Through the keyhole: what the doctor sees


By - Friday 10th August, 2018

How a visit to Croydon University Hospital led to a reflection on what we can do to reduce the burden on the NHS


Photo public domain.

In early April, I took a heavy fall on my shoulder while walking my dog in Lloyd Park. When my arm failed to regain its normal leverage after several weeks, I had an X-ray, then an MRI scan to reveal the true extent of the damage. It emerged that I had torn the rotator cuff, or the sheath of muscle and tendons that keeps the shoulder joint firmly in place. My consultant at Croydon University Hospital said this would necessitate an operation to re-attach it as soon as possible before it retracted and became inoperable. Although the condition was far from life-threatening, I was duly admitted a month later.

Doctors Kotrba and Mirza carefully outlined the procedure to me. I rode down from the ward on a trolley to the theatre and was given a general anaesthetic and a nerve blocker in the shoulder area. I awoke from a dreamless sleep in Recovery, feeling none of the pain and nausea I had experienced after my previous operation to repair a knee cartilage fifty years earlier. The cup of tea felt like a kiss of life.

The op had caused my pulse to go a bit skittish, so I was told I’d be kept in another unit for monitoring overnight. In the event, there were no beds available, so I had to remain in Recovery, where I was attended round the clock by Rachel, Hannah, Peace and Amber. Their tender ministrations caused my pulse to settle back at once. They were clearly concerned that I would complain in the face of this unavoidable blockage. They needn’t have worried, since no patients arrived back from the theatre to occupy my space until the next morning, when I was discharged, feeling positively bionic.

NHS staff are coping magnificently against the odds

We need to keep the NHS in perspective. It has become totemic of our national psyche, a kind of cult, something to swear by, a backstop to the overrunning of our existential angst. I believe it cannot bear the weight of expectation thrust upon it, the demands and downright and quite unjustified abuse. The constant harping on how stretched and run ragged it is on TV and in the press can do nothing for the morale of the staff, who are coping magnificently against enormous odds. It is only underfunded from our taxes because it ministers to each and every ailment – real or imaginary – that we may claim to suffer. I think the elderly should be prepared to pay a part of their prescription charges as a contribution to offsetting the overwhelming cost of their treatment and to ease the blocking of beds. As for ‘mental health’ relief, assistance and maintenance, I personally believe this is not the business and responsibility of the state, but of the family, the schools, the churches and, only as a last resort, social services – for, as the poet Philip Larkin describes the human condition: “Where can we live but days? / Ah, solving that question / Brings the priest and the doctor/ In their long coats/ Running over the fields”.

The body may not be the ‘temple of the spirit’ for many people – but it remains the vessel of the mind for us all. In my opinion, if the body is abused, the mind weakens and falters and the will and initiative are sapped. The NHS is on permanent standby as an ever-ready fallback position.

When Sir William Beveridge, a National Insurance specialist, sat down in 1942 to draft his now-famous report on the future welfare of the nation, he felt impelled to extend his remit to cover the root causes of poverty and immiseration. These he memorably characterised in the form of the ‘five giant evils’ – want, disease, ignorance, squalor and idleness – blocking the road to reconstruction after the war. Today, at least two of these – ignorance and idleness – appear to be more like great, fat toads squatting on opportunity. But then attitudes have changed with the spread of the welfare state with its ‘cradle to grave’ provision of social services for all. People were no longer deemed to be ‘arbiters of their own hardships’, but rather collectively in need of protection from (often self-inflicted) poverty and harm in the name of social justice. At the time, the Archbishop of Canterbury hailed the report as “the first time anyone had set out to embody the whole spirit of the Christian ethic as an Act of Parliament”.

We now suffer more troublesome modern scourges

Beveridge’s three remaining ‘giant evils’ – want, disease and squalor – have been largely eradicated, being more concrete phenomena, more easily and visibly addressed. Society’s besetting ‘ills’ today, as Mr Corbyn describes them, are inequality, prejudice, discrimination, neglect and insecurity – all high-sounding abstract nouns, much less easy to qualify and quantify. In place of want, disease and squalor, we now suffer more troublesome modern scourges.

