Childcare woes

Posted on January 4, 2026 by Elen Samuel

Yesterday I was flipping through a medical journal and read something that brought back the past very vividly. It was an account of how a young GP, who was a mother of school age children, was struck off the medical register for 5 months, because she had been dishonest in saying that she was already working (and therefore could not be given any more work) when in fact she had to leave in order to pick up her children from school, at 6 pm. It appeared that she had put in the appointments book two fictional patients and given fictitious details, at the end of her surgery, because her sessions often overran, and she had been unable to find some-one else to do the pick-up.
It took me back to the early eighties when I was in that situation fairly frequently, finding myself still seeing patients an hour after I was supposed to finish, and needing to find someone to pick the kids up. It is every parents nightmare, At that time I usually called upon my long suffering parents, who would always come. But when the children were ill, not very often fortunately, and I had to call in to be excused a booked surgery, I felt I couldn’t tell my partners the real reason, because my male partners, who always had a wife or some other female to look after the children would tut-tut and not be sympathetic at all. Once my excuse was that my car wouldn’t start and I had to take it to the garage. They would always understand that because it was a rural practice and transport was crucial – and they had found themselves in that situation. It showed how difficult it was in those days to be a female GP with children. Things are so much better now in that regard.


However I wouldn’t say that conditions for young GPs in general have improved over the years. Far from it. Yes, we had to do on-calls regularly at night (and go out to actually see patients in their own homes!) and still work the next day, and we certainly didn’t get paid much in the early days. But we didn’t have any student debt to repay, and I felt well enough remunerated to buy a small house myself in the year after joining the practice. Now, as I have said before, junior, now called “resident”, doctors both in hospital and in general practice have seen their pay slashed since 2008. Doctors who have qualified recently find that they cannot afford the lifestyle that they expected to have and are struggling. Well, you might say, this applies to many young professionals, who think they are hard done by compared to their parents. But doctors in training are the lifeblood of our health system; they do all the day to day work (supervised by their seniors), and we need to keep them. But the system of training doctors has remained the same for decades. Once qualified, you have to apply for and get a series of jobs in different specialities, sometimes in the same speciality if you are sure what career you want, or to try ones out if you don’t know. In my day there was always competition for the best jobs, but there was no problem getting some sort of job. But now, I read that there is an extreme shortage of jobs in most specialities, and so you cannot be sure you will get a job at all, with all the pressures on finances and your professional development that that entails. In order to make sure that doctors expensively trained in the NHS get jobs, they now get preference over doctors trained overseas. This is obviously sensible and all countries prioritise their own, but this means that fewer overseas doctors are applying, The NHS has always depended on them coming, and for their part they see the training they get here far superior to that anywhere else, but we can ill afford to reduce the numbers coming in. The answer of course is to make sure there are enough jobs for everyone who wants to work here (and many overseas doctors do not and go home), for the future of the service. But at the moment hospitals are cutting the jobs because they can’t pay them in the present straitened circumstances. So we have a double whammy – young doctors see better jobs advertised in Australia and Canada and other places and go abroad, and young doctors in Europe and all over the world are reluctant to come. Apparently there is now such an increase in casual racism in the NHS that doctors of colour are thinking twice about coming. If we can’t get enough resident doctors then patients won’t get treated. I think we have a very dangerous situation developing. It is a reason why doctors are promising to go on holding strikes. They see the pathways to becoming a reasonably paid professional in this country disappearing and some are becoming desperate.

So back to this lady who has been suspended for 5 months because she “fiddled” the rota in order to ensure she could pick up her kids from school. This means that she will lose pay for 5 months, and the practice will have to find someone else to do the job for just 5 months.They are short staffed as it is. She did apologise profusely and say that she would never do anything like it again; the practice supported her and wanted her back. But the panel on the GMC were adamant that nothing short of full suspension for 5 months would do to protect patients. Really? would not a fine and a telling off do?
The GMC has always policed doctors’ behaviour very vigorously and most doctors in my day were terrified of complaints and the possibility of referral to the GMC’s “fitness to practice” committee. It doesn’t seem to have changed much, and is completely out of touch with the realities facing doctors now. It is yet another pressure on young doctors,. Real fraud, bad behaviour and dishonesty should be called out, but the punishments really should be more appropriate, in my view.

References

1.https://news.doctors.net.uk/news/5Egp918msjzkofTRMQYEE7#forumDiscussionArea

2. https://scepticalgp.com/2024/01/03/can-the-nhs-survive/comment-page-1/#comment-184

However a Financial Times analysis of occupational pay over the last 10 years indicates that doctors’ pay have performed worst of all. This was compiled in 2024 and as a result of strikes, doctors’ pay has increased further.

Gross annual pay rebased 100 = 2011
Train drivers 140
All workers 132
Fire service. 121

Nurses 105
Higher education teaching 104
Medical practitioners 86

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Interesting snippets on getting adequate medical care

Posted on October 29, 2025 by Elen Samuel

Last year I wrote a blog “Women’s bodies shamed in medicine”, (1) on how women are treated both as doctors and as patients, and how their position as doctors has improved out of all recognition in the last fifty years. There are far more women in senior positions in medicine in the UK now,  and their contribution to the advancement of medicine has been crucial in many fields. Their position is now secure.

But I read the recent case of a senior doctor, Dr Deborah Burns, who rushed her seriously ill adult son to an east London hospital where she worked, and where he later died of sepsis, (2). and I felt perhaps that we are being complacent. What happened was unforgivable. Despite the doctor having phoned the hospital in advance, given them the diagnosis of sepsis, and indicating that her son  needed  immediate emergency treatment,  the staff who received the patient did not take his case seriously enough or quickly enough, and he died of sepsis.  In March this year the coroner decided that his care was not up to standard and that she would  would issue a prevention of future deaths report to the hospital, calling on it to share the changes it had made since the patient’s death.  It was made clear that the patient was very seriously ill and he might not have survived  even with immediate treatment.  But the patient was not  treated with not treated as the senior consultant (in Paediatrics), in that very hospital where she worked, but as a patient’s mother, whose medical knowledge was not listen to.  I don’t know what was in the minds of those staff, nurses, doctors, and others, when they ignored the evidence of the very ill patient in front of them and refused (despite being asked eight times) to  provide the immediate antibiotics and intravenous fluids he so desperately needed, and which was mandated by every rule for treatment of sepsis.  In the event, they delayed treatment until other less important procedures had been done. 

 If you turn this on its head, and imagine that the consultant was an equally senior man, with an authority that came from a long tradition in that hospital of being obeyed quickly at all times, would the same thing have happened? Somehow, I doubt it. It was the very fact that a women in such a senior role at that hospital could be ignored in such a way, that has left this doctor unable to work, with a diagnosis of complex grief, and continues to feel betrayed over her son’s death.  Especially as the hospital never admitted any liability. That really worries me. 

The fact is that every patient can be treated badly, men as well as women, and doctors do not necessarily have the status they expect. As a society, in every encounter we have with other people, we tend to categorise them in terms of their physical attractiveness, height, gender, colour of skin, presence/ absence of disability and so on.This is human nature, and we can only try to be fair to people. But when considering the vulnerability of patients in a medical setting, it is essential to put these feelings aside and treat every patient well. Rank, gender or race  should not count.. But “rank” of medical staff, of patients, of diseases, and in organizations more generally, permeates medical culture. Consultants, junior staff and nurses are ranked at the top, doctors in their foundation year at the bottom, and “resident  doctors” (formerly “junior doctors”) in the middle, do nearly all the day to day work of treating patients. Nurses also have their ranks which have  been extremely rigid over the years in the NHS, and are only now beginning to soften a little. 

Diseases too are seen in relative importance, with serious and curable illnesses at the top, (like the one above),  and these get the lion’s share of resources, research, and status.  Going down the scale you get routine curable illnesses, then serious but incurable diseases, then diseases considered to be contributed to actions by the patients themselves (they may be considered less worthy of treatment, even though that should never happen). Minor diseases of the elderly, which are a considerable nuisance, don’t need the full gamut of excellence that other conditions might get. In a way, it is to do with making sure patients are treated efficiently, spending the resources on those you know you can help. So varicose veins, piles, dental decay, chronic skin diseases, nasal and eye discharge – all at the bottom of the pile.  And I totally understand that. 

Looking through that list, dental decay stands out as one condition which should have much more money spent on it, and the law should be changed.  Because of the food industry’s need to make money, more and more processed food is packed with harmful substances, with sugar the worst of them as it rots children’s teeth, So the commonest reason for admission of children to hospital is extraction of carious teeth. That is dreadful for them, and very bad for their health in later life. The solutions have to lie in government action to prompt the food industry to stop packing food with cheap sugary ingredients. Despite many entreaties from dentists and others interested in preventative diseases, it hasn’t happened yet.  Tooth decay is seen as self inflicted, even though it is often a direct result of poverty. Children can get free dental care on the NHS, but too many disadvantaged children never get the care they need. Or it may not even be a  problem of poverty  – well-off parents are now using pouches to feed their babies. This is what I got when I googled baby pouches recently – “Baby food pouches offer convenience but should be used sparingly as a primary food source, as some can lack key nutrients like vitamin C and iron, and they may hinder the development of fine motor skills from not chewing. When including them in a diet, check labels carefully for added sugars, even if the sugar is from fruit, and prioritize whole foods for better nutrition and developmental benefits”.

