Category Archives: Medication

There have been bacteria on this planet for at least the last 3.5 billion years. For the entirety of our species’ existence we have relied on bacteria to aid us in breaking down food, whilst being helpless to guard against their wrath whenever we had a bacterial infection. It wasn’t until the late 19th century that more powerful microscopes lead us to understand what bacteria were and how the infections spread, in what was known at the time as ‘germ theory.’

Understanding how bacteria made people unwell led us to greatly improve hygiene; with large government programmes to build sanitation systems, doctors started to wash their hands and utensils, and people started to drink clean water. These changes, along with other medical innovation, lead to dramatic improvements in people’s health: in 1900 one in every 125 Americans were killed every year by infection and life expectancy was just 46; by 1941, it had risen to 65 and the number of people dying annually from infections had fallen to just one in 500. It was in this year that humans finally took the upper hand in our battle to stave of infection, when a research team in Oxford demonstrated how penicillin can cure bacterial infections. By 1955 just one in every 1670 Americans were killed by infections annually (the rate has plateaued since then).

Over the next few decades, antibiotics transformed modern medicine, not only allowing us to treat people who had bacterial infections, but also creating a safety net for other areas of medicine. Doctors can now treat other illnesses through surgery or by using drugs that have the unfortunate side effect of greatly lower immune systems (such as chemotherapy), with the knowledge that if someone picks up a bacterial infection, it can be treated.

Sadly, however, this was not the end of the story. Every time bacteria come into contact with antibiotics there is the possibility that through a process of natural selection, they may evolve to evade the drugs, creating what is referred to as ‘superbugs’. These superbugs can often not be killed by antibiotics. They have altered their membranes so the antibiotic cannot get into their cell, developed efflux pumps to remove the antibiotic from their system or learned to make enzymes that break down the antibiotic. In the early years of antibiotic development researchers were able to come up with enough new antibiotics to replace the ones that we had lost to resistance, but this is no longer the case. There has not been a new class of antibiotic able to treat gram-negative bacteria since the 1980s. This has led to a slowly-building crisis that kills 58,000 neonates in India every year and about 1.5 million people globally. If we do not start to take robust action against superbugs, then we are looking at returning to an era where bacteria are once again a major killer for which there is no cure.

In our recent book Superbugs: An Arms Race Against Bacteria,’ Will Hall, Jim O’Neill, and I look at the scientific, economic, and political failures that have led us to the point where antibiotics are ceasing to work, examine what will happen if we fail to act, before outlining the policy interventions that we think are required to keep us ahead in this vital arms race. In short, we need to new antibiotics to replace those lost to resistance; but more importantly we need to slow down the rise of resistance by preventing people from becoming sick, having better prescription practices when people become ill, and stop the environmental pollution from agriculture and manufacturing that sees antibiotics pumped into the environment.

All of these problems are held back by market failures. In order to prevent the rise of resistance, public health officials often rightly try to limit the sales of new antibiotics – the more valuable a drug the stronger the impulse to protect it is likely to be. This is problematic because innovators make greater returns the more of their product they sell though their patent system, which uses price and volume as a proxy for societal value. We need a new system for rewarding antibiotic producers that incentivise new drugs without encouraging companies to oversell.

Sanitation systems need to be improved in almost all low and many middle-income countries, so that people stop becoming sick. When we prevent illness then people will not need antibiotics. For example, at the moment, 1.7 million children die annually from diarrhoea or pneumonia, and research indicates that simply by getting people access to soap we could more than half this number. This is not just a problem in resource-constrained environments: in the US, research suggests that while 68% of people wash their hands after going to the toilet, only 5% did so thoroughly enough to remove all the bacteria on their hands.

Finally, with diagnostics and pollution we need to find ways of getting decision makers to internalise the societal benefits that accrue from good antibiotic stewardship. Regulation or taxation should be used to stop the environmental pollution of antibiotics. Rapid diagnostics can greatly improve prescriber practices, but there is a lack of investment into this area, and often when these diagnostics exist they end up costing more than the antibiotics, and so people do not use them. This means we are ignoring the societal benefit of using diagnostics to keep resistance at bay.

First published by the British Politics and Policy blog

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Did you know there are a group of 7,000 UK health professionals whose employer has spent 7 years, and who knows how much money, preventing them from gaining an independent voice at work?

What if I told you that part of this situation involves an entity, which is supposed to represent workers, that has signed an agreement with management committing to only “collective bargain” resources for their own officials and committing not to collective bargain for the employment terms of their members?

This is what happened at Boots when the company signed an agreement with the “Boots Pharmacists Association” (BPA) in 2012 and in law this is enough to block an independent trade union, the PDA Union, from following the statutory process for recognition at that employer.

The BPA is on the certification officer’s list of trade unions, but it is not independent. BPA was refused a certificate of independence in 2013. Part of the certification officer’s decision said: “looking at the picture as a whole that there emerges, in my judgement, a clear image of a union that has over the years been drawn into a situation in which it is indeed liable to interference by Boots… tending towards domination or control.”.

Boots is the largest and most well-known community pharmacy business in the UK. The multi-billion pound global enterprise is a vertically integrated business profiting from both wholesale and retail sales of medicines, with much of that coming from the taxpayer via the NHS. The company has tried “everything” to block their employed pharmacists from getting independent representation and that includes the blocking agreement signed in secret with BPA at a time the company was simultaneously talking to PDA Union about statutory recognition.

