Although the ‘local NHS’ always seemed to be in a state of flux, and constituted a major distraction, it was the day to day running of the practice that was all important.

We were very keen on high quality antenatal care and, as I mentioned before, at a time when the quality of care was at an all time low, we employed our own midwife (the wonderful Margaret) to ensure our patients did not fall through the cracks. At Brickfields Surgery, Dr Anne Dyson did her own antenatal clinics so that her patients also had continuity of quality care.

With regard to intrapartum care, we weren’t so keen on home deliveries as, although they were wonderful when they went well, there was the worry that, when things go wrong, they can go very wrong very quickly – and we were a long way from St John’s Hospital (where maternity services used to be based) and even further from Broomfield Hospital (to which maternity services were transferred when the old hospital closed.) During the St John’s era (and at a time when paramedics were few and far between so ambulances were more basic … they were more a means of transport rather than a high-tech mini-hospital where sophisticated emergency care could be administered on-site) I did once ask what arrangements were in place if there was a crisis which needed specialist back up. I had been told there was a ‘flying squad’ based at the hospital that would come out at a moment’s notice – but nobody had ever seen this elite unit in action. It took a long time to get to the bottom of it – nobody knew who was responsible for organising the ‘flying squad’ or how to contact them. We eventually discovered that the ‘flying squad’ was just a box of emergency equipment stored in a dusty cupboard for which nobody had a key. As for the highly trained personnel who’d spring into action at a moment’s notice … this team was just a distant memory.

Apparently, when flying squads existed and were well managed they worked well and perinatal mortality dropped – but, in the NHS, there is rarely any ‘slack in the system’ so presumably they were eventually deemed impractical.

Another factor was that we were told they used to send two of the most experienced midwives out for home deliveries which sometimes left the hospital delivery suite short staffed and more reliant on those with less experience. So we were placed in a difficult situation; on the one hand we sympathised with those who felt that a heavily medicalised approach, driven by fear of litigation, leads to unnecessary interventions … but, on the other, the safety of mother and baby was paramount. As for the current vogue for ‘freebirth’ deliveries, ‘expert opinion’ urges caution as preventable brain injuries and deaths highlight the danger of lacking trained professionals to deal with emergencies like respiratory distress or failed resuscitation.

If we didn’t encourage being born at home, we were very keen to support people who wanted to die at home. At that time we didn’t have the guidance the surgeries now have – the ‘Daffodil Standards‘ which are an evidence-based quality improvement framework in designed by the Royal College of General Practitioners (RCGP) and the charity Marie Curie to help general practices, pharmacies, and Primary Care Networks provide high-quality terminal and end-of-life care. Even so we seemed to tick most of the boxes.

I used to give the relatives of patients needing terminal care my mobile phone number. The rationale was that, by the time mobile phones were widely available, I’d known most of these patients for decades, and allowing them to deal directly with somebody who knew the patient and the family well and was up to speed on the medical history meant that problems could be sorted out quickly and efficiently. I occasionally used to hear people say things like: “So I phoned the district nurse about my Mum and she said that it was a problem that really needed to be dealt with by the GP so I phoned the practice and was told that the hospice was the best place to get advice … so I phoned the hospice and they said they didn’t have anybody they could send out so could I phone the district nurse … and so it went on.” This sort of thing seemed like an unnecessary complication. By and large, the relatives looking after a dying patient did a great job BUT they’d usually never done it before so they worried that they should have been doing a whole lot better. To give them the confidence they craved, all that was needed was for somebody to say: “You’re doing brilliantly!”

Earlier in my career, SWF had it’s own team of district nurses who knew much more about terminal care than I did and knew the patients well … so there was far less need for me to be closely involved. Latterly, however, management torpedoed this team which was a huge retrograde step as far as the patients were concerned. However, as time passed and my kids grew up there was less need for me to rush home to see them before they went to bed so I was able to pick up some of the slack. Indeed, towards the end of my career, I worked late at the practice most nights – so it was no problem to pop in on my way home to make sure the patients were comfortable for the night. All in all, I found giving patients the wherewithal to die comfortably at home surrounded by their loved ones was immensely satisfying.

Dr John Cormack