal emotions rather than objective facts. Paul Weller and ‘The Jam’ sang, ‘The public gets what the public wants’ and it seems today the public is at least sometimes promised what it feels it wants, independently of what it needs, because it is politically expedient so to do. I am left wondering if all the anxiety we see, and feel, stems from the fact that, with the throwing out of the still clean, clear bathwater of objective truth, we have thrown out the baby of any sense of assurance.

If nothing is certain, how can our patients be anything but anxious about everything? How can they be reassured that their symptoms are not concerning when the opinion we hold can never be more than what we feel to be true? Our feeling, that their symptoms are not worrying, can never counter their feeling that they are, since their feelings are no less valid than ours. I was surprised once when my assurances, that a lesion on a patient’s scalp was a harmless seborrheic wart, were not accepted by the patient because her hairdresser had felt it was a skin cancer. But then, if truth is relative, an expert’s opinion (and I use the term lightly) has no more authority over that of a non specialist.

Another patient once challenged a consultant cardiologist’s opinion that her ECG was normal as she felt her symptoms were consistent with what she had read of Wolf-Parkinson-White syndrome. The objectively normal ECG, and the expert opinion of the consultant on that ECG, was contrary to the patients feelings. And so a second opinion was requested and, when this was declined, the patient chose to write directly to the consultant expressing her belief that her concerns were being ignored.

This notion extends to the anxieties we experience as doctors. If truth is relative, how can we have any confidence in what we feel to be true, and, if the patient feels differently to us, how can we say that we are right and they are wrong? I am aware, of course, that there are, inevitably, times when a diagnosis is in doubt, when the truth is uncertain, but it sometimes seems we are no longer confident that we know anything for sure. In a society suspicious of intellectualism, the learned are themselves suspicious of their learning. Too concerned that our patients be happy with our opinion, our clinical diagnoses have to be malleable, tempered to acknowledge the validity of the patients’ opinion regardless of how lacking in objectivity that opinion might be.

Is it only me who, knelt at a patients feet and examining their sylph like ankles, has reluctantly murmured; “They are a little swollen I suppose”?

Is it only me who, knelt at a patients feet and examining their sylph like ankles, has reluctantly murmured: “They are a little swollen I suppose”. Of course it is no wonder we sometimes behave like this since we have had it driven into us that we be ‘patient centred’ when all along we really should have been urged to be ‘truth centred’. But it’s arrogant to claim to be right about anything these days – facts prove nothing. In a consumer society, the customer is always right. Is it any wonder then that, as medicine was opened up to market forces, the result would be that the patient is always right too?

And if feelings are what are important, then what others feel about me are every bit as much an indicator of who I am as what I feel about myself. After all, a satisfactory satisfaction survey is sacrosanct – I’m OK, if you’re OK with me. But if everybody’s feelings are different, how can I be OK, since how can I be OK with everyone? How can I make everybody feel positively toward me when they all have different criteria for what it is that would cause them to feel in such a way?

Anxiety is, I think, largely, a fear of unhappiness in the future which leads inevitably to us being unhappy in the here and now. That’s why anxiety and depression are such common bedfellows. With, to a great extent, the loss of religious belief, and with it the hope of a better time and place to come, society no longer is prepared to accept that we must sometimes wait for happiness. In an age when everything is instant, waiting is not an option – we must be happy now. But in a materialistic, consumerist society, which daily advertises to us our discontentment by displaying what it insists we need, but do not have, to be happy, it is no surprise that we are anxious that life is passing us by, that we are missing out on being fulfilled today.

And so the National Health Service has become the National Health Slave.

And of course it’s not just material goods that our society consumes. We consume health – it is the ‘must have’ we assume and insist upon. No suffering, however small, ought to be tolerated. We must have health and we must have it now – not next month, nor next week, not even tomorrow. The doctor will see me now – be it Tuesday morning or Sunday afternoon. And so the National Health Service has become the National Health Slave even as the NHS itself, colluding with society that it can meet its greatest needs if it would just do as it was told, slavishly insists patients behave in ways current medical opinion deems appropriate. Don’t smoke, don’t drink, don’t fail to exercise, don’t eat just four of your five a day, and whatever you do, don’t forget your Vitamin D. Don’t, don’t, don’t, don’t, don’t – and you might just live forever.

