Editor's Choice

Old wisdoms

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39595.468634.47 (Published 29 May 2008) Cite this as: BMJ 2008;336:0
  1. Jane Smith, deputy editor, BMJ
  1. jsmith{at}bmj.com

    The NHS will be 60 this July. The anniversary will provide an excuse for a bit of nostalgia—those black and white pictures of tidily dressed men, women, and children in orderly queues—but also for much analysis about the role and survival of a comprehensive, universal, centrally funded, free-at-the-point-of-use healthcare system in the 21st century.

    Our contribution to that analysis begins this week with the start of Tony Delamothe’s six-part series on the NHS at 60 (doi: 10.1136/bmj.39582.501192.94). In his first article he looks at how “the socialist dream came to be dreamt in the first place.” Although the NHS derived its immediate impetus from the second world war and the election of a Labour government with a mandate for radical change, the idea of a national health service had been around for much longer. As Delamothe explains, although the aspirations were widely shared, the arguments over the detail, and in particular over funding and ownership, were bitter—and, he argues, they remain unsettled even now. Over the next five weeks he examines how the founding principles have fared.

    In constructing this series of articles Tony Delamothe might have quoted: “The past is not always a foreign country, and it still has a lot to teach us,” but in fact it is Simon Wessely who does so this week, in his review of the Textbook of Disaster Psychiatry (doi: 10.1136/bmj.39587.679086.3A).

    Wessely explains that before 1980 everyone assumed that people who were mentally robust before a disaster would recover smoothly afterwards. After 1980 some argued that long term disorders could arise even in the most robust individuals. The “result was an explosion of interest and research” in post traumatic stress disorder and the belief (now recognised to have been mistaken) that everyone who experienced a disaster needed help in the form of immediate psychological interventions such as debriefing. Yet, Wessely says, lessons learnt in the second world war remain true today: people in cities bombed into submission don’t necessarily cave in. As a 1940 report put it: “The morale of the bombed largely depends on the care they get in the first 36 hours . . . rest centres, facilities for children, information, health care and the provision of food.”

    Another bit of revisionism comes from Narci Teoh and Francis Bowden, who argue for bringing back the long case as a means of assessing medical students’ clinical skills (doi: 10.1136/bmj.39583.596111.94). The long case has fallen into disuse because of doubts about its inter-case reliability, but Teoh and Bowden think it is valuable because it encourages trainees to learn medicine in an integrated way. They argue that the clinical skills of some final year medical students deteriorate if they spend most of their time studying for written assessments. Omitting the long case plays down the centrality in medical practice of the encounter with the patient: “Could we conceive of a music student [whose acceptability depends] on a series of assessments of scales and short pieces but never on a recital of a complete piece of music?”

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