Better Than Joe Wicks

On my mum's birthday, three days after Christmas, my gallbladder finally had enough of DEALING with my SHIT. Dealing with CHEESE, and MILK, and CHOCOLATE. In fact, it had probably had enough several days before since I'd been feeling sick and off food since Christmas Eve. I remember saying to Tom that I hoped I wasn't coming down with a sick bug because I would hate to not be able to eat at Christmas. OH. OH THE NAIVETE.

I spent that night in screaming, doubled up agony, with absolutely no idea what was wrong. At first, I thought I had trapped wind. Ha. No. I developed rigors, which is a Bad Sign, but didn't even recognise them. I couldn't wake Tom up. I had to keep putting Alex back to bed when he followed me to the toilet when I was being sick, and at one point felt something rip in my back. At no point did it occur to me to ring an ambulance, because it turns out I am only good at diagnosing other people. I googled. I worked out it was my gallbladder. I figured it probably wouldn't kill me (turns out I was wrong, it can kill you quite easily). At about 6am, I woke Tom up enough to get me some ibuprofen and then managed to sleep for a bit. I managed to sort myself out enough to ring the doctors and then rang 111 to see if I wouldn't be better off just going to hospital. They sent a paramedic out. The paramedic decided I didn't need admitting because I was in far less pain than before. The doctor put me on antibiotics. Another doctor put me on more antibiotics a week later. A week after that, I went to A+E and finally had a blood test to check there were no stones in my liver since I was still jaundiced. This showed the infection had cleared. I went for a scan a few days later, more than three weeks since I first got ill, which showed my gallbladder was absolutely fucking RAMMED with stones. So much so that the sono was surprised my gallbladder was still intact. So, at least I knew what was wrong. It also showed I have a fatty liver, which is not great in someone my age. I managed to get a surgical referral four weeks and three days after my initial diagnosis. 

Just a note here. The NICE guideline for acute cholecystitis, which is the proper name for a gallbladder infection, is bloods, scan, admission, IV antibiotics and a cholecystectomy within a week. This is because of the risk of chronic infection, sepsis and death (woo). I am still kinda fucking salty that this did not happen for me, because my temperature was 0.4 degrees under admission criteria when the paramedic came out. 

My first hospital appointment got cancelled because a water main burst under the hospital and they had to close the hospital down, so I didn't see a surgeon until eleven weeks after diagnosis. His happy news was that my surgery will be in the next twelve weeks. He gave me a diet sheet to force my liver to burn up its fat store before surgery. It reads like a diet of kings... two eggs for dinner? In what universe?

Now, some people get gallstones and they get the odd twinge if they eat the wrong thing. My dad is one of these lucky bastards - he's had a couple of biliary colic episodes ever (biliary colic is all the pain, no infection). Other people get gallstones and suddenly find they have zero tolerance for fat. Your gallbladder is a little organ that hangs out by your liver, injecting bile and helping digest fat. It spasms to release bile when you eat fatty food. Stones aren't always a problem, but if they get caught in the opening of the gallbladder, these spasms are CHRONIC FUCKING AWFUL AGONY. I mean it. I have had three huge-headed sons without painkillers, and gallbladder pain is worse than that. You can't get away from it, it's like a massive belt around the bottom of your ribs, squeezing and making you feel sick and wrong and breathless. I most commonly get pain on the opposite side of my rib cage and diaphragm, and in my back, because it rebounds all round your ribcage. My diaphragm always hurts and is distended. Breathing is a real issue when it's bad, as is the accompanying nausea.

via http://theawkwardyeti.com/

Unusually, I had no pain from my gallbladder until it got infected. Since then, constant fucking pain. I can't tolerate saturated fat at all. At. All. The first week or so was terrible, I thought I would die of hunger. It was the first time since childhood where I can honestly say I was properly hungry. I went ketotic for ages, and I know that's some sort of bizarre holy grail for dieting, but fuck me it's horrible. Your pee reeks of sugar, your mouth tastes constantly sweet, you feel achey and wrong and tired and sort of gluey in the limbs. But it passed, and now I'm used to it, and it's OK. Boring as fuck, but OK. 

I cry when I have to do the shopping because I can't eat what the kids have. Cooking for the kids is an endless nightmare - a few days back, they had jacket potatoes so I picked at the grated cheese. It hurt for hours. And I can't watch food programmes because I start to imagine the joys of food and then my gallbladder hurts because FOOD IS A THOUGHT CRIME. In terms of funsies, I've missed Christmas food, New Year booze, pancake day, Mother's Day, Jim's birthday cake (which I've just sobbingly made, without licking the bowl), and I will miss Easter and my birthday as well. 

I'm listed for surgery now. I can't wait. I cannot wait. I literally cannot wait. If I could spare six grand, I would have had it out privately weeks ago, but...lol, no. This is the most miserable illness I've ever had, and doubly cruel to take my cheese away. I know the recovery can be a bit rough, but I really don't care. 

But I have lost 20kg in less than three months. So there is a tiny silver lining. If you would like to experience this weightloss for yourself, but inconveniently lack gallstones, here's how*:

- Eat twice a day - muesli and Skyr for lunch with some jam for calories, and then something fatless and dense in lentils and other veg for tea. Shellfish are good. So is rice. Plain chicken is your only real meaty option. Jelly and fruit pastilles are allowed, Haribo isn't. If you haven't been in pain all day, you  might risk a stick of kikat as a snack in the evening. Otherwise, fast for eighteen hours out of twenty four.

- Should you eat eggs, chocolate, cake, pastry, pie, red meat, cheese, oily fish, butter, yoghurt or full fat milk by accident, don't panic. Fetch a metal kebab skewer and stick it in, nice and deep, under your ribs. Oh sure, it'll bleed and hurt, and you might end up with an infection or rupture, but it will remind you why you don't eat these things anymore.

- Drink plenty because you will be dehydrated as hell, and it's a useful way of getting calories in. Enjoy your single cup of tea a day (unless you can drink black tea), and remember, no alcohol. If you forget and have a glass of wine, ask someone to punch you in the upper abdomen or mid-back. You won't do it again.

- Take supplements. No, really, you will die otherwise.

- Now and then, regardless of how obedient you've been with your diet, stab yourself again with that skewer. Just in case you get complacent.

- Carry this diet on for a minimum of three months, and then wonder at your weight loss, strawlike hair, fragile skin, reduced concentration, poor mood, exhaustion and decimated social life!


*NB: Don't do any of this. I mean it. 

Charlie Gard

Charlie Gard is dying. He's been dying since the moment he was conceived. He has mitochondrial deletion syndrome. To put it very simply, the batteries in his cells don't work. There is no treatment for his condition: it's extremely rare and where diseases are rare, you have to improvise as you go along. He has been in Great Ormond Street Hospital for months, kept alive by machines, because keeping him alive is all they can do for him. My family has personal experience with GOSH's genetics team and you'll find no criticism of them here. Where there is hope, they will do whatever they can.

But it's hard, so hard to accept there's no hope, especially in a child so small. His parents have gone to every single court in this land and in Europe, begging for a chance to send Charlie to the US for experimental treatment: experimental treatment that even the doctor advocating it admits won't save him. They have blamed GOSH's workplace culture, saying GOSH refuse to admit they may be wrong about his chances, his prognosis. Their case has gone, to use a rather grim medical term, viral. Donald Trump has stuck his oar in. So has the Pope.
Today, the case goes back to court, to be tried on fresh evidence that Charlie is growing. The hospital say he is not growing. His parents say he is. The judge says he wants proof, and will base his judgement on that proof.

There are several contentious points here:

Medical Ethics
Is it ethical to send Charlie to the USA for treatment? In the UK, candidates for experimental treatment must be able to consent, they must be kept safe, there must be a fair chance of a good outcome. Charlie cannot consent. There is almost zero chance of a good outcome. The reason GOSH do not want him to take part in the trial is because it will make no difference. The reason the US doctor wants him in the trial is because people with mtDNA conditions this severe rarely survive - he's a useful little guinea pig. The key ethic in medicine is DO NO HARM - do nothing that will make the patient worse. Now, Charlie's ultimate outcome is death whichever way you look at it, but there is real suffering implicated in making a tiny baby travel nine hours across the Atlantic, in intensive care, for futile treatment which may kill him in the USA meaning his parents will have to repatriate his body, far away from their network of support. If he survives, he will come home and continue to require high dependency care for the rest of his life. It is traumatic enough to have a child in GOSH, which is often miles away from the family home. To have that child on a different continent is many times more traumatic.

The Rights of Charlie vs The Rights of his Parents
I have seen a lot (A LOT) of people insist that Charlie's parents have the right to decide whatever they want for their child. This is, fortunately, absolute bollocks in law and in practice, to prevent child abuse. As soon as a child is born, they have rights in law to be protected by the state in cases where a parent could do them harm. As described above, the move to send Charlie to the US can easily be considered causing harm to him. No parent is capable of making objective medical decisions about their child, which is why ethics panels exist, which is why doctors try to work with parents to do what is fair to the child. This is why Charlie has his own advocate in court. His parents are fighting for his life at all costs. GOSH are fighting to end that life. Charlie is neither old enough nor capable of having a voice. He gets no say in this.
But his parents, his poor parents. They have the most difficult time of all. Not only are they fighting to save their child, however fruitlessly, they are fighting the state on this matter. When you have a disabled child, however small the disability is, you have to fight and advocate and it feels like the entire system is set out to be as obstructive and difficult as possible. The NHS is an enormously potent and powerful institution. Of course his parents want to take Charlie to the US. Of course they want to exhaust every single possibility. How will they live with themselves if they give up? Every parent would do the same. There may be an unreality about their hopes and ambitions, but he's their baby and they're with him every day. What else can they do but fight?

