One Medicine

I picked this up on a whim at Hay literature festival. Only short, so it can be read in a day or so. The premise is an interesting one – the idea that human and animal medicine have a huge overlap and adaptations animals have made to the world around them have a huge application in human medicine. 

The first half of the book seemed to stray a little from the core premise of the book to me and at times it was a little self indulgent, dare I say a bit melodramatic. But there is almost a palpable shift half way through (almost from dusk till dawnesque) in which the book really begins to delve into interesting medical trivia and genuinely intriguing information concerning the overlaps in animal and human physiology. When it does return to the more personal storytelling at the end, the melodrama is gone and the closing thoughts are genuinely quite moving.

Blood and Guts: A Short History of Medicine

Lovely book this. It takes the reader through a couple of millennia of medicine and the way it was practised in a concise and well written way. The illustrations add to the effect and it’s as good a book one might find on the subject. Really enjoyed it. 

Health in the UK – an updated reflection

I was speaking to an elderly patient last week, well into their 90s, who was frail, unwell and needed some attention. Throughout the conversation, they could not stop apologising for, in their words ‘wasting my time’ as they knew how busy we all were. The conversation left me quite emotional if I’m honest, not least because that very same day I lost count of the number of appointment requests we received from, for example, people who had woken up with a bit of a raspy throat, or who had been congested and coughing from a cold or chest infection for the last week. The contrast in perspective of what the role of the health service should be could not have been sharper.

The average number of times an adult saw their GP in 2015 was seven times a year. Twenty years prior to that it was Three times a year. Much of the increase is related to an increase in chronic disease with which GPs must contend. But it also seems that the threshold with which patients seek help from their doctors, even in the face of headlines about how overwhelmed the NHS is, has lowered. The average adult will get two or three colds a year (the number is higher for children at eight or even more) and at no time is that something a GP needs to see. Yet GP surgeries are inundated with people suffering from sinus infections, colds and chest infections, the vast majority of which are caused by viruses and which will get better eventually on their own. Crucially there is nothing a GP can do to treat these infections. Antibiotics do not work against viruses. The natural course of these infections tends to be an initial sore throat and/or fever followed by congestion, coughing and fatigue. Often people will say the cough has gone to their chest. It seems to be a common misconception that this is the time to go and see a GP whereas it simply means the virus is either a bronchitis, effecting an area a bit lower down in the respiratory tract or even that the congestion is beginning to loosen and the virus us on the road to recovery. Granted the viruses are bad at the moment. Having endured a bit of down time during the social distancing prompted by covid, our bodies are a little less resilient to them and so they are more severe and last a bit longer. Three weeks is not uncommon. That still makes no difference ultimately in how we manage them.

Flu is also causing problems for much the same reason. Flu is also a virus and the vast majority of cases require rest, fluids and will get better on their own. Severe flu can be more serious and so if you are breathless at rest, really drowsy or unable to get enough fluid on board to stay hydrated, then contact your GP. Otherwise, no it’s not nice, no you probably won’t get out of bed for a few days, yes you’ll have a high fever, yes you’ll feel achy and tired but you don’t need to automatically contact your GP and you certainly don’t need antibiotics.

If you are at all worried, your first step should be to look at the NHS website. If you are not sure having looked at that, your next port of call is the pharmacy. Only after that should you consider contacting the GP surgery.

Part of the demand issue at the moment has been the Strep A outbreak which has understandably caused some concern, particularly for parents of school age children. Of course if you are concerned that this may be effecting your child, of course contact your GP but please do apply some common sense. There are lots of viruses that cause similar symptoms but if they develop the characteristic rash and red tongue should you call the GP.

GPs are commonly faced with demands for antibiotics from patients and surveys have shown that a majority have felt pressured into prescribing them even when they know they will do no good.  Clearly it is inappropriate for patients to come in with such demands, but we as clinicians must take some of the blame. The truth is, in a busy hectic day (and they really are non-stop), sometimes the easy thing for a GP to do is to give someone an antibiotic. All that does is increase the number of people that come in for antibiotics the following year whilst adding to the already huge problem of antibiotic resistance – a calamity hiding in plain sight.