The good news is that the pharmacists have never given up and last summer six pharmacists, supported by PDA Union, applied to the Central Arbitration Committee to have the Boots-BPA agreement ended. Over 1,000 more employees pledged online to support the application, and after a further legal hearing at which the company and BPA’s joint attempt to give votes to senior managers (if they are a registered pharmacist) was overcome, a ballot is about to be held of almost 7,000 pharmacists working in Boots stores to end the blocking agreement.

The law under which this ballot is happening has never been used before in any sector and the union must achieve 40% of those eligible to vote, to vote in support, hence their #2780pharmacists campaign hashtag.

Ballot papers go out from 10 May and must be returned by 23 May in order to be counted. Anyone interested in supporting the PDA Union and their members can help by spreading the word about this historic trade union campaign.

  • Paul Day, National Officer, PDA Union @the_pda_union
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The mass majority of couples will eventually want to take their relationship to a whole new level. This will involve getting married, moving in with one another and having a child together. Sadly, a lot of couples will face great difficulty when attempting to get pregnant. The couple will need to visit their primary doctor together to find the source of the problem. While the blame is often placed on the female, it is also important to remember that men can also suffer from infertility problems. In fact, there are fertility pills for men and women. Once the problem has been diagnosed, your doctor will be able to choose a fertility medication that can help rectify your problem. If you’re looking for the most effective fertility drug why not visit your local Fertility clinic in London, to get all of the answers you’re looking for.

Below, you will discover some of the most common fertility pills on the market and their overall effectiveness.

Dostinex

Women can suffer from a wide variety of problems, which will leave them unable to conceive. If it is determined that you’re suffering from excessive levels of prolactin, your doctor may decide to treat the problem with Dostinex. This medication is commonly used to lower the levels of prolactin in the body. It can be used by men and women. Women that suffer from excess prolactin in their body will often create unwanted break milk and they may also miss their periods. The latter problem can directly lead to difficulty getting pregnant.

By lowering your prolactin levels with Dostinex, it may be possible to normalize your periods and encourage your body to get pregnant naturally. Once you’ve met with your primary physician, you will be provided with instructions and a dosage. The medication will then be consumed by mouth at least once or twice a week. The benefits delivered will be maximized, if the medication is consumed regularly.

The potential side effects of Dostinex include vomiting, constipation, dizziness, and lethargy. Nonetheless, these side effects are rare and most patients will never experience them.

Femara

A lot of women, who suffer from infertility, will discover that their problem stems from ovulation problems. There are various fertility medications that may be able to help rectify this problem with Femara being one of the most common. In fact, Femara just happens to be one of the most frequently purchased medications from Fertility Drugs Online. This drug is taken orally and it has proven numerous times to be effective for aiding women, who suffer from ovulation problems. The medication is also used frequently to treat a few specific types of breast cancer.

Femara is an effective solution, because it can help to induce ovulation, while simultaneously encouraging the female body to release multiple eggs. The medication works by increasing the body’s production of FSH or follicle stimulating hormone. The effectiveness of Femara depends on the patient’s age, the condition of their fallopian tubes and their partner’s sperm quality. Nonetheless, it has been proven to be very effective for treating women under the age of 35.

Zoladex

Cancer is undeniably a very frightening condition. Even worse is the fact that cancer treatments tend to lead to a wide variety of negative side effects, including infertility. Many women that contract breast cancer will immediately become concerned with their ability to get pregnant and have a child. Chemotherapy and other cancer treatments can make it very difficult for the female to conceive. In fact, these treatments can sometimes cause temporary infertility.

Recent research has shown that Zoladex may be able to preserve fertility for women going through chemotherapy. Women that consume Zoladex before undergoing chemotherapy and surgery are much less likely to suffer from infertility, after the chemotherapy treatments has concluded. If you are forced to undergo cancer treatments and want to increase your chances of getting pregnant in the future, you should ultimately speak to your primary physician about Zoladex.

Clomiphene Citrate

After a quick checkup with your doctor, it may be determined that your body has been unable to release a mature egg. If this is the case, you should not panic immediately. There are various fertility medications that can help promote the growth and release of a health egg. Your doctor may decide that you’re a prime candidate for Clomiphene Citrate. This medication is commonly used by women experiencing infertility problems. The pills will help increase the hormones in the female body, while also supporting the development and release of a mature egg.

While the medication is generally considered to be very effective, it should not be used by woman that have ovaries no longer capable of producing eggs properly. This fertility medication is taken by mouth and should not be consumed in more than 6 cycles. Never consume Clomiphene Citrate more frequently than recommended by your doctor. Finally, you may be instructed to keep records of your body temperature and also perform ovulation tests. This will help your doctor determine whether or not the medication is working as intended.

Ovidrel

Depending on the diagnosis by your doctor, it may be determined that you’ve been unable to conceive, due to a lack of hCG or human choriogonadotropin alfa. This will prove to be a big problem, since this specific hormone is responsible for causing the eggs to mature and be released by the body. Nonetheless, there are numerous fertility medications that may be able to help you overcome this problem. If you’re not afraid of needles, you should consider asking your doctor about Ovidrel. In general, this medication comes in pre-filled syringes.