I couldn’t have put it better myself! though actually it was written using Artificial Intelligence, as most summaries are these days.  I personally think such pouches  should be banned.”

Older patients can get a lot of trouble with their eyes.  The common ones, cataracts and glaucoma, are treated very well, with the services having been developed to such an extent that almost every elderly patient  can expect to get fast, appropriate and expert high tech treatment,. Such operations may be done more quickly in the private sector, but the expertise is there for everyone.  Retinal detachment is an emergency and treatment improving all the time, There is also good treatment for the wet form of macular degeneration, a drug called Avastin.(4) This really was a breakthrough. It was first developed for colon cancer, and was out of patent by the time its use for macular degeneration was discovered. Some ophthalmologists reasoned that the way it worked could help in macular degeneration and tried it out, and it worked well for the wet form of the disease.  Even so the pharmaceutical industry fought a long action against it being used for this purpose  and wanted to charge a very high price, even though the companies had not incurred any expense at all in its development for this condition. There were several court cases, eventually reaching the Supreme Court in 2020 when it was found to be lawful for the NHS to use cheap generic drugs like avastin  for this purpose. There was a huge saving for the NHS as macular degeneration is so common, and opened the way for other medications to be developed.  

But there is a huge range of conditions which should not affect eyesight but may be painful, irritating and generally an awful nuisance. The commonest are dry eyes, which causes extreme irritation,  and is sometimes difficult to diagnose. The treatment is primarily lubricants, which can be bought over the counter, but sometimes more effective treatments, such as ciclosporin, an immune suppressing drug which prevents transplanted organs being rejected, is used.  This, given in injection form, can have  serious side effects. However,  it seems safe enough given as eye drops for dry eyes resistant to other treatment, but it can still be absorbed into the body so care should be taken. Some ophthalmologists in Scotland use it for children with severe hay fever. But It should only be prescribed by specialists, and most patients jog along with artificial tears, bought over the counter.  It  is rare to get referred to specialists though.  

It is true to say that in any of these troublesome conditions it is very rare for a breakthrough treatment to be found. 

To start with, most of the treatments are Over The Counter  treatments (OTC) – substances not on the NHS list, which the patient will pay for at the chemist.  There is little incentive for the pharmaceutical companies to do expensive clinical trials which would prove their value as prices are high enough for them to make a big profit.  If it were proved, then the NHS would bargain very strongly to bring the price down in order that more people could get the benefit. The NHS is known the world over for driving a hard bargain because it is such a large market. (In the USA Pharmaceutical companies  have managed to push prices to the limit because there is no central government negotiation, and no price controls)

The same is true with other OTC remedies such as vitamins, gels for arthritis and herbal remedies – they are very profitable for the Pharma companies.  Vitamins are available on the NHS if it is proved that you are sufficiently deficient in it, and then you will get the exact dose you need to make up the deficiency.  People who really believe in the power of vitamins to cure many maladies  will happily pay a lot of money for them, even though in most cases it is a waste of money. 

The second reason is that with such “nuisance”  illnesses is that there would be very little tolerance for any harmful side effects. All medications can have bad effects, but if they are rare, the good that can be done is worth while if it cures, or helps, long term  serious diseases. I remember a new treatment that came out for irritable bowel syndrome about ten years ago. But it had rare but serious side effects and so it was withdrawn. Now treatment for that, and many other disease are managed by changes in diet, which is a very welcome development.   Even diets  can have bad effects though, in general, it is better than taking tablets. 

And the third reason is that we need the media to tell us about exciting new breakthroughs (such as with metagenomics  (5)which I wrote about in a previous blog), but they are less keen to headline treatments for more mundane diseases. And we all know of media stories for breakthroughs in treatment that work wonderfully well, yet it is only in the fine print that you see that the studies have been in mice and it will be at least ten years, if ever, before a suitable treatment is found for human beings. In these “Nuisance” conditions,  pharmaceutical companies will advertise new treatments to doctors, but they don’t get to hear of everything.  In other countries where pharmaceutical companies can advertise directly to patients, it is different, but advertising can lead to over-promotion and misleading claims.

So it can be difficult for patients to know how to navigate the system – how to know when their troublesome symptom really is best managed by themselves, and when there really might be an answer somewhere out there which will work better.   Primary Care teams include dentists, optometrists, nurses, physiotherapists  and pharmacists and they are now very important as a first port of call for patients, and may be attached to doctors’ surgeries.  There are now well established pathways whereby pharmacists are paid to give professional advice when they sell OTC treatments, and I welcome that, and in a previous life helped to introduce such a scheme locally.  

I was disappointed though when I went to a Pharmacist to buy 1% hydrocortisone cream recently (for mild eczema). I was sold it without question but when I got home I found that they had actually sold me something for athletes foot, which contains an anti fungal  medication. No problem I thought, I will take it back and exchange it for the simple hydrocortisone cream.  But no, they can’t do that (because of rules saying that once dispensed it can’t be re-dispensed)  so they would not make any money by giving me a free tube of HC 1%. So they put me through the minor ailments scheme (unfortunately relaying each question through the non qualified person at the desk ) asking me why I needed it, even though the first time I got it without advice and paid for it myself.  Now that costs the NHS a fair amount of money, rightly so as the pharmacist is giving me the benefit of their expertise. They then dispensed the 1% HC cream and told me to keep the anti fungal cream.  Perfectly legal, but the scheme is for giving people advice as to which cream to use and other advice on management without medication, not providing medication needed because of their mistake.  Optometrists provide the same sort of service in Scotland and Wales for free, as they can give you a full examination with a slit lamp, which a GP can’t, and there is a wide range of OTC eye treatments available; they can prescribe a limited number of medications. Some of them are very expensive, though. 

But more generally, if the condition is getting worse, of course you should see your GP and follow their instructions. They will note any “red flag” symptoms and act accordingly.  Referral onwards to  a consultant should be might be necessary even without the “red flags”. If you still don’t get anywhere at the moment you may well have to pay privately. And if the consultant can’t offer any treatment you may have to live with it. There is no legal right to a second opinion on the NHS, but in secondary care (in hospitals) in severe cases patients and relatives have the right to request one, and healthcare professionals must consider their requests seriously.  More recently Martha’s Rule (6). has been introduced in England (Scotland already had such a rule), after Martha Mills died in hospital with sepsis.  If a patient’s condition is deteriorating and parents or relatives are worried they can get  a rapid review from a critical care outreach team.   Sadly there was no time for that in the case of Dr Burns’ son, but patients and their relatives are getting more rights in the NHS which could prevent tragic deaths. 

With the present difficulties of the NHS, more and more patients are having to pay privately  in order to get timely treatment. I have written about this before, about how the private system is allowed to cream off the easy straightforward cases and pass back cases to the NHS if things go wrong; the NHS is still the only organisation which trains doctors, with all the associated costs, and the fact that as consultants have usually worked for the NHS, and some still do,  they are doing it in their “spare time” which means that they can’t give either their NHS or their private patients much time for discussion for unexpected events. This means that private care is often more expensive in Britain than in the rest of the world, not less. 

One last thing. It seems that this whole article is about to get completely out of date. It seems that in China, and in some places in the USA, patients are using Chat boxes as their go-to place for medical information. Apparently they are very knowledgable, and give advice in a very friendly manner, and you don’t even have to leave your home!  Sometimes platforms even combine AI interaction with a human doctor to get  a final diagnosis. What’s not to like? Unless you are a doctor of course, as we might need a lot fewer of them in the future!

References

(1) elen samuel  https://scepticalgp.com/2024/07/07/womens-bodies-shamed-in-medicine/

(2). https://www.bbc.co.uk/news/articles/cwyg0844q1jo

(3). https://www.landmarkchambers.co.uk/news-and-cases/supreme-court-ends-legal-challenges-over-lawfulness-of-using-avastin-off-label-to-treat-nhs-wet-amd-patients#:~:text=

(4).https://uk.news.yahoo.com/doctor-eye-removed-sight-saved-060829577.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAAA
(5). https://www.england.nhs.uk/2024/12/marthas-rule-already-saving-lives-in-nhs-hospitals/https://restofworld.org/2025/ai-

(6) chatbot-china-sick/

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SEEING CLEARLY

Posted on May 8, 2025 by Elen Samuel

There was a very interesting medical story on all the main British TV channels recently. It was about a young female medical student who developed a serious problem with one eye, which caused recurrent iritis. (1). As I well remember, being a medical student was very challenging, but when you have to put eye drops in your eye every hour, it must have been almost impossible to work and study. Iritis, or anterior uveitis to use its correct name, is very painful and affects your eyesight, and there are lots of conditions that can cause it. She was fully investigated for infections and autoimmune diseases and other rarer conditions, but nothing was found. The treatment is steroid drops into the eye, which does control the symptoms, but the condition kept  returning. The high steroid dose caused a cataract to develop, which had to be removed surgically. Even after this the doctors still couldn’t find a cause. She was considering having her eye removed as she was in so much pain. But then the doctors made a  breakthrough. 

The only way currently to diagnose any infection is to take a swab of the infected area, and smear it on to a petri dish containing a nutrient. Then you have to incubate it for at least 24 hrs, after which the pathology worker can look at it and see what has grown. Sometimes one bug is grown, sometimes several, and an expert has to be able to identify them and work out whether any of these could be causing the symptoms the patient has. This process has to be gone through whatever the problem is, so that if you have a cut which isn’t healing for instance, a swab has to be sent off, or, for really serious things like sepsis, a series of swabs including specimens of blood  have to be taken, but the doctors have to treat anyway while waiting for the result. They do this on the basis of current expert clinical opinion, but doctors can easily get this wrong, and choose an antibiotic which doesn’t work. So a lot of time has been wasted, with the patient getting sicker and sicker. This can be a life and death choice with urgent conditions like sepsis.

