Money well spent?

I had an unusual consultation this week with a man in his 40's who has extremely poorly controlled diabetes. He seemed rather sheepish throughout, with his shoulders hunched, fidgeting nervously. It was clear that there was something he was ashamed of. Eventually it came out. To my surprise it wasn't anything to do with a fetish for cream cakes or an inability to steer clear of deep fried mars bars, as I had been expecting. Instead, it was the furtive admission that he was seeing a private specialist.

Shock and horror. Imagine my fury at this blatant betrayal of the NHS. He began to spurt excuses that it was only because he had insurance through work and so he thought he 'might as well use it'. He was upset, and clearly felt that he had somehow been disloyal. I was amused to see that he seemed genuinely surprised when I explained that I was not in fact hurt by this revelation. Instead, this piece of news meant that I would be getting speedy help in managing a complicated patient, and I was delighted.

The reality is that this particular patient is likely to get better care privately than he would through the NHS. His disease is poorly controlled, largely due to a lack of motivation on his part, and a patient like this often gets lost in the NHS. He is someone who, after years of not taking much interest in his health, has suddenly decided he must sort himself out. He needs to be seen quickly, while his enthusiasm lasts.

And so I am back to the debate that I so often have with myself on the relative benefits of private medicine versus the NHS. My instinct has always been to reject private health care in favour of the NHS, the core values of which I respect enormously. The concept of providing health care for all irrespective of status or wealth sits better on the conscience of a doctor than demanding cash for your assistance. And yet the NHS has become all about money too. True, it's about saving money rather than making money, but is that any better for the patient?

As a GP, I have actually often thought that working within the constraints of the NHS tends to result in a better level of care. Due to the fact that resources are limited I have to think much harder about what investigations are really important and which patients I do or do not need specialist help with. I hope most would agree that this is actually better medicine than just subjecting anyone who comes your way to a barrage of tests. Where the NHS fails however is in those situations when an individual is unwell and needs investigations quickly, but is not quite ill enough to be in hospital. These patients often have to wait weeks rather than days for vital tests which increases anxiety and delays treatment.

In truth, I am the NHS' biggest fan and if I was ever seriously ill it would be the NHS that I would want to look after me. I do believe however that there is a place for private medicine for those who can afford it. Not only can it reduce the demands on the NHS, but in certain situations it can be better for the patient too. If the two can work together, all the better, and perhaps then my diabetic would feel less of a traitor.

A problem like Maria

I've been seeing the same middle aged Italian lady at least once a fortnight for a couple of months now. We'll call her Maria. Her symptoms are minor, and despite my best efforts to help, her name continues to appear on my morning surgery list. As the weeks have gone on, I have begun to dread seeing her, to dread that feeling of not knowing what on earth I can do for her.

On Tuesday however, she came with her mother, and all of a sudden I began to understand what I had missed before. Maria's mother is in her 80's and suffers from dementia. You can see that she was once charming, and I saw glimpses of that from time to time, but the disease has changed her. She has become impossibly forgetful, making conversation hopeless and frustrating for all. There is aggression at times, and she was openly rude both to me and to her daughter, who sat helplessly beside her, tears in her eyes.

Maria has been looking after her mother on her own for some years. She needs to work, and so during the day she pays carers to come and sit with her mother. This is of course expensive and she cannot afford any help in addition to this. Her mother becomes frightened if left on her own and has a tendency to wander, and so Maria spends every evening at home. She has few friends and no other family.

She is a saint. In looking after her elderly mother she is doing what I think we would all hope to be able to do, and yet it is slowly eating away at her happiness and destroying her life. Her options are limited. She earns too much to qualify for NHS help, and too little to pay for it herself. She can't bear to consider a nursing home for her mother, and I've no doubt that she would not be forgiven if she did.

It is now all too clear why I had not been able to help Maria. I think her frequent visits have more to do with her unhappiness then the symptoms she describes. The thing that troubles me most is that I'm still no clearer as to how I can help.

Swine fever

Over the last month or so, anyone who is over 65, pregnant or has a chronic health condition has been invited to their surgery for their annual flu vaccination, courtesy of the NHS. They come, year after year, to endure the puncturing needle in the hope that they may be spared that grim, sweat dripping, limb aching, all flattening illness that is the flu.

This year however, things have been a little different. This year of course, we have swine flu.

Since April 2009 the world has been obsessed with swine flu. Unsurprisingly the media has been only too happy to add drama to every twist and turn, and so by the time cases began to spread across the UK, word on the street was that this one really might be the killer pandemic we had all been fearing.

Forget bird flu, a piggy variant was now on the rampage.

This week, after much procrastination, surgeries across the UK will receive their first supplies of the swine flu vaccination. Perhaps it is a little surprising then, that rather than being met with trumpet sound and wild cheering, nobody actually seems to want it any more. Time and time again over the last month, when poised to jab someone with their flu vaccination I have heard the words, "I don't want anything to do with that swine flu jab, it's not in this one is it?"

So why this sudden change of heart? Why, when only a few months ago we were gladly chewing on Tamiflu at the first sign of a cold, do we now not want the protection offered by a vaccine?

The problem is that the great swine flu scare has simply gone on for too long. The media have lost interest and we've lost interest. But there also seems to be a sense of anger, that we have somehow been taken for a ride. It's still too early to tell whether swine flu will live up to its fearsome expectations, but there seems to be a general assumption that it won't, and with this a perhaps inevitable loss of confidence in the people who have been advising us.