The syringes will include the hCG hormone in an injectable form. This medication must be injected and cannot be consumed by mouth. The syringes will contain a single dosage, so this will make it somewhat easier to administer. While this fertility drug medication is considered very effective and safe, it should not be used by anyone who has an allergic reaction to Mannitol, Sodium hydroxide, or L-methionine. Those with cancer or primary ovarian failure should also avoid this specific medication. If you’re unsure whether or not Ovidrel will be effective for you, it is time to speak with your primary doctor.

Lupron

Those suffering from endometriosis will sometimes be prescribed with Lupron. This medication is capable of effectively treating this ailment, because it can drastically decrease the levels of estrogen in your body. Lupron is often used in conjunction with IVF. The Lupron is capable of shutting down the normal functions of the female reproductive home system. From there, the patient will be provided with some type of drug capable of stimulating the growth of FSH. Just remember that ovulation cannot occur naturally while the patient is consuming Lupron.

Therefore, it is generally used as an aid for IVF.

Follistim AQ

When most people think of infertility, they immediately link the issue to the female. What these people are missing is the fact that men suffer from infertility issues, just like women, even though the occurrences are not as common. One example of fertility pills for women is Follistim AQ, but many fertility specialists will also prescribe this drug to men. Follistim AQ has proven to be very effective in treating low sperm count that is linked to a hormonal imbalance. It is not unusual for a man suffering from poor sperm quality to be prescribed the drug, as well. Each case is unique, so the decision is totally left up to the fertility specialist.

Follistim AQ is not a suitable choice for men with primary testicular failure or women with primary ovarian failure. The specialist will need to determine the genuine cause of the infertility, before prescribing this drug to a male or female patient.

Menopur

When a female is partaking in the assisted reproductive technology (ART) program, they will often be prescribed Menopur. This fertility drug consists of various types of hormones, which will stimulate the ovaries to produce an egg. Menopur is used in conjunction with human chorionic gonadotropin, since it can cause the egg to be released from the ovary. Menopur offers many benefits, with the main one being that it can be taken at home. The drug comes in a vile and must be injected into the subcutaneous injection. Many women will undergo training to learn how to administer the drug properly, but the process is extremely easy, so it will not take long to learn the skill.

Pregnyl

Pregnyl is a chorionic gonadotropin utilized to treat infertility in females, before the onset of menopause. The drug is also utilized in males with testicular development problems, especially those between the ages of 4 and 9. Pregnyl is a hormone that is capable of stimulating the cells found in the testicles that are responsible for producing androgen. It can also stimulate the cells in the ovaries, so they will begin to produce progesterone. Pregnyl can be administered in a clinical setting or at home after undergoing a training course.

A common side effect that is linked to Pregnyl is multiple births. If you have any questions about the changes and risks of a multiple birth, you should speak with the fertility specialist, before agreeing to undergo this type of treatment. Other potential side effects include headache, fatigue, nausea, irritability, restlessness and bruising and redness at the injection site. You can place a cold towel on the injection site to reduce the edema, pain and redness.

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According to the Centers for Disease Control and Prevention there are over 52 million adults living with some form of arthritic disorder. Most of these individuals are forced to rely on a daily multi-dose nonsteroidal anti-inflammatory drug (NSAID). These drugs are highly known for their side effects, which can range from extreme fatigue to the development of peptic ulcers. Believe it or not, there are other options out there that are much safer and may or may not include prescription or over-the-counter NSAIDs. Below, you will discover more information on this topic, so you can start living and enjoying your life pain free.

Routine Exercise

Many individuals suffering from arthritic disorders will just give up on living. The main reason for this is because they are forced to endure a fair amount of pain 24-hours a day. The pain may also cause them to avoid physical activity, because they are afraid that it will enhance the pain and inflammation. This is a huge misconception that will on hinder your ability to enjoy your life. Walking, water aerobics, and biking are wonderful strengthening exercises that will help reduce markers of inflammation, which is the root of your pain. Palmitoylethanolamide (Palmidrol) is a safer alternative to harmful NSAIDs.

arthritic hands Nonsteroidal Anti-Inflammatory

Acupuncture

Cortisol is a natural chemical or hormone produced in the adrenal glands. Cortisol’s main function is to increase blood glucose levels, which in turn will suppress the immune system and force the body to burn more body fat. Individuals exhibiting high levels of pain will have higher levels of cortisol than individuals living pain-free. The production of cortisol will increase in high-stress situations, which is why it is so important to keep your stress levels to a minimum. Acupuncture is a very effective alternative to expensive prescription drugs such as steroids, because it can decrease edema and inflammation. However, acupuncture is not classified as an immunosuppressant, even though it can be a favorable anti-inflammatory. Taking Palmidrol with routine acupuncture injection therapy will be great start to getting back to your normal self.

Chiropractic Therapy

Many arthritis suffers will head straight to their physician’s office, when they develop an onset of inflammation. Did you know that you might potentially receive more benefits from chiropractic therapy than prescription drugs? Many opioid pain relievers are highly addictive and they only mask the pain, without treating the underlying problem. Chiropractic therapy does not involve prescription pain medication, but it does help to eliminate muscle spasms, inflammation, and pain. The chiropractor will also encourage you to utilize cold and heat treatments before and after each therapy session. By combining these two treatments, you will be able to return to normalcy in just a matter of time.

Physical Therapy

If you are a long-term arthritis suffer, you have probably been sitting in that recliner for an extremely long time. Getting back on your feet will be challenging and nearly impossible without the assistance of a licensed physical therapist. This professional will provide you with educational and training techniques that will help reduce your pain level and aid in poor condition recovery. When combining physical therapy with Palmidrol, you will be back on your feet in no time at all.