So this isn’t a quick test; results can take a week or more to come back. Sometimes no organism is grown at all and the patient still hasn’t got better. This might happen if the cause is a virus for instance. So over the years doctors, especially GPs, have stopped doing swabs, and use the most likely antibiotic for the condition they are seeing clinically. In the case of this young doctor, no swab had ever grown any bacteria that might cause the condition. 

Her  case was so important – a young doctor facing having her eye removed at the beginning of her career and just before she was due to get married, – that all the stops were pulled. In a last ditch effort, the doctors used an experimental department in Great Ormond Street hospital, which uses a new method of diagnosing infections – metagenomics. This is a field of biology which focuses on studying all the DNA (the genome) of organisms such as microbes, and their structure and function. It is often used to study a specific community of micro-organisms, such as those residing on human skin, in the soil or in a water sample. So It provides a means of studying microbial communities in situ, without having to make them multiply themselves on a petri dish. 

This method will recognise the DNA of any microbe. Miraculously, the scientists identified a bug which no one had foreseen. It was leptospira, a zoonotic infection (one transmitted by animals), not normally found in Europe. It is known to cause iritis, although not frequently diagnosed according to one study in 2022. (2) .The organism is well reported worldwide, as leptospirosis is also known as Weil’s disease, which I learnt about in medical school 60 years ago – it causes liver disease. Anyway there is a well-known treatment for it, and she had a three week course, and her vision quickly cleared, and the pain went away. It appeared that she may have contracted  it when swimming in the Amazon on holiday five years previously. The patient was over the  moon and she was able to have a wonderful wedding, and to continue her career. That was a fantastic  break through.

It seems that eventually this sort  of procedure could be developed further, so that it can be used in many more cases. We should be able to identify a  bacterial  or viral cause of any infection very quickly in the future. I believe the method is already being scaled up so that other hospitals will be able to use it in the next few years. 

So now from the sublime to the ridiculous – or at least from a very serious infection in the eye, to a much more mundane one – conjunctivitis. it is a condition I developed in the last eighteen months, which is of course why I am particularly interested in it. Infection of the conjunctiva, that is the outer lining of the eye, is common, because it is the part of the eye totally exposed to anything damaging in the atmosphere. It generally clears up quite quickly, with or without treatment because of the action of the body’s immune system. Recurrent conjunctivitis is quite rare, although it can be associated with blepharitis, where the eyelids are infected and this does recur. The mainstay of treatment is good lid hygiene done by the patient. In the past, GPs used to treat conjunctivitis with antibiotic eye drops if it was severe, but now pharmacists, optometrists and nurses are often trained in when to treat with antibiotics or not. But in general it is not given any priority, and patients tend to be shunted from one health care professional to another. It is a bit of a “sink” condition in that respect. 

Conjunctivitis is common in all ages, especially children. But as people get older there can be age degeneration of the fatty tissue of the eyelid causing the eyes to be more sunken, and a pouch can develop  behind the upper eyelid deep in the tissues, and this can trap bacteria causing severe recurrent bacterial conjunctivitis.  This condition is called Giant Fornix Syndrome (fornix is Latin name for “arch”) and was described 20 years ago at Moorfields hospital in London. (3) But is the medical profession aware of this? Not in my experience. Sufferers  (they are usually women between the ages of 75 and 90) try to get treatment for their “sticky eyes” and usually get told to clean their eyelids properly. Unfortunately the symptoms tend to get worse, and steroid drops have to be used. It is an annoying and sometimes painful condition which causes very blurry vision due to the mucus discharge and discomfort. But nearly all people with this condition have to wait up to 2 years to get anything done.  I waited over a year, and I am a retired GP, who was already seeing hospital eye doctors because of another unrelated condition. Some people get permanent damage to their eyes before referral (corneal vascularization and scarring, and some corneal perforation or thinning) so it is not entirely benign.

No swabs seem to be done to see which infection it is, which would definitely give an indication that there is something more to it than it seems, as bacteria grow there that never grow anywhere else.  The only health professionals in the community that can do eye swabs are GP’s, as they are trained in bacteriology and infections, which Optometrists and Pharmacists aren’t, and are never likely to be. But at the moment many GPs refuse to see patients with eye problems unless they have seen an Optometrists first. 

The unusual thing about this disease is that there is a very simple operation which will cure it completely in most cases. It involves re-fashioning the lids, in an operating theatre under local anaesthetic to get rid of the the pouch, which takes about 45 minutes.

So why is the condition not known about?  Only, I believe, because conjunctivitis  is such a common condition, not serious, and is not treated well by any of the various health professionals who are trained to deal with it.  And the clientele – elderly women – aren’t considered interesting to the media, so no stories have been done to publicise the condition. 

And finally, to link these two conditions, if the metagenomics revolution takes off, then there would be no need for the complicated pathway to get antibiotics for this infection, when, often by the time the result has come back from the lab, the infection has either changed or gone away temporarily.  You could get an answer the same day, so treatment should be always be much more accurate. And this would be true for so many other conditions. I do hope it can be developed soon!

In the meantime I would like use this column to do a sort of awareness campaign for elderly ladies with sticky painful eyes. if you, or some-one you know in the relevant age group, suffers from such symptoms, one of the things you could ask your GP to do, is to send off an eye swab to the bacteriology department. If bacteria are grown and identified, then the appropriate treatment can be given. But if it recurs several times, then an urgent referral should be made. I was told that no-one gets frequent bacterial  infections without an underlying cause. But if eye swabs aren’t done, then doctors will dismiss it as a viral infections or blepharitis which you have to put up with. 

  How common is it? We don’t know. My eye specialist tells me he has done six such operations in his present job – not very many.  But then he hardly gets any cases referred with possible GFS, if my experience is anything to go by, and has a huge list of patient waiting to be seen.  And even different departments of the eye hospital may not know about it, so the doctors there do not refer to Oculoplastics (the subspecialty which deals with this condition). Maybe it is better known in other parts of the country, I don’t know. But I definitely think there is a need for more education for all levels of health care including all hospital specialists, resident doctors in hospitals, and especially including registrars in general practice, who are quite likely to come across eye problems like this that, at the moment, they neither want to see or to treat. 

(1) https://uk.news.yahoo.com/doctor-eye-removed-sight-saved-060829577.html?

(2) https://www.aaojournal.org/article/S0161-6420(04)00528-7/abstract

(3) https://pmc.ncbi.nlm.nih.gov/articles/PMC9773111/

https://www.aaojournal.org/article/S0161-6420(04)00528-7/abstract

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A brave new world of lower waiting lists in the NHS?

Posted on January 7, 2025 by Elen Samuel

Thank goodness, the new government is trying very hard to speed up the process of diagnosis and treatment to reduce waiting lists in the NHS, and I think they are on the right track. Allowing patients to book their own X-rays, scans, blood tests, rather than have to be seen by GPs is a good idea. Presumably they would be triaging with an algorithm on an online form, and those that fail would have to see a GP. Diagnostic hubs are a great idea, and using the private sector where possible (with the caveats I referred to in my previous blog) would also help. After all it is usually the same personnel.especially consultants in both private and NHS settings.

The latest wheeze they have come up with is to pay GPs £20 every time they access the “Advice and Guidance pathway” to reduce the number of referrals to hospital. Apparently when GP’s do use it the number of cases being referred for care in the hospital itself was halved, the others being referred for treatment outside hospital, which is what the government wants as it is cheaper. However apparently the hospitals are paid about £50 per case to cover the cost of consultants need to use the system, so it isn’t that cheap.

I did a lot of work on this 15 years ago, and it is essential to have such a pathway. Our scheme 2. involved GPs and Consultants getting together to formulate best practice locally and to develop local pathways which didn’t involve the consultants where it wasn’t necessary. We found that it is essential to have good relationships between doctors in primary and secondary care, and the system worked well then. But we also found that if doctors are not recompensed for the extra time in being involved,3. they will not continue to use these pathways – human nature I suppose! But will £20 cut any ice?

I saw a graph recently which shed a light on the real problem with the NHS. To see the graph click on ref 4 below. Apparently doctors, and to a lesser extent nurses have suffered the worst drop in income of any other key workers over the last 10 years. Here are the figures –

Increases in gross annual pay for key workers in UK from 2011 to 2022
gross annual pay rebased 100 = 2011
Train drivers increase to 140
All workers 134
Fire service officers 120
Nurses 110
Higher education, teachers 108
Medical practitioners decrease to 86.

I don’t know Simon Fleming, and I am assuming that these figures are true (one rather distrusts anything on twitter these days), but if it is accurate, then this shows the real reason why the NHS is not going to recover any time soon, When the last Labour Government came in and needed to rescue the NHS from the underfunding of the NHS, it was able to improve doctors’ pay considerably and it ploughed a lot of money into the NHS to develop out of hospital care. Of course some grumbled, (they always will) but general practice was a good place to work then.