There are many things that need addressing in the NHS at the moment. Nurse to patient ratios on hospital wards have been unsafe for a long time. In the UK there are 2.8 doctors to every 1,000 patients compared with 3.7 per 1,000 in comparable EU nations. The population is ageing and the increase in prevalence of chronic issues such as diabetes, obesity, alcohol and substance abuse, heart disease and mental health mean that as people age, they do so with a high level of morbidity. In other words, people are less healthy. This necessitates a lot more GP and nursing time as they care for ever more complex patients as they spill over from hospitals and secondary care. One study showed that around 40% of all GP appointments are accounted for by just 10% of patients. This has doubled in the last 20 years.

Most of these people really do require that care but there is a proportion of patients that access health services entirely inappropriately and put extra strain on the system as a result.

As healthcare professionals we want to help people. But when it isn’t possible and moreover, when it starts to impact upon other people who are far more in need or our help – the person who is unwell with cancer, the person who’s been having symptoms preluding a heart attack, the person who is suicidal, the elderly in need of support and care – that is when it becomes more than a little frustrating from our side of things. When people start taking liberties with a health system that is on its knees, the system falls apart. Those who shout loudest are not always the ones who need help.

With that I wanted to end with a couple of suggestions. I won’t get involved in the political aspects. But there are two things that I think would make a huge difference to the pressures the service faces.  

At the moment, much of the focus is on more funding, more staff, more hospitals and greater infrastructure. While that is all important, it is only necessary because demand has gone up. If the demand was impossible to reduce any further then absolutely, focus everything on increasing supply. But of course demand is no way near that lower threshold.  

In the short term, reducing unnecessary utilization of the health service is something that could have a fairly immediate effect. Looking forwards, it is a case of empowering people to keep themselves healthier so that, even though the population is older, it is healthier and so requires less intensive input. It may seem simple and maybe even a little vague, but I have heard no better suggestion in the face of the ageing population.

As such, the following suggestions are the two key things I think we need to fight for in the face of the NHS crisis which deepens every year.

1 – Health and medicine as part of the school curriculum – while people need to know when it is not appropriate to access health care, it is at least as important for people to know when they should. There are lots of people out there who ignore health issues and do not get help when they need it. Education around health will also have invaluable longer-term benefits for a healthier and happier population.

2 – More aggressive action on the availability of food containing high levels of sugar and salt. Diabetes and heart disease along with obesity are chronic issues which are only getting worse. Shops lined with junk food are a feature only of the last few decades. Another example of the luxuries that we now take for granted but which have long been creating repercussions which affect us all, whether it be directly or indirectly.  

As we see yet another ‘winter crisis’, rather than wait for the next shake-up or the next cash injection from the powers that be, the best way to heal the NHS – perhaps the only way – is if we take some ownership of the problem ourselves rather than relying on someone else to heal it for us.

 

It was fairly obvious from the outset that this book was going to be biased. It felt consistently as if the author was trying to ‘sell’ biogerontology. This became even more blatant during the last chapter where he as good as admits the book was written to raise political pressure to push forwards the drive to ‘cure’ ageing altogether. While he has obviously done a lot of research into a field that is still significantly speculative and in its infancy, he comes across as almost fanatic at times, treating the subject as would a child with a toy. It is occasionally rambling. What concerns me the most however is the glaring absence of any discussion about the ethical effects on the world should ageing be successfully cured. That is but for a small paragraph near the end. He even includes a link to an extra chapter which goes into the ‘counter argument’. Perhaps he didn’t want to write this in his book because of the obvious role it would play in completely undermining everything he has written about. To leave this aspect out is hugely irresponsible and his comment that the net ethical benefit would so clearly be in favour of stopping us from ageing that it is not really worth including is utter nonsense. This is not a balanced popular science book no matter what it is marketed as. It is a sales pitch – propaganda. Don’t be fooled. And to be honest, it was a bit boring.