Lose Weight

It should be pretty obvious that being overweight can put more stress on your joints. If you are experiencing arthritis the extra weight is only going to apply more pressure on the entire musculoskeletal system. This is especially true for the hips, knees, and ankle regions. Loosing a little bit of weight can go a long way to making you feel better, reducing your pain, and getting your healthier.

Less weight on your joints will allow you to move are easier, feel less pain when moving, and stop you from further damaging your joints.

Using Electricity To Help With Arthritis

Most people aren’t aware of the fact that electricity can also be used to aid in reducing arthritis pain. In fact, electrical stimulators have been used ever since the 1960s to aid in pain relief. Of course, new advances and discoveries have made since then. Physical therapists will often times use what is known as a transcutaneous electrostimulation (TENS) to aid in swelling and pain relief around the arthritic area. Basically, the process just involves placing electrodes around the joint that is affected with arthritis and delivering a few electromagnetic pulses.

Some individuals are also turning to a new form of acupuncture known as electroacupunture. This form of acupuncture just basically involves adding a little electricity to the acupuncture needles. Whichever method you might decide to go with, you will be happy to know that both have shown evidence of short-term pain relief and easing of stiffness in the infected joints.

Assistive Devices That Can Aid In Arthritis Pain

There are a variety of devices that you can aid in your daily struggle of arthritic pain. Some of these devices include shoe inserts, splints, braces, and canes. All of these devices can help take pain off the infected area and redistribute it. These devices will also prevent you from damaging the infected area any further than it is already damaged. It is recommended to speak with your physician, before starting any of the above treatment options. Your physician may recommend continuing your current medication regimen, but you can also inquire about these methods, just to get an idea if they will effectively work in your favor.

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The excellent Clare Gerada, Chair of the Royal College of GPs is calling for a brave and honest debate about rationing medicine.  According to GP magasine two thirds of GPs think that the NHS should stop providing free prescriptions for drugs that are available over the counter.  Generally stuff like Calpol which you can buy without a prescription is cheap, less than the £7.65 prescription charge we have to pay in England.  So it seems unlikely that requests for this stuff are coming from the people who have to pay charges.  Only a small minority of prescriptions attract a charge  – and none at all in Scotland, Wales or Northern Ireland.  So some of these requests may be coming from people who really have trouble finding small sums for medication.

Honest debate about rationing medicine

Child taking medicine

Gordon Brown was talking about abolishing prescription charges in England in 2008, and we investigated the options.  Prescription charges were imposed in 1952 as a rather primitive form of rationing.  Apart from the free prescriptions for the poor, the old and the young there is a list of medical conditions which entitle a patient to free prescriptions – because in 1968 when prescriptions were reintroduced by the Wilson government there was life saving long term medication for those conditions.  The list hasn’t been revised since.   As the charges tend to deter people just above the level which qualifies them for free prescriptions from taking all their medication there is a downside.  Some of those people will end up in hospital because they don’t take their medication.

Rationing healthcare is universal and inevitable.  The only question is how it should be done. Asking people to pay at the time they need treatment is agreed to be the worst possible way of doing it.

Dr Gerada has often called for decisions about rationing to be made by politicians, not doctors.  We haven’t seen a rush of politicians stepping up to make proposals about what should be rationed or how.  The NHS reforms introduced by this government are designed to insulate politicians as far as possible from unpleasant decisions of this kind.  In reality it’s probably better for most of these decisions to be made in the consulting room than in Whitehall.  The introduction of Clinical Commissioning Groups does seem to have had beneficial effects in many areas, because it’s forcing GPs to look at each other’s practise and see where money could be saved.

Perhaps the price doctors should ask in return for taking responsibility for rationing decision is that prescription charges should be abolished in England. Then the discussions in the consulting room need not be complicated by considerations about charges.

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The National Health Service (NHS) Act was promised in the Labour landslide election of 1945, passed into law in 1946, and the service itself launched in 1948: a non-contributory comprehensive service making all forms of medical, dental and nursing care, in hospitals or in the community, available free to the whole population, paid entirely from central government funding. I qualified from St. George’s Hospital in London four years later, and will retire from full-time clinical practice in 1988; the NHS allowed me to do my own work and refer my patients to the full range of specialist services during an entire working lifetime, without ever having to collect a fee. Several generations of British doctors have followed, with essentially the same historically novel experience.

We have come a long way since then; there have been huge changes in the work and effectiveness of medical care, and exponential growth in medical science which will require even bigger changes in the future. If advances in medical science are to be available for all of the people, the principles on which the NHS was founded must be both restored from their present shorn condition, and extended in entirely new directions. The NHS is under attack as never before, its enemies confident that medical care can again become a commodity on the market, many of its former friends confused and capitulating. The whole world has entered a dangerous time, perhaps most dangerous of all in our own destabilizing society.

Some Illustrative Autobiography

All history must be selective, and therefore judgmental. Its contemporary actors, by living through one set of experiences, are denied others. Like everyone else, my assumptions derive from my own background, experience, the books that I read and the books I avoided, and my readers deserve to be warned what these were.