You can see from the graph that train workers did best. This I presume was entirely due to the fact that even minimal reduction in flexibility in train drivers’ rotas through industrial action causes such disruption that they have a lot of financial clout. Doctors don’t strike (often) and if they do the NHS has to keep disruption to patient care to a minimum, so they don’t have much clout there. But what does happen is that they migrate. There is a world market in medical expertise and Australia, Canada, Saudi Arabis and the Middle East are able to pay much higher salaries, My Ophthalmic consultant aged 55 working full time in the NHS, decided to relocate to Saudi Arabia to earn lots of money before he retired. He hasn’t been replaced – other consultants have had to take up the load.

Every day, there are advertisements for young doctors to work in Australia and Canada, that are extremely attractive, The fact is that if the UK cannot pay a comparative rate they will not get enough fully trained doctors. So at the moment we are in a dreadful situation. I spoke to a middle manager in the NHS recently and she said that no reform or new way of using staff will work if the pay is low. Being a doctor is very stressful, but also fulfilling in most cases, but if you can’t pay the mortgage or rent it is normal to think of alternatives, and what can beat working in a functioning system in a sunnier clime?

Working doctors have recently voted against allowing Physician’s Associates (who have had 2 years of clinical training) to take some of the work of GP’s and in hospitals, because undoubtedly some mistakes will be made and some patients might suffer. I myself think that it is right to devolve functions to lesser trained individuals if you possibly can, but the problem is that it is the doctors who have to manage their workload and certify that their work is safe, and this is an additional responsibility The thinking is “with all this supervision it is easier, quicker and safer to do it myself”. I think the authorities will have to go back to the drawing board on this.

If nurses, radiographers, lab staff and everyone else can get better money working in a supermarket then they will leave too. The NHS has to be resourced properly. If it is not, voters will think that a privatised system is best. They may go for a party like Reform, which would like to privatise the NHS, even though that would turn out to be exactly the same as Brexit – the promises of better services would not materialise and 90% of people would be very much worse off. And if that privatised service was like the American system many people would be bankrupted by any serious illness. European systems are better, as they are based on a social democratic model, but costs to patients will be considerable.

So if the country is really as broke as it seems (I wonder sometimes if that is really true as Germany and France seem to have very severe economic problems too but they still manage to pay their doctors), then we are stuffed – we will never get back to the golden days of. the previous Labour government.


Refs
1.https://news.doctors.net.uk/news/32QVBGLvb9xbvQGtZUqRbq
2 The Torfaen referral evaluation project https://pubmed.ncbi.nlm.nih.gov/20051193/
3. Reducing variation in General practitioner referral rate https://pubmed.ncbi.nlm.nih.gov/21902906/
4. https://x.com/OrthopodReg/status/1613204462910246912?s=20
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NHS funding – Where should our priorities be?

Posted on November 7, 2024 by Elen Samuel

With all this talk of the latest budget giving a huge amount of money to the NHS, it is now necessary to look at how this amount of money can be spent in order to rescue the health of this country. 

So far, the BMA ( the doctors’ trade union) has said, “New funding for the NHS is welcome, but what is glaringly absent from today’s Budget is a concrete plan to rebuild general practice, which is the front door of the NHS”.

This has been a constant refrain in the health service,  When I was working as a GP, and also as a medical manager in the local health board, what always struck me was when there was any extra funding available, how quickly the local hospital trusts managed to get their hands on it.  Their needs were always said to be greater than ours (the GP’s)  and there were always new developments and improvements in medical care in hospitals which should  be given priority. It was more exciting to have more shiny new equipment which might save lives, or saving eyes if you were an ophthalmologist, than to improve the facilities and expand the remit of general practice. The consultants’ committees and  connections to politicians seemed to work extremely fast and efficiently, but GPs were always waiting for crumbs from the table.  

At one time when  I worked in medical management, I was tasked with reducing unnecessary referrals from GPs to hospital consultants. I found that indeed there were some referrals which were inappropriate or unnecessary, but the main problem was that the consultants were very unwilling to let go of the some of the work which could be done in primary care,For instance  In the 1980s  there were extremely long waits for a first orthopaedic appointment (as there are now of course) but at that time the main reason was that physiotherapy was  a hospital based speciality that could only be accessed by a referral to Orthopaedics. We GP’s campaigned long and hard for years to get access but we were always refused. The reason given — the consultants wanted to keep physiotherapy to themselves because they could then refer patients to physios when they could not help the patient surgically. It was such a backward idea. Patients need physio first to prevent their condition getting worse, and sometimes to cure the patient, but not at the end of surgical procedures which actually would not have been needed if the patient had had physio first! That battle was eventually won and now it is normal for physios to  be attached to GP surgeries  and patients get better much more quickly. And now many other services are available in primary care, but many more services can and should be moved out of hospital and put into local hubs. Though there wasn’t much about this in the budget,  there is a lot of talk about this in both the medical press and I am sure some of this will happen, if the money is provided.  But so often there is talk about doing this (there was a lot of talk about it when I was working), but the money always went to the hospitals and got siphoned off into acute care.  

The other place the money needs to go is into joint social care and community services.  If we don’t fix social care, the NHS doesn’t stand a chance. I remember helping to organise a joint venture for a rehab centre in our town that was to be funded jointly by the hospital trust, the local council and social services. All the plans were made, and the new centre was set up. But at the last minute the hospital trust refused to pay its share, as it said they didn’t have the money. And the council and social care  had to fund it, and I expect still do. It still works well to get patients out of hospital immediately after an operation or after an emergency and get them fit enough to go home, so the hospital benefitted enormously from it.  At the moment the problem of people being well enough to leave hospital but can’t because of lack of rehabilitation facilities or home based care, is threatening the whole system. 

So it is absolutely essential that the new money coming in is not spent exclusively  on funding waiting lists, new developments and more activity in acute hospitals, exciting and worthwhile though they may be.  It is the usual story of the best being the enemy of the good.  I am in favour of local initiatives in the community for specific routine operations, even by the private sector, so long as it isn’t leaching on the NHS (see previous article).  More money must be put into prevention.  But we were talking about this constantly 30 years ago, and it hasn’t happened. It MUST happen this time, or all the money will just disappear down a black hole. 

 GPs are the front door of the NHS, and the BMA asked the Government to increase their funding by at least £40 per patient per year – just 11p per day. However, the increase in employers’  NI  contributions will again squeeze GP practices while the hospitals are unaffected. 

“Funding general practice properly saves money.  It leads to better patient care and fewer people needing to go to hospital, consequently reducing pressure on the already overstretched NHS.”

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Women’s bodies shamed in medicine.

Posted on July 7, 2024 by Elen Samuel

It is said that historically women have had a raw deal in Western systems of medicine. Women’s bodies have been routinely sexualized or their characteristics ignored or shamed. In a recent book1 a leading cancer doctor in the US, Dr Elizabeth Comen, has attributed it to centuries of being put down by the medical establishment and this has resulted in women being more likely to be misdiagnosed when suffering from common disorders such as cancer and heart disease. Their symptoms have been more likely to be written off as anxiety, and women sometimes react by apologising when they are speaking to their doctors.She argues that there is still misogyny in modern western health systems. And it is also more deeply felt by women lower down in the pecking order – such as being poor, of colour, of a different nationality, elderly, or having had lots of medical problems in the past. Examples she gives are doctors diagnosing women who were short of breath and complaining of palpitations, with “pseudo-angina”- a collection of neurosis-induced symptoms masquerading as genuine disease. It took a long time before it was realized there is no such thing as “pseudo angina” and that women were in fact being routinely under-diagnosed.
You might think that this is likely to be the case where the doctors in question were older and male, and that as more female doctors have come into the system this becomes less of a problem, and I am sure that this is correct to some extent. But female doctors are by no means immune from the temptation to treat women patients differently to men. As I am now retired from medical practice, and indubitably old, I get this treatment too. I have a longstanding, troublesome but non serious eyelid problem, and I have learnt that it is necessary to apologise in advance every time I see a doctor, and also sometimes an optometrist as well! Of course, I don’t know whether an elderly man would get the same brush-off, or whether they would learn to apologise. My memory of being a GP was that very few men would ever apologise to me for just presenting their symptoms, which they had every right to do. Perhaps I ought to do a survey!
In the same vein, women historically had a hard time in entering the closed world of medicine. Young women faced many barriers which had to be demolished. Historically in the UK, Medicine was a bastion of male influence, and this has changed only in my lifetime. When I applied for medical school in 1962, I found that some medical schools had a quota for girls. For the prestigious London medical schools, this wasn’t a quota to be reached but a ceiling – no more than 10% girls, regardless of quality of the applicant. For Oxford and Cambridge, there were a limited number of colleges for females (all colleges were for either males or females) so at Cambridge there were 9 boys for every girl starting their undergraduate courses. This certainly made it great for girls’ social lives!
I remember when I timidly spoke in a University medical debate, I put forward the fairly revolutionary idea that medicine needed female doctors, and so the profession should start to make it easier for girls to be doctors. Sadly, my suggestion was received in silence and the meeting swiftly moved on. Afterwards an elderly (perhaps he was about 50) gentleman took me aside and explained that women would not make good doctors and the profession should remain mostly male!
However I thoroughly enjoyed the training and took to being a junior doctor with alacrity. As one of the 10% I found getting house jobs easy, but as I looked around all I could see were men in senior positions in all branches of medicine, and women were in jobs like family planning, part time general practice and palliative care. I certainly felt that hospital medicine would be very difficult, and opted for general practice as an area where one could tread one’s own path. Later as a principal in general practice things became easier, though in meetings it was difficult to make oneself heard without provoking people (which I did, a lot).
However in 1975 the first UK sex discrimination act was passed, which outlawed discriminationand on the grounds of sex or marital status. It covered employment, training, education, harassment, the provision of goods and services, and the disposal of premises. It took time for this to be accepted in medicine, and I again was not popular when I took up the cause of female doctors being sidelined, and especially not when I pointed out that junior doctors with personal objections to abortion were attempting to prevent abortions happening. Abortion had been legal since 1967, and I well remember the situation at medical school where girls were being referred to consultants who had to try to find a legal loophole to allow a termination when they were good medical grounds why the abortion should go ahead. It was heartbreaking at times.
But slowly more and more women began to prioritise their careers while still having children, and even in my cohort there was one (but only one) who became not only a consultant in a prestigious speciality but also a professor. She had great determination and drive and was incredibly successful, but also empathetic and approachable. She is also tall, good-looking, with impeccable schooling and poise.
Female doctors have made great strides, and several recent studies have found that when medical patients (of both sexes) in hospital are cared for by female physicians, they may have less chance of dying (i.e., decreased mortality rates) compared with patients of male physicians. 2 Also female patients have a greater benefit from being treated by females. When doctors get complaints against them or are accused of poor conduct, it was found that significantly more male doctors were referred for investigation than female ones. This sex difference in who gets referred for disciplinary action is similar throughout the world. For instance, after controlling for all demographic factors, male doctors in the United States were three times more likely than women to have claims for malpractice made against them. In England only six of the 49 career doctors with problems reported by Donaldson were women.

