Michael Bamber - Medicine
Bamber, Dr. Michael , Colsterworth General Practitioner
My name is Michael Bamber and I was born in Liverpool, the elder of two children of a skin doctor and his somewhat younger wife. I was educated in Liverpool and when I was seventeen or eighteen, my father said, `What are you going to do`? I said that I had no idea. He replied, `At your age I was in the trenches in 1916`. I said that it was now 1966 to which he responded, ` Don`t be impertinent !` and returned to reading the newspaper. A fortnight later I was asked the same question. This time I answered, `Medicine`. `God help us ! ` he said.
That is how I found myself in Medical School in St Andrews. I had to do physics, chemistry and biology. I hadn`t done biology before and that was quite interesting. I also started doing Spanish in my first year which I found rather more interesting than physics and chemistry. In the second year I moved on to doing anatomy and physiology which were part of the basic medical training. This went on for five terms at the end of which I failed my exams. I repeated the year and then resat them and was thrown out. I think I was distracted by the Spanish really.
By this time my father had died and I had my widowed mother to cope with. My brother was in the Army at that stage. Then I became a seller of second-hand commercial vehicles in Liverpool which was very useful in learning such skills as telling lies. I could tell some amazing stories concerning the black market which thrived in Liverpool 35 years ago. However, I decided that it was really a waste of the previous 4 years if I didn`t continue my medical training.
It was more difficult to get in medical school at that point so I became an external student of the University of London. This university was founded in about 1828 for people who weren`t members of the Church of England. About 1890 they created the first external degrees. They were really for expats who were living in Poonah or Delalli. Lo and behold one could be an external medical student. So I enrolled, paid my money and essentially resat the exams. I was very fortunate to be friendly with an anatomist in Liverpool and I attended (on an extramural basis) anatomy lectures.
Then I had a little problem as no medical school would accept me having passed that sort of exams. I spent another year working as an amanuensis for a pathologist under supervision doing autopsies which was very interesting because that was a training opportunity denied to people then, and now. At the same time I had to do an introduction to psychology. The next three years were fairly uneventful. I discovered that I could qualify before the rest of the year if I worked in Liverpool for a con-joint diploma run by the College of Physicians in London, the College of Surgeons. So I did that.
My first job was working as a junior doctor in the V.D. Department in Liverpool. It was absolutely fantastic - grateful patients, cheerful patients, co-operative patients. These were patients who always took their treatment, who caused very few problems. It opened my eyes to peoples` behaviour.
I then started the conventional house and pre-registration jobs, both of which I did in Liverpool. Some years before I had a mentor who said that it was important that all doctors should be generally trained. Every doctor should work in the casualty department and I spent six months at the University College Hospital in London. That was very interesting. My leader had a large name badge made the size of a letter-box so that it would show up when he was filmed for television. He wanted to be quite sure that his name was seen by the viewers. I thought I would be seeing casualty patients, those who had fallen off lorries or buildings instead of which they were mainly psychiatric and drug addicts in Central London. People would wander in and say `I don`t know who I am`. This was quite a challenging problem to deal with at 2 o`clock in the morning; or at 2 o`clock in the afternoon for that matter.
My now wife was working at the Hospital for Sick Children in Great Ormand Street for the Medical Research Council. We got married about then and it was just after that I worked for a month in Peterborough where my parents-in-law lived, just while looking for another job, which I got in Hampshire. Here I was a junior doctor in Internal Medicine for two years and after that I got a job in Dundee in the Department of Medicine at the Royal Infirmary there. This was a yearly job. All junior doctors` jobs then would last for perhaps a year or two years and then they had to move across the country. We stayed here for 3 years and did renal medicine, general medicine and a lot of teaching medical students and young doctors.
I was not sure what I really wanted to do. I did think I might become an eye surgeon and that seemed very interesting work which required no help from other people. But I then thought that infectious diseases might suit me so I applied for a job in Edinburgh but I was told that there was no future in the job this was in 1980 and there was certainly no promotion in the job because the intel candidate was spending a year in Zibwawe. This job was extremely interesting as for the first time in my life I dealt with children as patients. Young children suffering from meningitis or fevers or tropical diseases, and adults also. This job lasted for 2 years and then it was indeed apparent that there was no further job.