I was what Americans call a ‘red diaper child’, my mother in the Labour Party, my father in the Communist Party, our home among other things a transit camp for anti-Fascist refugees from Austria, Germany and Italy. Both my parents were doctors, my father a GP recruited by the South Wales Miners’ Federation to help them in a dispute with general practitioners in Llanelli (a redleg?) who later went off to Spain as a surgeon for the International Brigades. Unlike most medical students in 1947, I knew exactly what I wanted to do before I left school; to become a general practitioner in a coal-mining community, because to me that was the highest possible ambition. Like others of that immediately post-war generation, I also felt unjustly spared. My survival was, quite possibly, accidental. Had I been born one year sooner, I might have died in the war, and therefore felt permanently bound not merely to enjoy the peace, but to win and defend it; and not just any peace, but precisely the peace that was won at that time, against Fascism and for a new era of the Common Man, as we still said in those days.

After qualifying in 1952 and disenchanted with teaching hospitals, I sought ‘real life’ as a House Physician at Kettering General Hospital in the East Midlands, just as general practitioner (GP) surgeons in provincial hospitals were beginning to be replaced by professionals. All routine and much emergency surgery in Kettering had always been done by GPs, helped once a week by a part-time consultant who travelled 100 miles by rail from London. About six months previously, one of the GP-surgeons had been presented with a young woman with acute intestinal obstruction, a condition easily reversed by early surgery but otherwise rapidly fatal. He opened the abdomen, to find multiple obstructions by scarring from Crohn’s disease. He excised four or five segments at several points along the seven metres of small intestine, leaving the loose ends to be reconnected. Then his troubles began; which end belonged to which? Never having met this unusual condition before, he had waded into the macaroni without planning his return. In those days emergency surgery was still regarded by patients as a gamble with death. If he had confidently reconnected the tubes as best he could, praying he hadn’t created any collisions, dead ends, or inner circles, he would probably have been acclaimed whatever the outcome. Being a man of integrity, he persuaded his GP-anaesthetist colleague to keep the patient unconscious for what turned out to be four hours with a small coppice of metal clamps splayed out from the incision, telephoned the London consultant, and waited for him to come up by the next train to sort it all out. Remarkably, the patient survived. It was the last anecdote of a closing era of GP surgery; the professionals put an end to all that, and not before time.

The General Hospital served two distinct catchment areas: on one hand, the pleasant market towns of Kettering and Wellingborough and their surrounding countryside, with deeply rooted populations of middling provincial gentlefolk and workers in farms, breweries, railways, shops and light industry; on the other, the steel manufacturing town of Corby, with a population largely imported from Glasgow. From Kettering we had people generally at an early stage of illness, with helpful, informative letters from their GPs, who often visited the wards or at least telephoned to see how their patients were getting on, and made use of the x-ray department and laboratory to investigate patients themselves before referral. From Corby we received patients with gross end-stage disease, and hastily scribbled notes from their GPs:

Dear doctor,

Billy  Briggs,  22 Tipslag Terrace, Corby ? acute abdomen (or chest, heart, or whatever), please admit.

Yrs etc.

Hearts sank when requests for admission came from Corby. They were usually about some medical crisis, often avoidable by earlier diagnosis and appropriate action. The Corby and Kettering GPs seemed to work, as their patients lived, in different worlds. It was my first introduction to the divisions of medicine corresponding to the two nations of British society.

My boss was a bachelor who ran an Austin-Healey sports car, and endlessly complained to his junior staff about his poverty and sufferings under the NHS. I earned £250 a year looking after 20 men, 20 women and 16 children on acute medical wards, on call 24 hours a day, without right to any evenings or weekends off for six months except those personally wheedled from the boss. We differed about the NHS: he believed it would end enterprise and reward sloth, I thought it was the best thing that could have happened for the future of medicine. When he went off for the weekend he would fix me with his pale blue eye: ‘Hart: when I come back on Monday I don’t want to find the beds filled with rubbish. Old men with chronic bronchitis belong in Local Authority Part III accommodation, not this hospital.’ Some old man living alone with advanced smoker’s lung was sure to tip into pneumonia, and his GP, rightly acting as advocate, would press for admission. Though squalid dormitory geriatric accommodation did exist under Part III of the Insurance Act in what had been the Kettering workhouse, it was not bad enough to deter a queue to get in. The real choices were between solitary death at home, or a hospital bed with warm nursing, antibiotics (all requiring injection in 1952), and a good chance of recovery. That was my introduction to contradictions between what doctors were interested in and what mattered to patients.

I asked for a reference at the end of my six months, which read as follows: ‘Dr Hart has performed his duties as a House Physician adequately during the past six months.’ At the time this seemed faint praise, but only later did I realise it conveyed the same lethal message to any experienced medical employer as Hamlet’s note on his journey with Rosencrantz and Guildenstern; my introduction to the 18th Century structure of servility and patronage endured by all doctors for some of their lives, and by many for all of their lives.

My junior hospital career was therefore on course for self-destruct, postponed for a few more months by a consultant chest physician who persuaded me to work for him as registrar at the Watford Chest Clinic on the outskirts of London, dealing almost entirely with tuberculosis, then still a common cause of death. I was not properly trained for such respon­sibility, but the previous man in the job was an alcoholic with drug problems, and no other applicant could be found. The clinic was responsible for tuberculosis patients on the wards of a local hospital which had been a workhouse until 1948. The workhouse master and matron still lived in an elegant residence within the walls, waited on by high-grade mentally defective or so-called morally defective inmates. The barrack-complex contained geriatric and chest wards for sick people, as well as dormitory accommodation for the workhouse inmates who, though liberated by repeal of the Poor Law and advent of the Welfare State, had nowhere else to go. Men lived at one end of the building, women at the other. Most were old people without either money or relatives able to look after them, but there were also mentally or physically handicapped younger people, and several young homeless families. Young or old, married, widowed, or single, males over seven years of age were separated from females except at strictly enforced visiting times.  The work was interesting but uncomfortable, not because of the Dickensian surroundings but because I knew I was under-trained. Sink or swim, I learned as I went along; I swam, patients sank.