The Interference of Donald Trump
Urgghh, this man. In case you know nothing of US healthcare, they don't have an NHS. All their healthcare runs on insurance, to a capitalist model that doesn't really work (as previously discussed, it's very difficult to run a capitalist health market when the ultimate outcome of the consumer is death - no profit). Obama brought in an Affordable Healthcare Act (known as Obamacare) to try and implement universal healthcare provision. Trump and the Republicans FUCKING HATE the ACA. Not only are they dismantling it, they are also attempting to bring in legislation to give insurers more power to refuse healthcare to people with preexisting conditions - preexisting conditions like having previously taken contraception, having been pregnant, having been raped. The Republicans do not believe that healthcare is a right.
So, it's somewhat ironic to have both Trump and his VP, Mike Pence, shout that Charlie should be allowed to go there for medical treatment. It is likely that they are going to use this as a stick to beat the NHS with, and since the NHS is one of the bargaining chips that Theresa May has admitted she is prepared to use to establish a trade deal with the US, WE SHOULD BE CONCERNED.

The Interference of the Pope
The Roman Catholic church believe in the inviolable right to life. No abortion. No euthanasia. You would think that the Pope would accept God's divine will in this sort of situation. Apparently not.

Money
BUT THEY HAVE RAISED OVER A MILLION POUNDS!?!! It's not about money. The NHS regularly invest millions in treatment for dying children to improve their quality of life - essentially throwing that money away since it's not curative. But it works both ways. You cannot throw money at illness and hope it goes away (although, money sure helps).

The shift in media's tone has moved away from SHOULD he be allowed to have this treatment to WHY WON'T ANYONE SAVE HIM? There seems to be a total disconnect of the reality of Charlie's condition. If the court rules he can go to the US, he has the treatment, the treatment somehow works a bit and he comes home, he will STILL be terribly ill and disabled for life.

Sometimes, medicine can't help, and that's the real problem here. It's not about citizenship, the perceived failings of the NHS, the monopoly of GOSH, the court system, money, or human rights. It's about the fact that medicine is unlikely to help this child and that is a blow to the heart of us all. Our culture has a faith in medicine, that one day it will destroy death itself, and this sort of case reminds us that medicine is fallible, some illness is written on the genes, and any of us could have a child like Charlie.

Stewart Jackson: Redux

It's election time once more! Last time, despite my pleas, Peterborough foolishly elected Stewart Jackson as MP once more by a scant 1950 votes. And, as his leaflet dropped on our doormat the other day, let's take a look at the Life and Lies of Stewart Jackson.

So, the front page. Stewart Jackson stands with Theresa May, as you'd expect really, considering he's a Tory. He's hardly going to claim he hates the bitch and would make a much better PM. There's also a photo of him beaming in front of Peterborough guildhall and supporting a bee protection charity. That's ironic since he's consistently voted against climate change protection measures.

Within the leaflet, he marks out the work he's done for the area, like blocking the solar energy farm that was going to be built on Newborough fen; raising a petition about Werrington freight line  - he doesn't mention it submitted before GE2015, went unanswered, and the plans went to the secretary of state three months ago - and trying to improve the A47, which is underway, notably with the FUCKING AWFUL traffic lights at Wansford A1 junction. Such a trooper. In fairness to Stewart Jackson, he does write to the cabinet with questions pertaining to Peterborough (most of which already have answers available in the public domain), and voted in around 85% of all votes. He pushed for Brexit, which is no surprise, and he's even curbed his expenses a little. He's very proud of Peterborough's low unemployment rates. He also claims that the NHS is his top local priority, which is an absolute joke considering his voting history.

His voting record remains a catalogue of misery for anyone who isn't an older, healthy, white, heterosexual, salaried, homeowning British citizen.
He has consistently voted against gay rights, race laws, benefits being raised in line with inflation, and increasing jobs for young people. He has voted for the bedroom tax, for restricting disability benefit, for restricting disability benefit to those who have been disabled from birth/youth. He has voted against limiting letting fees for tenants. He has voted against people with cancer receiving extended ESA, He voted for the tuition fees raise, for the academy system, and for the various bills undermining the NHS. He has voted against ID cards, but for mass data retention (the Snooper's charter). He voted against a right to remain for EU citizens. He has voted against special provision for military families in the welfare system. He has voted against slowing the rise of rail fares. He has voted against nationalisation of public transport.
Of course he has, he's a Tory.


The rest of the leaflet is given over to the words of The Great Leader Theresa May. Theresa swears she has set out a clear approach to Brexit, which...has she? Really? She says she has a strong negotiating hand. The Tories have been openly mocked by the rest of the EU and Theresa May has demonstrated that she couldn't successfully negotiate a child's bedtime. We have nothing to negotiate with, except tax haven status,
And then, in a rehash of the last election, we are told our election choice is Strong and Stable Leadership in the National Interest OR A COALITION OF CHAOS with Jeremy Corbyn and Tim Farron. DO YOU MEAN TO TELL ME, CONSERVATIVES, THAT A COALITION GOVERNMENT WITH THE LIB DEMS IS A BAD IDEA???

The leaflet then tells us that Trump winning was a shock, even though Theresa May fell over herself to rush over there and hold his grubby, orange mitt. Brexit was a shock, even though the Tories definitely wanted it and it's gonna be amazing, honest guv. And Corbyn winning two leadership elections was a shock.

Maybe Britain is fed up of your lying bullshit about caring, Theresa. Maybe hardworking British families, who are also apparently irresponsible benefit scroungers, have had enough of your shit, of your punishing the economically weak for the faults of the strong, of being told if they would JUST WORK HARDER, they too could be RICH. Maybe normal British people fancy someone with a bit of integrity, someone who is decent, who inspires faith in the politically inactive. Someone who hasn't promised on national TV to NUKE THE WORLD, you fucking bloodthirsty maniac. Maybe the national debt going from five hundred billion pounds under Gordon Brown to a staggering ONE THOUSAND SEVEN HUNDRED AND THIRTY BILLION POUNDS in just SEVEN YEARS of Conservative government doesn't inspire a lot of confidence about your FUCKING ECONOMIC NOUS, which has always been the Tory selling point.

People are dying under this government, unnecessarily. The NHS is being stealthily dismantled, as is the social care contract. We go headlong into Brexit, fronted by a vindictive racist who couldn't lead herself out of a paper bag; who thinks you will vote Tory because you think they're a safe pair of hands. They aren't.


All voting information from They Work For You. Economic information from UK Public Spending. Leaflet published by Matthew Dalton on behalf of Stewart Jackson. Vitriol my own. 

Hospitals - Not For Tripadvisor

When you have to visit the same department of a hospital several times, you memorise the signs. I now know that domestic violence spikes during sports events, and what different nursing uniforms mean. I know that if you dare try and get NHS treatment fraudulently, Teresa May herself is coming round with the boys. I know that, despite brexit, we can still get EHIC cards. And I know whether or not I would recommend the department to my nearest and dearest.

Wait, what?

We have spent a lot of time in ambulatory care at Peterborough hospital of late. It's a strange, useful department, designed for people who are too poorly to be seen in outpatients but who don't require an inpatient bed. A lot of people in there are being followed up from A+E, or having transfusions. Almost everyone in there feels like shit and a lot of them look it too. It's not the sort of place you go for a picnic, or the stunning view of the car park and Macmillan unit next door. The water's cold, the outside benches were designed for people with waves for arses, and they really need more reading material, but I'm not about to go on Tripadvisor and leave an excoriating review of the amenities. It's not somewhere you go for a jolly - we are there because Mum has to be there.

And yet, would I recommend this department to my friends and relatives? What a bizarre thing to ask people in an acute care centre. A few years back, I had a brain injury and about two weeks later, someone rang me up and asked me how I would rate the A+E dept. I can barely remember being in A+E, so how I was expected to rate it, I do not know.

The NHS likes to bang on about choice, namely choice of provider. Sometimes this can be really useful - I was able to get my son re-referred to his old hospital for an operation despite being out of area - but mostly it is meaningless, particularly in terms of acute care. When dripping blood everywhere, who has time to ponder to which A+E they are going to drag their detaching limb? Who has that level of local choice outside big cities? Where I live, there is Peterborough, which is five minutes away, but the next nearest large hospital is Hinchingbrooke, which is half an hour in good traffic. In an emergency, there's no question of where I'm going to go. Offering choice in acute care is illusory. Being asked to rate it is meaningless.

Treating patients as customers within the NHS is a real bugbear of mine. A good patient experience is very difficult to quantify. For example, excellently executed palliative care still results in a dead patient. Conversely, a live mother and baby is considered the best outcome in maternity care (as well it should be) regardless of trauma suffered. Patients experience the same illness in very different ways, every clinician has a slightly different approach to treatment, illness progression and injury healing can be very difficult to predict. How high patients are likely to rate departments surely depends on their mood, their particular problems and their experience on that day.

