1. A Health Care Study Tour
- Peter Batty |
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I was unexpectedly invited to join a Health Care Study Tour of Cuba by the former West Midlands Regional Health Authority in November 1995. It was organised
by the Institute of Health Service Management in London through a travel agency called Master Travel and lasted one week. This account is necessarily brief and
many facts have had to be omitted.
There were 13 individuals in the tour party - a motley crew of current and past health care professionals and managers including two doctors (one GP and one
anaesthetist) - from as far away as Glasgow, Northumberland, Kent and Devon. The objective of the tour was to see if the Primary Health Care Systems
(PHCS) in Cuba was as good as had been reported in spite of the American er;nbargo
allegedly causing severe problems with supplies of food, equipment, power (oil) and
their major export crop, sugar. If this PHCS could thrive on so little might the Cubans
have ideas that could be transferred to the UK? Cuba is the size of England in land mass with a population of 11 million.
Health care is free to the whole population. The infrastructure appears to be well
established (roads, motorways, railways, electricity and water supplies etc) but the
general appearance of buildings and roads, cars, vehicles in general was one of quite
gross dilapidation through lack of investment.
We were based in Havana and visited several hospitals, GP surgeries and polyclinics. At the Ministry of Public Health their Directors of Health Analysis and
Health Forecasting gave us a large number of statistics; there are 55,000 doctors,
25,000 of whom are GPs (60% female). There are 278 hospitals, 435 polyclinics, 25
blood banks, 8,000 nurses (graduates) and 25,000 GP nurses. 12% of their population is >65yrs (expected to rise by year 2005 to 25%) with a life expectancy of
75 for females, 73 for males. The incidence of child abuse was said to be low, cot
death nil, a high suicide rate ( 18/100,000), and asthma an important problem (8-9%).
Five years ago the Cuban health service had achieved all its year 2000 WHO targets
on a budget of 6 billion per year. Today this has been slashed to $2 billion, because
of the poor economic state of the country as a result of the embargo and because
their sugar crop failed in 1994/95. An equivalent cut in our health funding would be
from £34 billion to £11 billion - could we survive that?
There are three distinct levels of care - primary care, hospital care and tertiary
care leading to research. GPs each work in a local community with a single GP nurse
and live on the surgery premises. They have a well ordered health prevention programme (immunisation, cervical cytology, mammography) and the GP's role is
one of total health care for the population - she/he will check every home, their water
supply and sanitation arrangements etc. Each will have about 500 patients ( 150 families). Doctors earn between 230 pesos ( 1 peso = 2% pence) and 600 pesos per
month. The average wage in Cuba is between 180 - 250 pesos per month. GPs are on duty day and night every day of every week except for a short holiday. Many
health care professionals reported to us that they work "from the heart" for the
common good. The 'managers' we met, almost without exception, were practising doctors.
Medical student training is free with a few scholarships offered to foreign nationals. We visited the main medical school in Havana with 500 students. Each
student has free accommodation (often at home!), free clothes and food, but the normal diet is as follows: Breakfast - tea and milk, Lunch and Supper - beans, rice
and vegetable of the day. There is rice pudding for sweet at times. They are allowed
about two eggs per month and one portion of fish a month. No medical student has
had meat for over two years. Having said that they were nutritionally looking very fit
and happy. They are expected to take regular exercise as part of their training. They
have to pay for their own shoes. There are gross food shortages as regards meat and fish, although the hotels
were well supplied. The population's staple diet of rice, beans and vegetables appears
to be nutritionally sound. Since the health care programme of illness prevention started
when Castro came to power the life expectancy has improved from 55yrs to 75yrs - a tremendous achievement.
Patients carry their own health care records and there was therefore very little evidence of paperwork in the GPs' surgeries.
GPs are responsible for making returns to the Ministry of Health of the incidence of each consultation by t(\ completing a
one line entry on a loose A4 sheet of the details.
