"When you became ill - thank goodness for the NHS- Some of the past, what of the future?"
Stewart - Introduction
You might have wondered, Why us? – Margaret grew up in a doctor’s household, her father being a "general practitioner", or as I prefer "family doctor" in Framlingham for 37 years.
I trained as a doctor in Cambridge and London, first came to Suffolk in 1952, returned to work in Ipswich Hospital in 1964 and never left.
I am going to start with the early days, Margaret will comment about the 1940’s, and later the 1960’s and I will return to bring things up to the present, with a taste of the future.
Few young people to day realise how fortunate we are. In the latter part of the nineteenth century, there was a very high death rate and life expectancy was barely over 50 years of age. The illnesses of measles, smallpox, cholera (from 1831), diphtheria, whooping cough, tuberculosis and typhoid were rife, childbirth and operations were risky and painful and being ill was expensive.
The Public Health Act of 1848 had only limited effect, being implemented in only 180 towns in the land, but bringing about some improvements to water supplies and sewage disposal. Then as now, there was a reluctance to spend public money in interfering in peoples private lives. In general the wealthy did not believe that helping the poor was any of their business and there was no general acceptance of the cause of the problems, as we know them today. The situation of the poor factory workers was desperate, living in crowded (five to fifteen families to a house) cold, damp and very insanitary conditions.
Further cholera outbreaks in 1854 and 1856 terrified the authorities. At about that time Dr John Snow a London doctor had made the link between cholera and the water supply and two further Public Health acts in 1872 and 1875 started things moving at last. Councils were compelled to provide clean water and sewage disposal, and were permitted to clear slum dwellings and provide new homes to a much improved standard.
The effectiveness of vaccination against smallpox had been discovered in 1796, but was not implemented compulsorily until 1870. At about the same time Lister, who was a professor of surgery at Glasgow University began using carbolic acid sprays to prevent the infection of wounds, following Pasteur’s discovery of the significance of germs in the 1860’s. This together with the discovery of anaesthetics at about the same time, revolutionised the practice and success of surgical operations.
In 1906, the Liberals including David Lloyd George and Winston Churchill, then a Liberal, were elected with a huge majority and introduced a number of measures, including the "labour exchange", free school meals and pensions (for the over 70’s). The National Insurance Act of 1911 introduced a small contributory insurance scheme for low paid workers and free medical care, for the workers only, but NOT their families. They had to register with a "panel" doctor who was apparently paid 6 old shillings per patient per year for looking after them (? 30 new pence).
The First World War then intervened and you might be interested to know that, during that war, my father was largely responsible for the tabulating, analysing and comparing of the medical records of patients with wounds and diseases which were sent to London from the various theatres of war. The work of collecting, copying, card indexing and codifying these records continued uninterruptedly during the war and for some years afterwards. Finally a card index of 22 million cards was prepared from which it was possible to obtain, without delay, full information about any serviceman, of any rank, who had attended a hospital or even casualty clearing station during the war. How much easier that might have been with the aid of computers.
But, as has occurred in subsequent wars, the second World War, Korea, Vietnam, the Falklands and the Gulf, enormous advances were made in the treatment of injuries as a result of experience recorded on the battle field because of the need for the medical and first aid staff and ordinary troops to act unrestrained by the conventions of hospital practice. (I am thinking particularly of the administering of pain relief and life saving fluids, which led ultimately to the development of Paramedic skills as we know them to-day).
During the time between the wars, the Government had to concentrate on the economy, which was in a parlous start, the general strike, the Crash in the 30’s and little money was left available for further Welfare reforms, although it was already evident that the arrangements were very disorganised and fragmented. We thus reach the outbreak of the Second World War in 1940 and move to Framlingham, where Margaret was just 4 years old.
From the point of view of a Doctor's daughter - Doctor's wife - Doctor's mother
Till about the 1960's the family doctor was considered a pillar of the community, along with the priest and the school teacher. The doctor usually lived in a big house, with the surgery, waiting room and dispensary an integral part of it. The house was in the middle of the village or practice area, everyone knew where it was and when you wanted the doctor you literally sent for him: someone had to come and knock on the door. As the telephone became more available, patients phoned him at home. Our number was Framlingham 27.