Investigators thought that the factors driving the differences, such as male doctors underestimating the severity of their female patients’ illness, could be due to female doctors being better at communicating with their female patients, and female patients being more comfortable with receiving sensitive examinations and having detailed conversations with female physicians.
So not to put too fine a point on it, it seems to be clear that female doctors are now well established in medical teams in most countries of the world, except where barriers are put up against them for cultural or religious reasons.
But gender bias is still alive and well in the workplace, though not as prevalent as racial bias. which is sadly widesprad in the NHS. Some specialities are much favoured by women. For instance Obstetrics and Gynaecology, and Public Health had the highest proportion of female applicants (72.4% and 67.2% respectively) and surgical specialities and radiology had the lowest (34.7% and 35.7% respectively). Nowadays women have made successful careers in medical politics as well as in mainstream medicine, and though it takes exceptional social skills as well as ability, women have revolutionised medicine.
As a footnote, I was saddened to hear recently that there are professions where women have not yet achieved success. A young friend of mine has recently become a pilot, where the current percentage of female pilots is about 7%, and I see her facing the same difficulties that I experienced all these years ago. She has been accused of behaviour problems (such as swearing – think of male pilots being criticised for that!), and safety issues when the problem lay with a senior pilot, not her. She was sanctioned and is finding it difficult to get back her confidence. Misogyny is rife in that profession. The world still has a long way to go in getting equality of the sexes.

“All in Her Head: The Truth and Lies Early Medicine Taught Us About Women’s Bodies and Why It Matters Today.” Dr. Elizabeth Comen, a breast cancer specialist at Memorial Sloan Kettering Hospital in Manhattan,

JAMA Health Forum. 2021 Jul; 2(7): e211615.
Published online 2021 Jul 16. doi: 10.1001/jamahealthforum.2021.1615
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Can the NHS survive?

Posted on January 3, 2024 by Elen Samuel

While going about my normal life, fitting in appointments for dentists and  eye tests amongst shopping and hair appointments, I sometimes think about the changes in provision for these first two since I retired from clinical practice  over ten years ago.   I particularly think about how many patients I used to see for dental problems, despite the ruling from our college and health board that we should never see them.  It was usually for painful things like dental abscesses or gum disease  where patients knew that we could prescribe painkillers or antibiotics. It was a complete misuse of our time.  Dentists were trained to give preventative and  appropriate advice  in every consultation, which would lead to the patients taking better care of their teeth, and it was  a core part of their NHS contract.  At that time most dentists did some NHS work, and always saw children, but patients still appeared in our surgeries.  The problem for us was that the patient would make an appointment, and we wouldn’t know until they arrived that this was a dental problem.  We then had to  tell them that we couldn’t treat them, but these were our patients that we saw for medical conditions, and we didn’t want to  have a long argument about antibiotics in the middle of a busy surgery.  We used to put notices up telling patients to see their dentist, but as NHS dentists became scarce, (after implementation of contracts that didn’t pay them enough), the pressure didn’t go away.  Then, overnight, all that stopped in its tracks when the pandemic hit.  GP’s  closed their doors and had to implement a system whereby patients with covid could be triaged safely. 

So suddenly for the first time in the history of the NHS, GPs could do what they had always wanted to do, that is, implement a triage system, so that patients could be directed to the most appropriate professional – nurse, counsellor, physio, dentist and so on, and this immediately improved the flow through the system.  We had tried to do that in our practice years before I retired, but it had always caused controversy, with receptionists becoming a barrier and getting abuse. 

As everyone knows, once the pandemic was over, most practice continued this system, whereby the patients have to state their reason for needing an appointment, and whether they want a face to face appointment or a telephone consultation, before an appointment is given.  It must have completely revolutionised  doctors’ workload, but it doesn’t seem to have made it easier to see a doctor, mostly because of a severe shortage of doctors and other health care workers after the pandemic.

The shortages have led to some non-essential services being withdrawn from general practice.  Consider ENT and ear wax.  We GP’s used to give our nurses a day’s training, an old metal syringe, and they would remove the wax.  It was a tribute to the nurses that they mostly did an excellent job despite poor equipment.  The GP practice did not get any extra money from the NHS for providing  this service, but patients needed it done.  It is very debilitating and unpleasant to have one’s ears blocked by ear wax. But now quite rightly, it is mandatory to have better equipment, especially to visualise the ear drum, which is often obscured by the wax.  If a patient had ear pain, and the GP could only see ear wax, the GP would probably back both horses as it were, and treat with antibiotics in case it was an ear infection (otitis media), as well as ear drops to soften the wax. There was certainly potential for missing more serious infections and chronic external ear infections, caused by eczema, which would need steroid drops.  But GP practices would have to buy this extra kit, and probably do more of the work themselves, and were unwilling to make this investment when there were staff shortages, so the authorities decided that ear syringing was no longer to be done in general practice.  So now you go to SpecSavers, where they provide an excellent service with first class equipment.  But of course there is a fee; quite a reasonable one I would say. But we know that many patients really cannot afford to pay anything nowadays with the cost of living crisis. Where do they go?  I’m not sure but many will end up in overcrowded ENT emergency clinic seeing a hospital doctor, adding to waiting lists.

Nowadays in the UK most dentists have withdrawn from the NHS.  If you can’t pay the high fees  when you have a dental emergency, there are often local emergency services available, at a modest charge, but the treatment is usually quite basic.  It is definitely a two tier system as most dentists  have improved their surgeries with more and more expensive  kit, and can do more and more cutting edge  treatment and more cosmetic dentistry.  If you are well off you will get a first class service.

A similar situation now happens with eye problems. Most patients, even when I was practising, knew it was no use going to a GP for visual problems such as poor vision, floaters, and so on; the place to go is the optometrist, even though there was always a charge.  But I used to see patients in primary care with acute conjunctivitis, hay fever, and tear duct problems, and did the best I could armed with only an ophthalmoscope.  At that time optometrists could not prescribe antibiotic or steroid eye drops. But with contact lenses  becoming so popular, most optometrists went on courses to enable them to prescribe, whether privately or for NHS medications.  High street pharmacists can also prescribe antibiotics for simple conjunctivitis, if they have been specially trained to do so, but not many are.  In England, Pharmacists are about to be paid for seeing patients, but GPs are complaining that the former are going to be paid twice as much as they are.  GPs get about £164 per year per patient, with a bit more for the elderly. That shows exactly how efficient they are.

Recognising the difficulty, both Wales and Scotland  have set up NHS services in Optometrist practices, if they agree.  Under the Eye Health Examination Wales initiative, “you are entitled to have your eyes examined free of charge by a registered optometrist if you have an eye problem that occurred suddenly [acutely) which you think requires urgent attention”. 1 This has been in existence for many years and can work quite well.  Optometrists can use their skills and equipment to examine the eyes in more detail, and so can diagnose serious illnesses such as glaucoma, diabetic eye problems and tumours.  But there are problems.  In my part of Scotland some GP practices won’t see eye problems at all and refer patients direct to Optometrists.  Optometrists triage the scheme vigorously and don’t advertise it in case they get overloaded,  and they also aren’t able to provide the full range of primary care eye care which requires liaison between hospital consultants.  Patients can be shunted from GP to Optometrist and back again and patients never know whether they are expected to pay for the services or not. Some Optometrists also want to recoup their expenditure on scans and other  tests and  will perform them, and charge, despite there being no relevant indication for their use at that time. 

Patients with painful eye conditions don’t expect to pay fo this service and Optometrists can put barriers in the way.  I suspect many patients will go to their local eye department in the hospital if there aren’t such schemes operating and they can’t pay. 

We always come back to the difficulty with private services sitting alongside “free at the point of use” services – how to manage demand.  When the workforce is depleted it becomes impossible.  Patients paying to see a consultant privately and hoping they can be pushed up the waiting list has been happening for years. 