Extreme Medicine

This one missed the mark for me unfortunately. It markets itself as a book looking at how exploration transformed medicine and even has a polar explorer on the cover. I had envisaged exciting accounts of expeditions to dangerous corners of the earth in which people had to draw upon medicine to help them out. Think jungle medicine to treat gangrene or the account of a polar doctor having to perform his own appendectomy. In reality it mentions people like Scott  only in passing as a way to justify the title and then goes off in completely different directions. It lacks a focus, darting between different areas of medicine with basic text book-like physiology lessons alongside scattered and padded out anecdotes. The space bit towards the end is the only bit that really fits the bill but, for me, is only mildly interesting.

There are better books out there on exploration and medicine. This falls through the cracks of both. 

Breath

This was recommended to me, so I thought I should read it. It turned out to be very interesting. The author goes into all sorts of detail about breathing techniques, ancient and modern, all the while threading it together with his own experiment – for a week he breathes just through his mouth and another just through his nose. As might be expected, he feels rubbish after breathing just through the mouth but much better after the nose week. Sorry if I’ve ruined it for you there. 

The science seems well researched – although there is always that nagging feeling things have been cherry picked a bit – and there is some interesting stuff about the developed of our jaws etc but the take home message is fairly simplistic. Breathing is good for you and doing it through the nose is a bit better. An enjoyable read, accessible and interesting. 

Previously on Covid-19

As we approach June, I thought it might be a useful exercise to recap on the last few months. After all, there’s quite a lot that has happened and it’s been a bit of a blur thus far! Who knows what the next few months will hold but these are the key events from a Coronavirus point of view since it all began.


31 Dec 2019 – The Wuhan Municipal Health Commission reports a cluster of pneumonia cases in the Wuhan province of China.

8 Jan 2020 – Chinese scientists announce that they have found a new strain of coronavirus.

12 Jan – The genetic sequence of the new coronavirus known to be causing these new cases is released publicly by China. The virus is known as SARS-CoV-2.

13 Jan – the first official case outside of China is identified in Thailand.

30 Jan – There are now 98 confirmed cases in 18 other countries and the WHO declares a Public Health Emergency of International concern.

31st Jan – The first 2 cases are confirmed in the UK.

11 Feb – The disease caused by the virus is named as Covid-19 by the WHO.

5 March – The first confirmed UK death related to Covid-19 is reported.

11 March – Due to being “deeply concerned by both the alarming levels of spread and severity and by the alarming levels of infection” the WHO announce a pandemic. The 2011 film ‘Contagion’ begins trending on various streaming platforms.

12 March – The UK moves from the “contain” approach to what is referred to as the “delay” phase. This means that people with symptoms are no longer tested unless requiring admission to hospital.

16 March – The WHO advises “test, test, test”.

20 March – Schools, nurseries, restaurants and pubs all ordered to close.

21 March – The government shielding scheme started. This has caused some confusion, both then and now. Letters were initially sent by NHS England to those with features suggesting they were ultra vulnerable should they contract Covid-19; even more so than the vulnerable groups normally granted free flu jabs annually. These included those with organ transplants, undergoing active chemotherapy or with any immunosuppressive condition. Some letters were sent to people who did not need to be on the list while others who did need to be on the list were not initially identified as the data used to draw up the lists was from a national database. Subsequently, lists have been revised at a more local level. The letters advised shielded patients not to leave their houses at all if possible and offered information about local support agencies.

23 March – The government announces lockdown measures with advice that people stay at home, only leaving for one form of exercise a day, for work if absolutely necessary, to shop for essential items and to fulfil any medical and care needs.

2 April – Suspected Covid-19 hospital admissions peak in the UK at more than 3,400 in a single day.

3 April – Worldwide cases of Covid-19 pass 1 million.

5 April – It is announced that Boris Johnson has been admitted to hospital with Covid-19.

6 April – The Primeminister is moved to ICU.

10 April – The UK daily hospital death rate reaches its peak at 980 for cases involving Covid-19.

12 April – Mr Johnson is discharged from hospital.

20 April – The government furlough scheme officially comes into effect.

23 April – Testing begins on the vaccine developed at Oxford University which uses an inactivated adenovirus with an additional “spike” protein found on SARS-CoV-2 in the hope that the body will develop an immune response to this protein, thereby potentially providing some immunity to SARS-CoV-2 itself. (Due to the more recent drop off in cases, there have been some reports that the trial may struggle to get results because a sufficient number of participants will need to be exposed to the virus for it to be reasonably certain that the vaccine works.)