Patients had total trust in the doctor and did not question his advice, even though right up to the Second World War what the doctor could actually do was limited. Most could diagnose what was wrong following their five years training and knowledge of anatomy and physiology, but they had few tools to effect a cure.
They could do a lot to boost morale, they used their instincts - my father always said he could smell an infected appendix from across the room, but they did not have the vast array of drugs or the technology available to doctors today - people either got better (perhaps sometimes despite the remedies recommended), or they went to hospital, or they died. In fact, looking back, they were probably more effective surgeons than physicians - they were used to dealing with accidents, stitching up wounds, sorting out animal bites etc, but were less effective in dealing with infections, diseases of the heart or kidneys or blood, or of course cancer.
Life in our house followed a strict regime - morning surgery was from 9 - 10.00 a.m. during which time the children had to behave like mice - woe betide any of our friends who rang up during that time - they did not do it twice. At 10.00 the outer door was locked and after the last patient had been seen coffee was served in the dining room. Then my father went out on his visits - the short distance town ones in the morning, the more distant ones being kept for the afternoon. Lunch was at one, and then he would do his country visits, often accompanied by my mother or one of us, and always by the dog. The dog was exercised by being taught to run in front of the car down a country lane. We usually got back for tea about 5 and evening surgery was from 6 to 7. Once a week my father played bridge in a men's four. There was no television of course and we were not encouraged to listen to the radio or music because he really did not like noise. (This makes him sound a very strict father but actually he was one of the most interesting people to be with. He did not like small talk, but enjoyed nothing more than a good discussion of something in which he was interested - the history of Egypt, or some scientific discovery or anything to do with sailing, or Holland, a country of which he was very fond. When he could relax and was enjoying himself he was a great person to be with and had a good sense of humour. The ankylosing spondilitis from which he suffered after the war meant that he was often in great pain and I think the war had a tremendous effect on him. His sister Mary has said that he was not the same person after it as he was before.)
He worked extremely hard. Wednesday afternoon was a half day and once a fortnight he had Saturday afternoon and Sunday off, but it wasn't till we were grown up that we realised that he was on duty every night of the year except when he was away on holiday. We discovered this when my husband was doing a week's locum for him. We did not answer the phone in the middle of a Wednesday night and got into great trouble the next day when the partner's wife informed us that we were only off duty on a Wednesday till midnight! We did not know because he had never complained about it. The three weeks' sailing holiday in August were lovely but slightly spoilt at the end because the next three weeks were fairly awful when the partner was away.
The routine was broken when one of the patients was going to have a baby - known then as a confinement. There was always an air of excitement and other things had to go by the board, as my father always attended helped by the midwife who was also the district nurse. It was always an occasion for great rejoicing when it went well and great sorrow when it didn't.
There were no surgery staff other than the cleaning lady - and the phone had to be answered. The telephone directory did have a note to ring the other doctor if there was no reply, and he usually left a list of where he was going and could be contacted in emergency but the practice was large and he could be some miles away. A lady came in on some afternoons to answer the phone to allow my mother to go out, and we had daily help, but there were no secretaries or nurses or receptionists. Bills had to be written and sent out every quarter and I was enlisted to help write the envelopes. Payment was according to means - as the doctor saw it. Rich farmers were charged more than the farm hands and the poorer patients were on the panel and paid 1/- a week to ensure their care. As a result my mother worked hard too - my grandmother actually warned her against marrying a country doctor - she thought it would be too tough!
When the National Health Service came in 1948 doctors were apprehensive - I think they thought it would not work and that they would lose their freedom. People had to fill in a little card with their names and addresses and birth dates and pop them through our door - I can remember them arriving on the mat and a certain sense of excitement at the numbers grew as of course our income would depend on the number of patients registering with us. Again I helped write the names and addresses on the new NHS envelopes. Things did change after that - some indeed for the better as at least everyone was entitled to care and did not have to pay for it. However, instead of reducing the work load it seemed to increase it, as people made many more demands and were not prepared to wait a little and let things get better of their own accord as in the past. After all it was free.