So I had a little bit of a problem as to what to do. Fortunately a neighbour in Edinburgh where we then lived, suggested that there was a trainee job for a year in general practice. I spoke to the girl who was doing the job at the time, and she said that it was very strange because the doctor who was training her was in the habit at the end of every day of discussing the patients that had been seen during that day. She thought that this was quite unnecessary as she had been qualified for 5 years. I had been qualified for 9 years and I thought the practise was very useful. My brother-in-law who is a surgeon spent fifteen years with nobody training him! This is par for the course in a lot of British medical training. This job was in a village just outside Edinburgh and there were 5 doctors in the practice. One doctor insisted on doing referred to as the Senior Doctor, Doctor Burns, a nice man who said to me that he had a rule for trainee doctors however old they were. He explained to me that I was the oldest and the most experienced of any he had had but the rule remained the same: it was that things were done his way and if the trainee didn`t like it the trainee left. I was used to seeing patients at a fairly leisurely rate and I was allowed extra time. The first day, my leader seemed overcome by the age of the guttering gas fire in the corner. He was semi-poisoned by the gas fire and explained that he really couldn`t discuss all the patients I`d seen that day. He asked who was the third patient I`d seen and I consulted my notes and picked one out, let`s say it was Jeannie MeGregor.
`Age ?` he asked.
` 23 years`.
` Sore throat`.
`What was the first thing you thought of when you examined her `?
`Oral gonorrhoea`.At this point he looked very ill. He got up. He removed his half-moon spectacles and he said, `What an extraordinary comment, doctor. What made you say that? I don`t think we have that sort of thing in Edinburgh!`
I had to explain to him that perhaps he was a little out of touch with what was happening in the practice and in Edinburgh.
At that point he decided to go home.
He held the practice in complete control. The young men and women waving free gifts from the drug companies were not welcome on the premises. When he went away on holiday all these people appeared, waving biros, free meals in restaurants etcc the staff were like small children just released.
The senior doctor was a most interesting man. He told me that what I most particularly needed was a proper mackintosh for General Practice, a riding mackintosh made by Scottish Traditional Rainwear with riding straps and a trilby hat. This was in 1985-86! So equipped in my traditional Scottish rainwear with riding straps and trilby hat I went to look for a job. There were no jobs, not least because I was not in the normal mould of production-line doctors. I was extremely likely to have ideas of my own which did not coincide with those who might seek to be partners with me.
I then had perhaps a two-year period without any regular employment which meant that sometimes I might be doing locum work in Scotland or hospital work in London. It was quite a difficult time. I applied for numerous jobs, as many as 230-240 jobs. I was about 36 years of age by now. I applied all over the country and eventually I had an interview in Colsterworth. The initial interview was conducted in front of an Ordinance Survey map which indicated the area of the practice. Dr Stafford interviewed me although I was to be working with his former partner, Dr. Monteith. Later I received a letter asking me to come for a second interview. This time Dr. Stafford was in bed suffering from severe back pain. I joined the practice and worked with Dr Monteith for 4 years until she retired. Then my wife, Dr. McKechnie, joined me. She came as a full-time partner, whereas Dr Monteith was part-time.
The practice ran on very ordered lines. There was no formal appointment system. Patients arrived in the morning to await their turn and the same in the evenings. There were just two staff. We had about 3 thousand patients spread over a circular area with Colsterworth at the centre. The circle was 12 miles in diameter, Dr. Stafford`s rationale being that he didn`t want a sick child at one extremity of the circle and a sick old man at the other. There was a sort of branch surgery in South Witham which was 3 miles away and 2 others, one at Skillington and one at Buckminster, both about 3 miles away. These two were in elderly patients` front rooms. What rapidly came apparent was that there was no possibility of my examining people and there was the sensation that someone might just be listening at the door. We went to the villages armed with what appeared to be a picnic hamper containing a selection of drugs, medicines for constipation and paracetimol and we would see the same few people every time. It was quite clearly unworkable. With some howls of protest from this very small number of people, I decided it just had to stop because it wasn`t good medical practice. It wasn`t safe and there was no possibility of talking to people in privacy or to examine them.