And so it seems to me that what this all ultimately boils down to the existential question of death. It is the one thing certain about life but we, increasingly perhaps, try to pretend that this too is uncertain as we pursue, and push, eternal life through medicine, lifestyle adaptations and sentimental and fanciful notions of how those who undeniably have died, somehow live on. In a world where nothing is certain, the certainty of death is above all to be doubted.

But we need to face facts, and so must our patients. Despite how much money is pumped into the  NHS to fund all that medicine increasingly can do, despite how long GP surgeries are open or how short waiting times in A&E departments become, and despite how much we heed medical advice and adjust our lifestyles accordingly, we, and our patients, will all one day die. Regardless of what we may or may not believe about life after death, if we are to find any happiness in this life, we need to stop pretending otherwise. We must stop believing that our interventions could ever prevent the inevitable. Rather than doing more for longer, if we want a population that is healthy in the fullest sense of the word, we need to do less. Yes the NHS must be funded adequately but it must be funded adequately to do what a long hard look determines is objectively thought to be important rather than subjectively felt to be urgent.

We must stop pandering to those who are intolerant to even the slightest inconvenience or hardship.

We must stop pandering to those who are intolerant to even the slightest inconvenience or hardship and we must stop suggesting to our patients that life is all about attending to our cholesterol, BP and vitamin D levels so that future suffering is prevented. Why? Because a good life is not solely determined by the absence of suffering – now or in the future. Unrealistic attempts to deny the inevitability of death all too often serves only as an expensive and time consuming distraction that compels us to look down at the temporary and trivial and leaves us neglecting to look up at the significant and satisfying.

We and our patients need to learn to ignore the mundane and consider instead the transcendent. Only then will we, and they, instead of enduring an existence weighed down with anxiety and depression, enjoy a life buoyed by contentment and joy.

Book Review: The State of Medicine by Margaret McCartney

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

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thestateofmedicine300The State of Medicine is an eloquent, passionate, comprehensive, and, in many ways, dispiriting overview of the repeated damage inflicted on the NHS at the whim of successive governments. The frustration of the author, a GP from Glasgow, pours from every page, every paragraph and every sentence, as she contrasts the efforts of doctors to practice evidence based, safe, humane and cost-effective medicine, in a system that is routinely upended and overhauled according to manifesto sound bite, political opinion and, occasionally, outright self-interest.

Whilst the general themes of this book will surprise few who work in the NHS, the actual facts and figures, such as the vast sums wasted on management consultancy firms, may make the eyes of even the most hardened cynic water.

Each chapter begins with an interview with someone who is able to give a different perspective on our collective woes. Amongst these are some real gems that offer unexpected insights into different niches of the NHS world. The words of an A&E consultant who was working at Mid Staffs during the scandal may send a there-but-for-the-grace-of God shiver down your spine, and the thoughts of a Nobel prize winning economist will have you bewildered that there are still so many advocates of insurance based health care systems.

Dr McCartney offers a clear account of the follies of the last few decades and a personal view of where and how the NHS should proceed from here with ideas such as buffering the NHS from policy makers, funding it properly, treating health professionals with respect, and actually basing policy on evidence.

The message of this book is important. We must hope that it reaches a general readership, or, hoping even more bravely, that it reaches an audience amongst the political classes.

Acute primary care in an integrated NHS

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

The tsunami of chronic disease management – the ageing population, rocketing rates of non-communicable diseases, and increasing complexity – have dominated much of the debate about the future of general practice and of the NHS. The crucial function of general practitioners in making accurate, timely diagnoses in patients presenting with acute symptoms is easily overlooked, yet is at the very core of primary care. The implications of this for mending the fractures in the system and for the design of integrated models of care came home to me in the course of three conferences over the last couple of weeks.

The first was a European meeting on screening for colorectal cancer, held in the Czech Republic, involving European Commission and Parliament policy-makers, as well as clinicians and epidemiologists. The focus was on increasing the momentum in member states of the EU to develop and extend screening programmes for colon cancer, which is an enormous health problem in Europe. However, the flip side of this debate is the fact that the huge majority of bowel cancers are diagnosed outside screening programs, either in patients presenting in general practice with suspicious symptoms or, in a substantial minority, in emergency hospital admissions for the complications of advanced disease.

