Personal views: The NHS revisited
Authors: Chris Ellis
Journal: BMJ (2001)

Iwas one of those doctors who emigrated from Great Britain in the late 1960s, now over 30 years ago. At that time the NHS seemed to have reached its lowest point since its inception in 1948. I have been in practice in Africa for over 25 years.


Since emigrating I have hardly ever returned to England, so recently I decided to do some general practice locums and get the feel and rhythm of the NHS again. I worked in five London general practices and one in Essex. The man from the locum agency, who acted rather like a controller from a John Le Carre spy novel, would ring me up and send me off. 


Practice seemed to have become part time, bitty, sessional, and agency driven



My first locum was for a singlehanded general practitioner in south London. Over half the practice patients were either on housing or income support. I had forgotten about the sheer drudgery of inner city life. The lonely aged person's ceremonial visit to the doctor. The smell of urine in the tenement lift. It all made me feel profoundly depressed.

What surprised me most was that the practice itself was such a shambles. Data retrieval was a nightmare. There were an estimated 3000 patients but only four filing cabinets and there was an overflow of files into shoe boxes along the window sills and on to the floor. The weighing machine was broken and so was the latch on the consulting room door, which drifted slowly open when the wind blew.

My second patient had wax in his ears so I went to the basin to get some warm water to syringe them only to find that there was one tap. There was no hot running water. I had to boil up the water in an old kettle with a frayed wire.

I had come from under my tree in Africa back to the capital of my old country to find a practice whose only concession to the twentieth century was a telephone and a typewriter. It had technically and intellectually not yet reached the same level of development as the rural Devon practice I had left almost 30 years ago.

My controller at the locum agency, who was obviously a man with a well developed sense of the paradoxes of life, then sent me to a practice in west London. It was a state of the art, architect designed building. Computers hummed on the consulting room desks and filing cabinets moved on oiled rollers. There was complete orderliness with the appointments in a neat column on the screen and a large waiting room with a couple of silent patients sitting next to a designer plant. I had been transferred from Jurassic Park to a Star Ship within the same city.

During my stay I continually found myself in a time warp from the 1960s. My glasses were heavy with the tint of rose. I was saddened by the lack of confidence of the patients. I had remembered the confident British mothers and nannies secure in their positions as wives and mothers. The ones who had handed out the tea in the Blitz.

The modern media of press and television seemed to have frightened the elderly patients into a perpetual fear of cancer, heart attacks, and stroke and the young mothers into a state of apprehension of all sorts of strange and exotic children's diseases.

There had also been a lot written about the single parent family, but I had not anticipated the reality of the numbers of single mothers and their orbiting children that packed the waiting rooms.

I was also surprised at the divorce rate in the elderly. In one week I met two patients in their 60s who had recently got divorced and one at 70 years old. I wondered whether they were they catching it from their children.

Then there was the phenomenon of young men and women smelling of alcohol in the morning surgery. In the 1960s the stereotype of an alcoholic was of a tramp in the park. The family alcoholic was still hidden in the Victorian closet. Now looking at me were these young faces, deep with some kind of Orwellian despair and almost frighteningly uncaring of their fate.

Sadly, I also sensed that many doctors had been worn down by the obstacles placed between themselves and the patients. They were floating downstream and focused on retirement or ways of getting out. Practice seemed to have become part time, bitty, sessional, and agency driven.

Perhaps one of the reasons was the time that I found wasted with interminably drawn out complaints from patients about waiting times for hospital appointments, delayed or lost reports, and general administrative problems. I felt as if I was trying to swim through porridge. This is probably such an accustomed feeling for those who have been working in the system for a long time that they have come to accept it.