29 April – Official figures show UK deaths pass 26,000 as care homes deaths related to Covid-19 are included for the first time.

5 May – Doctors in France report that, having retested a swab taken on 27th December 2019 on a patient at a hospital near Paris (who had no recent travel history), Covid-19 had been identified. This has raised questions over how long the virus has really been in circulation.

13 May – It is announced that lockdown measures are to be eased somewhat. Members of the public are still to observe previous measures but are now able to take unlimited exercise, restart open air sports and meet one person from another household in the open as long as social distancing measures are observed.

14 May – Data are published that show A&E attendances for April were 0.9 million, down 57% on April 2019. While clearly a very large number of A&E attendances are unnecessary, this raised concerns over how many serious medical conditions may have gone untreated or undiagnosed as a result of people’s reluctance to attend.

20 May – The official figures show that there have been 250,908 confirmed positive Covid-19 cases in the UK to date and 36,042 deaths. Bear in mind the drawbacks of such statistics without a robust and extensive testing system in place.

22 May – Testing is finally rolled out again for those with symptoms and, theoretically, anyone above the age of 5 and with symptoms (which now include loss of taste or smell) can access either home testing kits or testing at one of the regional sites via the NHS website. (Not via your GP).
These tests are swabs and detect the presence of viral RNA on the mucosa and in the saliva and can tell whether there is current infection or not.
In order to detect whether one has had the virus at some point in the past and therefore probably has a level of immunity (although this is not yet proven), an antibody test is needed. There has been much talk of these, first mentioned by the government in March as being imminent. However, as yet, no antibody tests are available. Two tests (developed by Abbott and Roche) were validated by Public Health England on the 14th May and will apparently be used from next week to test NHS and care workers. These tests are available privately from various centres but people should be cautious about the results. For a start, it could take up to 28 days after the infection before the test can properly confirm if a person has had the virus. Secondly, as mentioned above, there is currently no telling how much immunity one gets from having had Covid-19 so, until this is better understood, the benefit of antibody testing is largely for community statistical purposes.

So there you have it. The story so far. The next few weeks will no doubt contribute to our ever expanding knowledge about the virus. It might be useful to mention at this point an app developed by Kings in London called ‘COVID Symptom Study’ that I would encourage everyone to download and fill in if you haven’t already.

The more we know, the better we can understand how best to open things up and prevent a slide back into a second peak. Data, for all their faults, are key. Testing is integral to this.

Thoughts on our Healthcare

“It is forecast that by 2030, the global consumption of antibiotics will rise by more than 30% (200% if it continues at current growth levels). By 2050, the annual death rate will have risen from 700,000 to 10 million with no action.”

 

It is a humbling situation when one realises how fragile we are in the face of nature and how little we really know in the battle to protect ourselves.

My generation have the unique honour of having grown up at a zenith of medical know-how. As a child, I often reassured myself that, if I or anyone I knew ever became unwell, everything would be fine. I always comforted myself that, should it be needed, there would be the medical expertise somewhere to cure anything. I was confident that the medical care and consensus behind every treatment was solid and complete; its efficiency spotless. Now I realise that this was simply a form of therapeutic self-delusion.

The truth is that, although our capabilities far exceed the wildest dreams of Hippocrates and Aristotle, we are far from perfect. What we don’t know far outweighs what we do. Treatments remain speculative, their quality reliant upon where we fall at any one time on the curves of demand and supply. Despite officious regulation, treatment remains highly subjective according to who treats you (bearing in mind this may be an exhausted doctor or nurse running on empty), and could still be based on faulty or unreliable evidence. We can’t guarantee a cure for your cancer and we can’t always tell for sure why you’re feeling so tired and achy, so sometimes we have to guess a bit.