The next was a conference summarising the achievements of the Discovery programme, a large, NIHR and charity funded research programme of research aimed at collecting evidence to support early cancer diagnosis in general practice (http://discovery-programme.org). One of many important messages for primary care was the need to be prepared to investigate patients with potential cancer symptoms much more promptly than we do at present, and the consequent requirement for better investigative services that can be readily accessed by general practitioners. Discovery investigators presented new data to show that many of the “typical” symptoms associated with cancer presentations are, in fact, much less common than more general,  often vague, complaints, such as fatigue and “feeling different”. They have also demonstrated that patients presented with vignettes of possible cancer scenarios are much more willing to undergo investigations at an earlier stage than previously recognised.

The third meeting was the Annual Conference of the South London Faculty of the RCGP which took as this year’s theme “Early diagnosis in general practice”. I presented some recently-published data, including the important recent BMJ Open paper from Peter Rose and a number of European colleagues which shows that GPs in England, Wales and Northern Ireland are much less likely to request investigations for potentially worrying symptoms then their general practice colleagues in most of the eight other European countries taking part in the study. Given the relatively poor cancer outcomes in the UK (and, for some reason, in Denmark), this is an important finding, adding weight to the need for speed and accuracy in investigations for suspected cancer.

Taken together, these studies and observations are powerful ammunition for the commissioning of better access to investigations, and for careful review of two-week wait criteria. They do, I think, mean more than this, and have major implications for the kind of integration between primary and secondary care that should develop within the NHS in the near to medium term future. In his Five Year Forward View, Simon Stevens, the NHS Chief Executive, describes two possible models of integration – the so-called Multi-speciality Community Provider (MCP) model and the Primary and Acute Care Systems (PACS) model. The first of these is a more horizontal integrative approach to community-based services, including of course general practice, whilst in the PACS model there is scope for a single provider organisation to deliver both primary and secondary care services, with no pre-defined requirement for this to be general practice-led or hospital-led.

The RCGP has, understandably, focused on developing the MCP model, which is probably more likely to keep general practice in the “driving seat”, and meets the five College criteria for an acceptable approach to integration. However, it seems to me that much might be gained by looking more positively at the PACS model, within which investigative pathways for patients with potentially serious conditions – and this of course doesn’t just apply to cancer, but to a host of potentially serious clinical problems – could be developed jointly between generalists and specialists. This approach could, I believe, lead to the creation of much less delay and misunderstanding by removing many of the barriers to speedy diagnosis and swift intervention that presently exist at the primary: secondary care interface. It would be simplistic to suggest that the MCP model is better suited to chronic disease management and the PACS to acute presentations and treatment, but that may not be far from the truth.

It is also possible to see other potential advantages of the PACS system, in locations where it would provide the most clinical benefit. A single employing organisation could provide economies of scale that the small-business model of general practice simply cannot achieve. Making use of joint infrastructures, including finance, HR, and procurement is likely to have significant cost benefits. Beyond this, the possibility that primary care specialists might be employed under similar contractual arrangements to hospital specialists, with benefits for continuing professional development,  career structure and work force planning, and with potential positive spin-offs for recruitment and retention, should not be underestimated or discounted.

When Simon Stevens spoke on the BBC’s, Andrew Marr show recently, he was candid in saying that general practice has suffered from 10 years of under-investment. The RCGP has done a terrific job in making this argument and articulating a strong case for substantially increased investment in the infrastructure and in the general practice workforce. Whilst the burden of an elderly, co-morbid and increasingly dependent population is undoubtedly making general practice creak at the seams, it will be important in the future – in the very near future, given the shortage of doctors wishing to become general practitioners – to look at how other professions can support the central role of GPs in delivering primary medical care. It will also be crucial for general practice to forge alliances with other parts of the health service and, when this is in the best interests of patient care, to collaborate, as well as lead, in new systems of integrated care likely to provide the best clinical outcomes.

A letter to the Health Secretary

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

LETTER TO THE HEALTH SECRETARY

Dear Mr Hunt,

Many congratulations on being re-appointed as Secretary of State for Health in the Conservative cabinet. May I suggest we treat your re-appointment as a fresh start?

As a gynaecology SHO performing intimate examinations I was once told to ‘go in like a butterfly and come out like a lion.’ The idea was to cause minimum discomfort by combining a gentle approach with a swift withdrawal. This was not a strategy you adopted when you began your intimate examination of the NHS in 2012. It did in fact feel quite rough and quite prolonged. This time around perhaps you could be a little more gentle with your ideas and re-organisations and, when we finally get a period of stability, come out like a lion and stop meddling.