One of the other things I remember well was making up medicines in the dispensary after lunch or before evening surgery - we were allowed in sometimes to watch or help. There were great Winchesters of coloured liquids and powders to be mixed - some of them drugs others flavourings or colourings - and then poured into glass medicines bottles with the ounces marked on the side. These were labelled with beautiful pre printed labels and firmly corked. There were pills to be counted and put into little cardboard pill boxes. Patients brought their bottles back when empty and they all had to be washed - no disposables here as they all had to be paid for. The smell of the dispensary lingers still in my mind - especially the cough mixtures and the ether. There was also pure alcohol - my father used to make a delicious sloe gin with this.
Our father was also our doctor - and no one thought twice about it. He actually delivered two of us as my mother's doctor live some seven miles away and didn't get there in time. We were also used as guinea pigs for samples from the drug rep. I remember having penicillin for the first time for tonsillitis - huge tablets which were placed under the tongue to dissolve. When we had measles mum caught it too and was very ill so the new sulphonamides, known as M and B after their maker were tried out on her. My youngest brother was only a few months old and deemed too young to be allowed to catch the measles so my father took a blood sample from me and injected him with the serum to provide him with antibodies - I was made to feel very proud to help
When we had severe earache, in the days before antibiotics, Mr. Mackenzie came from Ipswich, pressed a chloroform pad over our mouths and let out the pus from an ear on the kitchen table, so it did not develop into a mastoid, and you then went around with bandages round your head.
When the 2nd World war came, both Framlingham doctors were called up into the forces and the town was served by a series of very strange locums, most of them women. Lady doctors were a rarety then and were looked at with suspicion - one of them didn't like children and my brother and I aged 4 and 3 were dispatched to Fonnereau Road Nursing Home me with appendix and Frank with both appendix and tonsils. He was lucky and sent home but I had my appendix out and had to stay there, in bed, for three weeks. Parents were not allowed to visit as it was thought to be upsetting for the children - how much worse to be left all that time without them. It was terrible and has coloured my view of hospital ever since.
Stewart has mentioned how the war accelerated the introduction of new drugs and treatments. My father had a tough war, particularly when he was Medical Officer on H.M.S. Dido a battle cruiser in the Mediterranean. During the battle of Crete they were involved in the evacuation of the island and 1000 soldiers embarked on the ship on the 29th May. At 8.15 that evening an 1100 lb bomb hit the ship blowing half of one of the gun turrets overboard. In his report he says:
"The blast travelled downwards wrecking the marines mess deck and penetrating the deck below into the torpedo men's mess deck. The explosion was followed by a serious fire which was quickly got under control. The casualties were 46 killed of which 27 were naval and 19 army, and 36 wounded (many severely)."
He goes on to describe the conditions under which he and the sick berth attendants had to work, the mess, congestion and lack of light and water, the three operations they carried out during a lull in the fighting and the type of wounds they were dealing with. Most of the men were very young - a truly horrendous event. I only once heard him talk about it when he gave a talk to the boys at Framlingham College, and from that I know he, as medical officer, was the first to go into the mess deck to begin to sort out the dead from the living. He was awarded the D.S.O., very unusually for a medical officer as they are not often in the front line. From such events maybe medical progress has been made as having to perform procedures under extraordinary conditions produces new ideas and surprising improvements in treatment. The introduction of antibiotics, sulphonamides and treatment for tuberculosis were all hastened by the demands of war.
Stewart takes over:
As you have heard, following the second world war, attention returned to further welfare reform leading up to the NHS Act of 1948. The government decided to buy all the then private GP’s practices fixing a valuation on 1st April 1948, but only paying out any money when the individual doctor concerned finally retired, together with a modest amount of interest on the money retained.
