The GMC changed the guidance determining the duties of all doctors working in the United Kingdom in 2006. Since then doctors have had a duty to take the priorities of their patients into account at all times. The draft guidance had a subtly different emphasis instructing doctors to give priority to their patients’ preferences. I am sure that I was not the only doctor who commented to the GMC that that wording could make our decision making difficult if a patient’s priorities were based on a non-scientific world view.

Those who attribute their symptoms to a process, biological, chemical or physiological, for which there is no scientific basis or their friend’s cure to a treatment that has been shown not to work by research trials continue to present a challenge in the consultation. However, I continue to learn that not everything that I believe, trying to be as scientific and up to date as possible, is true. Examples include:

• Careful research by Dr TJ Dyke into the cholera epidemics in Merthyr Tydfil in the Nineteenth Century to show that the new theory of Dr John Snow about cholera transmission and water was wrong,

• The Nobel Prize for medicine and physiology in 1949 was awarded to the inventor of lobotomy as a treatment for mental illness,

• Hospital bed rest for ten days was the recommended treatment for a heart attack until the late 1970’s,

• I have spent the last five years putting people with diabetes or high blood pressure onto aspirin thinking that it will reduce the risks of them experiencing heart disease or stroke. Now I am taking them all off the drug since the consensus from research is that it causes such people more harm than good,

• Research published in 2007 demonstrated that a tablet given to many people with diabetes could double the risk that they might have a heart attack. Experts I spoke to at the time disagreed with the research findings and continued to use the drug. A recent series of articles document how the information was handled and why there are still patients being prescribed the medication.

• An essay was published in 2007 suggesting that “women will not change the date of their death certificate by taking a statin”. This related to women who had not had a heart attack or a stroke since there is research evidence to indicate that they may benefit from taking the commonly prescribed cholesterol-lowering medications. The essayist’s view has yet to be rebutted by the pharmaceutical industry and an analysis published in 2009 confirmed it when you looked in the very small print of one large table of results. I no longer offer such tablets routinely before assessing the personal risk for each woman and sharing my uncertainties about the science with her. She can then make what I hope is a more informed choice about whether or not to take the medication.

I am very conscious that people in glass houses should not throw stones and that the log in my eye is likely to be bigger than the splinter in yours. There is an interesting rabbinical insight: when your splinter makes me very angry, it is because my log is from the same tree.

I was interested to note references to ‘AOF targets and requirements’ sprinkled through her documentation.  The Annual Operating Framework for 2010/2011 was published just before Christmas. The Minister concludes her covering letter to the bosses of the NHS in Wales: ‘I am looking to you to make sure that your organisations are aware of their responsibilities and deliver the AOF requirements’. The AOF makes a surprisingly good read.

The NHS in Wales has been moving along in a unique direction since devolution and this year’s strategies and targets build upon the strengths of policies, programmes and people that have been established in recent years. It makes me even happier to be a general practitioner serving the Welsh NHS.

If you have not read Scott Greer’s analysis of the priorities within each devolved administration and their styles I warmly commend his paper ‘Devolution and divergence in UK health policies’ to you. 

I have been mulling over how the NHS might become a political issue in the forthcoming General Election. Surely there will be no debates in the media or hustings in Wales since Welsh MPs have no say in Welsh NHS affairs? Why should precious time and energy be spent during the Welsh campaign on political issues that only matter in England?

Last week the Nuffield Report about the differences in healthcare between the four Nations ten years after devolution was published.  The media paid the most attention to the headline figures in the Report about “efficiency”. It was reported that the Welsh NHS was less cost-efficient than the English Service. The Governments in Cardiff and Edinburgh made some cogent criticisms of the report’s methods and conclusion. The report was reviewed in the British Medical Journal by Peter Donnelly, now Professor of Public Health Medicine at St Andrew’s.  Peter will be remembered in Wales as a dynamic public health doctor who worked in Cardiff and Swansea. His concluding remarks are very interesting in the context of the General Election: ‘Ten years on, anxiety on behalf of the devolved administrations is unnecessary and perhaps even patronising. Their parliaments are accountable for the performance of their versions of the NHS. The UK parliament is accountable for the financial settlement with these devolved administrations.’

What does this mean for the General Election contest in Wales? Should the manifestos of the Welsh parties only be tackling strategy and policy in relation to the ways in which Westminster will influence the Assembly? How much influence do MPs have upon decision making about the financial settlement?

Anyone who has ever been involved in any of the big NHS IT projects will cross their fingers as so many of these projects have failed to deliver and run over budget and time. But worse, people who do not use online services will, once again, miss out.  

For example, 70% of people over 65 have never used the internet let alone are savvy enough to book appointments.  Similarly, nearly a quarter of people in routine / manual occupations have never used the internet, compared with less than 6% of people in professional and managerial occupations.  Yet older people and people on low incomes are precisely those who have the poorest health and make the greatest use of the NHS.  

I am sure this idea will prove very convenient for those in office jobs with freedom to do personal business via the works PC, or with the internet at home.  But for the thousands of people who don’t, it is yet another IT initiative that penalises the poor and reinforces health inequalities.

Interestingly, they found that even when all these risk factors were accounted for, individuals from the most deprived areas had around a 1.5-fold to 2-fold higher risk of plaque presence than those from least deprived areas.

The authors concluded: Health status is a reflection not only of features of the individual but also of wider social and economic influences, health and social services, early life experiences, and environmental factors. These findings fit in with the work of Marmot and Wilkinson who have been studying these issues for more than twenty years. Blaxter, reported in the Health and Lifestyle Survey, a large research study published in 1990, that only wealthy people could improve their health by changing their lifestyles. Indeed, she also showed that poor women who smoked enjoyed better health than poor women who did not smoke; a message that the Health Promotion industry has chosen to ignore.