On many occasions you have talked of ending a culture of bullying within the health service and yet have yourself employed a beatings-will-continue-until-morale-improves attitude when dealing with its staff and this has endeared you to few. Attempting to bully the allied health professions of the NHS to fall into line with your ideas has not won you many friends.

For years NHS staff have hardly been able to turn on an NHS computer terminal without being greeted by your semi-psychotic stare and oddly geometric haircut as your picture has headed the endless bulletins and memoranda that spew forth from the Department of Health. Whilst producing a new edict may feel like a good days work to you, for those of us receiving it, it feels like an imposition, an interference and the promise of much more work for very little gain.

The smoke and mirrors re-organisations of the health care system that health ministers like yourself are fond of, the kind that generate a lot of activity, a rebranding or two and an apparent improvement in outcomes, actually distract from the business of treating patients.

Please remember too that the health care system is just that, a system for delivering health care. It is not a government tool to be used to address whatever national woes are troubling the electorate at any given moment. The NHS is not a branch of the benefits system nor is it an outpost of the immigration service.

Please dispense with ethically barren ideas such as denying benefits to people who refuse treatment for obesity. Doctors, nurses and other NHS staff should not feel obliged to coerce patients into treatments for purely financial reasons. Ideas such as this are eye catching and superficially gratifying to our vindictive sides but are unethical and unworkable in reality.

Neither can GPs solve the problems with immigration. Whilst it may seem an appealing idea to catch unsuspecting illegal immigrants whilst they are at their most vulnerable, the point when they seek medical help, most GPs would be reluctant to guilefully dupe immigrants into believing they were going to be given treatment for their illnesses before gleefully slinging them into detention. Please resist the compulsion to medicalise problems that are essentially social and political.

No-one would say that the NHS is a perfect system, but it is a good system. There is work to be done and changes to be made but trying to force all of them through between election cycles is devastating to the day-to-day functioning of health care.

You may like to think of the NHS as a wild stallion galloping powerfully through the plains of the UK. To tame it you can tie it up, beat it and try to break its will. This might work but, at the end of it, your stallion will be damaged both inside and out. Or you can whisper to it, coax it to your will with gentle reason and calm debate, and together we can ride off into the sunset.
I wish you well in your second stint at the helm of the NHS, and I hope you will wish us well in return.

Yours sincerely.

The elephant in the room: how are we going to fund the NHS?

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

Last weekend The Times published a leading article which described the financial straitjacket in which the NHS finds itself, and suggested that the additional funding required to keep the service going should be found from sources outside general taxation. I wrote a letter supporting this view, pointing out that other healthcare systems, with perfectly respectable health outcomes, some better than ours, work on a combination or some variation of co-payment and insurance mechanisms. none of which, importantly, equate to privatisation.

I described this discussion as an elephant in the room – something that no one really wants to talk about and certainly won’t talk about in the run-up to the general election. I concluded by saying that I hoped the next government has the courage and gumption to bring into the open a discussion that everyone knows needs to take place, and which must take place if we are to preserve a national health service.

Extra money is going to be needed because the NHS is going to become increasingly expensive and there is going to be ever greater competition for money among government departments. A few years ago John Appleby, the chief economist at the Kings Fund, described three funding scenarios for the NHS – tepid, cold and arctic – and these three funding futures are reflected in Simon Stevens’ Five Year Forward View. Note that none of them are “comfortable” or “balmy”. It doesn’t require much detective work to read between some of the lines of this document to discern a lack of absolute certainty of the affordability of a publicly funded health system in the future. New models of integrated care may or may not turn out to be more cost-effective, but the NHS does not have a strong record on cost containment.

In my response to the Times leader I used the phrase “Those more able to pay for healthcare simply pay more”, and I don’t think that this is a bad mantra for the future of health funding in this country. It is consistent with social justice and I understand that there is some opinion poll evidence that it would not be an unpopular direction of travel for more affluent citizens. I think we have to tread carefully around the “free at the point of need” slogan – the NHS was never free – and we certainly would not wish to introduce a system in which health care providers need to see the colour of your money before treating you. It has been often said that the decency of a society can be judged by the way that it treats its most vulnerable and needy citizens. Requiring that the more fortunate members of our society make a greater contribution to the costs of health care could help to ensure that their less fortunate fellows continue to receive the care that they need.