Payment to the doctors became based on a fixed amount of money per patient per year, including families and children, financed partially on a levy, the weekly National Insurance payment from employees and employers and partly form general taxation. From the doctors point of view there was little change for the first few years. But of course there was a huge change for the patients, health care was free, and at first and for some years after, NO payment being required from the users of the service. Later payments became required to obtain prescriptions, dental treatment and glasses.
To take our story back a bit, as with many professional organisations, the medical profession had a benevolent fund the RMBF, to which many doctors contributed.. My family became very involved as my mother was left a widow in 1940, when my father died of pulmonary tuberculosis at the relatively early age of 53, there being no active treatment available. We survived through the war, things were not too easy. Hence in 1951, when Margaret’s mother and father, a wonderful couple felt that they could offer a short holiday to someone who would benefit from it, they asked the Ladies Guild of the RMBF to suggest someone. The first candidate suffered from severe asthma, and as the holiday involved camping on the marshes at Orford and asthma was a high risk and then virtually untreatable, they felt unable to accept the young man first suggested. Thus it was that in 1952, just over 50 years ago that I, being second on the list, first found out where Suffolk was. The "short" holiday, turned into a series of winter and summer breaks and the rest, as they say is history.
The system of medical training in the fifties was firmly based on hospital bedside teaching, following on from a grounding in pure science, anatomy, physiololgy pharmacology and biochemistry. Much of course has changed over the years with new discoveries, but the study of Anatomy has not. I have a beautiful Anatomy book published in 1887, possibly a first edition signed by the author, withwonderful drawings of child anatomy.
Our course size was 35 students every 6 months, the emphasis on training to become a "proper doctor", i.e. a consultant. In many cases, to become a General Practitioner or family doctor was regarded as having failed. Thankfully, this is not so now.
The family doctors were then organised as independent contractors, with very little degree of central control, but they did co-operate as a team with the local District Nurses and Health Visitors. They acted largely as gate-keepers of the hospital service, often many miles distant. The hospitals Casualty department (later A & E department) was a fairly basic unfriendly place positioned at the entrance to the hospital. The doctors there dealt mainly with injuries, from traffic accidents, falls, foreign bodies in eyes and very few non-emergencies.
In more recent times, as a result of the changes in society we are talking about the A & E department has become much more of an interface between the outside world and the hospital and has been forced to revise the service offered to the public. Patients with all manner of problems now find their way into the department, assaults, various forms of abuse, the consequences of alcohol and drug abuse and in particular many cases of illness, which would previously have been within the province of a GP. The department has in many ways become a point of alternative access to the NHS, a situation with which many who work in this field are very unhappy. On occasion the waits endured by the less seriously ill patients are quite extraordinary and unacceptable.
The expansion of treatment opportunities and the increasing tendency for us to survive longer has led to an increased need for trained medical staff and changes in the form of training itself. There has been a rationalisation of the London hospitals, with the closure of small units and the amalgamation of larger units on sites where expansion is possible. There are a number of new medical schools and all schools are taking in much larger groups of doctors There is, for example a new medical school at the Norfolk and Norwich University Hospital with an entry of 120 and Manchester is now training 450 per year, albeit on 3 sites.
I qualified in 1961, at which time there was a job shortage for doctors. It was important to obtain at least the first 6 month appointment in one’s own hospital, good for the CV, how things have changed. At that time, few houseman, residents or interns, those titles being synonymous, were married and the prohibition of overnight visits, by all members of the opposite sex, including the wives or husbands of those who were married, led to severely strained relationships in some cases. I well remember the Sunday paper headlines when it was discovered that this was the situation at University College Hospital.
The employment difficulties continued and this was long before any thought of equal opportunities and the prohibition of discrimination. One progressed by applying for the job one desired well in advance and if successful, waiting for the vacancy with ones chosen consultant.
Thus it was that I came back to Suffolk again, Obstetrics and Gynaecology, a rota of 7days and nights on, followed by - 7 days on but nights and the week-end off emergency call. Compared with to-day patients stayed in much longer, the real stress being only on admission and discharge, rather like the aeroplane taking off and landing in association with a long haul flight. We were busy if there we three or four admissions each day, compared with the 20 – 30 to-day. The Ipswich O and G departmentwas then served by 2 consultants, one registrar and two housemen: to-day there are 6 consultants, 7 registrars (1 p/t) and 6 senior house officers, partly of course due to the increasing population.