Our exaggerated opinion of our own ability as a species extends beyond just medicine of course. While that can be catastrophic in other fields, it does at least provide some benefit in a healthcare setting. Confidence in physicians can be a therapy in itself. Despite what I have said, this trust is important and well placed. Though not perfect, we are better than nothing! And yet, when something like the Covid-19 pandemic hits – something so undeniably out of our control – it highlights those cracks that we’ve otherwise consciously chosen to ignore. 

What has struck me most about the Covid-19 pandemic is our reaction to it. While in some places it has highlighted tremendous courageous and community spirit, in others it has merely brought out human attributes that are the polar opposites of the aforementioned. For me, it has emphasised the prospect (and quite possibly the need) for fundamental change in how we utilise the medical expertise and the knowledge we have accumulated.

The meaning of ‘our NHS’ has become a bit warped in recent times. When someone has been treated with kindness and care, it is the NHS that gets the thanks. In reality, it is the people that work for the NHS who should be thanked as well as the organisation as a whole; a distinction that I feel too often gets overlooked. Obviously this is semantics and very often that is what people will mean when they praise the NHS. But in merging the two, a powerful message is being lost.

The people that work in healthcare, whether it be within or without an NHS, deserve all the praise they are getting. Likewise, the idea of a National Health Service that provides universal, comprehensive and free healthcare should also be praised. The problem is, at its inception in 1948, the idea of comprehensive healthcare is very different from what it is now.

In 1948, paracetamol was yet to become readily available, open heart surgery was 4 years old, statins had not yet been invented and antibiotics were in their infancy. Fast forward to the present day and we are seeing around 200 heart transplants a year in the UK, an entire pharmacy of medications available to us at our beck and call, lifesaving emergency services 24/7 and access to state of the art intensive monitoring equipment. Around half of the UK population takes at least one regular prescription medication. If your hips or knees go, you are entitled to have metal replacements inserted for no extra charge. If you have a rash, you can have it seen to or if you want your ingrowing toenail sorted, you can have it clipped or lopped off. If your ears are blocked, someone will clear that for you too.

With our population increasing and growing older, it is little wonder that the whole thing is beginning to creak. The outcome…? You have to wait a long time for your hip replacement, you might be denied the chance to have your bunions sorted out because it is a low funding priority. Your GP is running late by 20 minutes or even a bit longer. That may seem a bit insensitive or flippant (or both) but believe me, I’m not happy about it, certainly if it means people are waiting for treatments in agony. While some have a rational grip on such situations, others will not. Those are the ones that abuse the staff who are only trying their best in impossible circumstances.

Demand has far outstripped supply already. At current levels of funding, the promise of delivering a comprehensive service is no longer accurate. But that is only if we all agree on what counts as comprehensive.

We have been rather spoilt with the NHS, rather like a child who is given one sweet and then pleads for several more, never content with what they are given. The level at which our baselines have shifted (there is an actual concept know as shifting baselines syndrome that one could probably apply to much that is wrong with the world) is significant. Consider 100 years ago, antibiotics were non-existent, surgery was more dangerous than beneficial and not long before that there wasn’t even the luxury of an anaesthetic. Just read the 1810 diary account of Fanny Burney, the English novelist, who developed Breast cancer and underwent a mastectomy without anaesthetic to see what I mean.

Antibiotics and our use of them serve as a perfect microcosm to demonstrate my point. For all they have given us, they have also contributed to levels of antibiotic resistant infections that kill 700,000 people a year globally. Don’t get me wrong, antibiotics are great; a lifesaver in fact. Prior to their widespread utilisation, a cut or scratch could become infected to life threatening degrees and as such they have arguably become the single most important tool in our therapeutic arsenal (vaccination is arguably more important). And yet they have suffered a severe case of mission creep. They lend a hand in all sorts of unexpected ways. Caesarean-sections and routine hip replacements would be rather more hit and miss in terms of survival without them. Not content with saving lives, in fact they have become somewhat of a luxury, whether it be to shorten a cough or a bout of diarrhoea or to fatten up our animals so their meat is better.

