Stephanie J. Snow

Access to general practice in England: time for a policy rethink.

Improving access to general practice is one of the current priorities of healthcare policy in England and offering patients timely access is central to this agenda. A £50 million ‘Challenge Fund’ to support pilot initiatives offering GP appointments earlier and later in the day was set up in 2013 and a further £400 million has now been pledged to expand this programme. British Prime Minister David Cameron has promised that patients will be able to see a GP 7 days a week from 8 am to 8 pm and his Health Secretary Jeremy Hunt has outlined plans to recruit an additional 5000 GPs to make this possible.1,2 The Government believes that this policy will reduce admissions to accident and emergency (A&E) services.3 However, its approach is not based on any detailed evidence that there is a strong link between access to general practice and recourse to A&E.4 It also involves privileging a particular dimension of access to general practice over others. This article explores how policy came to be dominated by concerns about speed and convenience, and calls for a wider debate that incorporates other aspects of access.nnAccess to general practice can be described as having three main components:5 nnIf this definition is borne in mind, it would be logical to conclude that policy aimed at improving access would involve addressing these different dimensions of care …

‘I’ve Never Found Doctors to be a Difficult Bunch’: Doctors, Managers and NHS Reorganisations in Manchester and Salford, 1948–2007

Since 1974 the National Health Service (NHS) has been subject to successive reorganisations which have shaped and reshaped patterns of administration, clinical care and services. This paper uses two sources of oral evidence: a Witness Seminar with a group of administrators who attended the NHS National Administrators’ Training Scheme in the late 1950s and a collection of interviews with doctors and managers who have played key roles in the health services of Manchester and Salford between 1974 and 2007. It surveys the day-to-day interactions between doctors and administrators/managers in hospital settings and analyses what these reveal about relationships within the broader context of shifting organisational structures and management styles. It suggests that the evidence challenges the historical stereotyping of the two groups and that strong working relationships have been determined as much by the values of respect and association as by changes to structures or management styles.

Translating new knowledge into practices: reconceptualising stroke as an emergency condition

Objectives To examine how the new concept of stroke as an emergency condition led to the development of new clinical pathways for stroke patients in Newcastle Upon Tyne, implemented through protocols which were then rapidly adopted across the UK and further afield. Methods Historical analysis using health policy documents, published papers and correspondence on stroke alongside 17 interviews with stroke clinicians and managers in the UK and the US. Results The challenges of implementation stemmed from organisational and professional barriers rather than scientific or technological difficulties. Stroke’s historical status as a non-treatable illness was a barrier to the adoption of acute treatments. Building new pathways for stroke patients by developing protocols for paramedics and emergency room staff originated as a local solution to a local problem but were taken up widely. Discussion Understanding the clinical response to the reconceptualisation of stroke as a treatable disease contributes to our understandings of the relations between clinical research and practice. These findings have implications for how we understand the translation of new knowledge into practice and its transfer across different clinical communities and settings. Protocols are shown to be a particularly valuable tool, bridging knowledge between communities and manifesting a new identity for stroke.

Migration and danger: ethnicity and health

Ethnicity and health are contested terms that are difficult to define, arising from a moment in the development of public health where difference – both constructed and embodied – was recognised to intersect with inequalities in health. The complex, contingent nature of both ethnicity and of health mean that proxies are used as means of trying to capture key dimensions of these complex concepts (Bradby 2003). Any research involves sampling: even the richest of ethnographic accounts selects material and excludes other, while variable construction is always a sampling of all possible indicators. In setting the context for this special issue, we consider recent migration to Europe, and how the current political and economic concerns have delimited understandings of the wider links between health and ethnicity. Throughout 2015 and 2016, migrants seeking entry to Europe have been in the news with the scale of the displacement through the summer of 2015 and the continuous arrival of people across national borders widely reported. Movements have continued over land and sea, despite winter weather, in unprecedented numbers with over a million people registered for asylum in Europe in 2015. According to Eurostat figures for 2015, more than 450,000 asylum applications have been lodged in Germany (35% of all applications within the EU), more than 150,000 in Hungary (14% of all applications within the EU) and Sweden (12% of all applications within the EU), more than 50,000 in Austria (7% of all applications within the EU), Italy (7% of all applications within the EU) and France (6% of all applications within the EU), with around 40,000 in the Netherlands, Belgium and the UK. Behind the figures lie stories of migrant journeys that have involved significant dangers in order to achieve mobility for a range of compelling reasons. In addition to registered asylum seekers, large numbers of refugees entered Europe by land and sea throughout 2015 and 2016. A boat overloaded with 800 passengers capsized off the Libyan coast in April 2015, resulting in hundreds of deaths. Images of Aylan Kurdi’s (2012–2015) drowned body, washed up on a beach in Turkey, spread rapidly via social media in September 2015. Greek island beaches, marketed as ideal holiday locations, featured in news feeds strewn with boat wreckage, discarded life-jackets and wet clothing. Images of columns of people walking through the Balkans and Hungary to seek protection and shelter from war, civil war and persecution, and to attain the status of a ‘recognised refugee’ in European countries, demonstrated the desperation and determination that underpinned the movement. Images of families carrying children and supporting elderly and disabled relatives through long journeys, despite the new

Health and Greater Manchester in Historical Perspective.