The level of equipment in one GP's surgery was extremely basic having to light her
room with an x-ray viewing box as there was no light bulb; but why did she need a viewing
box? She had no x-ray facilities. Her equipment cupboard was empty and the few
bottles in her drug cabil1et also appeared empty. She had a stethoscope,
auroscope, ophthalmoscope & sphygmo manometer
The embargo means they cannot get many drug supplies and therefore they have been
producing their own brands of various essential drugs such as antibiotics. We went round one factory producing a
different drug each week. This has a controlling influence on what GPs can prescribe as the local pharmacist will inform the GPs that
perhaps only one type of antibiotic is available this week; this would change the following week depending on supply. Children are kept under regular review via
the nurse or the GP; all adults are expected to have had a consultation with their GP at
least twice a year. The GP is expected to visit the homes of those that haven't seen
her/him during the year.
On one of our visits we were essentially shown a 'show-piece' hospital which had 24 floors each with a similar design and lay-out. Many beds were empty and the
level of equipment was quite basic. We were determined to try and gain access to a -
high dependency unit or an ITU - this was denied in this hospital, but we managed to
engineer a visit to a hospital in Havana which was more like a local DGH. Here we had
a brief visit to an ITU. One patie.nt, four beds. A portable x-ray machine which didn't
work, a working cardiac monitor, an IV drip (one being put up without gloves - very
short supply) and oxygen. Nothing else appeared to be available. All supplies of
needles, syringes, dressings etc are very short and glass syringes are used. This
patient had had a fit whilst on her push-bike and been hit by a car; she was unconscious and was due to be visited by a neurosurgeon and was going to have a
CT scan. We didn't see the CT scan equipment. The Cubans are partially self- sufficient and have built their own CT scanners as the embargo prevents them from
importing this level of equipment. In the medical school research lab a spectrometer
wasn't working because the halogen lamp had blown two months before. We were told
there was one other bulb in the country and the Ministry of Health was deciding which
department should be allowed to have it! In other areas of the health service we found
equipment that was old and not working such as ultrasound scanners.
In conclusion I felt the health care system infrastructure was well established,
community morale was good in spite of the obvious problems because of the 'common
good' goal and primary care was dealing, in collaboration with the polyclinics, well with
preventing illness within the community. However it was impossible to assess the
outcomes of surgery and so on with any certainty. One can only see what one is shown and one has to take at face value.
Peter Batty
Once again the annual dinner at Spring Grove House proved to be a memorable evening - although having
said that it is surprising how many remember morning after headaches even more clearly! Well done, once
again, David Malcomson for fitting a quart into the pint pot; at one stage it
seemed .that . the evening was overtlooked until he realised he'd counted the same party twice. Even
so, Spring Grove House was packed with society members looking forward to the evening.
And an evening to remember it was. Excellent food superbly served, fine wines consumed in abundance
and an after dinner speaker whose wit and repartee brought tears to the eyes and many a side aching with laughter.
David Gunson, with his memories of life as an air traffic controller spiced with stories that, if it were not for the
influence of the wine, could have seiously jeopardised many holiday flight plans, entertained us all for over
an hour. A memorable event.
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Francis Sydney Alfred 'Mike' Doran
Francis Sydney Alfred Doran was born in Cheshire on 1st November 1910. I do not know when he began to be addressed as "Mike" but that is how he was always known to his
friends and colleagues here today though to his family, for equally mysterious reasons, as
"Fud". He was a man who recoiled from any over demonstration of emotion and that would
be good enough reason, if one were needed, whatever sadness we may feel today, to treat
our gathering here as a Celebration of a life well spent. Mike's father was a dentist and
clearly a man of very strong principles. Mike once told me of the advice given by his father to
him before his wedding to Anne. Summoned to his study for what might have been a deeply
embarrassing session father offered but one piece of advice. He strongly cautioned him that
if invited to carve the joint early in marriage be sure to drop the joint on the
floor. "You will never be asked to do it again." he said, "It was good advice. I wasn't!" said Mike later in life.
First I will say something of the chronology of his life and then something of Mike as a person. He was educated at
Shrewsbury where he became a notable oarsman leading to a life long addiction to Henley Regatta. He also acquired a
reputation as a drawer of spy-like caricatures which he persisted with in his early days in medicine illustrating most of his
colleagues. His eye and skill in this respect were apparent throughout his life in the careful and often beautiful clinical
diagrams which adorned his notes, in his collection of paintings and in the style in which he helped to furnish and decorate
houses in which he lived. He read pre-clinical medicine at Emmanuel College, in the gaps between rowing engagements.