Just before the lethal reference could catch up with me, I was saved and diverted prematurely into general practice in the wrong place. At the end of 1952 I was chatting to an old Irish GP, Dr Henry Blaker, in a corner dairy in North Kensington. He had retired from a lifetime of work for the Indian Medical Service in Calcutta, to buy a practice from an old colleague, Dr Sweeney, in the slums of North Kensington, with about 2,000 registered patients. His sight was failing from cataracts and he was no longer able to drive, doing his home visits on foot or on the underground. On hearing I was a Cambridge graduate, a fact which impressed him more than me, he asked me to join him as an equal partner starting tomorrow. Only later did I realize how exceptionally just he was; then even more than now entry into general practice, or into almost any other medical job, was difficult, and many established GPs took full advantage of this to exploit their younger colleagues with grossly unequal partnership contracts. Postgraduate experience before starting practice was still an optional extra generally reserved for entry into ‘practices of the better type’. North Kensington was Corby not Kettering country, and even the scanty hospital experience I had seemed much more than my local colleagues expected. Under personal pressures which are irrelevant here, I took the job.

Urban Industrial General Practice in the 1950s

The surgery was in what had been a large corner pub in Clarendon Road, off Holland Park. The area is now gentrified beyond recognition, full of media persons and croupiers at the Stock Exchange, but then it was the edge of one of the worst slums in London, stretching from the bottom of Notting Hill in the south, to Harrow Road and the Grand Union Canal in the north. The pub was all elaborately decorated plaster cornices, frosted glass, and engraved mirrors still advertising various ales, stouts, porters and whiskys. Dr Blaker’s surgery was in the saloon bar, the waiting room in a narrow adjoining room previously used for off-licence sales. It was nearly always full of people waiting to get in, often with more standing in the street, sometimes in the rain. Patients entered the consulting room at one corner, stepped down from the raised area previously behind the bar counter, and sat in front of an enormous oak desk covered with wooden boxes, books, urine test glassware, and unopened copies of the British Medical Journal. When I eventually sorted this out, I found one of the boxes contained a full set of equipment for post-mortem examination, with bone saws and knives of every size and description. A small working area of desk was cleared in front of the doctor’s swivel chair. Behind him was a threadbare printed fabric screen, folded and apparently rarely used. Behind this again was a low divan couch covered in American cloth and stuffed with horsehair, much of it bursting out through ulcers and abrasions acquired in forty or fifty years of combat. On the wall to his right was a large white semicircular washbasin with a single brass cold water tap, an amenity added a few months previously; Dr Blaker warned me not to pee in it, as some previous locums had done. Next to this was a metal stand with a china bowl and ewer, now redundant but, like the junk on the desk, kept on standby in case the 19th Century returned, a not unlikely event to any thoughtful observer. This time-warped impression was strengthened by a glass fronted cup­board set in the wall of the waiting room, still full of dusty medicine bottles waiting to be collected by patients whose names could still just be made out on the elegantly scripted labels. Apparently Dr Sweeney had done his own dispensing, and when the practice finally gave up competing with the local pharmacy this cupboard was simply locked and left as it stood!

There was no receptionist, so patients’ medical records, the small pocket envelopes devised in 1916 for the Lloyd George Act and still used by nine out of ten English GPs, were housed to the left of the great oak desk in a nest of wooden drawers. Virtually the only entries ever made were of medicines prescribed, but occasionally there would be a brief diagnosis (‘asthma’, ‘fractured femur’, ‘neurotic’) without any of the evidence on which the diagnosis was based. Useful clinical information, if any, was confined to hospital correspondence, folded and pushed into the record envelope in a more or less randomly ordered and increasingly tattered bundle.

Twenty to thirty patients came each morning, about the same number in the evening, and between these two sessions I was supposed to fit in about 15 house calls. There were nearly always two or three visits left to do after the evening session, together with any late calls. I would finish by 7.30 if I was lucky, by 9.00 if I was not. I did all the night work for that first year.

One year to the day after I started, without warning or discussion, I found a note from Dr Blaker on the desk to say he had retired and the practice was mine. I took a partner of my own age and we built up the practice to about 3,000 when I left in 1957 to resume my interrupted hospital train­ing, this time on the children’s wards at Hammersmith Hospital. Workload steadily fell, reduced by good practice organization, employing a receptionist and dealing with the underlying causes of such clinical problems as were soluble, rather than sidestepping them with symptomatic treatment. When I left the practice, we often saw only ten or twelve patients at each session, despite a much larger population at risk.