To give an example, when my mum was in Scarborough hospital (rated as requiring improvement by the CQC), some of her care on the ward and in transit was substandard from a professional point of view, but we are all so grateful that they saved her life that we wouldn't consider complaint. If asked whether I would recommend their emergency care team, I would give them a very high rating despite seeing some negligent care later on, because of that gratitude. However, when we have been sitting in ACU at Peterborough for six hours, waiting for medication that seems to take days to dispense, while Mum cries and dozes on a bed, I am disinclined to rate them highly. It's not their fault, their care is always excellent, but my mood is never good there.

To rate patient experience requires more detail and nuance than a simple "How likely are you to recommend us to friends or relatives? 1-5" rating, like you get in bloody Argos. If my curtains take thirty minutes to come down the chute in Argos, perhaps I have cause for complaint. Perhaps my giving them a 2 rating is justified. But giving a hospital a low rating because I had bad news that day? Because a poorly toddler was screaming and it made my migraine worse? Because some drunk vomited all over the waiting room and it took a while to clean up? Because I was scared? Because I was in pain? No. That's not a fair way to rate a department.

When I worked in general practice, we had to do patient surveys. For a month a year, everyone on reception would sick of the sight of this stack of questionnaires, ignored upon the desk because nobody coming to an urgent GP appointments wants to rate the surgery - they want to get their medication and go home. So what ended up happening was that all the regular patients would fill them in, rating us generally highly because they absolutely loved the GP or rating all the reception staff poorly because everyone hates GP receptionists. It never felt like a particularly fair way to assess patient opinion, least of all with all the staff fearful of what they might write (I believe now the CCG sends questionnaires direct to patients).

The NHS is not a shop. It is not Argos. It's not even Amazon. It's a public service. Hospitals are not theme parks, or holiday homes, or somewhere you can reasonably expect to enjoy yourself (unless you're some sort of fetishist). Rating your care is so subjective as to be almost meaningless outside of detailed debriefs after the event. Complaining is one thing: I am a seasoned complainer, usually because of instances of negligence or misconduct rather than bitching about a receptionist's tone, and the NHS needs to be open to justified complaint, but giving a flash rating subject to emotion at the point of care is ridiculous. Make it stop.

The £10 GP Charge

In an act of either smug self-importance, or epic trolling, Dr David Jones, a junior endocrinologist at  Worthing, has written to the BMJ stating that GPs should charge £10 a visit to prevent people wasting appointments. You'll note Dr Jones is not a GP, because any GP who has been practicing more than twenty minutes knows this would be disastrous.

First, how many patients do you think don't get their prescriptions filled because they can't really spare the £8.20? Loads. Way more than you'd imagine, because why else go to the doctor if you're not planning to use the medication you're obviously seeking? Many people don't go to the doctor for a cure, but for answers. If the answer is a medication they can't afford, well at least they know the answer. So, the country already has all these demonstrably unwell people not getting their medicine because of the cost. What's going to happen to all these demonstrably unwell people who cannot afford to go to the doctor's in the first place?

Then you have the people who can afford £10 to visit the GP, and therefore will assume it entitles them to special treatment. You see it all the time. People ask for a referral to the hospital clinic, find out the waiting time, and then decide they would like to go private because they envisage a system where they can be seen on the same day. Their optimism turns to rage when this mythical same-day-service turns out to be a two week wait. Bringing in a GP charge is unlikely to change patient turnover much at all in some areas, so instead there will be a crowd of furious people who have TEN WHOLE POUNDS AND EXPECT TO BE SEEN IMMEDIATELY! You already get this entitlement in the NHS. I cannot tell you how many times someone has huffed "I pay your wages" down the phone because I couldn't give them an appointment for three weeks, like that meant they owned the appointment system. Bring actual money changing hands instead of the invisibility of national insurance contributions and you have a recipe for a lot of upset patients, and stressed, threatened staff.
There would be people who, having paid their £10, would be furious because their three week cold is still a three week cold, and not pneumonia, demanding their money back on the basis of incompetence. And if the GP did get the diagnosis or treatment wrong, what then? Refunds?

Dr Jones seems to think the entire population of Britain has his medical knowledge and thus know when they should or should not seek a GP's advice. They don't. How many people can tell the difference between a viral infection and a bacterial infection when it is happening to them? Even people who are aware of the clinical differences between the two in presentation sometimes need it confirmed by a doctor. When you phone NHS Direct for PRETTY MUCH ANYTHING, they tell you to see your GP immediately or go straight to A+E, which does nothing to help patient anxiety. We have collectively lost our medical common sense in this country, partly as a result of being dependent on the NHS. We are told not to take painkillers for more than 3 days without seeing a GP. We are told to consult our GP before starting an exercise regime. We have to see a GP to be referred to hospital or for a blood test, even for longstanding complaints the GP is well aware of. Pregnant? See the GP, even though s/he will have absolutely nothing to do with your pregnancy care unless you're unwell.

What about when the doctor tells you to come back in a week? Do you have to pay another £10 just to be told you're better? Or when you have to see the GP for medication reviews on a regular basis? Chronic illness, already depressing and financially shite, could become very expensive. I had to have five injections in one week once - that would have been £50 just to stop me dying.

I strongly suspect that if the NHS introduced a £10 GP charge, the only change GPs would see would be a lot more people going to A+E (this already happens in massive numbers when people just can't get an appointment, like A+E give a shit about earache) and a lot more post-mortem reports coming through. Those who can afford to pay £10 for reassurance every time their elbow twangs will continue to waste GP time. Those who cannot afford to pay £10 when they're genuinely very ill will get worse and either overcrowd hospitals or die.

The whole point of general practice is that it's a gateway to medical help. Yes, if your arm is hanging off, you really do need to attend A+E, but what if your arm is just very swollen and painful at the elbow? And then it's your finger joints, your wrist, and then all your joints? And you have to pay £10 to be seen the first time, to have tests ordered, and then £10 to see the doctor again to be told the tests showed up rheumatoid arthritis, and then £10 again to see if the drugs (that you didn't get because you'd just spent your last tenner on the GP) prescribed last time actually worked, and then £10 a few weeks later to see if the drugs that you actually got last time have worked, and then another £10 because the GP forgot to refer you to rheumatology and just needs to check something again...and so on and so on.

GPs are massively oversubscribed, we all know that. If you don't believe me, ring up and find out how long you have to wait for a routine appointment. But GPs don't just deal with ill people and timewasters. It's not a dichotomy of the sick and the well.
They deal with people who are very sick indeed, but seem well. They deal with people who are physically fine, but full of psychosomatic illness because of anxiety or depression. They deal with people who are just lonely, who are slowly dying, who are actually dying right there in the waiting room. They deal with those who are absolutely fine but won't believe it, who seem absolutely fine but are definitely not. They deal with chronic illness, with acute illness, with tiny babies, and with centenarians.
So how to relieve the pressure? How about better patient education and empowerment in dealing with minor ailments? How about NHS Direct not telling absolutely everyone to go to the GP or A+E (down with NHS Direct!)? How about giving pharmacists and nurses more power?

The NHS needs to remain free at the point of access.

Love Your NHS

I am not afraid of hospitals. In fact, they are almost a second home. The NHS has saved my life twice, mended me in various small ways since then, and also seen my three boys safely into the world. I worked for the NHS for eight years, in various administrative and minor healthcare roles. My degree's mainly focused on healthcare delivery. The NHS has been my lifeline, employer, coworker, chief educator, and friend.
I get exasperated by the NHS. Sometimes, I get thoroughly pissed off with it. But mainly, I adore it and think it's the greatest thing our country does.

My eldest boy, Jim, had his second ever surgery yesterday; a reasonably routine hernia repair. The hospital were completely amazing. Once admitted, the play therapist was on hand to run through the preop procedures with him, and then went off to find him colouring to do to distract him from his raging hunger and anxiety. His nurse then found him a portable TV to watch The Lego Movie on as his surgery was delayed for several hours, and a starving autistic kid does not a happy patient make. We were left alone to watch it, and as it finished, the orderly came to warn us it was almost time. The same orderly made going to the theatres fun, and held an ipad with Angry Birds up to Jim's face while he was cannulated and put under, so he would keep still. He then explained where to go, how long it would be, and gave me a pager to summon me at the end. The recovery nurses explained why he was in so much distress, answered my slightly-too-clinical-for-a-parent questions, and calmly gave him extra pain relief. One of the students made him four rounds of toast, which he declared the greatest thing he'd ever eaten. The handover to the main ward was smooth, and everyone was happy to wait long enough for Tom to come back with some food for me, and to let him stay with us until we were all ready for sleep. They turned a blind eye to me keeping Alex on the ward with us on account of breastfeeding. A HCA took Jim's cannula out this morning and he didn't even wince. Everyone asked us constantly if we were ok, if we needed anything, if everything was OK. And it was immensely, enormously reassuring in the circumstances.
And that's 'just' the nursing and support staff. The surgeon, anaesthetist and various registrars and house officers we saw were equally amazing. They took the time to ask if we had questions, to listen to those questions, and answer them. They had god-knows-how-many patients to cover, but they didn't seem rushed.
Doing anything out of the ordinary with Jimmy can be difficult and stressful, but this was astonishingly easy. Exhausting, and emotional for me, but not harder than it needed to be, mainly because the staff were so wonderful. The day was fairly standard, a child admission, a routine procedure, their daily bread, nothing unusual or exciting here. They could have been blasé about it. They could have been dismissive of our fears. They weren't, not once. We felt safe. We felt reassured. We felt OK about something parents generally find very difficult to be OK about.