Conjoint examination in 1936, his MB in 1937, doing his clinical midwifery in Dublin, and his FRCS in 1940. During the war
he was in the RAF as a surgeon in India, where he first met Anne, and then saw active service in Burma where he was part
of the surrounded forces on the Imphal plain. After demob he obtained a Cambrid~e.' MD and after working around
Manchester, including a spell at the Christie Cancer Hospital, he came tq Bromsgrove and Redditch as the first Consultant
Surgeon at All Saints Hospital. The quintet of new consultants, Friel, Doran, Kenny, Cruickshank and Di Harris, together
with Matron Boggan, developed a new hospital in the face of very great physical difficulties. Theirs was not always an easy
relationship but together they built a first class service for the citizens with second class facilities and many hundreds of
patients owe them an enormous debt of gratitude. Mike worked there and at Redditch and Kidderminster until his retirement
nearly twenty years ago and then moved away to Ledbury keeping his contacts with his many friends and colleagues right
until a few weeks before his death.
Such a little chronicle to paint will alone tell a a picture of the story of service but does little to pain a picture of the
man himself. He was an intellectual possessing a great sense of reason and logic. I used to think we all lost something by
his not working in a more academic milieu that might have allowed him more time to think, teach and write but, quite
remarkably for one who bore more than his fair share of clinical work/his writings and research over forty years still obtained
for him a national reputation. These ranged from his book "Mind", a Substantial philosophical work with a foreword written by
Bertrand Russell, to a wide series of papers on subjects such as pioneering the repair of various hernias with man made
materials, developments in the surgery of varicose veins, original work on the prevention of post-operative embolism, the
exploration of early discharge after surgery and the complexities of medical manpower logistics. He was a tireless worker,
dedicated to the conception of the National Health Service and opposed in principle to private practice. His outpatient
sessions and operating lists were extremely lengthy but he never failed to respond to any request for advice or to see a
patient at the Bromsgrove Cottage Hospital or Smallwood or in their home, day or
night, but always jointly with the GP, thus demonstrating his firm belief in the partnership between the Consultant and the General Practitioner. His reliability,
dedication, and good humour made him the best of colleagues and the sight of his aged Land Rover ploughing slowly and
implacably through the traffic was a symbol of the rock like qualities of the man. Not that this Land Rover was not feared as
well and many a gate post, drain pipe and car bore the marks of unwisely attempting to impede its progress. All this might
sound as if he was dull but far from it. His mischievous sense of humour was a constant source of delight. It was to be found
in his conversation, his letters to colleagues about patients and in the wonderful parties he and Anne gave. But his humour
was always kind; always laughing with people or more often at himself and never at others. He was a doughty horseman.
He rode fearlessly, and was knocked off from time to time, a very large horse as befits a large man and his dedication to
hunting can be measured by the way he had some of his suits lined with leather so that he could leave the operating
theatre, mount the horse tethered in the hospital car park and proceed to hounds
without delay. In of all this he had the support of Anne. Elegant, quiet and supportive, although not always enjoying the best of health. She also gave much
dedicated care to his older mother in later years. Gill, who he referred to as 'the metastasis' for many years, was a great
source of pride to him and those of us who regularly took coffee and tea with him at work, as I did three or more days a
week for more than twenty years, can testify had her achievements charted to us whilst he feigned astonishment. Many
years ago there was a bus crash in Bromsgrove with a number of injured. All of us on the surgical side were pressed into
action. I had the task of operating on a very terrified lady who expressed loudly and repeatedly her certainty that she was
dying. When she awoke stitched, bandaged and recovering she opened her eyes and Mike Doran, dressed over all in
theatre white, was the first person she saw. "Who are you?" she asked. "I, Madam, 1 am the Archangel Gabriel" he replied. I
cannot but believe that now that the trumpets have surely sounded for him on the other side Gabriel will forgive him that
momentary impersonation
Professor Sir Michael Drury
Roger Frow 1943 - 1996
It was with total disbelief that I heard of Roger's death in Selly Oak Hospital on the
15th of June. Roger was 53 and much sought after for his dental skills. He qualified in
1965 at Kings College Hospital with honours in surgery and then became a resident at
Kings College. Later he became a lecturer for 3 years and during this time he married
Jenny who had recently qualified as a doctor. He took his Dental Fellowship and then
decided to leave the hospital rat race for the life of a dentist in the Shires. Not only was he full time in practice in Worcester, but for many years he worked
on Wednesday aftenoons at Lea Castle Hospital where he was much loved. He was on
the FPC and FHSA and was on the Dental Services Committee of the FHSA. He spent 13 years as Secretary of the LDC - no mean feat.