NHS and astrology: GP with a special interest in witchcraft

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

When MP and member of the health select committee David Treddinick suggested that the NHS should offer astrology to its patients he was widely ridiculed. To me it seemed wildly unfair that this man was so heavily criticised for expressing his personal views. Although he has no experience in healthcare provision, and although he holds beliefs that are almost universally disparaged, I see this as absolutely no reason why he shouldn’t hold a position on the most influential health committee in the House of Commons. If I believed in earthly politics he is exactly the kind of man I would vote for.

To the best of my knowledge I am the only GP in the country who has a specialist interest in witchcraft. When I realised that my surgery stood at the intersection of two particularly propitious ley lines I could feel the Wicca spirits practically insisting that I undertake some rigorous further training in spell casting, crystal healing and blind optimism. Once my training was complete I began offering the service to my patients and, I must admit, I have now almost entirely moved away from traditional general practice.

It is easy to deride a service like mine as ‘hocus pocus’ but I have a long waiting list full of free thinking individuals. My patients include those clear minded people who know that the Illuminati are suppressing the truth that vitamins will cure cancer so that big pharma can continue to make money from pointless ‘medicines’, or other people who can see that the childhood vaccination programme is merely a fiendish government plot to stop our children dying.

Fortunately my waiting list is oddly self regulating. Curiously many of my patients seem to pass over to the next world despite my attentive ministrations. Whilst many in modern medicine would see the death of a patient as something of a failure, I tend to think of it as a referral onto secondary care. In fact, once my patients have passed over, I am able to hand their care over to my in house psychic who continues to soothe their chakras in the afterlife. Unfortunately a small fee has to be charged for this service.

This is supposed to be the era of evidence based medicine so how is it possible that the medical establishment wilfully ignores the evidence that thousands and thousands of people are willing to pay good money for these services? I may not have a double blinded, placebo controlled, randomised trial providing an evidence base for my treatments but I do have a pretty strong sense that there is more to this life than we currently understand and surely that is evidence enough to justify some NHS expenditure into the area?

So I applaud David Treddinick for his ideas and I am grateful that we still have strong input from politicians into our health service. Without it how would MPs be able to give a voice to people like myself at the highest levels of government and influence health policy accordingly? How else would we ever make the NHS provide such services as my own?

May the spirit of the mother goddess be with you all.

NHS and astrology: a morning zodiac clinic

Camera 360Tim Senior trained as a GP in Sheffield, and now works in Aboriginal and Torres Strait Islander Health in Australia. He is a Scorpio, whatever that means. He can be found tweeting from @timsenior

News reaches us from the UK Health Select Committee that one of their members has suggested that there’s a simple solution to the woes of the NHS in the UK: astrology.

Now, I’m as sceptical as the next doctor about how stars thousands of light-years away from Earth, that, with the trick of parallax error, suggested vague shapes to ancestors entertaining themselves on dark nights can influence the progress of little Maisy’s appendicitis.

That was before a recent clinic.  I saw just twelve patients…

The first patient was Michael Aries. “I feel a bit sheepish coming to see you,” he told me. He spoke for quite a while, but the story was quite woolly. I’m still not really sure what he wanted.

Darren Taurus told me that he’d been violently sick for the last few days, but was fine now, and needed a certificate for missing work for the last few days. I couldn’t disprove it, but I suspected it was all bull.

Maria Gemini brought her new (and very cute) babies, Christine and Sonia. They were doing well now, but at birth one looked big and healthy, the other small and pale. They’d probably never know about their twin-to-twin transfusion syndrome.

Melanie Cancer told me she was very unwell, and thought she might be about to die. We talked around this, neither of us wanting to mention the C-word… until I realised I’d misunderstood, and she was having to deal with a nasty case of crabs.

Bill Leo was a rather large man coming to see me with his young son, who said nothing but stared aggressively at me without blinking throughout the consultation. “The mane problem,” said the father, “is that school says he roars aggressively at the other children.”

“Ummm…,” I said, swallowing.

“He’s not aggressive. He’s a pussy cat at home. I think it’s just his pride….”

Theresa Virgo was an elderly nun, looking a little confused about a letter she had received from the practice. I had to check the guidelines before reassuring her that, no, on consideration she didn’t actually need to come for a PAP test.

Susanna Libra just had a scaly rash

Peter Scorpio had pancreatitis. I went through the causes in the textbook in my head, and the only one possible was the most memorable – a scorpion sting.

Jimmy Sagittarius had shooting pains in his chest, and had come clutching his X-Rays. The radiologist had helped me out with the diagnosis by putting a large arrow through his ribs.