I support the junior doctors strike absolutely. I would support a strike if every single clinician in the NHS was involved, because the NHS is the greatest thing we have, and the government seems absolutely intent on destroying it, through a carefully considered strategy of underfunding care and undermining clinicians.
Fight it. Support your healthcare network. Love your NHS.

Image via telegraph.co.uk

NHS Bureaucrazy

I am cross.
Last year, I had a head injury that led to concussion and whiplash. I had all sorts of terrifying symptoms at the time like slurring, amnesia, dizziness, nausea, night blindness, peripheral vision loss and anomic aphasia. I couldn't stand up for a week, but I was back to normal within a few weeks.
Except that I still have a small blind spot in my peripheral vision. At first, I thought I was imagining it, and ignored it. Then I went for an eye test a month ago, mentioned it, had all the tests done and was referred because I wasn't imagining it.
Normally, if you have a dodgy eye test, the optician refers you directly to the hospital, but (presumably because of the head injury) I had to go and visit my GP first and talk about it to decide whether to send me to ophthalmology or neurology. The GP thought it was either caused by damage to my retina, optic nerve or visual cortex. The initial injury was on the right side, but it's my left eye that's affected. She referred me to ophthalmology. This was early last week, because GP appointments are gold dust.

Now, the bit that's made me cross.
Today, I got a letter that looked suspiciously like junk mail. I get a lot of junk mail at the moment, thanks to foolishly letting the Bounty woman have my details in the hospital after Alex was born. So, I opened it, expecting yet another life insurance offer because PARENTS DIE, and instead found a letter from some random fucking 'care innovations' company who the LGC apparently employ to triage ophthalmology referrals. Obviously, GPs cannot be trusted to refer to the right people, so this company in Henley-on-Thames does it for them.
The letter told me I needed to be triaged by an optometrist, and gave me a list of four clinics to go to for triage. In order to select one, I had to either ring up and tell them who I wanted to be referred to, or go online and do it. WHY NOT JUST SEND ME TO THE NEAREST? WHY THE FUCK WOULD I WANT TO GO TO A CLINIC 30 MILES AWAY?
Ahem.
So, I did this, only to be told that my 'chosen provider' will send me an appointment in the post.
*jumps up and down in a rage*

In ye olden days of eye referrals pre-NHS-sell-off, you saw your optician, they sent a referral to your GP who passed it on to ophthalmology, who trusted their secretaries to triage it and send you a suitable appointment. The process took perhaps a couple of weeks. This has already taken a month.
Now, I don't talk about it much because it's evil, but I am suffering quite severe postnatal anxiety at the moment. The very IDEA of going blind, never exactly appealing in the first place, has been preying on my mind like a giant wasp that will not stop hovering by my face. All I really want is an appointment to be told what the hell is up with my eye, so I can work my flailing anxiety into something like a sensible approach to the whole thing. And now I have to go and see an optometrist, who will then probably send me to ophthalmology anyway, lengthening the whole process into one of months rather than weeks.

Not to mention how confusing this must be to people who are perhaps less computer savvy or presume the crappy junk-maily scam-ish letter is junk mail, particularly if their sight is poor. I mean, it doesn't even have anything visual to suggest it represents the NHS:

SEEMS LEGIT!

It's almost like they're trying to get people to ignore the letters so they can cancel the referral (she said, cynically).

Prescriptions

So, Jeremy Hunt, who will best be remembered as the man who attempted to demolish the NHS (and will probably succeed) has a new idea. He has decreed that the wholesale cost of drugs costing more than £20 should be printed on the prescription label, to tell the person taking those drugs that they are funded by taxpayers.

I used to work in a rural dispensing practice. I absolutely loathed working in the dispensary, and only did during very busy periods, but sometimes I helped unpack the drug order upon which the wholesale cost of drugs is printed. This is the cost your CCG actually pay for the drugs, which you then pay £8.20 per item for, if you pay at all.

Now, in some cases, the price of the drug is less than the prescription cost, so you can bet Jeremy Hunt isn't going to put THAT on your drug box. It would not do for people to know they are paying £8.20 for a drug which has cost less than a quid. They might lose their faith in the prescription charge altogether, and then there would be issues.
However, many drugs cost an absolute fucking fortune. I used to use an asthma drug called Seretide, through an accuhaler (which is a type of inhaler where you don't have to co-ordinate breathing and squeezing). They cost £75 each, wholesale. I often used two a month when my asthma was severe, because I was on double dose. I paid standard prescription cost for it (£6-something back then). My GP recently changed it to the much cheaper Qvar, which is nowhere near as effective, but considering I'm "poorly compliant", it's cheaper for them.
One of my least-favourite jobs when working for the NHS was changing people's drugs, in batches, to something cheaper (usually statins and contraceptives) because the CCG had decided X drug was exactly the same and 5p cheaper, so upsetting hundreds of people's medication routines was worth it. And I could see their point, because that 5p multiplied by a few thousand people per month was a large saving. I hated the impersonality of it.

Now, Jeremy Hunt claims that this new measure will reduce drug wastage. Drug wastage is a HUGE problem for the NHS. If you take your drugs out of the chemist, change your mind and pop back in, those drugs have to be thrown away. They cannot be recycled. They cannot be put back on the shelf. Once they've been signed over to you, they're gone whether you take them or not. Sometimes, an elderly patient would die and their relatives would bring in binbags full of unused medication, hoping we could recycle it. Medication collected month on month, for which they'd paid nothing, never used because they hadn't told the GP they'd stopped taking X four years ago, or they didn't trust the new packaging and weren't sure it was the same drug, or they didn't NEED a fresh bottle of psoriasis shampoo every month, or they weren't sure if they were supposed to take the red tablets with the little white ones. Regular medication reviews may be a pain in the arse if you're on repeat prescriptions, but they're designed to stop this sort of thing happening. I daresay it still does, particularly with older people who live alone and struggle with transport.
But I doubt Jeremy Hunt's measure will make any difference. In fact, if I know elderly, often anxious patients on numerous medications, it's more likely to make them scared to get their medication at all. They don't want to make a fuss. They don't want to cost anyone £80 a month. They don't want any trouble. They'll just leave it. If they only take the pills every other day, that'll help save the NHS money. And that calcium tablet, they only take that once a week anyway, so maybe they don't need it at all?
And you can imagine the damage.

Well, if you can't, increased falls, increased stroke, increased heart attacks, increased extremely expensive operations and intensive care therapies, increased inpatients, increased A+E attendance, increased premature death. None of which will particularly save the NHS money. Except the deaths, I suppose.

There is another issue here. If there is one thing I could not loathe more about this toxic fucking government, it's the buzzwords of taxpayer and hardworking families. As a former taxpayer, married to a current taxpayer, in a hardworking family (I assume we're hardworking, I haven't ACTUALLY sent the kids to work down the mine yet, but it's only a matter of time) with fuck all money, I can honestly say that if I get ill, paying for a prescription vs waiting to see if I get better is often a genuine ethical conundrum. I frequently don't bother ordering asthma medication because it costs me almost £17 a month in prescription fees that I don't feel able to justify. It's not a problem at the moment because I have a maternity exemption certificate, but in another year, that'll be gone and I'll be back to poorly managed asthma and recurrent chest infections. Woop. If I was on multiple therapies, the problem would be multiplied. SOME people with life-threatening conditions get their medication free, but not all. And most people who have to pay for their prescriptions ARE taxpayers. This is the sheer bloody idiocy of it.
Taxpayers aren't IMMUNE from illness. Indeed, in the current economic climate, taxpayers are more likely to need antidepressants, anxiolytics and painkillers than usual. Wealth directly correlates to good health, less disability affected years, and longer life expectancy. The poorer you are, the sicker and more disabled you are likely to be (see The Black Report, The Marmot Review for more info) regardless of whether you work enough to pay tax or not.
Not to mention that the elderly, who probably cost the NHS the most in free prescription charges, have been taxpayers. Just as the government like to put pensions in the 'benefits' bracket of government spending, they also put them in the 'workshy' bracket of usefulness. Bloody old people, living too long and costing us money. Let's have a cull.

The money raised by prescription charges helps pay for everyone's medication cost. You might pay £8.20 for your one pound pack of painkillers, but the old lady behind you in the queue has paid nothing for her monthly bag worth £80 or so. And there is a massive deficit, because people live longer thanks to a regime of drugs aimed to hold chronic illness at bay. One day, you will probably need one of those chronic disease drugs, be it aspirin, insulin, a statin, a betablocker, or inhaled steroids. Maybe you're already on them, but begrudge having to pay for it because you'll die without it. Or you begrudge having to pay when you already pay your tax. But National Insurance doesn't just cover medication.
As a five year old, I cut my arm in half, lengthways. The NHS sent an ambulance, X-rayed my arm, cleaned all the glass out, fetched a plastic surgeon in on call to repair tendons and stitch a ligament back together, sewed it back up, gave me two days of inpatient care and then sent me home to recover, with painkillers. The staff, equipment, anaesthetic drugs, bedspace and care were not cheap. Without it, I was unlikely to have died from my injury, (unless it got infected) but I would have lost the use of my right hand, effectively disabling me for life. The NHS has emergencies like that every single SECOND across the country.