In the UK, at least 20% of antibiotics prescribed in primary care are inappropriate (I would probably argue that figure is higher depending on your definition of inappropriate). At any one time, a third of patients in hospital are on an antibiotic. 

Resistant organisms transfer at will from one person to another, or to food and animals. As they do, we edge ever closer to a circumstance in which we are unable to treat them at all. There are already strains of TB and gonorrhoea that cannot be treated even by the antibiotics reserved as last resort.

The WHO cites antibiotic resistance as the biggest threat from global pandemic. Considering what is going on at the moment that should prick some ears.  Just as there are warnings about antibiotics, so there were for coronavirus. A pandemic such as the one we find ourselves in isn’t exactly a surprise and yet to a large extent, we have all been caught napping.  I liken it to sitting on a beach with a bag of popcorn, admiring the spectacle of a tsunami rolling in. Suffice to say, a tsunami of antibiotic resistance is far less palatable than the comparative swell of coronavirus we are seeing now.

It may therefore be time for some realism and some hard choices. This includes both those at the very highest levels but also, I’m afraid, for us all. Who knows in what shape we’ll emerge from the current saga.

In an ideal world, the government would pledge a suitable amount of money for the NHS to cater perfectly for everything from the largest and most severe of our medical needs down to the smallest and most trivial. Failing that, management of the entire system must get realistic and we must allow it to do so. No one wants to see a privatised NHS, (including the government if what they say is to be believed). Clarity of mission alongside acknowledgement of the problems– not spin – is what we need. Without this, whispers and rumours of privatisation will continue. If measures are to be painful, in my opinion telling people that is far better than trying to sneak it under their noses. Better still, a cross party approach in order to depoliticise proceedings is preferable so election success no longer rides on it. What we don’t want to see are more layers of management. Time and time again, we experience instructions from those at the top, far removed from the realities and often the progress we make is in spite of these targets instead of because of them. In any situation, the more layers you add, the more complex it becomes and the easier it is to trip over yourself. A bit like the game Tetris – a certain amount of blocks at the right speed will build something solid but as soon as the rate and number of bricks increases, it all runs away from you.

Just as importantly, perhaps even more so, is our individual role in all of this. As we clap our health workers every Thursday evening while in lockdown, perhaps take a moment to consider what we ask of them under normal circumstances. A large proportion of GP consultations are unnecessary and could be dealt with either by a pharmacist, or by the patient themselves. The NHS website has the information available if people were only to access it.

Between February and March, there has been a 22% fall in A&E attendances, many of would have been unnecessary anyway and would have taken up valuable resources and time.  General practice and outpatient secondary care has also seen a sharp drop in demand for routine enquiries. Many issues will have gone away on their own, or have been dealt with using online advice. Still more infections will have settled without antibiotics. We must harness this new way of using the health service.

This current situation may therefore serve as a not so gentle reminder of what are reasonable expectations in terms of our healthcare. That said, between early and late March, there has been a fall of 150 patients per day presenting with symptoms of heart attack. Now, it is unlikely that the Covid-19 pandemic has somehow cured heart disease altogether and though many people with chest pain turn out to be fine, there will be some within that cohort of 150 who have had real heart attacks; heart attacks that are currently going untreated.

Lack of presentation for this sort of thing, or indeed other worrying symptoms of things like cancer (loss of weight and appetite or a change in bowel habit to name just three), means the health impact of this pandemic will not be just related to Covid-19. For anyone with worrying symptoms like this, you absolutely must not ignore them just because of the outbreak.

We need to use the NHS sensibly. Not too much, but not too little. We have swung from one extreme to the other in the last few months. Once we emerge from this, we must all consider how best to use it going forwards, and focus on the bigger issues at hand, no doubt at a time of great change. Self-care is a big part of that, not just in how we deal with an acute medical situation but also in how we look after ourselves in general. Smoking alcohol, diet and exercise are the key areas that cost nothing to improve.