I came to Merthyr as a general practitioner inspired by Julian Tudor Hart to “walk one mile up the river” in order to help people not to fall into the rivers of disease, disability and death. There are many changes that I can help individuals to make to reduce the risks of bad things happening to them, but the real health and well being dangers that my patients face have much more to do with inequality and inequity.

Will the new leader of Welsh Labour have the ideas and the policies to tackle these challenges and make a real difference to our health statistics?

What surprised me as I engaged in discussion was that that all that I could say was: “that is the result of ministerial policy.” Usually people moan and I can explore their expectations or misunderstandings of policy or of practice.

How do politicians decide how to make the NHS better? Is it by considering their own core values, studying the evidence for what works best, consulting widely and then preparing policy? Experience suggests not.

Mrs Thatcher was advised by a general practitioner friend and her NHS soon resembled his model and style. Mr Blair had a 30-something adviser and a reviewer of the changes that New Labour pushed through commented when he presented his research findings that the new systems for access only suited 30-something middle class men. Mr Blair was memorably caught out by a BBC TV viewers’ panel on the topic during the following general election campaign.

I have not responded to the Welsh Health Minister’s requests for consultation since she announced to the Assembly that she had read all the responses about proposed NHS changes and was still going to do what she thought best and was then found to have ignored all the strong advice about neurosurgery service provision in South Wales. I am told that the Minister has an adviser on NHS policy and I wonder if the new Welsh NHS reflects his or her values and principles.

I would like to see the identities and priorities of the advisers of each candidate made public. Their identities may be known to a select few in the Sennedd village, but we should all know who they are. Then perhaps we can make a more informed decision about who is best placed to take Wales to where we want it to be.

The 2008 Sleep in America poll, conducted by the National Sleep Foundation, found that nearly one-third of adults who work at least 30 hours a week have fallen asleep or become extremely drowsy on the job, behaviour that employers frown on.

Should they lighten up? Perhaps, in a knowledge-based economy that dependent on sharp minds, a few minutes of shut-eye could be really good for business.

A report in the June 2009 Proceedings of the National Academy of Sciences showed that a nap with REM (or “dream”) sleep improves people’s ability to integrate unassociated information for creative problem solving, and study after study has shown that sleep boosts memory. If you memorise a list of words and then take a nap, you’ll remember more words than you would without sleeping first. Even micro naps of six minutes-not including the time it takes to fall asleep, which is about five minutes if you’re really tired-make a difference.
When you’re in need of sleep, though, certain skills start to slide. Visual discrimination, which allows you to sort out what you see, can fade over the course of a day.

The many effects of too little sleep and how our health can be affected are well documented may be some of those need to be looked at in terms of how we work and how we can be more productive in work. A 30-minute nap can stop the burnout, and 60 to 90 minutes that include some REM sleep will improve visual discrimination.

So may be along with staff canteens and showers that employers provide how about some comfy chairs and black out rooms. But I think we should draw the line at jim jams and cosy slippers!

Thomas Dyke was Medical Officer of Health for Merthyr Tydfil from 1848-1894. He was born in Merthyr in 1816, apprenticed to the surgeons at the Cyfarthfa Ironworks before completing his training in London. He served the community for all his working life, surviving an attack of cholera in 1849. He strived to introduce sanitation to the town, working against the resistance of nearly all the Iron Masters. It took fifteen years to get the Penybryn waterworks built, the first source of healthy water for the workers and their families.

His life story has a number of contemporary resonances. He was a Merthyr lad who returned to the town to work as a doctor. A Victorian essayist writing about the doctors of Merthyr Tydfil commented: “Merthyr was the nursery ground of many men of ability who afterwards settled down in other towns”. He went on to report that nearly all of the other doctors working here had “arrived from elsewhere”. Nothing has changed.

Every year, between five and ten of our brightest young people leave Merthyr to train to become doctors. In my twenty eight years working here, I am aware of only three who have returned to work in their home town. Some have returned for some of their postgraduate training, some have settled in other Valleys communities. Where have the rest gone? What has kept them away?

The former Archbishop of Liverpool, David Sheppard described the inner cities of England in the 1980’s as “communities of the left behind”. I was reflecting on this with a patient who replied: “anyone with get up and go has got up and gone”.

How can today’s men and women of ability be encouraged or challenged to contribute to the health and wellbeing of the communities that nurtured them?

UPDATE:  

As soon as I had uploaded my first ever blog I noticed flaws in my thinking! Lots of the ‘brightest young people’ choose other careers. It seems that those who choose nursing and teaching for example do return and work locally. Do people who do not have the resilience required to continue living in a community like Merthyr choose certain professions, perhaps thinking of them as a way out?

For a generation the Danish capital has prioritised investment and planning to make cycling around the area the easiest and most convineint way to get about.  Here’s what it looks like.

At a discussionon vaccinations we held in June, Age Concern highlighted that take-up of flu vaccination would hugely increase if NHS staff thought about the patient’s needs when planning services. For example they found much greater flu vaccine take-up when administered in community settings – rather than expecting older people to go to their GP surgery vaccinations would be done e.g. at day centres or lunch clubs. There were logistical issues, but these could be overcome. 

With some way to go before vaccinations against measles reaches the magic 95%, and with the prospect of mass swine flu vaccinations in the autumn / winter, perhaps it is time to think about a more radical ways of reaching people.