Healthcare at the Edinburgh Festival

Last year, the Wellcome Foundation inaugurated a programme at the Edinburgh Festival called The Sick of the Fringe (#TSOTF16) to explore some of the boundaries and synergies between the worlds of medicine and the arts.  Healthcare is a major issue in Scotland; barely a day goes by without an article in the national press about the impending obesity, stroke or heart attack crisis and the effect it will have on healthcare provision.  In the second year of TSOTF it was interesting to see whether it had started to have an effect.  There certainly seemed to be some progress in the way new writing tackled healthcare issues.

Today’s stand-up comedy acts owe a lot to the medic’s revues of the 1960s.  There’s been a long tradition of doctors giving up their white coats for the stage, either full time, or as a part time holiday from medicine and the Edinburgh Fringe has been the launch platform for many of them.  In recent years, the fringe has also been a home for innumerable one-man or one-woman shows exploring various aspects of mental health or medical issues, often highly personal accounts which aimed to inform or help provide catharsis.  Medical comedy was still there this year, and there’s nowhere better to start than with Phil Hammond, who has probably done more to publicise problems within the NHS than anyone else.

I first saw Phil Hammond around 20 years ago when he made his comedy debut as half of an act called Struck off and Die.  He was a young GP who had a passion to expose issues.  Over the years he has become the public voice of the whistle-blower, writing a column for Private Eye, helping to inform patients and promoting evidence based medicine.  This year he celebrated the efforts of the junior doctors in standing up and becoming an effective political force.  He also brought on the excellent Margaret McCartney to help promote the cause of evidence in the NHS.

Phil had an interesting message for the long term survival of the NHS, which is a request not to use it.  He’s based his message on the old children’s TV series, the Clangers (small knitted creatures which live on the moon, fed by a soup dragon – you can find them on Youtube).  He feels they provide a useful acrostic:

• C to Connect with people and don’t live in isolation to others;
• L to Learn new things and continually challenge yourself;
• A to be Active;
• N to Notice the world around you and savour the moment;
• G to Give Back, do something nice for someone, smile, volunteer;
• E to Eat well;
• R to Relax, take time out to chill; and
• S to Sleep, getting 6-8 hours of good quality sleep is fundamental.

His point is that if people made a greater effort to live in a healthy way, over 70% of visits to the GP could be avoided.  That’s important, as every day you don’t need to use the NHS, someone else benefits.  A compassionate society should provide free healthcare, but there needs to be a contract where we do our best to ensure we take care of ourselves.  Johnny and the Baptists made a similar point with a bit more bite and more music in Eat the Poor.

Phil’s other bête noire is the continuing lack of support for whistle-blowers, which forms the core of his campaign for greater openness.  Over the years he has supported doctors who have exposed major failings in the NHS, through his columns and articles in Private Eye.  It is an obvious source of regret that despite his help, none of them have won their job back.

Although nothing to do with medicine, the need for a no blame culture was brilliantly demonstrated in My Eyes went Dark, a fictionalised account of the aftermath of a mid-air collision between two aircraft over Germany in 2002, which was the result of an incorrect decision by a Swiss air traffic controller.  The father, whose wife and two children died in the crash, pursued the controller through the courts.  When no-one was imprisoned, he tracked him down and killed him.  This was probably the best play I saw this year, and it would have been interesting to take a poll of the audience half-way through to see how many agreed with the court when they acquitted the air traffic controller.  I suspect few would.  Like the father, people want to see what they feel is justice.  However, this trade of forgiveness for openness is key to any no-blame culture, where everyone involved is encouraged to report accidents and mistakes.  We have a no-blame culture in aviation, which is why very few planes fall out of the sky.  In the NHS, we don’t.  Instead, if you expose accidents which put patients at risk, you’re likely to lose your job.  That needs to change and politicians need to listen to campaigners like Phil Hammond.

Phil wasn’t the only GP treading the boards.  Doctor Ahmed made his debut with Doctor in the House.  Most new stand-ups probably worry about hecklers.  On the night I saw him, he possibly had an even worse experience.  The consultant who had taught him to insert an IUD coil was sitting in the audience with her daughter.  He still managed an amusing evening of GP anecdotes, along with an interesting exercise, which was to ask the audience firstly how many were taking any medication (around 50%), how many knew the names of the drugs they were taking (about 30%) and how many knew the dosage?  At that point it was down to around 10%, despite the fact that almost half the audience had confessed to working in the NHS.  It reinforced Phil Hammond’s point that we need to take more notice of our health, both in staying healthy and being engaged with our treatment, rather than expecting our healthcare system to do everything for us.

It used to be the case that to succeed as a consultant you needed a white coat and testicles.  That still seems to be true if you’re a medic who wants to have a stage career, as the headline stand-up acts are still predominantly male.  So it was refreshing to see The Monologues of a Tired Nurse, which portrayed a young, fairly naïve nurse at the start of her career in an Intensive Therapy Unit, being mentored by an older nurse who is close to burning out.  It portrayed the raw underbelly of the NHS with nurses being given ever more to do, but with less funding, especially in terms of their training.  Whilst not wanting to detract from the current struggle of the junior doctors, it demonstrated that there are other groups within the NHS who also need to fight for their rights.

