Hard Times

Roger Jones

doi:10.3399/bjgp16X684421

One of the targets of Charles Dickens’ Hard Times is the 19th century equivalent of the bloodless, box-ticking bureaucracy that many people feel is now strangling the NHS. Mr Gradgrind demands facts, facts unadorned by sensitivities, emotions, or other human foibles. And facts we have — league tables, performance indicators, Care Quality Commission inspection scores, 2-week waiting time performance — facts coming out of our ears. Measuring the cost of everything and the value of practically nothing. Striking junior doctors march across the battlefield of British health care, weaving their way between closing GPs’ surgeries, the elderly, migrants, and refugees baffled by the complexity of the system, bankrupt hospital trusts, callous care homes, and a social fabric unable to support the loads placed upon it by the contraction of medical care. Love the NHS we might, but we are still struggling to provide health outcomes that match up to our European neighbours. Hard times indeed.

In a hard-hitting leading editorial, Dominic Patterson addresses the problems that doctors working under pressure are likely to encounter, writing that ‘In caring for patients in the environment of the NHS, doctors’ health is being damaged, and damaged doctors provide worse care for patients. For too long the needs of doctors with mental illness or addiction have been neglected.’ These problems have been repeatedly documented and, Patterson adds, there is no need for more evidence, no need for more discussion or debate. ‘It is time at last for a binding covenant of care to be drawn up between the NHS and its damaged doctors.’

There are now some reasons for optimism, as these problems have become more widely acknowledged and initiatives to put in place support for doctors in difficulty are being launched. None of this, of course, is a substitute for dealing with the root causes of our struggling health service, which include serious underinvestment and under-staffing, and pointless reorganisation.

There is plenty of clinical controversy in this issue of the BJGP. The database study by Armstrong and colleagues, examining the incidence of viral and bacterial meningitis in relation to previous antibiotic prescriptions, suggests that patients who have received one or more prescriptions in the preceding year are significantly more likely to develop meningitis, even when prescribing in the few weeks leading up to the index diagnosis is accounted for. Their initial hypothesis, that antibiotic prescribing may disturb the microbiome, allowing the proliferation of pathogenic organisms, remains to be confirmed, but this is an intriguing twist on the antibiotic overprescription story, and at the very least another warning to prescribe with caution.

Cautious prescribing is the theme of another editorial by Davis and Robson, on the dangers of NSAID prescription, and how to avoid them. NSAIDS, they say, cause more deaths than do road traffic accidents, and twice as many as asthma or cervical cancer. They should be avoided whenever possible and, if they appear to be unavoidable, naproxen with proton pump inhibitor cover is the ‘least worst’ option. They recommend the development of system-wide methods to identify older patients at high risk of bleeding and cardiovascular disease, and to involve all concerned in prescribing, patients included, in attempts to improve patient safety.

The study by Carey and colleagues focuses on another under-served group: people with intellectual disabilities. They have additional comorbidities and greater mortality rates, yet often encounter difficulties in accessing adequate care. The authors of this article make a strong plea for special arrangements to be put in place in practices to improve access for people with intellectual disability, and to provide longer appointments for them.

The recurrent theme in Out of Hours this month is the community relevance of general practice, in an effervescent description of a new primary care facility in an unpromising part of Glasgow, a new colocated GP federation in Tyne and Wear and, from Cardiff, a community hub with a distinctly caffeinated flavour. The winning Dangerous Idea in the Society for Academic Primary Care competition takes community participation several steps further, and proposes a model of patient-driven research, crowdfunded through a platform called Kickstarter. There are some good book reviews too.