After I had been here for about 4 years, it became apparent that the surgery which had been built by Dr Stafford in 1967 to replace the one where he had hordes of children crawling all over his house (which had been the case since about 1902) was not really big enough for the size of the practice and the sort of things expected of doctors now. So we altered the premises, increasing the floor area by about 50% to 60% so that there are 5 rooms where a patient can be put on a couch or a bed. This is quite useful because if an elderly patient needs to get undressed it gives them complete privacy before they move on to the next room. Dare one say it, it is rather like a production line. At the same time we doubled the area of our premises at South Witham. That branch had been built about 1965. Interestingly, the population of South Witham is greater than that of Colsterworth. We attend the surgery there twice a week. We are not the only GPs for all the people in that village, perhaps because many do not see us as being there. There are even some people in Colsterworth who don`t know that there is a surgery here on Back Lane.
I and my co-partner, Dr. McKechnie, don`t think that we should advertise. There are some cases where doctors are behaving like they had tattooist parlours, as far as I can see, offering their wares. It is not the sort of thing that would appeal to Dr. Stafford and his predecessors. It certainly doesn`t appeal to me nor my partner. But times change.
The most significant thing that has happened that is destroying medical practice is government policy. It was announced by the Prime Minister in the Lower House.a year or two ago that small practices are dangerous. They cannot offer the range of service of larger practices. Surveys of the general public show that people are much more happy with a smaller general practice. They can name their doctor, they know his strengths and his weaknesses and his peculiarities. In the last year or two things have certainly hotted up to the destruction of internal medicine in hospitals but also in general practice. In 2003, a new contract was suggested for General Practitioners by the Department of Health. Doctors are not employed by the Health Service whereas people who run local services like surgeons in the hospitals or the Accident and Emergency Service are employees. They are on P.A.Y.E. ( Pay As You Earn income tax) and are told what to do, increasingly. There are, at a quick guess, less than 1% of general practitioners who are employed by the Health Service. Doctors have contracts with the National Health Service, in the same was as N.H.S.dentists and ophthalmic opticians. But of course the person offering the contracts can define the terms. Doctors have not had a very happy tine at all since the introduction of the Health Service in 1948. My predecessor can speak with much more authority than I can about this. The central Government naturally wants to know what it is getting for its money. Of course it does; I have no problem with that at all. It is entirely right that public funds are seen to be used properly and appropriately.
But sticking to general practice, in 2003 the government decided it was time to offer the general practitioners this new contract, laughingly put forward as `we will reward the doctors for what they are doing. We will reward quality`. There are about 110,000 doctors in the country of which roughly 30,000 are general practitioners. Of all these doctors, about 40% have qualified overseas, (mainly from India and Pakistan), and have propped up the N.H.S. since about the 1950s. General practice and the hospital service was propped up by Irish graduates. Recently however, these doctors from the Indian sub-continent, despite being trained in the British way, are no longer allowed to practise here. Droves of them still come but are unable to find work whereas those from the European Union can come here and practise medicine even if their English is poor or even non-existent. Here in our local town there have already been disasters.
Going back to the general practitioners` contract of 2003, 30,000 were invited to vote. Put crudely, the Department of Health suggested that there would be 30% more money for the doctors to reward meretricious activity. The doctors would be available from 0800 hours to 18.30, five days a week, and there would be no week-end work and no night work. It seemed somewhat strange. Remarkably, of the 30,000, two thirds, (that is 20,000) voted. 12,000 voted for the new contract, and 8,000, like myself and my partner (clearly middle-aged renegades) voted against it. But the doctors were smiling. We will have more money and we won`t have to work at the week-ends and we won`t have to work at night! In Lincolnshire now, there are effectively no doctors on duty during the night hours, it is practically a nursing service. The national response time for an ambulance to respond to a 999 call is about 20 minutes. This is completely unworkable for somewhere like Lincolnshire.