As a nation, our perspective in terms of the scope of our healthcare has run away from us. Some expect miracles – you don’t need to go to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash. Meanwhile, the threshold for others is far too high and there is a proportion of people that will hold off in coming to a doctor when they actually need to be seen.

As doctors we want to ensure that everyone who needs to be seen, and who we can help, presents to us appropriately. At the same time, we would request that others, who might reasonably be able to manage their own minor issues, do so. It is a fine balance and even writing this makes me uneasy that some may stay away for fear of overusing the service. The level of disparity in comprehension of how best to use the NHS is, in my experience, remarkable.

Nevertheless, I think we all could perhaps do with shifting our baselines back a hundred years or so. As doctors, we need to look at how we are using our resources and considering whether far more significant changes are necessary. Antibiotics use is just one example. Fundamental change at the top is needed to streamline the provision of healthcare and cut out the obfuscating bureaucracy. Difficult lines must be drawn. Leaders must consider taking more than half a glance at the deeper issues facing us – after-all from our current position, an antimicrobial resistant pandemic suddenly doesn’t sound as far-fetched as it did a few months ago. If that change is severe then so be it. Sometimes you have to go backwards to go forwards. In that case, we all have a responsibility to understand it and adapt, though politicians must realise that we cannot be expected to do that if left in the dark.

Urgent care must remain a priority for the service as a whole, but how we look after an ageing population effectively is just as vital. Prevention of health problems is key. One of the best ways to help therefore is to look after yourselves properly (we can only do so much in that respect) but also to seek help when appropriate in order to avert bigger health issues down the line. Staying away isn’t always the answer (particularly at the moment) although granted, there is a fine balance. That balance has always been upset one way or another and we all need to contribute in order to redress it. Now might be the time to set it straight.

 

 

 

 

 

 

The Body

Now I don’t want to sound bitter at all, but this was the book I had planned to write. Fortunately I got wind of it before planning got out of hand, but still…

Fair play though, Bill Bryson is a master at this sort of thing, and for someone not primarily medical it is a huge achievement. He has essentially taught himself a large proportion of medicine! This is a superbly written and researched book and I love all of the anecdotes and tidbits. Indeed his previous books had been an influence on my own writing in this respect. 

Despite the fact that it has diverted my future writing projects, I don’t mind. I’m glad he wrote it. I’m not bitter. Probably it is something everyone should read. I would even say it should be on the curriculum at schools. 

Healthcare After Covid-19

“Just as important as the government’s role in the NHS as it emerges from Covid-19 is the responsibility all of us have. We must shift our baselines back a hundred years – maybe more”


As a civilisation, humanity knows so much. To have in our arsenal an understanding of physics that includes relativity and all of its applications alongside our almost infinite artistic creativity is testament to our intelligence. These examples only scratch the surface of what we can do. So it is hugely humbling when we experience something like the Cvoid-19 pandemic.


As powerful as we are, we are still painfully fragile in the wider context – something we have a tendency to forget. It was not so long ago that we had to undergo operations without the luxury of anaesthetic and before antibiotics, we were faced with the rather uncivilised prospect of fighting infections using just our own immune systems.


Indeed, so uncivilised has the idea of being even slightly unwell become, that people now will seek medical help for a few days of cough and sore throat. The expectation for these worried well is that it is their right to expect an immediate cure. “Surely if we can do all of these marvellous things with technology, there is no disease we cannot sort out if we put our minds to it,” these people think. But these people are living in a different world, one of their own imagination. Others more prudent, sensible or experienced will realise that what we can do falls far short of this idealistic expectation.


We as a species go further. We harm ourselves willingly and then expect our medical professionals to pick up the pieces – even become angry when they can’t. Smoking, lack of exercise, poor diets – take your pick. That these things are bad for us there can be no question.


Of course one cannot wholly blame individuals for this. Capitalistic society is to blame here as much as anything. Profit and competition introduce temptation at the expense of welfare. I am not preaching socialism here – far from it. I simply point out that the drive for business to gain custom at any cost is a huge flaw in the system and in our health.