There was a non-medical side to Roger as he had been a very active member of the Worcester Festival Choral Society for many years and in the late 80s he was made
their first Lay Chairman, the post he held with much distinction for 3 years. Roger still had time to be a good friend and never seemed to be too busy for a
chat or a joke. He often came to lead discussion groups in Kidderminster for the GP
trainees. He was an expert gardener and a keen trout fisherman on his bit of river in
Herefordshire. I am sure all of us who knew Roger are missing him enormously. Our love and
understanding go out to his wife Jenny and his sons Michael and Richard.
James
McLachlan
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South Shropshire is the most beautiful part of England and also one of the wildest. Buried away under the Glee, deep in Mortimer country is Cleobury Mortimer, home of peers ploughman and William Langlands and the Church with the crooked spire. Thirty years ago the town was extremely isolated, especially in Winter but in Summertime it was quite idyllic. With comparatively few motor cars Cleobury and the marches were quiet and unspoilt.
In the Summer of 1964 I had the great pleasure of being invited to do a locum in
the only medical practice in the town. The practice was then based in Langlands, a large
18th century country house on the High street and the home of the senior partner. There
were 2 partners, Peter Stanbury and Tony Williams and the practice dispensed to all its
patients. The practice area was enormous - from Glee Hill village to Cleobury Mortimer,
Kinlet to Bewdley and along to Abberley and Tenbury Wells. Together with the main
surgery in Cleobury, there were 5 branch surgeries - front parlours in Glee Hill Village
and Far Forest, a small purpose built bungalow at Glows Top ( previously the surgery of
a Dr Jerome), a pub in Kinlet and the Chapel (Methodist) at Hopton Bank.
It was still the early days of the .NHS and so with less natural demand and the stoicism of
country folk, the work was light and those you did see were much more likely to be
seriously ill. There was of course a great deal of visiting and a local knowledge of the area
(provided by the receptionist) was essential - a house number such as 7 Glee Hill could
be anywhere between Cleobury and Ludlow! My most abiding memory of that time however was of the welcome and
friendliness of the locals who took me in hand, showed me the ropes and helped whenever it was necessary. Friendly, helpful yet respectful to the new young doctor.
Yes, salad days indeed.
Graeme Wilcox
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PETER CHARLES
HUTCHINSON NEWBOLD
Obituary
Consultant Dermatologist
Worcester Royal 1973 - 95
Born Manchester 1938
Oxford / Guy's 1963 DM, FRCP
Died of leukaemia and an overwhelming antibiotic resistant septicaemia on 28 March 1996. There were two
strands to his life: professionally as a busy dermatologist (including, in keeping with
deeply held christian principles, the voluntary care of terminally ill patients) and as a
connoisseur of music, words, and the fine arts. An indefatigable traveller and fluent in many languages,
he would think nothing of flying to San Francisco for a few days to hear Joan Sutherland or of
spending a weekend in Erfurt, Germany, photographing stained glass in the church
where Luther had preached.
Both of his legs were broken in a traffic accident some years ago, and he had had repeated pulmonary emboli
and chest infections. When leukaemia was diagnosed two years ago he decided to retire
early, but he continued to travel.
Robert Mahler
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Tennis and Barbeque afternoon on Sunday 28th July
There was an excellent turn out for tennis on this muggy Sunday afternoon. Five courts were kept busy all afternoon despite persistent rain in the second half. Numerous
toddlers and babies played on the sidelines and dipped in the paddling pool while the
older children were kept well occupied on the practice wall and by playing hide and seek.
The barbeque sizzled despite the steady downpour and a good time was had by all.
Many thanks to Bewdley Tennis Club for the use of their facilities.
Liz Malcomson
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