In 1964 I joined Tom Fairbairn in general practice in Woodbridge and Kesgrave: a partnership of 2 GP’s, 5764 patients, 2882 per doctor; surgery hours 9.0 – 10.0 and 6.0 – 7.0; two premises 4 miles apart; 3 part time staff to cover surgery opening times only. Everybody who arrived within those times was seen, there were no appointments, and no real need for them. There was no requirement to routinely monitor regular medication, blood pressure, obesity or anything. The only patients who came were ill or injured.
There was virtually no paper work, hospital referral letters were hand written, no copies were kept and life proceeded very smoothly. Contemporary diaries show an average of 9 visits to patients at their own home each day, the maximum number I found was 17 home visits in one day ? an epidemic, being a mixture of return visits and new problems approximately equal. For most of our patients we still dispensed medicines at the surgery.
His records show that Tom, my partner, was responsible for 71 maternity cases, in one year, the majority of which he delivered himself or supervised a midwife at home or in the Maternity Home, the Phyllis at Melton, of fond memory, or at Wingfield Street in Ipswich. I only managed 56, I was the junior partner! We had a 1 in 2 rota, but thought noting of it, we knew it would be like this and every one else was in the same boat. However surgery was usually over by 11.0 am and I was able to attend District Council meetings in the morning from 11.0 – 1.0 - elected as an "independent".
We couldn’t do a lot, but we could ourselves do most of what could be done on a one to one basis. Yet my mother in law felt we were very fortunate regarding such things as time off and support staff, and in 1966, the Charter did make a real difference. New money to pay for staff reimbursement, premises reimbursement, certain items of service payments e.g. for immunisations, all benefited practices which had used their own money to develop services for their patients. However the downside, as always, was an increase in central control, together with the complicated paperwork necessary to prove an efficient use of the money involved.
Many names are still familiar to me from that time, Suffolk people don’t move far, or if they do they often move back again and we of course have been very, very fortunate to have been able to live in the same house, in Kesgrave, for the last 38 years.
Back to the doctor’s wife and Margaret again: -
Doctor's Wife 1960's
Things had changed a little by 1964 when Stewart and I settled in Kesgrave. There was one secretary in each of the surgeries in Kesgrave and Woodbridge, but only part time. Wives still had to be at home to answer the phone afternoons and weekends and were expected to be the unpaid support to their husbands. The best invitations always seemed to come when Stewart was working and it was quite hard. Following the health service reforms of 1966 things did change. Now surgery staff were actually encouraged by the government and wives were positively discouraged from helping as they were not allowed to be paid under the reimbursement scheme (in case they fiddled the books - (what about MP's wives, etc?). This gave us freedom however and we could follow our own careers if we wished - at that time not many did however and I felt that other wives looked at me rather as an odd being when I took off to be a teacher. My daughter in law, who is also a doctor's wife, took it for granted that she would follow her own profession as a physiotherapist when she married, and has had no part in her husband's medical work.
By the time we retired there were at least 25 part time staff working for us.
And what of those women who became doctors themselves? I have mentioned the difficulties faced by women doctors during the war. Progress was very slow after my ancestor, Elizabeth Garrett Anderson became the first British woman doctor in 1868 . Right up until the 1940's and 50's lady doctors were regarded as somewhat rare beings, who were somehow different from the rest of us. Since then the progress had been rapid - many women prefer to be treated by a woman, and now more than 50 per cent of medical students are women. This in turn has produced other problems, not least a shortage of doctors because women rarely work full time and many of them do not work at all as doctors some five years after qualification. Of all the medical specialities, general practice is one of the ones that suits the needs of wives and mothers best. With the coming of women into profession there have been great changes in the way the system works, for instance, part time working, the breaking down of surgery sessions into specialised clinics, and the change from overall responsibility. We are likely to see many more changes of this kind as the number of women overtakes the men.