Whichever way one looks at it, we have become spoilt. Our perspectives on what we might expect from our healthcare have been shifted gradually but significantly over the last century. Only now are we being brought down to earth with a more humbling realisation; the thin facade of our supposedly advanced age has been withdrawn. There is even a name for this sort of thing – shifting baselines syndrome. It could be applied to many things. We have come to accept the nonsense and bile that comes from Donald Trump’s horrible little mouth as just the way it is these days. The baseline has shifted.


Just in the same way, many have been spoilt by the healthcare provision that they expect as a given. What we expect as a free benefit from our NHS nowadays (toe nail surgery, access to a GP to tell them about your cough, state of the art surgical procedures, cures for cancer and lifesaving emergency response within minutes) would have been the stuff of dreams for our ancestors. That the ever-expanding achievements of the last 50 years of medicine has caused the entire system to creek under its own weight is not surprising.


When I was younger, I reassured myself that if I or anyone I knew ever became unwell, it would be fine because there would always be someone somewhere that could cure whatever ailment had befallen them. My impression of medicine was that it was water-tight and so much more precise than the reality. A reality that slowly dawned on me during medical school. Much of it is guess work. Barely any treatment is 100% effective. What we don’t know far outweighs what we do know. The assumption is that there will always be a medicine to solve all problems. In a profession that revolves around trust in the doctor or nurse (a reassurance that can be therapeutic in itself) it is difficult sometimes for us to admit that we don’t have all the answers and can only do so much. Perhaps it is time we were more open with its limitations or else we make a rod for our own backs.
One might argue that what we now provide under its umbrella has gone far beyond the boundaries of what is sensible. To argue that we can effectively achieve 100% of what we aspire to medically is not possible. The issue is, the more superfluous and luxurious perks we add in, it edges out or at best blunts the core services that are most important.


At a time in which we are faced with something as dangerous and universal as Covid-19, we must heed a wake up call. The work the NHS is doing at the moment is what it is there for. Add to that health prevention, basic surgical treatments, mental health support, serious disease detection and treatment (including cancer), dignified end of life care, and social care.


Beyond the essentials, it is time for government to look at what the NHS really stands for and what it can really achieve. (Or preferably a cross party response to side step the political distractions). In an ideal world it would do everything to maximum efficiency. If a government wants to invest enough to make this possible, then great. The reality though means that the healthier a population is, the older it gets. Add to that the ever increasing scope of potential therapeutic options and one may argue that we could reach a point where a line must be drawn in how far we go in prolonging life. Should we become reliant of a system of health to such an extent (and perhaps we have already reached that point), the consequences of that system and it’s resources failing do not bear thinking about.


Governments need to look at this, decide where the line is drawn in what the NHS does and is expected to do. More importantly, they must be open about this. To back the NHS in a blind head long rush into the future, pledging vague sums of money that don’t make any sense to those in the know – none of this is helpful in any other way than to win elections. To acknowledge the need to be sensible about what is achievable and what is not seems difficult for politicians. Hence back room deals, rumours of privatisation etc. No one wants to see a privatised NHS. If the politicians are to be believed then they are included in this group, so why the cloak and daggers? The public deserve transparency and straight forward answers. Most understand that there is no definite right answer to a problem, even more so if it is explained to them. Without this, conspiracy and disquiet will breed.


Just as important as the government’s role in the NHS as it emerges from Covid-19 is the responsibility all of us have. We must shift our baselines back a hundred years – maybe more. This is urgent. Everyone must consider how we use our health service. That cough or rash that you might normally have seen your GP about – seems to have gone now doesn’t it?! That lack of exercise, my poor diet, that smoking habit – I can do something about that myself. No one else can help and we shouldn’t have to hold your hand. (Of course we do this and will continue to do so). Self care has been important during this lockdown. And yet, it shouldn’t be any more so now than any other time.


The problems with the health care system are clear. We all know about them. Covid-19 has affected us all and is scary. But perhaps it is the wakeup call that we all need.