This article maps the history of health organisation across Greater Manchester (GM), primarily since the Second World War, to show how against a continuing backdrop of health inequalities, services have been driven (and constrained) by the needs and the politics of each period. Defining ‘success’ as benefits for patients the article identifies examples such as Salford’s mental health services (1950s and 1960s), public health in North Manchester (1970s and 1980s), the creation of centres for diabetes, sickle-cell and thalassaemia (1980s) and the formation of the Joint Health Unit in 2002. What this history shows is that over the period the common factors influencing the ‘success’ of health organisation across GM have been the championing of particular issues by multi-disciplinary groups working across health and social care and stability in structures and personnel.

Surgery and Anaesthesia: Revolutions in Practice

The discovery of anaesthesia in the 1840s was a defining moment in the history of surgery, though its introduction and establishment as a routine practice remain curiously under-explored by historians. The controversies that accompanied its introduction give insights into the social and cultural history of nineteenth-century attitudes to suffering, surgery, and risk. The broad divergence in patterns of anaesthetic use that persisted through to the mid-twentieth century and the different trajectories of specialist anaesthesia across the Western world speak to cultural differences around the calculation of risk and the making of surgical identities. In the twenty-first century anaesthesia continues to raise questions about the nature of pain and indeed, of life and death: its mechanism remains elusive; the process continues to be risky; and patients remain fearful of anaesthesia. Yet it is now impossible to imagine a world without it.

Adding the past to the policy mix: an historical approach to the issue of access to general practice in England

Abstract Historical perspectives can be embedded into policy initiatives through a process of ‘past-proofing’—ensuring new policies take the study of the past into consideration. We describe how this was done in a project looking at patient access to general practice in the NHS. We argue that current preoccupations with timeliness which have led to the marginalisation of other dimensions of access are connected to a broader process of neo-liberal reform since the 1970s. This reflection can support a reframing of the terms of current debates on a major issue in British health care. It has wider implications for the policy relevance of history.

Why We Should Try to Get the Joke: Humor, Laughter, and the History of Healthcare

Abstract This paper advances two central arguments. The first is that focusing on humor and laughter can play a central part in enhancing our understanding of the contemporary history of healthcare. The second is that the value of the meaning contained in humor and laughter has thus far been underestimated in the field of oral history. Our discussion of these issues is grounded in an analysis of oral history testimony and documents gathered in the course of research into the history of the London hospitals, Guy’s and St Thomas’, and of their associated institutions (i.e., medical schools, staff associations, and the like) since the 1970s. Note on Multimedia Content: The online version of this article doi:10.1093/ohr/ohw110 includes audio files that allow readers to listen to some of the printed interview excerpts. In the HTML version, readers may simply click and play; in the PDF version, it is necessary first to download the PDF.

‘Not everyone can be a Gandhi’: South Asian-trained doctors immigrating to Canada, c. 1961–71, by David Wright and Sasha Mullally

Wright and Mullally’s case study of the migration of South Asian-trained doctors to the Canadian province of Novia Scotia between 1961 and 1971 is a strong contribution to the growing literature on the global phenomenon of the international migration of healthcare workers since the 1950s. Its integration of quantitative data culled from the Canadian Medical Directories and annual returns of the ‘intended occupations’ of landed immigrants to Canada with oral history interviews produces an account revealing of the complex relationships between structural factors and individual agency. Arguing that migration was a response to multiple and organic socio-economic and political factors, the authors show how migration has operated as both cause and consequence: Canadian-trained doctors who moved to the United States to access advanced training opened up opportunities for South Asian-trained doctors to move from Britain where the emigration of British doctors to Canada, the United States and Australia had led to mass recruitment drives from South Asia to address doctor shortages in the British National Health Service (NHS). Multiple migration was common: many of the South Asian-trained doctors migrating to Novia Scotia did so from the NHS, sometimes to gain professional advancement, sometimes to fulfil personal desires by joining family who had already migrated there. This illustrates well how migration creates interdependency between nations. The evidence presented here challenges notions of medicine as a universal set of knowledges and practices that can be implemented in different contexts without consequences for health professionals or patients. As in other studies on migrant healthworkers, Wright and Mullally describe how moving to another healthcare system produces a patchwork of experiences for migrants, encompassing gratitude and satisfaction for professional success, alongside disillusionment, financial difficulties, professional glass ceilings, professional conflicts, cultural isolation and racial discrimination. Notably the evidence differentiates the Canadian context from existing work on South Asiantrained doctors in the NHS by showing how in Novia Scotia doctors were able to establish themselves across a ‘diversity of social and occupational spaces’. In contrast the ‘clustering’ of South Asian-trained doctors in unpopular specialties and geographical areas in the NHS speaks to the long history of embedded structures and hierarchies of British medicine (Simpson, Snow, and Esmail 2016). The article points to the way in which our studies and analyses of migration need to address its manifestation as a multi-layered phenomenon which manifests at global, national and local levels and is subject to multiple