Chronic disease causes heart attacks (for which you need intensive care, heart surgery, specialist care, rehabilitation and sometimes intensive care transport), strokes (see previous, but with brain surgery instead of heart), progressive lung disease (home oxygen therapy, home care), and of course, death. The medications used to tackle chronic disease attempts to reduce the need for these expensive interventions. They are ultimately cheaper than inpatient care.Which is also funded by the taxpayer. Perhaps if this measure is a success, we will have balloons at the end of each inpatient bed telling us how much our stay has cost the taxpayer. I mean, I'm due to have a baby any day now, and that'll cost the NHS between £800 and £1000. Perhaps I should go and thank my husband for his taxpaying contributions that will allow a (hopefully) safe birth.

Personally, I think the prescription charge should be reduced, and means tested. If more people paid it, it would be both more profitable even if it were cheaper for individuals. I don't think it's fair that (lifelong taxpayers or not) some very rich people get their medication for free while people scraping the barrel have to choose between food or drugs.

But I don't actually think Jeremy Hunt's new scheme is anything to do with reducing wastage, and the cost of medication to the NHS. If he was that bothered, he'd aim his ire at pharmaceutical companies, who never shy from making money out of the sick. I think this is an early attempt to frighten us into accepting the eventual demise of the NHS, and the use of health insurance.

The NHS Is Doomed

No election should be fought on a single issue. No party should stand on a single issue - one of my main problems with UKIP outside the rampant fascism is their focus on immigration at the cost of everything else. However, the NHS is a massive issue that should have totally dominated this election, far more than taxes, immigrants or the EU.

The NHS is a socialist ideal - free healthcare for all. It's a very simple, very expensive ideal. It was introduced as a post-war reform, to centralise, regulate and democratise healthcare. Prior to this, healthcare was paid for either as it was necessary, or by insurance. My granny and her sister were in hospital for weeks with diphtheria in the 1930s, and that was paid for by their father's work 'stamp'. There was a lot of self-medication then as well - this being in the days before antibiotics - mostly with unregulated supplies of opiate based medicine. Colicky baby? Opiates! It was to be paid for through work-related National Insurance, which was not dissimilar to what most people were used to paying anyway. It was an ideal system.
The NHS, since those days, has mutated into an enormous, bureaucratic beast. In attempts to save money, managers were brought in to regulate practice. They have ended up sucking more money out of the NHS in wages than they save in administration. I was an NHS administrator, I know we are very necessary people, but I was on minimum wage to begin with and some are on hundreds of thousands of pounds a year.
Labour had some interesting ideas on how to make the NHS more profitable - mainly by getting private firms to build hospitals on a sort of hire-purchase agreement. Then they started selling off the buildings and responsibility for hospitals and GP surgeries to private companies. That worked fine, until the private companies decided they couldn't afford to run them anymore, and withdrew. You see, that's the real problem with privatising aspects of healthcare, as it has been with privatising other public services. When it ceases to be profitable, the private sector simply run away. Free healthcare is not a very lucrative business, so this is likely to happen a lot more in future.

The coalition government also made a lot of cuts to the services offered on the NHS, as well as raising prescription costs enormously (£7.20 per item in 2010 to £8.20 in 2015). In a startling deviation from my usual lefty saucepan-banging, I believe prescription costs should be around £0.50 per item, but applicable to all but the critically ill and the extremely poor. I know how much medication costs wholesale: it shouldn't be free to as many people as it is, but neither should it be prohibitively expensive. The coalition government also cut staffing, particularly in nursing where I suppose they think people won't notice, and in A+E departments, where people certainly do. 

The problem with the new Conservative government and the NHS is that the Conservatives are ideologically opposed to the NHS. This isn't me being a bleeding-heart liberal: they believe in telling us what to do to keep healthy, and that is as far as it goes. The Conservative viewpoint on health is that it is your responsibility, your fault and your problem if you're ill.
Thatcherism took this even further into the realms of market liberalism. Don't be fooled by the name, the liberalism refers to the freedom of the markets, not you. Market liberalism holds that the market should be free to set costs without government interference. So not only are you ill (which is your fault), your treatment price is inflated. Hurrah for Thatcher (said nobody, ever).

And the thing is, that would be FINE if health was merely down to a matter of personal responsibility. But we all know it's not, even if we try and convince ourselves ideologically that people give themselves cancer, or depression, or chronic disease. We all know someone healthy cut down in their prime by some apparent fluke illness or accident. We all know someone who's done every single recklessly unhealthy thing you can imagine and lived to a ripe old age.

One of the biggest factors in your lifespan and your years of freedom from disability is your wealth. The more money you have, the healthier you are likelier to be, and the longer your life. There is a nine year gap in average lifespan between the richest and poorest areas of the UK. NINE YEARS. Not only is there that lifespan gap, there's also a huge gap in experience of disability.

Now, there are loads of reasons poor people experience poor health, and very few of them are down to personal factors. One of the main reasons is infrastructure. When you live in a poor area, your access to doctors, hospitals, transport, nutrition, good housing, employment, and exercise is limited. Your exposure to pollution, cigarette smoke, accidents, antisocial behaviour, stress and housing-related issues like mould is increased. Education also has an important, if unexplained, effect on health - more educated people tend to be healthier, and schools in poor areas tend to have lower qualification rates.
All of this is exacerbated by work. If you are fairly well off and work in the private sector, it's likely that you have a sick pay scheme. You may even have health insurance. Even so, suddenly being unable to work for a long period of time can be a disconcerting, depressing and stressful experience. However, when you work in lower class employment, or in the lower sectors of the public sector, you are dependent on statutory sick pay. SSP is currently £88.45 a week. You cannot claim SSP if you are on a zero-hours contract, or a very low wage. It's eligible for six months, after which you either continue on nothing, be sacked for continual absence and thus ineligible for jobseekers allowance, or leave work and switch to a disability benefit. I know a lady who was sacked because she'd had too many periods of sickness in the last few years, and then had a bad chest infection. Her previous absences were due to having chemotherapy. This was perfectly legal. Naturally, switching to a disability benefit is universally considered a bad thing by the Conservatives. Far better to keep the working masses in work, surely?

Yet it is the working mass, the seething, swarming low-paid mass, that needs the NHS most, potentially costs the benefit system most, and is capable of paying back into the economy. These are the people the Conservative government would prefer did not exist. The people they wish would be as wealthy as they are, so they didn't have to worry about society. The people they continually push down the ladder through social and economic inequality, and then seem surprised when it costs the state money to do so.  I'm sure there are plenty of individual Conservative MPs and voters that staunchly believe in the NHS, but that's not the party line, so they may as well piss in the wind.
Thatcher said there is no such thing as society. Unfortunately for her acolytes, there is, but don't expect the gentle dismantling of the NHS infrastructure to stop now the coalition has ended.

Expect it to get worse. Expect it to become more overt. Expect to become anaesthetised to the idea that the NHS is a salvageable , workable entity. Expect to be unsurprised when it's rebranded, or you are asked to put down a deposit when making a GP appointment 'to ensure your attendance'. Expect GPs to be blamed. Expect A+Es to be blamed. Expect managers to be blamed. Expect ill people to be blamed. Expect immigrants to be blamed. In fact, expect everyone else to be blamed for the sad, but necessary dissolution of the NHS except the government.

I love the NHS - I love it as staff, I love it as a patient, I even love it as a parent of a disabled child, where it's failed us most.
I hope I'm wrong about this. Ask me in five years. 

Choice (...or the biomedical dominance of obstetrics)

Why does pregnancy and birth often mean the loss of autonomy and free choice for women?

At no other stage in life have I been encouraged to have a flu jab with quite the demented intensity as in the last four months. I've always qualified for one, and never had one, and nobody has ever cared until NOW. Now, I know the risks of flu in pregnancy, and I know how little difference the flu jab makes to anything, so on balance I prefer not to put anything in my body I haven't had in there before (please don't confuse this with some sort of raging anti-vaccination stance - I don't react well to any vaccination and prefer not to have them if it's not strictly necessary).
I've also been told I WILL HAVE the whooping cough vaccination at 28 weeks. Again, I understand the rationale, actually completely agree with it, and will happily have it. But I've not been asked to consent. I've not even been told that dissent is an option.
I've been told I MUST have a GTT (glucose tolerance test, a blood test for diabetes) at 28 weeks on account of being fat and having had a big baby. Now, my 'big baby' was actually spot on in weight for my height and ethnicity, according to the hospital's own growth chart system. I've also had a majorly underweight baby. I've never had diabetes in my life, and certainly not in pregnancy, and yet I have been told to go to the hospital and have this test (which takes two hours) and have never been given the opportunity to dissent, or had it explained that it is a choice.

Then you have the large number of people, including politicians, who believe smoking and drinking in pregnancy should be illegalised. Now, it is perfectly legal to actually kill your baby before 24 weeks of pregnancy, if you want to, provided you go through the proper channels. How can you decide, in law, that a baby has no rights to life before 24 weeks, but definitely has the right to not to be poisoned? It's a totally flawed argument, with extremely limited evidence. As it is, you're told to stop drinking and smoking the second you find out you're pregnant. Now, this has never been a problem for me - I don't smoke, and I don't drink if I suspect I'm pregnant - but it's a big problem for a lot of other women, particularly smokers.