There is no doubt in my mind that the NHS has been neglected since 2010, and pay has fallen considerably. Professional people will go where they can earn more money and have better conditions. Last year, my ophthalmic consultant moved to Saudi Arabia, to earn more money before he retired, causing havoc in his department. A Psychiatrist  I know moved to New Zealand for the same reason, citing poor conditions and low pay.Young doctors are leaving the NHS early in their careers citing overwork and poor conditions. 

Marketisation and privatisation in the NHS is happening more and more.  There are so many on-line  advice lines where patients can  get up to date information about what to do about their symptoms.  The old system of a doctor knowing their patients has gone; general practice is hard work and many GPs are leaving, and their practices then have to be taken over by the Health Authority. So attention is turning to establishing centres which will do the full range of treatment, including eyes and dental work, physios and psychologists.   If Labour win the next election plans include ‘GP hubs’ where patients can walk in at evenings and weekends, bringing together doctors, nurses, dentists pharmacists and treatment of minor injuries to take pressures off A&E. 2  Chronic disease management, the core of primary care these days, could be managed there, by nurses and GPs who are already trained to cover these responsibilities.  This sort of neighbourhood primary care might be a good way forward.  It could be cost effective and allow scarce support services to address the needs of several practices at a sustainable level, but It should  be locally led with  several practices co-operating in each neighbourhood;

They could only do this, though, if extra money was provided, in addition to what is already spent on GP services.  This is what happened in Australia which offers walk-in services seven days a week, for situations that are urgent, but not a major emergency.

There would  undoubtedly be battles with patient care organizations and health service unions for this to happen.  While such plans may work quite well in big cities, in rural areas  it is not so easy and patients would have to travel long distances.  Getting staff would be difficult too. It would be imperative to invest more in training staff. 

One of the big problems since the pandemic has been that there has been an increase in the number of people who are too ill to work, and it is likely that failure to treat illnesses or do operations early enough is exacerbating this.  That is a very good reason to invest in the health service to get them back to work.  In a similar vein, most large companies who value their workforce will set up some sort of service locally to save their workers having to spend time going to the doctor.  And going further, I would like to see occupational health services provided for people in smaller workplaces.   But should all care be free? For some people it must be, and in the UK benefits system this is true for people who qualify.  But it is unrealistic these days to say that everything should be free at the point of use.

We also must tackle the built in advantages of private medicine that is entrenched in the UK.  Private medicine in the UK is like a leech on the NHS.  All its practitioners are fully trained doctors, the costs of whose training are born entirely by the NHS, where young doctors learn by doing procedures under supervision.  This takes up time and needs the skills of senior doctors who teach them.  I have never seen this happen in private hospitals, and I would think that patients would not agree to it, as they want the consultant to perform the operations if they are paying a lot of money.  The private sector also picks and chooses what it does — usually the straightforward operations and treatments.  Complicated and expensive treatments are left to the NHS, as are almost all cancer services.  Also, If anything goes wrong in a private hospital in the UK, the patient is immediately transferred to the NHS, so the private sector does not bear any of the secondary costs of treating them.  It is well known that the private sector in the UK is hugely profitable because of this, but still the costs to the patients are higher than in lots of countries where these advantages do not apply.  No wonder the big US  companies are champing at the bit to get control over this licence to print money.  There is evidence that the quality of healthcare declines after private equity involvement.  In a recent  American study in JAMA, 1, an analysis of more than 600,000 Medicare patients found that private equity hospitals did fewer procedures among younger and less disadvantaged patients.  There was also a doubling of surgical site infections in the private equity hospitals compared  with those in the public sector, and there was a fall in the number of surgical site infections in private equity hospitals, a 27% increase in patient falls, and a 38% increase in central-line associated infections, despite fewer central lines being done.  These changes happened following  private equity buy out.  Explanations could include decreased staffing, changes in “operator technique” or poorer clinician experience, according to this study. 3

While I continue to hope that NHS service can survive and improve in the future if a government is elected that will continue to invest in the NHS, I wonder whether it will be possible.  There is a huge amount of pent up demand with long waiting times,  and  the workforce is not increasing. The experiences I and my family have had recently however have shown that the goodwill  and expertise is still there.  My brother had first class care in a Glasgow hospital recently for an admission after a fall just before Christmas, and I myself have had good emergency care recently although it has to be said that I knew to access the services through my  GP rather than go through emergency departments.  I do feel that the staff on both occasions gave care with skill, compassion and first class diagnostic services  despite being very busy indeed, and this gives me hope that things can improve.  We just need politicians who understand the need for a professional service unencumbered by the need to make a profit, with patients at its heart. 

reference. 

1. https://thepracticeofhealth.nhs.wales/clinics-services/referrals/self-referrals/welsh-eye-care-scheme/

2. https://www.pulsetoday.co.uk/news/politics/labour-planning-gp-shake-up-resembling-darzi-centre-model/

3. https://original.newsbreak.com/@healthsia-1608606/3277518604178-private-equity-takeovers-linked-to-declining-quality-of-care-in-hospitals-nationwide-analysis

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Demographics as a tool in war in Gaza

Posted on October 27, 2023 by Elen Samuel
Our world does seem to be unwinding. Climate breakdown, wars, mass killings, pestilence, poverty and malnutrition are all related. From a planetary perspective, this is nothing new; as David Attenborough points out, our planet has seen this, and much worse, before. But life survived. What is different this time?

The obvious difference is that humanity, the human race, is observing this breakdown and knows that it is man made. But most of us are not thinking about the fact of climate change, we are worrying about us. About other humans, our family, friends, our culture and society, even other people’s culture in Ukraine and the middle East, and we see everything through this lens.

But unfortunately, we are not an intelligent species. Yes, some of us might be intelligent and aware of the dangers. But our species, homo sapiens, is not at all intelligent – we act primarily as animals, particularly clever animals, but still with the urges, drives and biology that comes with that.

Isn’t it obvious that an intelligent species would not breed itself into oblivion, would take steps to conserve the planet, and would arrange our society to harmonise with our environment?

But we can’t. We have the over-riding urge to maximise our own survival at the expense of everything else – all life in our environment ,and other human’s survival. Humans all over the world, but probably most of all in the successful societies of the developed West are totally
concerned only with our humanity. The Judaic religions, Jewish, Christian and Moslem, all preach the idea which has so dominated our world for so long, that humans are sacred in God’s view. Each human being is a blessing, and children are often the whole point of our existence. It permeates our thinking so that every child in the world, and every child yet to be born, is of fundamental importance to the world.

It is a wonderful idea, often so selfless, with people championing those worse off themselves, and working towards a better society. But, and it is a big but, how can you do this in a world where the population has long outgrown the resources of the world? We are now, in developed nations, consuming the resources of 2,3. even 4 planet earths in one year. Even if resources are spread equally, this is an unsustainable Ponzi scheme. Of course it isn’t spread equally,
and far too many men, (and few women) are getting richer and richer, at the expense of the rest of us.

I am arguing for the absolute need to remember other species, and other environments. They are just as important to the functioning of the planet as we humans are. . We are not the only species that matters, and we must stop prioritising ourselves and our children in this way.

The present Middle Eastern War is widely regarded as an impossible problem to solve, and it is. Take the two main combatant peoples and their religions; both want to dominant one area. If we were an intelligent species we would see that whatever the problems, they will be made worse by having more children. It is a stark choice – if you live in an area of 141 square miles with 2 million others, and you cannot move anywhere else because the world is too crowded and no-one else will have you, you should at the very least limit the growth of your population. But in Gaza, contraception and abortion are prohibited. Women are still expected to have 5, 6 or 7 children, never mind that the resources of the land have long been depleted, and the whole society is funded by the UN. The same ideas permeated orthodox Jewish communities – they are given the resources to have as many children as they want, as they are “God’s chosen people”.


It is worse than that of course. Both sides use demographics to achieve political aims. The more children, the more the rest of the world cannot help but support them. At present 47% of the populatiojn of Gaza are children – the highest proportion in the world. That isn’t a natural phenomenon in this day and age – it is engineered by Hamas for their own ends. The more populous a society the more importance they will have, Hamas does not care about the children – they are just pawns to get what they want, which is power, but they need women to have more of them. I am sure the women of Gaza are aware of this — but what can they do? And the more children they have, the more likely (they will reason) that at least some of them might survive.

The Israel government is almost as bad. For years ultra orthodox Jews have been pandered to, and subsidized so that the fathers of families can study instead of work, and have many children They have now influenced the government with the result that the current one is the most hard right it has ever been. It has been completely captured by the religious right, and behaving in a way which is even more ruthless than Hamas. This isn’t intelligent behaviour – this is madness. Religion is important and our societies have often been the better for it, and it certainly provided a central role for people’s understanding of the world and the meaning of life. But that religious bit of us is now the cause of so much human suffering.

The world is waking up to the overpopulation problem – or at least the half of the world that is female. Everywhere women who are beneficiaries of the means to have fewer children, are doing just that. The population of Europe, the Americas, even Bangladesh is now stabilising, despite the futile efforts of the men in charge of several countries to persuade women to have more babies, Women are taking advantage of contraception, making sure that they can give a better life for their 2 children and themselves than if they had 7. Africa will follow if there is time. But the lag due to historic high conception rates means that an actual reduction of the world population will not start before the ned of the century. And what will the world be like then?

Yes, in the current war, we will all grieve for the deaths of innocent children. But do we want the world to continue with humans on it living in harmony with our natural resources, or not? Surely all communitiues, including Gaza should be allowed contraception?