South Wales in the 1960s

After another three years of junior hospital posts and some experience of epidemiological research, first with Richard Doll and later with Archie Cochrane, in 1961 I finally reached my original goal, a single-handed general practice in a small coal-mining community in the Afan Valley in South Wales. The daily consulting rate in Glyncorrwg was roughly the same as when I started in London: 20 to 30 patients at the morning session, the same in the evening, 12 to 15 home visits, for about the same number of people at risk. The time available for each consultation was 5 or 6 minutes, slightly more than was found in a large study of practices in Aberdeen ten years later, (Buchan,   I.C.,   Richardson,  I.M.,   ‘Time study  of consultations in general practice’. Scottish Health Studies no. 27. Edinburgh: Scottish Home & Health Department, 1973.)  but less than the average 8.25 minutes found in the most recent survey of GP workload in 1986. (‘Survey   of  GPs’  workload’,  British  Medical  Journal  1987,  294:1241.) Unlike my London experience, improved practice organization had little effect on workload; the reserve of unmet need seemed inexhaustible.

The squalid conditions of industrial working-class practice I met, first in London and later in South Wales, were incompatible with the standards of clinical medicine taught in medical schools, denying self-respect and limiting the imaginations of GP and patient alike. They were essentially the same as those pilloried by Collings(Collings, J.S.,  ‘General practice in England  today’,  Lancet 1950,i:555-85) in his classic report in 1950 on British general practice. Thirty-four years later Eric Wilkes, Professor of general practice in Sheffield, described the same squalor in 1984 in a despairing paper entitled ‘Is good general practice possible?’ (Wilkes, E., ‘Is good  general  practice possible?’,  British Medical Journal 1984; 289:85-6.) . British general practice has changed in my lifetime, but very unevenly and very incompletely. It has changed least of all in the old areas of heavy industry, where the real wealth of this country was originally made, and where poverty and unemployment are now most miserably endured.

General Practitioner and Referred Care

Having worked a lifetime in general practice, that is the point from which I see the NHS as a whole, and the people it serves; a close underview from where the action begins, rather than an overview from hospital specialism where some of it ends, or from the outer space of a university library.

To an extent unique in Western Europe and North America, the British medical profession is and has for well over 50 years been divided into two easily defined groups, with little overlap: GPs responsible for registered lists of patients, who care for them only in their own homes and communities; and consultant specialists responsible for all hospital work, assisted by young doctors in training (most of whom later become GPs), who only see patients on referral from GPs. GPs therefore remain generalists, whose real specialized skills are based on familiarity with a specific local population. All other levels of the NHS rest on general practice; the quality, efficiency, and effectiveness of specialists are limited not only by the resources made available to them by the State, but also by the quality and completeness of GP care.

The National Health Service created, and was designed to create, a dramatic improvement in both the extent and the quality of care by specialists in hospitals. It also suddenly extended GP care from the minority of male manual workers covered by the old Lloyd George Insurance Act, to the entire population. It vastly increased the accessibility of general practice but did nothing, and was not designed to do any­thing, to improve its quality. Clinical medicine in British general practice did improve between 1948 and 1967 (the first important structural reform of NHS general practice), but not at anything like its pace of improvement in hospital care. Nor were improvements selective for those social and geographical areas most in need of them. In general, the quality of all medical care, and particularly of GP care, was lowest where the needs of the population were highest; what I later described as the Inverse Care Law. Neighbourhoods with the worst health inherited the worst traditions, expectations and resources, and were least competitive in the market for well-trained, innovative young doctors. General practice remains an area of relatively poor perform­ance, falling short even of its traditional task of meeting the immediate demands of patients for care of symptomatic illness; it is better, much better, than it was, but still far below what it should be. General practice is even now only beginning to accept its huge future potential for effective health conservation, through which its impact on the health of the general population could be greater than anything possible through specialist care in hospitals.

‘The Health Service is Hospitals

Most politicians, media persons, or members of the general public, asked for their mental picture of what is central, important, and effective in the NHS, will describe something going on in a hospital. For most people, hospitals appear to be virtually the only source of effective treatment for life-threatening or seriously disabling conditions; the job of GPs is to sort out major from minor conditions, referring major ones to specialists in hospitals, dealing with minor ones them­selves. Planned government investment in hospitals through­out the land, in their staff, equipment, and buildings, with demand from the whole population limited only by the process of GP referral, was the great leap forward which made the NHS such a huge public success.

Until 1967, there was virtually no investment at all in general practitioner services, except what GPs themselves were prepared to spend from their own pockets. The 1966 Package Deal (also known as the GP Charter) brought some indirect public investment in the form of 70% reimbursement of wages to encourage employment of office and nursing staff, 100% reimbursement of rent for suitable buildings, and incentive payments for group practice. Eventually this almost wiped out two common features of industrial general practice; the seedy front-parlour surgery in the GP’s own home, and the squalid shop on the high street with a half-painted glass front, staffed only by a harassed GP’s wife. It reduced the proportion of GPs working single-handed from 43% in 1952, to only 14% by 1980. This did not always improve access for patients, but did encourage sharing of staff and equipment, and placed some limit on the idiosyncratic behaviour of GPs. Even this investment was not fully taken up. GPs are now entitled to claim 70% reimbursement of office and nursing staff wages up to two Whole-Time-Equivalent (WTE) staff for each GP. For the past ten years the actual number employed has stuck around 1.1-1.2 WTE per GP, and only about 15% employ their full entitlement; (Hart’ J T , ‘Practice nurses: an under-used resource’, British Medical ‘ Journal, 1986, 290:1162-3.)most GPs evidently don’t think they need a larger team.

