December Focus

David Jewell

IT is increasingly hard to work out what passes for thinking in the Department of Health. Last month it announced the intention of opening walk-in centres (WICs) in mainline and underground train stations. Implicitly acknowledging that WICs are limited in what they can do when staffed by nurses alone, it also announced that doctors would be available at certain times, thereby ensuring that dealing with existing shortages of primary care doctors in our major cities will be accorded lower priority than staffing glitzy WICs. Whatever else is known, the current research is clear that WICs are not addressing the problem of social inequality and access. Encouraging people to squeeze in a consultation between getting off a train and reaching the office trivialises any notion of health. Besides, what is the Department thinking of when it plans a major investment to address the health needs of people who have already decided they are well enough to go to work?

On page 891 Iona Heath lambasts the Department over the plan to introduce ‘medical care practitioners’, accusing it of debasing both the language and its own historic role. She fears that this amounts to a tacit admission of its failure to provide proper medical care to the most needy, deprived communities. The existing failure is clearly set out in the paper on page 894, showing how the uneven distribution of doctors across England and Wales has not improved in the last few years. In contrast, the distribution of informal care that people provide freely to their families, friends, and neighbours is shown on page 899 to be strongly and positively associated with need. Julian Tudor Hart's leader on page 890 is a tirade against the idea that market solutions can be an answer to such problems, rather than the major cause. The same opinion is reflected in the review on page 967 of Allyson Pollock's book.

The lay public proved vital to the success of the study on page 914 working on a method to identify unmet needs in older people. In the discussion, the authors state that ‘unmet needs are fewer than expected …’, which should both relieve general practitioners of some guilt and encourage them to take on the task. Older people also may use the services more rationally than we sometimes think: the best predictor of consulting was a measure of physical ill-health (page 928). Then on page 932, we are reminded of the limitations of some of the labels we use to characterise patients' problems. Where knee problems are concerned, the symptoms may be much better predictors of disability than the apparently objective measures of disease severity — but then we have known for many years that using labels can be a tricky affair.

A careful longitudinal study of the records of patients in the Netherlands diagnosed with functional somatic symptoms showed how such patients tended to have higher rates of consultations with symptoms in different body systems for some time before the diagnosis was made. ‘The condition may … reflect a greater propensity to complain; however … patients with chronic functional somatic symptoms also have more reason to complain.’ Labelling also seems to be one of the problems underlying the difficulties of providing terminal care to patients who are dying of cardiorespiratory disease (page 909). Compared with patients dying of malignant disease they received less palliative medication, but were less likely to have a terminal phase of illness identified. The editorial on page 892 explores the reasons for this difficulty, but also suggests ways to improve the care we provide for such patients and their carers, starting with a more open attitude when discussing prognosis (see page 904).

The opening of this column revealed once again the regrettable preoccupation with matters in the United Kingdom (UK). However, we are not the only country in the world to illustrate such insular attitudes. On page 966 John Frey offers a useful guide to non-US citizens who are both perplexed and dismayed by last month's re-election of George Bush as president of the US, but offers few crumbs of comfort. Finally, although many doctors in the UK will welcome the demise of night work, a few, like Emyr Gravell (and myself), will regret its passing (page 976).