Choice remarks

James Willis

doi:10.3399/bjgp08X319891

‘I've been a bit rough,’ said my brave friend when I arrived. I suppose I should call her an elderly friend, at 85, but actually she isn't elderly at all. ‘I had to call the ambulance on Friday.’

The ambulance?'

‘Well, my catheter blocked again so I rang the ‘Twilight Nurse’ and, can you believe, she was in (she named a town)! So, if I was in pain, which of course I was, she said I'd have to ring the ambulance.’

I had only a vague idea where the town she mentioned was but she said she sometimes drove there and it took her 45 minutes. (I have checked this now with Google Maps — ‘18.6 miles — about 41 minutes’)

Anyway, as luck would have it the block had begun to clear just as the ambulance arrived. She apologised to the crewman and he was extremely nice as he came in to complete his forms. He was used to it, he said, they got a dozen calls for blocked catheters every day. Not that it would have been ‘in his remit’ to do anything other than take her to casualty.

‘Not in his REMIT!’ my friend spat out in disgust, ‘even though I've got all the equipment, and the instructions! I could have done it MYSELF, if I could see what I was doing!’

‘So,’ she continued, ‘that would have been another hour,’ (it has been a long, long saga and she knows about this better than anyone), ‘and then the nurses in casualty wouldn't have been allowed to do anything either, and they would have had to wait, with me in agony, until the urological nurse came on at 9 O'clock.’

Which story reminded me of another: I had been on duty for the Saturday and Sunday of a bank holiday weekend when I got a call at that dreaded hour just before hand-over on the Monday morning. My family were all ready for our eagerly-awaited day-out, not quite at the stage of tapping their feet at the door.

The call was to a village about 4 miles away and although it sounded like a catheter on the phone I took a silly chance and went straight there without calling at the health centre for a catheter pack first. And of course I got it wrong and had to go back for the pack and then go all the way back out again to do it.

The actual deed, it has to be said, was accomplished in far less time than it took the aforementioned amiable but impotent ambulance man to complete his paperwork, although it has remained, until now, essentially unrecorded.

These two stories are separated by not much more than a decade but they exemplify a fundamental change, which I believe is all to do with Responsibility.

Before the political/managerial takeover of clinical responsibility which began on 1 April 1990, all aspects of the medical care of our patients were our legitimate concern. We would not have tolerated a travesty in which huge areas of the country were madly crisscrossed by solitary frontline workers, whose non-clinical seniors worked office hours and progressively hemmed in their modus operandi with ever-more-restrictive ‘remits’. We would have seen the manifest instability of the current situation, with its prospect of ambulance and casualty services inevitably putting up barriers like everyone else, as a problem we had to address. It was that overriding responsibility to our patients, that ultimate independence from officialdom, that immunity from absurdly irrelevant political slogans such as the current preoccupation with ‘choice’, which defined our role as doctors.

Sitting here, writing in amazing comfort 3 days after a laparoscopic herniorrhaphy, I am highly conscious of the technical excellence of the modern NHS; the treatment I have had could scarcely have been bettered anywhere in the world. And the friend I mentioned earlier has, I happen to know, a particularly excellent and personally-engaged GP. But there remain issues in the NHS which are profoundly worrying, and if we should ever choose to see them as not part of our professional responsibility, it may be that we should also choose a name for ourselves which is not doctor.