Every single woman in England, if not the entire UK, has the right to ask for, and be permitted a homebirth except in high risk circumstances. Yet, I know many women who are never told it's even an option where they live. Presumably this is why homebirth rates are so low. I want a homebirth, and will blog about the whys and wherefores later on in pregnancy, but I've already had to see a consultant to be 'approved' for one, based on a one-off situation that's unlikely to be repeated. There is a strong sense among obstetricians that homebirths are inherently risky, as opposed to the safety of a hospital birth, ignoring the simple truth that BIRTH is a risky business, and yet women have been doing it to varying degrees of success since we evolved into bipeds.

Much is made of choices around labour. My maternity notes have a whole page in which to discuss my birth plan, and explain on what I would like to happen. Dear reader, I will totally ignore that page, because I know full well that the second something in my labour changes, that plan will get lobbed out the window. I strongly advise you to do the same. Birth choices are only acknowledged and acted upon until something changes. That can be as simple as not having a waterbirth because the waterbirth room is already occupied, to labouring far too fast to have a chance to light the myriad candles and incense, to needing an emergency caesarean. And women are not really made aware beforehand that the time and effort they put into organising their birth choices and preferences in their head, and in their notes, is wasted the second something goes slightly awry. This in itself can lead to angst and unhappiness postnatally.

Women's choice in labour is removed entirely if a risk is detected. Few women are ever given what would normally be called 'informed choice' prior to an emergency caesarean, on the basis that there simply isn't time. This can be accepted, if the baby or woman is dying. However, often women aren't given informed choice when there is no immediate risk to life. I've discussed how induction is rarely explained as an option rather than an inevitability. I was told when I was overdue with my last baby that it was up to the consultant whether I could decline an induction. Er no, it's definitely up to me!
The same can happen with episiotomy, although less so than in the days (1950s-1980s) when episiotomy was done as standard, and one woman was CUT AFTER DELIVERY so the midwife wouldn't get into trouble for not doing it during the birth.
Too often, in the chaos of the delivery room and the fear of perinatal death, the birthing woman is not told what is happening, what has gone wrong, and what needs to happen next.

I don't understand why women's choice is so heavily curtailed in pregnancy and birth. Are we really to be thought of as silly children, who are incapable of understanding risk? Who would put our own prejudices above the health of our babies? Are we thought of as not able to understand the rationale and say no, regardless of what current NICE guidelines are? I mean, it's not like consultants follow the NICE guidelines about perinatal care half the time anyway.  Perhaps the real problem is that midwives and consultants simply don't have the TIME to properly explain the reasons for certain tests and advice.
The only real choice I feel I've been given so far is whether or not to have the sexual health blood screening for HIV and syphillis, and whether or not to have the NT scan. Everything else has been done to me.
It's a strange feeling, to feel as though your body is not really your own anymore, simply because there's another person in it.

Labour pains

Once upon a time, there was no such thing as pain relief in labour. It didn't matter if your labour lasted an hour or three days: there was nothing to offer for the pain. As well as this, if your baby got stuck, it died and most of the time, so did you. This used to be considered part of the curse of womanhood - to punish Eve for her fall, God stated that women must bear their children in blood and pain. In our time, it is difficult to understand how absolute the word of the Bible was historically. Childbirth was a pain women had to bear.

Times have changed and obstetric practice has gone through various fashions. For example, twilight birth was first offered as a treatment for pain of childbirth in the 1860s, via chloroform (praised magnificently by Queen Victoria, who didn't have easy births despite her grand multiparity), and evolved to being normal practice in the US until the 1940s. Women were injected with a morphine based mixture in the early phases of labour, and then remained barely conscious and unaware of pain until after the birth. The side effect was a drowsy baby with decreased respiratory function.
In the 1970s, pethidine was given to labouring women in hospital, usually without consent. Our notion of informed consent is surprisingly modern - until the mid 1980s, women were shaved and subjected to enemas in early labour, monitored and confined to bed throughout the labour and then given an episiotomy during the birth without much explanation, as a matter of course, to keep things tidy and easy for the delivering doctor.
Radical midwifery began the change in obstetric practice in the 1980s, as a response to this overmedicalisation of childbirth. The radical midwifery movement saw childbirth as a natural and normal act, whereas the medical fraternity of the time saw it as fraught with risk.
Nowadays, obstetrics falls somewhere between the two extremes. Women are considered low risk, unless they fit one of a number of criteria which escalates them to high risk. Women now have a right to choose where to deliver their child, and have a choice of pain relieving medications. Some women are able to have a vaginal delivery, with minimal interference, at home or hospital. Other women have more technical deliveries, overseen by several clinicians. However, the assessment of who needs what kind of birth is done on a case by case basis, and the woman's needs are acknowledged in the process - or at least, they should be. As I've alluded to before, this isn't yet internalised procedure for all clinicians.

The issue of pain relief in childbirth is one that comes up, most often when women are in their first pregnancy and their midwife, family and friends ask them what they are planning to use. Midwives generally advise women not to plan their pain control too much, as it doesn't allow for adaptation in labour. Friends who have already had children, will often fall into one of two camps based on their experience - 'have ALL the pain relief because it's the worst pain ever and you'll DIE' or 'pain relief is for wusses'.
The red camp are scaremongerers, the blue camp are not being realistic. Nobody knows what they are capable of withstanding physically until they do it. No woman can predict how the length or intensity of their labour, whether it's their first child or ninth. There are women who have their children with no pain relief at all, and ones who have an epidural at 4cm because the pain is so vicious. Neither are wrong, or right, they're just doing what they need to do to get through it.
There are side effects of using pain relief - pethidine, diamorphine and meptid can lead to a dopey baby, or worse a baby in respiratory distress. Having an epidural contributes to birth interventions, because the woman cannot coordinate her physical pushing with the uterine contractions, and being confined to bed protracts labour as gravity cannot work. Gas and air is the safest form of pain relief, though it can lose it's effectiveness in the later stages of labour.
However, an excessively painful labour may lead to psychological problems postnatally. I had no pain relief in my first labour because it progressed so quickly that there wasn't time. For some time afterwards, I had vivid flashbacks to being in agony and terrified - pain is very frightening if you don't feel in control of it. The pain, and speed of delivery, alienated me from my baby to begin with. I simply couldn't comprehend that this child had come from me. I had been expecting a long first labour, mostly in hospital. Instead, I got two hours of agony on my toilet at home, an hour of trying not to push while I got to hospital, and then an hour of pushing. I don't know if my trauma would have been lessened if I had pain relief, but I probably would have felt more in control. It has been almost four years, and I can still feel my body trying not to push if I think about the half an hour or so before I was 'allowed' to push by a midwife.
Equally, a labour without pain relief can be extremely cathartic. I had my second child without pain relief, by choice, expecting a fast labour. I got a fast labour - 1 hour 50 minutes - and felt wholly in control throughout. The pain was awful, as labour pain is, but it never felt unmanageable. His birth was healing, both to the trauma of my first birth, and the trauma of my second pregnancy.
A drug-free labour can be extremely empowering, but a planned drug-free labour that goes awry for whatever reason can lead to feelings of failure and inadequacy. Some women consider using pain relief to be cheating, or an easy way out, rather than an advantage of modern medicine. Other women consider using pain relief as a normal part of life - after all, you take medication for a headache, why not for the worst pain you'll ever bear?

Labour pain requires management. Some women can manage it on their own, through sheer force of will, through breathing techniques or hypnosis. Some women need drugs to manage the pain. Pain thresholds vary from person to person, and people's perception of pain also varies. Most women are capable of giving birth vaginally, without pain relief, but not doing so, through choice or necessity, does not make them less of a woman, or less of a mother.

Chickenpox - a study of frontline care in action

The NHS relies on patients being able to self-diagnose. If every patient went to their GP, or a walk in centre or A+E with a sniffle (and some do), the service would be swamped. So, the NHS expects individuals to be able to decide when they are ill enough to need a professional opinion.

My eldest son has chickenpox. Chickenpox is the last remaining widespread childhood disease. In the USA and other countries, a vaccination is offered, but the NHS does not offer it as it's largely harmless and short lived. Some parents, in an effort to expose their child to the disease young, hold chickenpox parties to spread infection. Varicella infection is dangerous in non-immune pregnant women as unborn babies can die from it, so I think a chickenpox party is a bit daft. However, most children will have it before they leave primary school.
Parents expect it, they recognise it and they treat it largely without professional help.