Above and beyond persuading people to live within their means and provide for their futures, the report’s flagship initiative was the creation of the National Health Service. There was much wrangling at the time over whether social insurance was less important than bargaining about wages, as Ernest Bevin held. He called the report a ‘social ambulance scheme’. Social security, the report claimed, ‘must be achieved by co-operation between the state and the individual’. In the event, Nye Bevan as Health Minister won the day. The state would assist the individual to achieve minimal wealth if he or she would take responsibility for his or her health, both mental and physical. This was a bargain that has proven more than difficult to keep. I feel the benefits of the welfare state have become a kind of bounty, which consumes a disproportionate amount of the national budget. Wants have become needs and entitlements to a share of a depleted stock of resources and resourcefulness.

The great irony is that people are now living longer than ever before

The great irony of the situation is, as pointed out by an elderly doctor recently, that with all the advances in medical technology and the plugging of many of the formerly untreatable pathways to death, people are living much longer than expected and need more palliative care in older age if they are not to slip into barely manageable frailty and even total shipwreck, placing mounting demands on the NHS.

The problem of production is likely to remain unsolved as long as as energy and fitness levels continue to dwindle. Productivity is neither a capitalist nor a socialist notion; it is simply the cost of staying in business as a nation. Is the righting of this imbalance in the scales of social justice a matter of ideology or morality? Neither. I believe it’s actually a matter of mobility, an ability to shift for yourself, to harness your habits, to live and work where the means of production lie; in short, to strive to more than stay alive. A government health minister once made an unintentionally hilarious request of his civil servants: “Give me,” he said, “some statistics on the working population who are smokers, broken down by age and sex”.

Barnaby Powell

I'm a former development banker (in Europe and East and South-East Asia) and a Croydon resident for over 25 years. Currently I write and speak (mainly to schools and universities) on China and the impact of its rise on the rest of us. I'm also a school governor at Archbishop Tenison's School and a leader of the Croydon U3A China Group.

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  • John Gass

    The author writes: “As for ‘mental health’ relief, assistance and maintenance, I personally believe this is not the business and responsibility of the state, but of the family, the schools, the churches and, only as a last resort, social services…”

    Such profound ignorance and blatant prejudice is breathtaking in the twenty-first century. And to suggest churches have a good record in providing support for those with mental health issues (and, no, mental health should never be placed in inverted commas), I think many people, if asked about this, would first remember the church for having caused severe, often life-long, psychological damage to all of the many, many children who have suffered physical and sexual assaults at the hands of people who have been given the power to abuse by the church.

    I really value the Citizen, and admire its willingness to publish articles from the broadest possible range of Croydon residents, but this article would be only slightly more inflammatory had it compared the mentally ill with bank robbers and letter boxes.

    • Anne Giles

      Good for you, John!

  • Michael Swadling

    Barnaby good article. I share a concern with the NHS focusing on mental health. We are at the early end of a 25 year peak in baby boomers needing large amounts of medical and social care. This is going to push health care costs to a massively high proportion of GDP. Now isn’t the time to expand the NHS into a major mental as well as physical health service, even if you believe in the benefits of the expansion. Mental health is also an area that can grow. Clearly some people need and and benefit from treatment. Many more however could feel they need treatment when they don’t because of the focus on mental health across society. Regardless of government the NHS and wider society will struggle under the demand of a large retiree population (to be clear it’s great people are living longer lives). It’s doesn’t make sense to add to that struggle by expanding the scope of already stretched services.

    • John Gass

      Let’s add a few facts to a discussion that, thus far, has been little more than misinformed opinion.

      First of all, the NHS has had a chequered history in terms of mental healthcare provision, but no one could argue that its responsibility doesn’t date back to, at the very latest, the Mental Health Act of 1959. Here is a link to an NHS article that covers this.

      https://www.nhs.uk/NHSEngland/thenhs/nhshistory/Pages/NHShistory1948.aspx

      Secondly, to correct the misplaced notion that mental health services are bleeding the NHS dry, here is an extract from a King’s Fund report into relative funding of NHS mental and physical healthcare. I’ve provided a link to the full report below. As you will see, and as the government has recognised, mental healthcare is both chronically and acutely underfunded.

      “Mental health problems account for 23 per cent of the burden of disease in the United Kingdom, but spending on mental health services consumes only 11 per cent of the NHS budget.”

      https://www.kingsfund.org.uk/projects/verdict/has-government-put-mental-health-equal-footing-physical-health

      • Michael Swadling

        John – out of interest what “misinformed opinion” do you feel I gave?

