Bill
If I have come across as vindictive or offensive then I wish to correct
that impression. My criticism was not intended to be personal. We all make
mistakes in life; I’ve probably made more than all of you put together.
Therefore it would be quite wrong of me to pass judgment on our colleagues
in management in a spiteful fashion. I am not even sure that I would have
done anything different were I in the same position myself.
One has to recognise that for most, the primary obligation is to one’s own
family. Jeopardising one’s career by being obstinate and awkward is never
a good idea unless one is prepared to take a gamble on the family’s
security. Taking a stand can often be a lonely and isolated place to be.
The factors that determine the point that each of us reach, when we do
take a stand, will always vary from person to person. And in an
environment with institutionalised corporate bullying and intimidation
rife, at every turn, it is easy for our conscious to be suppressed even
more.
Professionally, I always considered my primary responsibility was towards
my patients. Second to that was a responsibility to my profession. My
responsibility to my employer, whenever I had one other than myself, was
contained in the contract of employment that bound both of us together,
namely that I would agree to provide the best of my clinical expertise in
a working environment that was provided for me exchange for a sum of money
at the end of each calendar month.
At no time during the last twenty three years have I seen or read a
contract of employment that obligates an employee to carry out duties that
fundamentally alter the founding principles of the NHS – namely ‘free at
the point of source’ and ‘irrespective of the ability to pay’. If a
chargeable scheme were to be introduced, it might very well require some
legislation to support it – at the very least it should be debated. That
is only right and proper. But the difficulty we have now found ourselves
in is that we already have introduced charges for many thousands of
patients. That is the net effect of the discharge policy. For whatever the
reasons (and not for a moment apportioning blame), that is what has
happened; we have privatised a substantial part of healthcare delivery by
the backdoor. I accept it might be social care; I accept that someone else
could be doing it. We used to provide the service through the state. Now
we don’t. We should have made sure that somebody did.
My point of intolerance was reached in a small clinic on the edge of the
North York Moors on a wet December day in 1998 when I had to try and
explain to a frightfully sweet eighty-nine year old lady that she was no
longer eligible to have her ‘feet done’ as the service was redefining
its ‘care packages as part of modernisation and a drive for improvement.’
For the last eight years I have worked almost exclusively as a locum
practitioner. That has been out of choice for a number of personal reasons
that I won’t bore you with here. What that has given me, in terms of
experience, is a rather unique insight of how we deliver our care in the
UK today. I have worked both in private practice and in the NHS, from
Ardnamurchan in the north-west highlands to Dorset in the south. I’ve been
from Wales to Norfolk and everywhere in between many times over – in total
with fifty-eight separate trusts and thirteen private practices. As much
as I can, I write my experiences down.
What has been startling are the variances in both the standards and the
manner by which the profession operates in Britain. I found many
departments to be stimulating whilst others were profoundly boring. Some
colleagues burn with a passion, for others the light went out long ago. No
two trusts were the same. No two worked the same. The same applies to the
individuals.
The NHS has got a lot to learn. So has the profession of podiatry. With
all the focus in recent years on general management, the organisation has
taken its eye of the one ball that matters the most – the patient. What
happened to the pensioners who were removed from our lists is a good case
and point. If our primary professional responsibility is to our patients,
then we should have ensured that their care was continuous and
uninterrupted. If we are to redesign service delivery then it is incumbent
on us that during that process, the patient is not endangered through an
irresponsible or discriminatory denial of care.
What has saddened me most is that I don’t believe that any of this need
have happened in the first place. Looking at the NHS delivery, I was
struck by the number of ways that capacity could have easily been
increased, without adding to the existing workload. The number of
different scheduling and appointment systems that are used beggars belief.
Few operate with any degree of efficiency. It would be relatively easy to
double NHS capacity if some simple procedures were adopted on a national
scale when it comes to the administration of our service. Clinically too,
the service could be transformed. Even with a high risk caseload the
majority of the work is chiropodial (actually this is a misnomer – the
majority of NHS patients are low and medium risk diabetics; even in the
high risk category only a small percentage actually present with limb
threatening pathology).
Yet it is the simple chiropodial skills that are failing with the
consistent approach to the ‘cut and come again’ regime that prevails in
most departments today. Similar variances in care are also evident in the
private sector too. Some practices –in state and private - are excellent;
modern in every sense of the word. Most of you reading these words will
come into that category. Sadly you are in a minority. Much has been talked
about the image of the profession and the value that the public attach to
us as a result of experiencing our care. To improve it, you’re going to
have to pick up the stragglers.
With the greatest respect to podiatry managers, the way the NHS discarded
its duty of care to many of our patients without due debate or consent,
devalued our profession, in the eyes of the public, tremendously. I don’t
intend to harbour on this point, but it was one worth making, out of
respect to my patients if nothing else. If I am critical; I hope it will
be seen as constructive. I don’t see the point of apportioning ‘blame’.
What I would like to see is a debate on how we move forward as a
profession from here. The HPC legislation has thrown us individually into
a collective melting pot, but the artificial barriers between state and
private clinician still remain. No sector can work in isolation of the
other without harming the prospects of the entire profession. That is one
lesson we can take away from the last twenty years. The question is how we
structure our profession to service the foot health needs of all society?
The ‘toenails issue’ was an opportunity for the profession seven years ago
to redefine its contract with the state. Does the opportunity still
present today?
Sincerely
Mark Russell
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