Book Review: The evolution of surgical instruments: an illustrated history from ancient times to the twentieth century

Surgery is pivotal to modern medicine and we have excellent histories of specific operations, surgical theories and concepts, the professionalization of surgeons, and studies of the relations between surgery, science and industry. Yet the surgical tools that facilitate operations by manipulating tissue and bone have received little attention. John Kirkup, a retired surgeon and Honorary Curator of the Historic Instruments Collection at the Royal College of Surgeons of England, has researched the history of surgical instruments for over twenty years with the objectives of analysing “the long evolution of operative instrumentation” and classifying “instruments in such a way that their structure, composition and function can be followed in a logical fashion”. The evolution of surgical instruments is the impressive outcome of this project. In scope, style, and detail its pages are redolent of eighteenth-century taxonomies of natural history. Its content is underpinned by a wide variety of sources including archaeological findings, surgical writings, instrument catalogues, and museum collections across the world. n nAn introductory section on surgical and technological factors and historical sources contains a chapter in which Kirkup develops his thesis that instruments evolved naturally from their human precursors—fingers, thumbs, nails and so on. Hence in earliest times, fingers could act as retractors or as dilators, prefiguring the later instruments created out of antlers or bone, and eventually bronze and steel. The merits of such an argument are debatable but it does serve to remind us of the intimacy between the surgeon and the instrument, and prompt reflection on the way in which new techniques such as endoscopy, lasers, and ultra-sound distance the surgeon from the body. The middle two sections on ‘Materials’ and ‘Structure and Form’ make up the heart of the book. Here, Kirkup painstakingly analyses the materials used to create instruments, including natural materials like stones and plants, nonferrous and ferrous metals, and gum, rubber, and plastics. He developed a point system to quantify the composition and distribution of materials over time in a range of instrument catalogues and collections held in Britain, Europe, and the United States of America. Instruments, he contends, can be organized into eight basic shapes although each shape has numerous modifications. The fine detail of his narrative, aided by the plentiful and varied illustrations will be invaluable aids for those attempting to identify and catalogue new instrument collections. The use of instruments in surgery is the subject of the final chapters. n nRelations between instrument construction and the discovery of new materials are well-grounded. Cast steel in the eighteenth century created finer and sharper knives that improved surgical techniques; traction equipment, portable urinals and catheters were a few of the items developed using hard rubber in the nineteenth century; and the production of stainless steel alloys around 1916 permitted the creation of non-rusting scissors and forceps, even though use of the steel increased costs between 30 and 50 per cent. Kirkup’s personal experience of surgery is of great advantage in mediating some of the intricacies of instruments to the reader. Writing of the French instrument maker J F Charriere’s creation of extensions for the jaws of pivoting forceps in the nineteenth century, Kirkup notes that when he tried the extensions he found them to be “awkward, even dangerous, for his fingers, as well as time-consuming to attach”. n nA history of limb amputation is an organic offshoot of Kirkup’s first book and maps chronologically the history of amputation from earliest times when epidemics of ergot poisoning could cause the loss of limbs, to the beginnings of elective amputation in the sixteenth century triggered by gunshot wounds, and pioneered by military and naval surgeons, to twenty-first-century innovations like limb transplantation. As in the earlier volume, Kirkup takes account of the wider context of surgery and the huge benefits derived from techniques to control bleeding, pain, and infection. The social and cultural meanings of the process are deep: “Amputation is often regarded as an opprobrium of the healing art”, wrote Joseph Lister in 1883. Elective amputation was contingent upon the social acceptance of non-surgical amputation, argues Kirkup, and he sketches out the different social and religious attitudes to amputation across the world. The primacy of a complete body at the time of death is a fundamental belief of Muslims. Some patients have found compromise between medical need and religious belief by preserving their amputated limbs or limb parts so they can be buried as a whole. These brief and tantalizing threads are ripe for fuller study and would complement nicely the emerging body of work on the history of disabilities. n nIn the first book, Kirkup has created an unparalleled reference tool that will be of use to the many communities—academic, medical and public—interested in surgery and its history. The second contributes to the historiography of specific operations and should stimulate further exploration of the cultural meanings of bodies and their parts. In an addendum to the final chapter of A history of limb amputation, Kirkup refers to new research which might solve the current surgical problems caused by infection occurring at the site of osseointegrated titanium implants. The idea originated, he says, from observations of the way in which the antlers of deer grow through overlying skin. Natural history it seems remains as central to the surgical present, as it was to the surgical past.