There are other flash-points with language and race being other trigger points for violence. All of these will worsen with climate change , which will make huge areas unliveable in. I have no idea whether our civilzation will survive it. The planet, and life on it will survive. Let’s at least make sure that our population reduces to a more sustainable level by contraception, not by mass annhliation.
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Looking Back on Covid-19

Posted on August 28, 2023 by Elen Samuel

As I write this, some scientists are urging us to start to wear masks again, because there is a new variant  and cases of covid are rising. Covid hasn’t gone away and we know that things may take a turn for the worse again. Yet it is remarkable how most of us have put the covid epidemic out of our minds, so soon. The success of scientists who managed to work out so quickly how this totally new disease worked, and develop effective vaccines, meant that the virus had to mutate to survive.  As has happened before  (after the 1918 “Spanish” flu epidemic),  it mutated in a way that made the infection much less dangerous, and now most of us can go back to our old way of life with little change.  Until the next surge of course. 

But now seems to me to be a good time to look back at the pandemic so far. As in many countries, in the UK there is an ongoing Inquiry into how the pandemic was managed, called “Every Story Matters – UK Covid-19 Inquiry”.     This inquiry looks at many aspects of the coronavirus epidemic and how prepared the country was, and how the NHS and other agencies responded. However, it is not going to be a quick look at the main important points but a long  exhaustive study with many aspects and discussions which could go on for years. 

Just now, I would like to consider just a few salient points even if it is very early to come to any definitive conclusions.These are personal observations and   recollections which may be helpful, but may eventually turn out to be not entirely accurate. We’ll see. I am not blaming any country or health system for what happened. Wrong choices are inevitable when politicians, health workers and  scientists are dealing with a completely new disease. A lot of people, scientists included, thought it was similar to flu, when it turned out not to be at all. But we do need to learn lessons. 

The first event to consider was the initial Chinese response. We may never know what part, if any, Chinese scientists in Wuhan had in the origin of the disease, but certainly the chaotic and sometimes entirely wrong choices they made indicate to me that they weren’t expecting it, or knew about it,  at least at that time and place. They tried to deny it, castigating health workers who tried to flag up this entirely new disease, even to the extent of silencing one brave front-line doctor, who then died of covid.  Then, to some extent they may have over-reacted, putting huge numbers of very elderly people through the trauma of intubation and artificial ventilation, and keeping them there for very long periods.  To do this they had to  build enormous new field hospitals, and train many more staff.  But  the survival rate for the frail elderly (over 80’s) was very low. — 3% in one study.* and the mental trauma these people had to undergo, and the effects on hospital care for everyone else and on the workers themselves  were horrific. When the disease spread rapidly to Europe, doctors assumed that the Chinese were doing something right, and copied them, ventilating all very sick patients for long periods of time. In Italy, the very sophisticated health system there was soon under immense strain and nearly collapsed  

During this time I remember discussing what was happening with a group of retired doctors, and we all felt that it was totally inappropriate. We were knowledgable enough about the effects and results of long term intubation on elderly people and we were all very sure  that we would not want that for ourselves.   We would take our chances without it. 

In Britain, huge field hospitals  were quickly  set up to enable long term ventilation in ICU conditions.  But hardly any of these beds were used for critical covid care. The problem was lack of staff. Extra hospital beds can’t be used if there aren’t available extra fully trained staff. (Who knew?, as they say.)  In a pandemic, difficult choices have to be made, but It took more than a year for the doctors to realise the futility of this well-meaning attempt, and soon they had to restrict ICU ventilation to younger fitter patients who had a better chance of survival. 

The “Spanish” flu epidemic after the first world war, (we had all learnt about this in medical school)  did not mainly affect the elderly but instead targeted and killed mostly young healthy people – in that case often men and their families who had survived the first world war. So I, as an elderly person, at least felt grateful that Covid was not affecting young people. 

The next completely new problem concerned  trying to stop the spread of the disease,  using Test and Trace. This is a well documented  historic method of stopping the spread of  any infectious disease,  which worked well with diseases like Ebola, TB and flu to some extent. But nobody knew at the start of the pandemic how the virus was transmitted.

Covid turned out to be spread by aerosols, not droplets like flu. Therefore you could not get it very easily from contaminated surfaces, but it could spread round rooms in aerosols in the air extremely quickly.  Also it was not realised at that time  that  Covid could spread to the next victim in the 24 hours after infection, during  the prodromal period, and before the infected persons even knew they had the disease. 

 This was completely new. We were all taught that with most infections you are most contagious in the 3 to 4 days after you start to feel sick, and you remain contagious as long as you have symptoms.  But with Covid it seems that people can spread the disease immediately after the virus gets into the body,  during the incubation period and early prodromal  period. At this time there are no symptoms because the body is only just gearing up to fight the infection, and the symptoms such as fever, pain, or inflammation come from activation of the immune system,,

So this fact, which is related to the novel way in which the virus gets in through the ACE receptor, puts a real spanner in the works. Historically in any community at risk from an infectious disease, public health workers would try to immediately isolate people with symptoms and prevent them mixing with any non-infected  people.  This  requires a very methodical approach and when done well it works even with very infectious diseases.  The initial Covid virus (SARS-CoV-2)  was not extremely infectious  – the “r” number of people each person infected was less than 2, while measles for instance is about 15. But if people can’t be  isolated because they don’t know they have  the disease then you have to do retrospective  tracing and isolation – looking back on the people who were in contact with an index case for many days before they presented,  and seeing where they had spread the disease. This is actually what Taiwan, which had had experience of a similar virus, Sars 1, did to great effect. On learning of the first case of SARS-CoV-2 in January 2020, the authorities immediately closed the border with China,  imposed universal mask wearing, hand hygiene, introduce of digital technology incorporating big data, and quarantine of COVID-19 cases. As a result in 2020 there were 823 recorded cases with 9 deaths in Taiwan, a tiny amount compared to other countries, which shows what can be done using strict methods. Ultimately however the virus escaped even Taiwan’s efforts, as an outbreak among Taiwanese crew members of the state-owned China Airlines in late April 2021 led to a sharp surge in cases, causing a total of 4,871 COVID-19 cases in June, 2021. There were ultinatelty a total of 17,172 deaths from Covid there, still a lot lower than in many other countries.   

But the half hearted contact tracing done in so many countries did not stand a chance, and in Britain where a privatised and fragmented system was used, it was very poor indeed. According to reports, too few people were getting tested, results were coming back too slowly and not enough people were sticking to the instructions to isolate. So test and trace in the UK was having a marginal impact on transmission, and infection rates were still rising exponentially. 

This is why, in retrospect, I think that the initial lockdown was essential to prevent the exponential spread of covid and complete breakdown of health services for everyone.  Nothing else would stop it. 

After that first long lockdown though, if a well thought out and comprehensive track and trace system had been in place then it might have been possible to avoid the draconian successive lockdowns that were so damaging to children, those in poor housing and those vulnerable to violence. 

There has been a lot of discussion about the fact that  nursing homes were not protected at the beginning and that so many vulnerable people died there despite the best efforts of staff. But even now I can’t see a really good method of doing this. A hospital has to be able to admit those really sick people with covid who need urgent treatment. Therefore they need to discharge those patients who don’t need active care. Of course they should always test those patients and ensure they are covid negative before they are transferred to nursing homes, and this didn’t happen for many weeks.  But what if they tested negative 2 hours before transfer but then became positive  during the transfer process? This must have happened many times.  If patients weren’t to go back to nursing homes,  where were they to go?  Staying in hospital with really good systems of decontamination  and PPE  would only lead to more pressure on beds and treatment facilities. If possible, patients could go home, but even there if they weren’t able to manage without  help, they would have care staff visiting them, who could get covid and spread it to people they visited.  The need to develop a rapid accurate test early on in the pandemic was paramount, and was done, but it took time. People in hospital without covid still needed to be treated at a less intensive level, and so they were transferred to other wards, but despite heroic anti-infection measures, the virus still got around.

Nosocomial infection is the name given to hospital-acquired infections, and these have been around as long as hospitals have existed.  They are devastating to patients and their relatives. You go to hospital to be treated, not to catch deadly diseases. But they have always occurred and always will, unless better methods of PPE  are found. In the more distant past ordinary people were only too aware that hospitals could be dangerous places, and often wouldn’t go there at all. Only in the most  wealthy countries  with the best precautions can the  risk of infection be safely ignored.  

I think that the inquiry should come to the conclusion that a better test and trace system and better PPE  would have prevented the need for so many harmful lockdowns.There is no doubt that lockdowns were extremely damaging  to the fabric of society, and especially to children and the young people. They damaged children’s mental health and especially their education, and this damage is continuing. However the ill effects were very much worse for the poorest. Lack of equipment, lack of space and lack of help made online learning impossible for many children in poor households.The government did not give targeted help to such areas – in fact they seemed to give targeted help to private schools instead.   And the effect on the work of social services was disastrous.  Social workers could not visit households which needed help. Bullies and control freaks within families got away literally with murder. As a result, many children have died at the hands of abusive parents behind locked doors, using covid as an excuse not to admit social workers. 

