Just another Sunday

British Medical Journal, March 21, 1998 by Timothy J. Stannard

I write this one Sunday evening having just finished a centre based session for our local cooperative, which has now been established for just over a year.

One patient in particular sticks in my mind. She was a temporary resident staying with her parents for the weekend and 30 weeks advanced in this her, so far uncomplicated, second pregnancy. Before leaving home she had experienced some mild suprapubic discomfort and frequency but thought little of it On the Sunday morning the symptoms had worsened and now she had obvious symptoms of a urinary tract infection. She had telephoned our helpline on the Sunday morning, been offered an appointment, and asked to bring a specimen. When I saw her, in the comfort of a consulting room, her urine had been "dip-sticked" (confirming the presence of leucocytes, nitrites, and protein), and a midstream urine specimen organised. She left me with a prescription to deal with her urinary tract infection. The whole consultation had taken me less than five minutes and the problem dealt with in an efficient and effective manner.

I contrast this with my own experience three years earlier while on holiday in rural Devon. My wife, who was similarly 30 weeks pregnant with our second son, developed similar symptoms over a weekend, but feeling stoical she said she could wait until Monday before seeking help. It became apparent by late Sunday morning that she could not wait any longer and we decided to seek further help. Having experienced many disturbed weekends on call we did not wish to disturb the local doctor and so drove to the nearest market town in an attempt to find a local chemist. Unfortunately, the only pharmacy open had closed just a few minutes before we arrived.

Not to worry, this small town possessed one of the gems of the British medical system, a cottage hospital. Unfortunately, this particular version had only a minor injuries unit open 9 am to 5 pm, Monday to Friday. Not to worry, the nearest large town was only 15 miles away. We decided to drive there and find a chemist On the way we passed through another small town and saw a sign to "The Hospital." This was another of those now renamed community hospitals, but we were in luck as this one had an 24 hour "casualty department." The nurse on duty was helpful, but said that she would have to telephone the general practitioner on call before issuing the antibiotics we required. His wife said that he was out on visits but she would contact him and ask him to call. The reply came that we could not be issued with antibiotics, and we were advised to go to the accident and emergency department of the nearby district general hospital. So we had another 10 mile drive in an attempt to resolve the problem. By this time we had spent two hours trying not to bother the doctor and were still not close to resolving the situation.

I did not think that this was a problem to be dealt with in an accident and emergency department but did call in to ask directions to a local pharmacy. The nurse on triage duty was as helpful as the first nurse but did not know which chemist was open; she would see what she could do about getting us a prescription. The staff grade doctor on duty was equally as helpful in the middle of a busy Sunday afternoon with a department full of sick and injured holidaymakers. Unfortunately, there was no antibiotic in the departmental stock, which was suitable or not contraindicated in pregnancy. They offered to call in the duty pharmacist. I declined this offer and finally obtained direction to an open pharmacy that accepted the prescription. Four hours on we were able to start the required treatment.

These two episodes contrast the difference between the old on call system, which we used to provide, and the somewhat less personal but I feel more efficient service now provided by cooperatives throughout Britain. My greatest concern as one of the local organisers is the continued viability of the service we provide. In our first year of operation we managed to balance the books because many doctors did not take up their share of the development money. This will not be the position this year or in future years. Many of my colleagues question the appropriateness of paying out of our own pockets for a service which is of benefit to patients. While I sympathise with this view I also perceive a benefit to me and my family. But which other branch of medicine would accept a personal financial disincentive in providing a better service?

Timothy J Stannard, general practitioner, Winchester