Frank Capricorn was next. “You know what gets my goat?” he told me. ”The Nanny state. How the government think they can interfere with what I eat. Or drink.”

“Or smoke,” I added.

“Yes, well,” he said. “That too….” He paused. I raised my eyebrows. I could sense there was a “Butt…” coming.

Mitchell Aquarius was carrying quite a lot of water due to his congestive cardiac failure. His ankle oedema and his ascites were certainly a non-traditional, but highly effective way of bearing liquid, I thought to myself.

Penelope Pisces was Susanna Libra’s sister and had a similar rash. Perhaps it wasn’t just any old rash, but icthyosis.

At the end of the clinic, I just wish there had been a medical student with me, as I’d seen more signs in one clinic than I usually see in a month.

Of course it’s possible I made the whole thing up. Much like real astrology. Sadly, though, I didn’t make up the story about the politician believing astrology would help the NHS. That’s completely strange but true.

The NHS – ‘S’ is for Service not Slave

photoPeter Aird is a GP in Bridgwater, Somerset.

It’s a confusing time for the NHS. One minute there’s talk of if being ‘weaponised’ like some all consuming superhero, the next it’s being sent to bed with no supper for causing all those ‘avoidable deaths’.

It seems the NHS is not so much a service that is offered but rather a slave that is used – and abused – by those who would seek to master it for their own, often political ends. But it’s not just the politicians who behave like this. Nor is it only the pharmaceutical industry who use it to push their products beyond where there is a genuine need. We patients also use the NHS, arrogantly proclaim that it is ‘our NHS’ and demand it meets ‘our wants’ – in a manner which we deem appropriate and in a time scale we consider acceptable. It’s time we appreciated that the NHS is just that – a service that we are privileged to have offered to us, not a slave we own and can demand of what we will. Something of a completely different perspective is required.

It’s time to free the NHS.

Free it from political interference, pharmaceutical manipulation and unreasonable consumer demand. Free it to become the genuine service that we require – one that seeks to meet only the genuine health needs of the nation.

So what exactly will this emancipated NHS offer us? That is something that needs to be decided upon by guardians of the service – appointed because they are wise enough to see that there is a difference between what medicine can do and what medicine should do. They need to be clear headed enough to appreciate that advances in medicine have outstripped the capacity that exists to deliver healthcare, both in terms of finances and workforce, and as such decisions on what services will and won’t be offered have to be made.

Decisions do need to be made, but not because they are politically expedient or serve an individual’s self interest, but because wisdom dictates that they are so made. Not all such decisions will be popular but they need to be made, and accepted, none the less. Of course where inefficiency and poor practice exists there needs to be improvements but the fact remains that with the body of medical knowledge increasing exponentially, and more and more expensive treatments appearing on the market on a daily basis, it is simply no longer possible to know all their is to know, or fund all that could be funded. Finances are limited – as are the human resources within the NHS. Constant promises by our politicians and demands by its users of what the NHS will provide, along with often unwarranted criticism and blame when these impossible targets are not met has a human cost on those who try to do their best in an increasingly difficult workplace – a workplace that is threatening to become a battleground.

It’s true that the NHS is ‘not the Messiah’ we would perhaps like it to be, but neither is it ‘a very naughty boy’.* As Goldacre has said, I think you’ll find it a bit more complicated than that.

It seems to me that the fundamental problem lies in the fact that we as a society continue in search of the holy grail of eternal life – death must be avoided at all costs. And we have charged medicine with delivering this dream. So certain have we become that this is possible, that when death does rear its ugly, unwelcome head, the appropriate response so often becomes one of moral censure of those who failed to deliver the impossible.

When things go wrong, it seems, we are more comfortable attributing the problem to the moral failings of those who have tried to help, than the reality that death and suffering are part of the world we live in. And here is the irony of it all. By treating the NHS as our slave, demanding it deliver us from our inevitable death, we have made medicine our master and have become ourselves enslaved by it. By making the meaning of life the avoidance of death, we are in bondage to the health parameters that we have imposed upon our selves, even as we strive to impose them on others. As Augustine wrote:

What does it matter by what kind of death life is bought to an end? When man’s life is ended he does not have to die again. Among the daily chances of this life every man on earth is threatened in the same way by innumerable deaths, and it is uncertain which of them will come to him. And so the question is whether it is better to suffer once in dying or to fear them all in living.

*With apologies to Monty Python.