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Reflections on retirement 2: 35 years in the NHS

The NHS at 70

nhs70By the time I retire in September, if you include my years as a medical student and exclude my year abroad in Cambodia, I will have spent 35 years as part of the British National Health Service: exactly half the time it has been in existence.

What a privilege to have been able to serve in what I still believe to be one of the best health systems in the world. In a recent poll, readers of the BMJ voted “providing care based on need and free at the point of delivery” as the NHS’s greatest achievement in its 70 years (https://www.bmj.com/content/361/bmj.k2809). I fully agree. Having seen people in Cambodia die because they haven’t been able to access proper health care, and families go into irrecoverable debt to pay for worryingly poor hospital treatment, I am incredibly grateful for the care we receive from the nurses, doctors, cleaners, porters and all the other dedicated, hard-working staff I’ve had the privilege to work alongside.

“Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community” Aneurin Bevan. 

 

There are, of course, countless other achievements of our national health service:

  • General practice as the foundation of care
  • Limiting commercial influence on patient care
  • Pioneering evidence-based practice
  • A comprehensive childhood vaccination programme
  • Free contraception for all women

To name but a few.

As one commentator put it though, ‘perhaps the NHS’s greatest achievement is its sheer survival’. In spite of political interference, budget freezes, almost constant reorganisations, rising public demand, and media criticism, the people who make up the NHS continue to offer a great service.

 

Survival and change

In the years that I’ve known it, the NHS has changed. Gone (I trust) are those days of traipsing down a ward with my fellow medical students in the wake of an arrogant surgeon who would then proceed to humiliate both us as students and the patients under his (invariably it was a he) care. Gone are those not-so-halcyon junior doctor days of being on call for upwards of 72 hours and struggling to keep our eyes open long enough to write out a prescription or calculate the fluid requirements of one of our patients. Gone (to a large extent) are those days of treating patients according to a consultant’s whim rather than following protocols based on sound evidence.

lancelot spratt

 

But I wonder whether, with some of that, we have also lost something of the heart of the NHS? Of the camaraderie of those evenings on call, where we would linger with the nurses over a cup of hot chocolate on the children’s ward; of the small cottage hospitals where everyone called each other by their first name; of the sense of fulfilment when you had cared for a patient right through from their initial clerking in the emergency department to writing (by hand) their discharge letter as they walked out once more happy and healthy; of the art as well as the science of medicine?

Who knows?

Whatever the changes, and whatever may lie ahead for the NHS, as I retire from it, I feel incredibly proud and grateful to have been a part of what it is.

 

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Presenteeism and the culture of indispensability

After stepping down from my clinical work in November, I received a lovely card from one of my patients thanking me for being his doctor and expressing his hope that ‘my new doctor will be as nice as you’.  Six weeks on, and we are no closer to finding a replacement, nice or otherwise!  So, while I don’t regret cutting back on my work and dropping my clinics, I do feel both saddened and frustrated: my decision is leaving my patients unsupported, my colleagues stretched, and my secretary struggling to troubleshoot and keep things ticking over.  I knew this was a possible, perhaps even likely scenario, but inevitably I feel some responsibility for that.

And yet, I am not indispensable.

 

Why doctors don’t take sick leave

bmj cover sick leaveA leader in this week’s BMJ highlighted how doctors tend to have much lower sickness absence rates than other healthcare workers (typically 1-1.5% compared to 4-5% for all healthcare staff).  There are many reasons why this might be so, but one of the most significant ones is a culture in which doctors avoid taking time off sick so as not to let others down – whether their patients or their colleagues.  This is admirable to a degree, and yet it betrays a deeper, potentially destructive culture of indispensability.  We have a tendency to believe that the service won’t function without us.  That, in turn, feeds a driven-ness that leads to long hours, apparent busyness and a kind of bizarre pride in always being overstretched.

This isn’t limited to doctors but seems to be a culture that pervades all professions.

It seems to me that this is an inherently dangerous and damaging culture.  Clare Gerada, medical director of the Practitioner Health Programme, commented that

“a common personal impact on doctors who are ill is that what goes isn’t their competence, it’s their compassion for patients”

 

Being overstretched

I suspect the same is true, not just for doctors who are ill, but for all of us when we are overstretched.  We can carry on performing our roles, but find it hard to offer that human touch: something that has perhaps been reflected in some of the scandals in care homes for the elderly and vulnerable adults in recent years.

I suspect that another element that goes by the board when we are overstretched is humility.  When we are constantly struggling to get things done it becomes increasingly difficult to acknowledge our own limitations, to take time to reflect, to learn and improve, to accept our need of others.  And ultimately, to recognise and value the very real contributions that we, uniquely, bring.

Ultimately what goes is also competence, though typically this comes some way down the line.  The reality though is that a driven culture of indispensability threatens effective working and patient safety.  I still remember the feeling, half way through a 104 hour shift as a junior doctor, sitting at a nursing station to calculate a drug dose, and realising that I couldn’t even think straight enough to carry out a simple 2-digit addition without the aid of a calculator, and recognising just how easily I could make a potentially fatal mistake.

That is why I am supportive of my junior doctor colleagues in their dispute with the government over a new contract.  The proposed industrial action is not just about pay – I would find it difficult to defend if it were – but about patient safety, and about challenging this pervasive culture with all its inherent dangers.

 

Challenging the culture

And I, too, will continue to challenge it, in my small way, by attempting to live and work in a way that isn’t indispensable.  I know I will continue to feel some responsibility for the gaps created by my cutting down my hours.  But I know, too, that since doing so I have felt more motivated and inspired, and been able to give myself more fully to those aspects of my work which are continuing.  I hope, ultimately, that will be of far greater benefit to my colleagues and to the children and families I am seeking to serve.