Despite its difficulties, I enjoyed being a doctor's wife and especially the part I have been able to play in village life, first in Framlingham and later in Kesgrave. People still come to us for help and support and I would not have it any other way. Although I realise change is inevitable, I think the patient nowadays often loses out because of the anonymity of modern medical care.
Stewart continues:
From the 1960’s, the local population grew, new partners joined to try and keep our numbers at about 2000 each, new premises were developed at Martlesham Heath. Some partners left and the part of our practice at Martlesham Heath declared independence unilaterally. We were not alone – comparisons with the changes in Education and other public sector activities were, and still are, frequent.
We recruited more and more internal staff, developed appointment systems, employed practice managers to assist with the paperwork, and manage the staff, took on local health authority attached staff, DN, Midwives, CPN’s, and developed close association with Social Workers, whose role became ever more and more important.
Tom Fairbairn died suddenly in 1989, just after having partially retired at 60 and this was a great blow. He was such a wise man, had hardly ever been ill before and left a huge gap. In 1990 the government introduced the Health of the Nation report which proposed targets to persuade doctors to concentrate their efforts on pursuing certain policies deemed to be important for the nations health. GP success in achieving their targets varied from area to area, and seemed to depend more on the make up of the practice’s patients than the efforts of individual doctors. We were rather aggrieved to find that that the money used to reward the winners appeared to have been obtained by clawing it back from the general remuneration pot.
With the increasing numbers of female family doctors, many part time, there developed a national concern about out of hours cover, the need to provide medical attention if needed through 24 hours every day of the year, especially in the cities. As a consequence, in 1995, Suffolk Doctors on Call began operations, to take over the responsibility for providing emergency cover for the patients of those doctors who wished to subscribe. Generally the younger doctors were the keenest to join, the older of whom I was one, more reluctant, but it did prove a great help.
We made more changes to maintain morale, our doctors began working from only one surgery, instead of two, and extended the surgeries hours, by appointment, 8.30 – 11.45 and 4.0 – 6.30, sometimes 2.0 – 4.0 but visits were averaging only 3, a maximum of 8 in day. In 1997 it all came to an end.
Did I miss it? Yes. I missed the people, my colleagues, our staff and the patients many of whom had been with me since the beginning.
WHAT OF THE FUTURE – this is personal speculation – I believe it is inevitable that there will be further fragmentation of health care among many helpers, with delegation to others.
The now old fashioned model of personal health care by one family doctor to a named group of personal patients has gone for ever never to return. However I certainly recognise, following my own illness last year, the psychological benefits to the individual patient of contact with familiar faces, unrealistic though that may be for everybody. There has to be further education towards and acceptance of individual increased personal responsibility, and wider information available to patients as is now being developed using modern technology.
The training of non medical people as first responders to assist in dealing with acute illnesses and accidents out in the community especially in rural areas, is already happening and there is, in Leeds a pilot scheme to provide assistance to people who make 999 calls, to the Ambulance Service, but who don’t really need to be taken to the nearest A & E department.
In my opinion, there must somehow be contrived the re-establishment of some spare capacity in the system, to allow for unexpected eventualities. In this respect therefore the NHS managers are no different from those trying to run a railway, airline or bus service to a timetable. I personally would like to see a reversal of the view that large is beautiful and necessarily the best option, I feel we need an extension of local services for local communities, to cope with the lack of transport facilities and this not only applies to health.
There is very properly an emphasis on value for money and the avoidance of waste and duplication, but we are all surely aware that there are some qualities in a good NHS which are very difficult to measure and justify in a financial sense, but which are of great benefit to our patients. Let us hope that in our drive for efficiency, there will remain time for courtesy, thoughtfulness, full explanation and patient choice.
So we have travelled from the mid 19th century to the beginning of the 21st century, sharing our very personal view. I would like to finish by saying that we have been and remain very happy with our lot; we have made some wonderful friends, and feel we have been privileged to share in many people's lives.