There didn’t seem to be much new writing which highlighted medical issues, but one which did an excellent job was Growth from Paines Plough.  It’s a well written piece which tackles the issues confronting men in doing anything about testicular cancer.  When Tobes’ new girlfriend tells him to go to the doctor, it illustrated the agonies that many men face as they try to deny they may have a problem.  It plays as a very funny piece of drama, but contains some important messages which have been hard for the health service to deliver.  It deservedly won a Fringe First and is well worth catching on its national tour.  The only small flaw is that it includes a misdiagnosis, which may negate some of its positive messages.

However, that’s a minor flaw compared with appalling denouement of the Traverse’s flagship production of a new play called Milk.  It’s no great shakes until it gets to the end where it basically turns into a corporate advert for Nestlé.  A young mother is having difficulty breastfeeding her baby and appears to be receiving no support from husband or health workers.  In a theatrical device of almost incredulous banality, a stranger appears at the door, at which point the mother gives him her baby and a bottle of formula, which he feeds to the baby.  Baby stops crying.  Actors beam.  The audience gives it a standing ovation and thirty years of campaigning by midwives, health visitors and Baby Milk Action flies out of the window.  It was a sad example of how far we still have to go to get positive health messages across.  Those involved with Milk should be ashamed that it got to the stage.

As well as birth, there was quite a lot about death this year, as old age and dying were unusually well represented.  The Lounge gave us a day in an old people’s home.  It was a brilliant, funny and touching portrayal of a day in an old folk’s home.  It showed a caring but overworked staff and the frustration of residents in coming to terms with their loss of independence and status.  It offered no answers, other than to highlight that we need to think about how we stay healthy and independent for as long as we can, which takes us back to Phil Hammond’s CLANGERS.

Phil had a second show, Life and Death, but mainly Death which was more autobiographical and touched on the impact of death, both in his family and professional experience.  We all die, but modern society doesn’t talk about it, which makes it frightening, not just for the person dying, but their family as well.  In his case, concealed knowledge affected him and his brother for thirty years after his father’s death.  An excellent complement was Liz Rothschild’s piece Outside the Box, explaining the options we have when we die.  As well as being an actor, Liz is a celebrant and runs a green burial ground.  She gave a fascinating history of funerals and the options we have.  How many people know that it’s legal to bury up to three people in your own garden?  Her message is that a funeral should be a celebration of a life, not an opportunity for another male dominated trade to make money from people when they are at their most vulnerable.  To learn more, catch her on tour or look at the resources on her website.

Outside the theatres, few health messages seem to have hit home.  I got a chance to catch up with some ex-colleagues who are working on diabetes and obesity and who see their incidence growing inexorably.  Despite having some of the best NHS services in Britain, Scotland also has some of the worst health demographics.  Reports in the Scotsman pointed out that the best way to increase your lifespan is to be part of an ethnic minority, which is nice to know, but not a lot of use in terms of preventative techniques.

In the middle of the festival, they also reported that Scotland had been missing healthy eating targets for fifteen years and that radical measures need to be taken.  Obesity allegedly costs NHS Scotland £4.6 billion every year; a figure which could double by 2030.  However, they failed to provide any answers about what to do.

The festival itself is not a good advertisement for healthy eating, with most visitors subsisting on alcohol and fast food, but in many ways, that’s an echo of the national diet.  A few months before the festival, there was a call for a ban on fast food deliveries to schools, after an RSPH report claiming that one in four 13-18 year olds had ordered a take-away to be delivered to their playground.  If you walk around Edinburgh at lunchtime, you’ll see queues of kids tucking into carbohydrates at the likes and Greggs and the local chippys.  If we don’t tackle these issues in childhood, then we will have little option other than picking up the pieces later on, at a prohibitive cost.  When the Government unveiled their obesity strategy in the middle of the festival, many noted that it had chosen a day when the news from Rio would eclipse the degree to which it had been watered down.  Or, to put it another way, don’t expect sugar and water based soft drinks to disappear anytime soon.

That’s a health message that I didn’t see getting aired in any theatre.  Lucy McCormick’s Triple Threat found some interesting new things to say about coffee, meringues and frankfurters, but we had no pieces about sugar.  There was an adventurous work on the effect of alcohol abuse in The Marked, but in general alcohol was presented as a way of getting through life.  As for obesity, it was still largely confined to female comics’ angst at their weight, dieting and the pressure of celebrity and selfie culture.  But the fact that Growth won a Fringe First is good news and may persuade more writers to tackle health issues.  We’re still only in year two of the Sick of the Fringe.  It will be interesting to see which subjects get tackled in coming years.