So, I phoned my doctor's surgery to ask them to record it on his notes. After all, doctors aren't psychic. The receptionist was astonished that I'd done this and told me only a doctor could record a diagnosis. So, I sighed a deep and heavy sigh, pointed out that I didn't want to infect her waiting room or waste an appointment, and my son isn't particularly unwell, just incredibly spotty and grumpy. Eventually, she agreed to put it on his notes.
Then I wandered up to my local chemist. There is a service called Pharmacy First that allows your chemist to diagnose and prescribe medications for children in the chemist. It's only really for over-the-counter medications, so parents can have them for free without using a GP appointment. They prescribe for conjunctivitis, hayfever and mild analgesia. I asked for piriton, if it was available, after asking for calamine. I didn't take my son with me, because he's INCREDIBLY spotty and likely INCREDIBLY contagious. After some argument about whether or not chickenpox is contagious after the spots come out (they said no, I said yes), they ummed and ahhed over whether to give me the medication without seeing the child. Eventually they agreed to - I use the chemist on a very regular basis, for all kinds of minor illness, so they're well acquainted with me and my kids.
But what else would I want free piriton for? I could buy it easily. I'm not going to sell it on the black market, or use it to drug my poor defenceless children. Their argument was that they had to be sure, and it wasn't a 'remote' service.

And you know, I understand that. It seems that the more the NHS tries to give patients additional autonomy, the more bureaucracy needs to be fulfilled, the more patients are put off. Why bother going through rigmarole and form filling at your pharmacy when you can go direct to your GP? I have eight years experience in general practice, as a receptionist, administrator and nursing assistant, I'm pretty confident I know how the system works and how to diagnose chickenpox, and everything I've done this morning has been aimed at saving GP time. My motives for doing so have been scrutinised. Is it that impossible to imagine a patient might genuinely want to avoid wasting resources? Is it impossible for a person to diagnose the most easily recognised rash without formal medical training?

The NHS relies on self-care and self-diagnosis. However, there seems to be another force at work trying to keep diagnostics firmly in the hands of professionals. Front line care is flooded by people who are anxious about minor symptoms, who need reassurance and OTC medication. The NHS needs to give people confidence in their autonomy.

Immunisation

Immunisation and cancer screening are the two of the leading forms of healthcare prevention practiced by the NHS. Most women will have smear tests regularly during their pre-menopausal years, and then breast screening when they are older. Men are increasingly offered prostate checks, and both genders are being offered bowel cancer screening. These screening tests are designed to catch early neoplasms, and in doing so, save lives.
Immunisation is routinely practised on children, from 8 weeks old until approximately 16 years. Immunisations carried out after that point are either for holiday/employment means or immunologically compromised patients.
In cancer screening, patients have the right to refuse. They might be exhorted to attend, for QOF measures and for their personal health, but they're under no obligation to go.
However, families who choose not to immunise their children are denounced.

 Childhood immunisation has been part of the NHS since it's inception, and was part of public health schemes long before that. The Diphtheria/tetanus/polio vaccine was administered regularly from the early 1960s, and as more vaccines have been developed, more have been offered. My children are immune to diphtheria, tetanus, polio, meningitis C, haemophilius influenzae type B, whooping cough, pneumonia, measles, mumps and rubella.
Pre-immunisation, these diseases killed millions. My grandmother suffered diphtheria in the days before the NHS, immunisation and penicillin. She was in an isolation hospital for months, forced to lie down constantly and kept away from her family (except her sister who was in with her). She watched other children on the ward die. This was not uncommon. Families who couldn't afford to send their children to hospital, if their child was suffering from a notifiable disease, were legally culpable. The child would usually die without good nursing. In my days working for the NHS, we had several patients suffering from ongoing disabilities from polio infections in their childhood, some dating from as late as the 1950s. For these families, a simple immunisation would have been a lifesaver.When I summarised patient notes, it was rare to find a patient growing up pre-1965 who didn't suffer from one of the childhood diseases that we now consider rare.
The MMR jab was not developed until the 80s. I suffered from mumps in 1988, and my brother suffered measles around the same time - neither of us were immunised, as we were too old when the vaccine became available. Cases of measles are now on the rise, as the herd immunity offered by mass vaccination wanes. This is largely due to the Wakefield Report, which linked autism to MMR vaccination, a report that has since been deemed false, and fraudulent.

There are many reasons that parents do not vaccinate their children. There are worries of autism/neurological illness, or a distrust of vaccination ingredients. Others do not believe the theory of vaccination. The common thread, from what I've seen on the internet, is fear inspired by ignorance. In one story I read, a woman refused to vaccinate because the immunisation contained ingredients she didn't know. This reminds me of the time my dad went through his PC and deleted every file he didn't recognise, and then wondered why his computer didn't work.

However, more common is the reluctance to introduce drugs to a newborn's baby. From conception, pregnant women are told not to smoke, not to drink, not to take medication unless it's necessary, not to eat raw fish, to cook meat properly, to avoid cheeses, with the clear message being "If you do, and something happens to your baby, it is YOUR FAULT."
Then, almost as soon as the baby is born, women are enjoined to take their precious newborn to a clinic to have an enormous needle stuck in it's leg, full of chemicals.

And if parents refuse to vaccinate their child, through fear, or ignorance, or cultural belief, or just because they don't want to, society vilifies them. They are called child abusers. Their friends are reluctant to let them play with their children, schools and nurseries are reluctant to take them on. The child and it's parents are punished for failing to conform to the biomedical patriachy. "The NHS has these lovely vaccinations, that could save your child's life, and you don't want it? You ungrateful swine, we hope you get diphtheria, just to prove how amazing we are!"

I remember telling a nurse, who I was friends with, that I wanted my eldest to have his first MMR and HIB/Men C booster separately. She looked at me askance and immediately started having a go about there being no proven link to autism. She could see no other reason why I didn't want my son exposed to two lots of vaccine at once. Nonetheless, after ranting at me like I was an idiot for a few minutes, she accepted my request. My reasons had nothing to do with fear of vaccination - I think vaccination is a wonderful thing - but because my son (like me) reacts badly to immunisation. He gets poorly, and has a localised reaction every time. I didn't want him to have to suffer a double lot of ouch if he didn't need to, and if he was allergic to the MMR, I wanted a clear cause. As it was, he had classic measles-type rash ten days after immunisation and was poorly for a day or so. I knew what had caused it, and didn't worry or panic. My younger son has the constitution of a horse, so there was no need to space out his immunisations. He also had the post-MMR rash.

There is definitely a feeling within the NHS that immunisation is not a parental choice, but a duty. Although a parent needs to give signed consent for administration, it is assumed that they will give this, and any questions are construed as dissent.

There are now a generation of parents and grandparents who do not remember life pre-vaccination. They do not remember fearing that an URTI would mutate into diphtheria. They do not remember worrying that a viral rash would be early measles.Parents are now able to look after their children without worrying about deadly childhood disease, meningitis excepted. There is very little education available on the components and benefits of immunisation, to the average first parent, because consent is assumed - some cursory leaflets and a bit of information in the 0-5 year book. Infectious childhood diseases, which are still rife in certain parts of the world, are assumed eradicated, the need to immunise questionable.

It does nobody any good to call anti-vaccination parents stupid, to act as though they are single handedly ruining the NHS and all it has striven for. Instead, the NHS needs encourage questions on how vaccines work, their ingredients and their necessity, with practitioners able to give answers there and then. An informed choice is better than blind conformity.

Informed choice and dissent in post-term induction of labour

Recently my little sister gave birth to her second baby. She was 42 weeks pregnant exactly, and had a spontaneous natural labour, that she described as peaceful. Her little girl was a healthy weight, and is absolutely beautiful.
However, the day before her labour started naturally, she was admitted for a routine induction of labour, which she refused. Despite saying repeatedly to her own midwife, the midwife on the phone and the midwife on the assessment ward that she did not want to be induced, she had to see an obstetrician to make sure she understood the risks of refusal. And that obstetrician did what all obstetricians do when women refuse induction solely for being overdue: she pulled the "YOUR BABY WILL DIE" card. Luckily, my sister refused to be scared, had a normal placental flow scan and was discharged. Her labour began properly the following evening and she had a quick, painkiller free delivery. I am VERY proud of her.
I had my second child at 42 weeks gestation as well. I was due to be admitted for an induction (which I did not want) a few hours after he was born. I had an exceptionally fast labour and when he was born, he was shown to have two knots in his umbilical cord. Not only could this have killed him at any time from around 14 weeks of pregnancy, if my membranes had been ruptured, he would have become distressed and I would have had either a caesarean or stillbirth. Instead, I had a natural birth at home, exactly as I'd wanted, and he was born healthy.
 My mother's sixth child (the sister mentioned above) was 19 days late before she was finally browbeaten into an induction, however she was already in early labour. Her EIGHTH child was twelve days late, when the obstetrician on call asked her if she wanted her baby to die, to try and force her into an induction. Considering my mother's seventh child was a premature stillbirth, this was incredibly cruel. My youngest sister was born safe and happy 12 hours later. 

Are there risks associated with overdue babies? Yes, of course there are, or it wouldn't be an issue. One study shows that at your due date, in a normal pregnancy, your risk of stillbirth and neonatal death sits at 0.24%. By 43 weeks, it has increased to 0.58% (Hilder, 1998). A much larger, longer case study was done in Scotland, which put the mortality rate at 43 weeks at 1.15%, as opposed to 0.22% at term. The baby, being presumed more mature, may pass meconium in labour, which may poison them. However, this is not exclusive to overdue babies.There has been a Dutch report that suggests there is increased likelihood of ADHD in postterm babies. (NHS choices, 2012). Otherwise, aside from fears of large babies, postmaturity syndrome, and placental problems, there are few risks associated with prolonged pregnancy that do not exist in ALL pregnancy.