Of course, inevitably this payment was going to be used as a management tool. Within months the rot started. General Practitioners were required to produce tick boxes electronically showing activity on various targets. At the moment I am faced with 135 targets, laughable things some of them. I am required to bully patients into having cancer smears and flu jabs. This Government spent about 7 million on anti-smoking propaganda last year but it was lip service. They raked in hundreds of millions a day in tobacco duty. The notion that people should survive past retirement age is an anthema to them. What has happened to the pension funds? We no longer cover retirement at sixty-five will it soon be 70?
Worse still, it has become quite apparent, (at least to those running the Health Service), that doctors cannot be trusted. Clearly cheating and gaming will occur. It could be possible, I suppose, for the doctor to look every month at the details of every patient seen during that month and tick the boxes as he is expected to. Has he asked everyone if they smoke or whether they drink or whether they take exercise or taken their 5 vegetables a day? How will the Department know that he is doing this? The answer is that our computers are trawled 4 times a day for information. The public are unaware of this; they have not been told. Doctors who have been immunising everything from the cat to the canary as well as patients are rewarded.
The Government has published the results on a web-site and 3 weeks ago one was invited to see how one`s doctor had scored on the Quality and Outcomes Framework. Out of 1,050 points, this practice scored 1,037 points. It ends up with our being paid extra for what we would normally be doing anyway. What I do find particularly chilling is the trawling through patients` notes. Software has been installed in England that spots additions to a patients` data at unusual times, like week-ends. The suggestion is that the doctors are cheating. This is outrageous! On a Saturday or a Sunday I am normally to be found catching up on work for which I have found no time during the week. I often sit at night-time dialling into my very own computer system it can be the only time I have. But now, they are producing graphs that show when the information is going in.
General practitioners are not paid a salary but a sum of money comes into the practice with additions for those over 65 and over 80, and there is a little bit more for extra activities. But the Department of Health decided that being relieved of the evening and week-end work was worth to the doctors 6000. Therefore 6000 per year would be deducted from the payments to general practitioners to cover the medical costs of the night-time service. I worked it out that at this rate the work of the doctors for those hours per year, was valued at less than the minimum wage!
Expenses are much greater these days. Larger practises have full-time managers purely number crunching to deal with these computers. The doctor can abdicate all responsibility, at which point it requires full-time staff to deal with all the problems. Larger practises of course need more doctors but there is a shortage of general practitioners. There are no locums around to be had in Britain any more. This year I have had no holiday at all, last year I had one week and the year before that I had one week and my partner had two weeks. Any hobbies have disappeared through the window. Ten years ago I played the piano and the organ; I went shooting and walking, but now there is virtually no time.
When I first came here I was on duty night and day, and Dr Stafford had dealt with the problem of people ringing up unnecessarily in the middle of the night perfectly well. The patients in this practice were absolutely first rate. I would struggle to think of a stupid call out of hours. Now, because there is no form of control of patients, they are dealt with by nurses who are firsttrate nurses but the change over was accomplished in a rather rapid manner and the nurses fine themselves looking for decision making.. Earlier this year, one of my patients had diarrhoea. She was 85. On the advice of a computer decision, she stripped down to her nightie and took plenty of fluids. When we saw her the next day, she was suffering from hypothermia!! There is no medical input for these night calls. The public have been conned.
These days anyone who speaks out and tells the truth is put down. We have seen an instance of this in the Press where that poor Russian chap was poisoned with polonium. There have been several instances of this happening in the Health Service where people get suspended ( though not poisoned!). Through standing up at a public meeting and describing the conditions in the A and E department at Grantham Hospital, one of the male nurses was suspended from duty for a year. One of my colleagues, a senior physician, supported him and was warned by a medically-qualified member of the Trust that his own job was in danger. He gave a short, sharp response. The Health Secretary, 12 years ago, said that complaints were the jewels in the N.H.S. crown and we were to treasure them. Hardly. Whistle-blowers are exterminated! The public are blissfully unaware of what is happening.