Actually, in my opinion, the Department of Health has handled the pandemic in an organised and efficient way, delivering updated information and management strategies as quickly as it was able. The Royal College of General Practitioners continues to send at least weekly emails to us GP's, ensuring that we have always had the best information to hand. No, the real culprits in my mind are the media, who have been at best a nuisance, and at worst, irresponsible. They're certainly the reason that I'm sick to death of swine flu.

Trouble sleeping

Sleep - we can't live without it and we spend a third of our lives getting our fill of it. Or not, as the case may be for a few unlucky people that I've seen this week. For them, this is a huge problem, leaving them feeling exhausted, frustrated and miserable. Given my seemingly complete incompetence in dealing with it, I am left feeling much the same.

The conversation seems to go the same way each time. It starts

with me explaining that by suggesting that they try and improve their 'sleep hygiene' I don't mean that they need to wash more before bed. This is the part where we talk about not eating too late, cutting out caffeine and alcohol, having a warm drink before bed, reading a book etc etc etc.

Whether or not this works for anyone I don't know. If it does, those must be the people who don't end up going to their doctor, because the ones who see me are rarely interested. No, the people I see want sleeping tablets, and thus the next part of the conversation involves me trying very hard not to give them what they want. I usually fail.

As far as I'm concerned, going on sleeping tablets is, more often than not, a one way track to a monthly prescription for life, and one which I will feel very guilty about signing. It's not just that some of them are physically addictive drugs, but it's their complete psychological addiction that worries me. How do you stop taking them once you've started? You'll lie in bed and think to yourself, 'I'm not going to sleep tonight, I haven't taken a tablet'. And then of course you won't.

I suppose the question to ask is; does it matter? I cheerily commit Mrs Smith to a lifetime of blood pressure medication, so why not sleeping tablets? (I'm certain that this is what my patients must be thinking when I meanly try and hold them back)

I think for me it's because its 'medicalising' the non medical. To have to take a tablet each night to do something that should come so naturally seems wrong. It's ignoring an underlying problem and just treating the symptom.

Of course that's easy for me to say, I happen to be rather good at sleeping, but I'm sure there must be a better way at helping people who aren't, and I'm busy looking for it....

Prove Yourself

Apologies in advance if this comes across as whinging, but I must shed light on one particularly nasty habit that I am regularly confronted with. It is exhibited by the patient who feels that words alone are not enough to convey their plight, but that hard evidence must also be given in support.

On Tuesday this was Mrs D, who had a terrible, and almost certainly life threatening... cold. On describing her symptoms, each was presented with one of a selection of unpleasant, virus spreading displays - a chesty cough, a snotty sniff, a sorrowful swallow - I refrained from asking her about her bowels...

It's an odd performance, and one which I presume is given in a drive to increase credibility or gain sympathy (unfortunately it has rather the opposite effect!). It has crossed my mind however that it is potentially my own fault - have I somehow presented myself as a tyrant? A menacing keeper of medication to whom a patient must prove themselves in order to be helped?

I hope not, and in fairness, I suspect that it's actually done subconsciously. However, if this is ringing any bells with you my advice is this; your doctor is on your side and will believe what you say even if it is not accompanied by sound effects. In omitting them, there is the added advantage that you may spare him from catching whatever it is that you have, and you're certainly more likely to remain friends.

The Fear

It's been a cancer week this week. Not people who have it, but people who are terrified that they might. Three patients on three consecutive days, each agonizing that their headache might mean a brain tumour, their indigestion could be stomach cancer or their mole, a skin cancer. And then it was my turn. For half an hour on Sunday I had cancer, or at least I thought I might.

So I've been wondering, what is it that makes this particular disease so utterly terrifying?

It can't simply be the fear of dying, as there are plenty of illnesses with the potential to end this way that don't give us the shivers quite like cancer does. The knowledge that the illness process is sometimes painful and debilitating perhaps explains it partly, but then what about a stroke? For me, it's the few tragic stories of healthy people being told they have 8 weeks to live - that sense that it could happen to anyone at any time and that you might not know about it until it was too late.

One thing I strongly believe though, is that the horror with which we regard this disease is unhelpful. I'd never want to underestimate the suffering that cancer can cause, but the stigma that we've attached to it only adds to this. What a difference it would make if we could remove the cloud of dread that envelops it and learn to accept it for what it is.

First Question

One of the best perks of being a GP is having the opportunity to meet a huge assortment of different people. It's not so much the variety in race, religion and culture that I find interesting, but the contrasts that you encounter in the way in which we all think, behave and express ourselves.

So this is 'amateur anthropology with a medical slant' part one, and the question that I have been mulling over this week is this; why do we lie to doctors?

There's a particular incident on my mind. I met Jim (a fictional name of course) for the first time on Monday. We were talking about his newly diagnosed Diabetes when the question of smoking came up. Happily, Jim doesn't smoke, and we both cheerfully agreed that this was great news. He did however look slightly awkward when I met him outside a cafe later that morning, drawing deeply on a cigarette! I don't suppose it was his first.

I wonder if there is anyone who hasn't done this? Who hasn't used the words 'occasional alcohol' and 'social smoker' to explain away a 20-a-day habit washed down with a couple of bottles of wine and a packet of pork scratchings?

Is it through shame of a bad habit or a desire to make a good impression? Perhaps there are some who just don't want the information recorded and others who are simply trying to avoid the lecture (I'll admit my 'smoking is bad for you' lecture is particularly unexciting). Maybe it's based on an element of denial and invincibility; 'I'll give up that morning bottle of Vodka soon, so the doctor doesn't really need to know about that'.

I wonder....