However, although the NICE guidelines are that pregnancy should not progress past 42 weeks, and suggests induction of labour in these circumstances it also states that "Women with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour." and "if a woman chooses not to have induction of labour, her decision should be respected. Healthcare professionals should discuss the woman's care with her from then on." (NICE, 2012). It also advises that induction of labour should not be offered solely because of likely macrosomia (NICE, 2012), otherwise known as a big baby.

My sister had previously told her midwife that she was uninterested in an induction, and was told that the last patient who'd done that had died, along with the baby, in a teepee in the garden. She then asked my sister if she was also planning on giving birth in a teepee. When I told my midwife that I did not want to be induced, she shrugged, said she had to follow protocol (in booking it) and that it was up to the consultant. A friend (who delivered under the same midwifery team as me) tells me how her midwife was equally surprised at her induction refusal and implied it was the consultant's choice.
Another describes her delivery team as: "I was given the impression that they thought I was a silly little girl for wanting it my way and that I'd change my mind and do what they wanted me to do."
Another women said "It didn't feel like a choice at all, just something I was told was going to happen. The actual process of breaking my waters was done without my prior consent - I was led to believe they were simply examining me."
Informed, unpressured consent in the small pool of women I consulted happened in just under one third of the cases. All women described an amount of expectation, and pressure that they would conform to having an induction.Several described having to demand the information on the procedure and risks, rather than it being given as a matter of course.

What of the risk in being induced? Induced labours are markedly more painful than natural, as the body is being forced to do something it is not ready to do. Induced labours can also be much slower, which in natural labour is not much of a problem - you just carry on until you're fully dilated, unless you want to be augmented with hormones. However, once the induction process begins, you are on a timer, and if your body fails to do as it's told, more intervention is necessary to bring forth the baby.
Both of these factors can cause problems with the labour. Painful labour often means an epidural, an epidural means lying around in bed, and that slows labour down. The labour is then not progressing fast enough for doctor's, who start considering instrumental or caesarean delivery. One study quotes a threefold increase in risk for induced labours to end in caesarean, versus spontaneous delivery (Thorsell et al, 2011). There is not a lot of data available for perinatal mortality rates in induced vs natural post-term labour, however one study suggests that induction does not reduce the mortality rate (Wennerholm et al, 2009)

A due date is an estimation. Unless you have a patient who knows categorically when she concieved (for example, in an IVF pregnancy), it is difficult to know when a woman ovulated, when the sperm met the egg, when the egg implanted. Early gestational scans make the dating process much more precise, but the five days for error allowed in them means the difference between being considered 9 or 14 days overdue. Not all babies who are supposedly overdue are born with postmaturity syndome. My youngest certainly wasn't, and he could not have been less than 11 days overdue by my dates (14 days by scan), though he did have a most luxuriant mane of hair. Equally, my new niece does not display the features of postmaturity syndrome, and she was at least 14, if not 17 days late. Babies do not all 'cook' at exactly the same rate.

When the NICE guidelines advise that women are fully counselled in the risks associated with continuing the pregnancy, or inducing it, they do not also advise belittling, or ignoring the woman's preferences; or scaring her with statistics. Quite the opposite: the woman is supposed to be informed and supported in her choice between induction and natural labour.
We need to find out why this is overlooked so frequently. Do obstetricians genuinely believe that they will have a flood of stillbirths on their hands if they allow women to go more than ten, or twelve, or fourteen days overdue? Or are they trying to control an otherwise uncontrollable natural process? Are we going to end up like certain parts of the USA, where inductions are booked before the expected due date is even reached, to fully medicalise the process? Inductions are not cheap: they require drugs, monitoring, observation, and bedspace, and like any birth, can require surgical intervention at any time. However, with the increased likelihood of interventions, is it cost-effective to panic women into induction of labour before 42 weeks has even been reached?

Women deserve informed choice, especially when they are on the cusp of undergoing a physically and emotionally demanding delivery. They do not deserve to be frightened or coerced into any procedure, least of all one as life-changing as birth.

Hilder, (1998) 'Stillbirth and infant mortality births in term and post-term gestation'  http://www.nice.org.uk/nicemedia/live/12012/41260/41260.pdf
Smith (2001), 'Perinatal death at term and post-term' in http://www.nice.org.uk/nicemedia/live/12012/41260/41260.pdf
NHS Choices (2012) http://www.nhs.uk/news/2012/05may/Pages/overdue-post-term-babies-adhd.aspx
National Institute for Clinical Excellence, 2012 http://publications.nice.org.uk/induction-of-labour-cg70/guidance
Thorsell, M,. Lyrenas, S. Andolf, E. and Kauser, M. (2011)  'Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women.' in Acta Obstetricia et Gynecologica Scandinavica; Oct2011, Vol. 90 Issue 10, p1094-1099
Wennerholm, U. Hagberg, H. Brorsson, B. Bergh, C. (2009) 'Induction of labour versus expectant management for post-date pregnancy. Is there sufficient evidence for a change in clinical practice?' in Atta Obstrecia et Gynecological Scandinavica; Jan2009, Vol 88 Issue 1, p.6-17
- Women's opinions and statistics gleaned by the author, from a brief online survey, comprising 13 participants between October 18th and 21st 2012.

The Evil Receptionist

I was a GP receptionist for eight long years. Even when I was doing mainly other admin work, the only time I was rota'd off reception completely was when I was heavily pregnant.

Receptionists: the most hated group of staff in primary care. We can do no right for doing wrong.
It's our fault there's no appointments, that the doctor is sick or on holiday, that the doctor is booked up for three weeks, and won't do home visits and doesn't want to phone you. It's our fault our available appointments only go four weeks ahead. It's our fault that all emergency appointments are gone at 8:35am. It's our fault that the doctor hasn't put your medication through, our fault that your hospital letter hasn't arrived yet and our fault that the hospital has delayed your referral. It's our fault that you don't like the locum, our fault you were misdiagnosed last time, our fault the new nurse is a bit brusque. And how dare we ask for personal information over the phone? We're not clinicians, we don't need to know, we're just being nosy. We're miserable, we're sour and we're grumpy. We think we're doctors, we're all power-mad, and we think you're scum.
These are all fairly standard complaints and voiced opinions, every day. People are oddly fine with telling receptionists how objectionable and loathsome they are.

It is some people's view that receptionists hate sick people and want to block their access to GPs every step of the way. It is their view that since all receptionists do is answer the phone (ha, I wish), they should bloody well be able to give out a million appointments a day.
And why does a receptionist need to know what's wrong with a patient anyway?

Well, mainly because we're minions of GPs. GPs vary in their working relationships between lovely, bending-over-backwards to help to absolute dictatorship. I've worked for both and all shades of grey in between. GPs, generally, own (at least partially) their surgery and are a receptionist's direct employer. They take all liability for our actions, and we do as we're bloody well told. If we don't, it's our job.

So, when the GP bellows 'no more phone calls', we receptionists must obey. When they tell us to find out as much information as we can before listing a callback, we have to do so. When the GP tells us to cancel an appointment, we have to do so.

And then, when the patient (who feels blocked, ill and frustrated) finally sees or speaks to the GP, the GP is lovely and accommodating.

So, again, receptionists get the blame. For we actually run the practice, and are in no way at the bottom of the ladder, trying to operate between a rock and a hard place.

I used to hate being on the desk when the surgery first opened and the mad rush for appointments began, because they'd all be gone in five minutes and then the incredulity in patient's voices on receiving this information would turn to contempt. And when we have to face anything up to ten hours being bellowed at by disgruntled patients, we get a bit grumpy.
You can say what you like to us, and it may get you struck off our patient list, but we aren't allowed to retaliate. Can you imagine any other sector where you might get a 6ft tall man bending over you (as you're sat down), threatening in demeanour, yelling for an appointment that you can't give them? Can you imagine being forced to stay calm and polite in that situation, when what you want to do is run away? Patients can be remarkably persistent if they take a shine to you. I was followed around by an amorous patient for some months at one point, and it's not unusual. Again, our only recourse is to ask for a troublesome patient to be removed from our list.

And our job may have no clinical responsibility, but we still get faced with life or death situations on a frequent basis. I've had patients come and bleed all over 'my' waiting room, collapse at reception, give birth in the treatment room and other dramas. And that's with plenty of clinical staff on hand to help.
A phone call can come at any time, where the patient is having a suspected stroke or, more often, a heart attack. Elderly patients are, if you'll pardon the language, a bugger for this. They're on their own, with chest pain, and they are too terrified to ring an ambulance. They think they'll go to hospital and not come out. They think it'll be a waste of time and they'll be charged for ringing the ambulance (not true, at all). They think it can wait. So, they ring us and ask for an appointment, underplaying the situation, only telling us they have chest pain after we've offered an appointment in a week or so. And then they refuse to ring an ambulance, so we do it for them. They think if we do it, we can take the blame if it's a waste of time. I've rung ambulances and sent them to patient's homes many times because when a patient dies after ringing us, it's very upsetting.

Being a GP receptionist is a seriously challenging job, considering it's an entry level admin role. And I loved it. I miss it every day, vile patients aside. I miss seeing the same people throughout the week, miss the banter, miss seeing people have a happy ending.
Be kind to your GP receptionist. They're not just answering the phone and blocking you for no reason. If they hated people as much as it's generally surmised, they wouldn't be doing the job!