There are some huge improvements in the N.H.S. But the general public is also unaware of the tremendous costs of the Health Service and treatment in one area can mean cuts in another. It is the vociferous groups that get attention and the money. Other services are being cut, like psychiatric treatment. There is poor support for this work which is so important. Staff are over-worked and stressed because of the cuts.
In spite of being free of working at night and at week-ends, I still have a heavy work-load. I am at the surgery most mornings at 0800 hrs and you will see my car here at 12.00 hrs. Bar one week this year, I have been here at the surgery every week-end, and I shall probably be here for 5 or 6 hours today. I have to say that all this work is not caused by the patients. Increasingly, one finds oneself doing these meretricious activities for the extra money. You must be seen to be bullying patients to have cancer smears or because they are too fat or you will be seen as an underperforming doctor. It is all to do with bureaucracy. In a small practice I am acutely aware of what has to be done. I can do all that my staff has to do, but not as well, absolutely not as well. In a large practice the doctors become detached; it is entirely different. There are some practices where the doctors don`t even know the names of the staff. I would find that a rather difficult environment to work in. I am pleased to follow the precepts set in this practice by Doctor Stafford and Doctor Monteith. I am not saying that we are better here than other practises, that would be extremely unwise, but we can offer a consistent service, a personal service. And in this horrible departmental criteria we perform well. Sadly, my partner and I are practising, not defensive medecine in terms of our patients, but certainly in terms of the Department of Health. We are being watched day in and day out.
I have been in medical practice for 30 years and have been in General Practice for 12 years now. This practice is a-typical. Again, I have to credit country people and the very straightforward principles on which Doctor Stafford and Doctor Monteith worked. What is called the Consultation Rate, that is the number of times the average patient attends the doctor in a year, is one of the lowest in the country in this practice. The average attendance is 4 times a year but here it is 2. My colleagues up the road say`, Oh well, Doctor Bamber, it is because you are being rude to them`. It could be that the patient is being told exactly what the doctor thinks! If the patient doesn`t like it he migrates to a practice more suited to his individual needs, which is fine. Also we have virtually no inappropriate consultations here. There may have been the odd one but I have to run this practise for the majority, not for the odd one. It can be a difficult decision to take. It is also interesting that our use of secondary care resources hospital care and so on is quite low. You might say that these two doctors are not exposing their patients to the full range of medical services. It is interesting that we have a higher number of medical practitioners as our patients than any practice in the area.
I have of course been giving you a middle-aged view. I met a friend of mine recently and he asked me how I was. I replied that I was a little bit gloomy. He said, `You must not confuse the gloom of middle age with the gloom of working for the N.H.S.` There are private general practitioners in London, I believe. The General Medical Council controls where a medical practitioner can have a license in Britain. Increasingly we are all subject to appraisal and any form of criticism is reported. I think it is chilling.
One thing this Government has done which is useful, is providing Broad Band Internet facilities free. I am using the internet every hour of the working day. Before, I subscribed to the British Medical Journal, the Lancet, the Newton Journal of Medecine, the Journal of Infection, quite an usual mixture for a general practitioner. The nearest medical library to here would be in Nottingham. Now virtually every bit of information I need will be on-line. I can send pictures of backs or skin lesions to colleagues and information from the Health Authority can come to me down-line. Also, I do not feel isolated, I can and do keep in touch on-line with other General Practitioners.
We have fast referrals for breast cancer or bowel cancer for examples, but the drawback to that is that people with minor ailments wait and wait and wait. Cataracts for instance. The Government awarded a 12 million pound contract to a South African firm to do cataracts. Only 25% of the work was done according to Private Eye which is usually pretty accurate on these things but they still got the money.
The interest for me in this job is the wide range of people I meet, the wide range of ages, with the caveat that in this practise I don`t see many young people. The countryside is depopulated of young people. In a town, 25% of G.P`s work is seeing young children under 8. I can go weeks without seeing a child here.
It is not a matter of putting a lot of money into the Health Service that is so important. It is the people who run it and who make things happen. I would not want to do any other job. It is very interesting; it is fantastic.