The most important feature of public investment in general practice, however, is that it is neither planned nor plannable. Though GPs now accept some public investment, they are not publicly accountable, except in the narrow and negative sense that they are answerable for complaints. General practice has for seldom-considered historical reasons become a public service privately administered. GPs are independent contractors with government, to provide a public service on their own initiative, with little public control, all of it negative. Even within the narrow limits set by the maximum resources available through the present GP contract, quality of service depends on autonomous decisions by GPs.

Imagine the state of our national road network, if it were financed by a multitude of turnpikes, the quality of each stretch depending on local owners and local expectations; a few miles of motorway, suddenly replaced by a three-lane A road, then a narrow, rutted, unpaved lane, then another mile of motorway, and so on, each depending on the interest and integrity of its owner. It would be an inherently corrupt situation, since whatever he spent on his stretch of road he would be unable to spend on himself or his family. It would be cheap, and occasionally charming, but ineffective as a transport system. For the same reasons, general practice is  also cheap, occasionally charming, and, if its task is so far as possible to maintain the health of the whole population, ineffective.

1935-1970: An Age of Optimism

Aneurin Bevan‘s bold nationalization and expansion of hospitals coincided with a worldwide wave of optimism about the effectiveness of medical science, and the feasibility of delivering it to all of the people.

The 35 years from the discovery of sulphonamides in 1935, the first antibiotics suitable for mass use by non-specialist doctors, were a golden age of uncritical faith in the social value of applied medical science. This began to collapse around 1970, with a general mood of radical criticism among young people, together with the beginnings of doubt and retreat from the commitments of the Welfare State and the social contract built on the double victory of 1945, the war and the Labour landslide election. Criticism of medical activity at all levels, focused particularly on high technology care in hospitals, has persisted ever since, both from ‘Left’ and from ‘Right’ perspectives.

Source of figures: Derived from Registrar General’s Decennial Supplement, England & Wales 1931, and Registrar General’s Statistical Review of England & Wales, various years. Figures reproduced from ‘Disorders which shorten life’, OHE 1966, by kind permission of the Office of Health Economics, London.

Fig 1-1  Maternal  mortality,   death  rate 1860-1964, England and Wales.

Maternal Mortality 1860-1964

Note: (1) Ten year averages 1861 to 1890, five year averages 1891 to 1930, annual rates 1931 to 1964. (2) Logarithmic scale.

Fig. 1.2 Pneumonia, death rate per million males living, by age, 1861-1964, England and Wales.

Pneumonia death rates 1861-1964

Note:   (1)   Females rates are similar and in order to facilitate graphic presentation are not shown.

Ten year averages 1861 to 1930, annual rates 1931 to 1964. Logarithmic scale.

There is little doubt about the starting date for this era, which more than most historic turning points derived from precise technical as well as less easily defined social and political change. Dramatic effects on valid indicators of disease susceptible to sulphonamide treatment are shown in Fig. 1.1 for death-rates of women in childbirth (maternal mortality), (Loudon, I.,  ‘Puerperal fever, the streptococcus, the sulphonamides,  911-1945’,   British   Medical  Journal   1987;   295:485-490) and in Fig. 1.2 for death-rates from pneumonia in young men.

Clearly something dramatic happened in the mid-1930s to two common causes of premature death, but it is important to remember that this advance in effective treatment occurred against a background of steady improvement in death rates from all causes, which seems to have started around 1870 (Fig. 1.3), with full industrialization of the British economy, and the beginning of intensive rather than extensive exploita­tion of industrial workers. This improvement in health was probably caused mainly by improved nutrition, education, and housing, and by reduced occupational risks (in that order of importance), all of which have bigger effects on health than personal medical care.(McKeown, T., The role of medicine, Oxford: Blackwell, 1979.)

Fig 1.3 Death rates per million living from all  causes,  by age,   1841-1964, England and Wales.

Death rates 1841-1964
Note:   (1)   Five year averages 1841 to 1960, annual rates 1961 to 1964. (2)   Logarithmic scale.

 Fig. 1.4  Diphtheria. Child death rates per million; England and Wales 1931-60.

Diptheria deaths in children 1931-60

Source: Registrar General’s Statistical Review, Part I. Figure repro­duced from ‘The lives of our children: a study in childhood mortality’, OHE 1962, by kind permission of the Office of Health Economics, London.

It is equally important to remember that advances in medical science only lead to improvements in health to the extent that they are generally applied; sulphonamides did not save women in childbirth or young men with pneumonia unless doctors prescribed them. On the other hand, sulphonamides were toxic in high dosage, and a lot of damage was done by doctors who used them inappropriately or carelessly. This is obvious, but seems to have been ignored both by pre-war Ministers of Health and by practising doctors. Fig. 1.4 shows deaths of children from diphtheria from 1931 to 1961. Clearly there was a dramatic improvement in 1941; an effective diphtheria vaccine had been commercially available from about 1922, but was not applied as an organized programme for mass immunization to the whole child popula­tion until nearly 20 years later.

The NHS is a social construct, whose advance or decline depends on social ideas and competing social pressures. Advances in medical science like the discovery of diphtheria vaccine are not automatically applied to the general popula­tion. The age of optimism in medicine was just one part of a general period of post-war liberal illusion, which denied the value or necessity of social struggle, and imagined that a classless society could be painlessly achieved by ‘levelling up’ in a consumerist, capitalist and corporate nation. That kind of liberal optimism died in Vietnam. It has been replaced by strategies of retreat, the subject of the next chapter.

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