The saddest case I read about was  the child disabled by spina bifida, who, unable to go to school during lockdown,  was confined to one room, unable to move from  her bed and fed solely on takeaways. She became morbidly obese and eventually died from infected bedsores. Her parents, who both worked, the mother as a carer, totally neglected her, and made excuse after excuse to refuse entry to social workers and others who wanted to check on what was happening.  We can have no idea what was going on in the minds of those parents, but the whole family obviously needed specialised help. It must be very hard for working parents to continue to look after a child as disabled as this for years. Undoubtedly the child should have been moved to a safe environment. But all normal checks and balances were prevented by the lockdown system, and the child got no help.The parents were both jailed for many years for the dreadful neglect and maltreatment. 

One other thing, on a separate health issue, this story shows is that it is what happens if a child eats nothing but fast food, and can get no exercise. The speed of progression of her obesity  where she went from 10 stone to 24 stone over the months of lockdown is mind boggling. Such fast food in this case was addictive, in that fast food was all this child had, and no doubt was the only thing that she enjoyed. But she would not have got so obese  if she was eating a balanced diet.   That fact is a lesson for everyone who thinks it is OK to eat a lot of junk food, and should be a lesson for the food industry which is providing such a lethal diet. But it would need government  direction for that to happen, 

Another big legacy of the pandemic is long covid. It may be that eventually long covid will prove to be the worst part of the pandemic worse even than the number of deaths and the effects on children and the poor.  This is because of the huge number of cases, and the severity of its effects on individuals. It is estimated that up to 10% of people contracting the Delta virus  developed long covid while less than 5% got it after Omicron. Vaccination also reduces the percentage of people getting long covid, so that if the virus does not mutate further there may eventually be a diminution of the number of new cases. But even so it is a huge number, at least 65 million cases world wide.

The severity of long covid varies a lot – some people have had extremely severe symptoms that have been likened to having had a stroke or a life changing accident, and which do not appear to be getting any better. Some are bed-bound and totally unable to care for themselves. Others have had less severe symptoms which nevertheless have a big effect on quality of life and ability to work. And the range of symptoms is huge, Neurological symptoms such as brain fog and poor concentration and memory can be very severe, resulting in their brains functioning at a level equivalent to being 10 years older. Long covid can lead to poor function of the autonomic system, giving rise to problems with low blood pressure and fainting; extreme fatigue,  especially after exercise, and also cardiac arrhythmias, chronic liver disease, cough and shortness of breath. The worst effects were seen in the 41 to 60 year age subgroup, and in those with more severe initial covid symptoms.  

To me,  it seemed very like the  disability caused by myalgic encephalitis, which I saw so often when I was in medical practice. Latest estimates are that around half of individuals with long COVID are estimated to meet the criteria for ME/CFS.   I hope that this might spur scientists on to find out exactly what is causing such disability. People with ME used to be told it was “all in the mind”, or at the very least, strongly influenced by mental factors such a depressions and anxiety, but  now iboth conditions are finally being taken very seriously. 

But the cause of Long Covid is still unknown. There is a wealth of evidence that  these symptoms could be caused by long term damage to various bodily systems, and can be measured by tests on blood cells and biochemical markers. It is likely that there are multiple, potentially overlapping, causes, such as  persistence of the virus in some tissues, immune dysregulation and mitochondrial dysfunction. Mitochondria are power house of the cells, and supply energy to the whole body, so damage to these organelles could well cause fatigue. What the exact mechanism is and why cold or flu viruses don’t cause such long term problems, is a mystery, but it is very obvious that the prevalence of these deleterious effects is  a game changer for health systems throughout the world. In  many individual cases of long covid there has been no improvement for months or years, and so far there is no treatment. 

So we can see that the personal and economic costs of long covid are very severe, and not many countries have really been able to come to terms with the amount of unmet medical need that exists. It is certainly true that ijn the UK, the well known reduction in participation in the labour market in the over 50’s is at least partly due to long covid, although there are other causes as well. 

The current inquiry is working to answer these questions, and many others, by examining  the UK’s response to and impact of the Covid-19 pandemic, and  to learn lessons for the future. I look forward to reading the report in due course, and hope the next pandemic is prepared for in a more thorough and scientific manner.   That said though, the next  pandemic will undoubtedly be very different again and may pose questions which are just as difficult. We just have to be quicker on the uptake next time.   

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Apps for Women’s Health

Posted on May 11, 2022 by Elen Samuel

The news that safe abortion is likely to be illegal in the USA, in vast swathes of the Midwest and south, is chilling.  The right to control what happens in one’s own body is a basic human right.   

In this blog I would like to move the conversation on to how to continue empowering women to make  choices over their bodies,  through using great advancements in the science of women’s health, both in contraception and in abortion. 

Abortion is never a first choice. It inevitably means that a woman (or teenager  or even a child)  has to make a choice to stop a bodily process which would lead to a new life, which if circumstances were right, might give great joy to the mother and her family and friends. Great advances in contraception have made it possible to prevent women and girls having to make that choice, because they can control their fertility more easily.  I remember the old days when girls would get pregnant out of complete ignorance, and had no choice but to have the baby. Sometimes they wanted to keep that baby, yet the “morals” of the day  dictated by religious institutions so that  they would be punished for getting pregnant and had to give their children up for adoption. Some of those women are  now telling of the awful effect on their lives.   That was another form of misogyny practiced by old men in positions of power in the big Christian  establishments, which was quite happy with young boys having sex but punished the girls who then got pregnant. 

These days we accept that young people will have sex when they feel ready for it, and where there is consent and no coercion. So why not make sure that girls are protected at the start? In my view it should be completely acceptable for all girls at the onset of puberty to be fitted with a long term contraceptive in their arm.   At the moment they can take the pill when they feel at risk of a pregnancy, but  a long lasting hormonal  implant would protect girls from the word go, and prevent the disastrous curtailing of their opportunities.  The implant is over 99% effective, and lasts for 3 years, and can be taken out sooner if desired. It can help reduce heavy periods and is completely safe. So the question is  “how can it be made more acceptable?”. In developed countries it would need education programs to advertise the benefits, which include preventing early marriage and economic benefits not only to the young girl, but also to the country as a whole.  The cost, as now, would be born mostly by international charities. It will be hard in countries such as in Africa, as I have written about in a previous blog. Access to education for girls may be severely limited, and many are married before they reach their eighteenth birthday. It will be a long hard road, but activists are continuing their work. 

As a result of the likelihood that Roe v Wade will be overturned in the USA,  women are getting together to fight, not only in the USA but all over the world where abortion  and contraception is restricted or prohibited.

The International Planned Parenthood Federation (IPPF) has published information about “safe at home” medical abortion services, which is being circulated world wide.  It is not well known that a high proportion of very early abortions are now being organised on-line in many countries;  the consultation  with a doctor is done online and the drugs posted to the woman in her own home. The method is recommended by the World Health Organization and the FDA ,and is perfectly safe, with a protocol that involves taking two drugs, Mifepristone  and Misoprostol, in tandem. The woman then has an early miscarriage at home. It was done legally during lockdown in the UK, up to 10 weeks  gestation without attending a clinic. It is also done extensively in Northern Ireland, which refuses to organise abortion services.  Of course sometimes it has to be done off the radar as anti-abortion activists will try to prevent it. But the situation in the USA and in many other part of the world is getting worse, with the rise in misogyny and sexual abuse, and we have to use such medical advances to fight the terrible  consequences of making abortion impossible to get.  So organizations such as  “Liberate Abortion”* which gives information  about abortion services and  “Aid Access”*  which gives practical help, are gearing up to expand even more for the USA. For the rest of the world, there is “Women on Web”* . There is a “Safe Abortion” app too. 

Aid Access is run by Dutch physician Rebecca Gomperts  and has provided a  cheap and readily accessible telemedicine service to people in the USA  since 2017, using a pharmacist in India who ships it to the patient in the US. India is the world leader in production of  generic medication, and the drugs are  of high quality, yet very cheap, so many more women can afford it.

Dr Gomperts says, “It is a medicine that should be available over the counter. It’s safer than many of the painkillers that you can buy in any pharmacy. The reason why it’s not possible has to do with politics and not medical science.” In richer countries girls are using apps to track their menstruation, so they know very early that they are probably pregnant. If there is a positive pregnancy test, then they can take abortion pills really early.  Clinically it is indistinguishable from delayed menstruation, or slightly later, a miscarriage. The   World Health Organization recently submitted  advice that women can safely self-manage medical abortion until 13 weeks of pregnancy, so it  really does empower more women and girls. Without the availability of such methods, women will turn to old fashioned methods of procuring an abortion  which cause  severe complications  such as  incomplete abortion with excessive blood loss and infection which often leads to death.  And why should any politicians seek to control the intimate details of a women’s menstrual cycle? Often people with such views are the very ones who say that they are against the state having any control over people’s lives.  What hypocrites they are!

So modern technology is definitely a force for good in allowing women to keep control of their own bodies, and fight off the challenges from groups that are anything but pro-life — they do not care about babies born into needless poverty once they are born, nor women who die because they are not allowed a timely abortion. The big challenge now is to spread these techniques to those who need them the most, women living in poverty in third world countries who are condemned to bear children that won’t have a future, especially if overpopulation and overconsumption mean that their homelands are disproportionately affected by climate change and they can no longer make a living.  It will need more organizations like the ones above to distribute  long term family planning to these areas, but education is key. Men and women need to know that these methods can guarantee a better life for all. A tall order of course, but  the alternative is horrendous. A world with many Afghanistans with no rights at all for half the population, more fighting, more poverty. Not a future for anyone to look forward to. 

https://aidaccess.org/en/

https://www.womenonweb.org/en/

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