        If we upscale the provision of mental health services to be 23% of NHS budgets we need to take that money from other services or find more money. Given we are currently deficit spending, taxes are at a 40 year high, and we have to find a lot more money for an aging population already, we are unlikely to find (or be able to find) even more for mental health. So what current NHS services do you suggest we stop or reduce the relative rate of funding for?

        • John Gass

          I’m not going to get drawn into giving my opinions – I’m trying to stay with hard facts plus the knowledge and observations that came from having been a trustee/director for a local mental health charity.

          For me, the two most significant problems I have with your post are:

          1. Your implication that millennials are needlessly, and undeservedly, trying to appropriate big chunks of the NHS budget that are needed to fund elderly care.

          2. Your belief that “Clearly some people need and and benefit from treatment. Many more however could feel they need treatment when they don’t because of the focus on mental health across society.”

          Please share the evidence that supports these opinions.

          But I assume we agree that the NHS is currently underfunded? If so, is it right for people to argue, based on very incomplete knowledge and insight, to define who deserves necessary health-care and who doesn’t?

          • Michael Swadling

            John,

            Re “1. Your implication that millennials are needlessly, and
            undeservedly, trying to appropriate big chunks of the NHS budget that are needed to fund elderly care.” – you just made this up no idea where you got that idea from.

            Re “2. Your belief that “Clearly some people need and benefit
            from treatment. Many more however could feel they need treatment when they don’t because of the focus on mental health across society.” Please share the evidence that supports these opinions.” The evidence of focus creating demand is the advertising industry.

            But I assume we agree that the NHS is currently underfunded? – Wrong assumption no I don’t. I think social care is and that has a drain on the NHS (I think we need to rebalance existing budgets). If you want to spend more on one service of the NHS the money needs to come from one of three sources. More tax (40 year high no evidence we can
            raise more money), debt (we have been deficit spending for 18 year, time to stop) or other services. When we already
            need (have no choice) to find more money for a 20 year peak, let’s not find new services to spend money on.

          • John Gass

            In the way that I won’t be drawn into a debate based on opinion, so I won’t be drawn into debating this as a political issue. Also, justifying an opinion about mental health provision by citing the advertising industry is, well, a stretch too far.

            However, you say I’ve made up point number one in an earlier reply to your first post. Let me quote what you wrote:

            “We are at the early end of a 25 year peak in baby boomers needing large amounts of medical and social care. This is going to push health care costs to a massively high proportion of GDP.” and “Regardless of government the NHS and wider society will struggle under the demand of a large retiree population […] It’s doesn’t make sense to add to that struggle by expanding the scope of already stretched services.”

            You can see why I don’t think I have misrepresented you at all.

          • Michael Swadling

            John you said:
            “1. Your implication that millennials are needlessly, and
            undeservedly, trying to appropriate big chunks of the NHS budget that are needed to fund elderly care.”

            Where have I mentioned millennials? You simply made that up.

          • John Gass

            Baby boomers/millennials, potatoes/potatoes, tomatoes/tomatoes.

            Let’s call the whole thing off… unless this thread moves on to fresh, worthwhile, territory, I’m done. I’ve made the points I wanted to make and am happy to let other readers decide where their sympathies and support lie.

  • Anne Giles

    The elderly should pay for part of their prescription charges? But pensioners do not have the sort of money you have because they don’t work. You also mention the overwhelming cost of their treatment. How do you know? People of all ages can suffer from ailments which are expensive to treat.

  • http://www.thegreenstoryteller.com Charles Barber

    An interesting and clearly provocative article. As someone who has benefited greatly from the NHS as regards both my physical and mental health, I suggest it is perhaps a mistake to make such a clear distinction between body and mind, as they are far more interconnected than perhaps Monsieur Descartes realized. An individual and a society’s investment into their respective healths usually leads to increased productivity, and so is rarely wasted.
    Times have changed. Whereas 50 years ago, there may have been less conspicuous consumption and more emphasis on personal responsibility and the value of civic society, today we have food banks, a comfortable few and most people, as ever just struggling to get by as best as their resources allow. We may no longer have such terrible slums, but it is an embarrassing fact for our society that we have a growing prison population and so many people are still struggling to get enough food to eat or a roof over their heads. The safety net that Beveridge helped to create has alas far more holes in it. There needs to be a serious conversation as to how our NHS should be funded, but the idea that with a growing ageing population that it doesn’t urgently need a lot more funding to be able to cope and eventually improve, is I fear a dangerous delusion.