Patients, heal yourselves

'. . . Have some strong beef tea made ready to give her as soon as the fever goes down. She can have the grapes now, and beef essence - and soda water and milk, and you'd better get in a bottle of brandy. The best brandy. Cheap brandy is worse than poison.'

From The Railway Children by Edith Nesbit

GETTING better was once an important part of being ill. Convalescence - from the Latin valescere meaning 'to grow strong' - was accepted by doctors and patients from the earliest times as a vital period of recovery following an acute illness, injury or surgery.

In parts of North Africa and Asia Minor where followers of the cult of Asclepius, the god of medicine and healing, settled, archaeologists have unearthed bronze statuettes of a smiling figure dressed in a cloak and cowl. He was, according to legend, Telesphorus, a minor deity but an important one; the god of convalescence or 'he who brings to a perfect end'.

It is becoming clear that this 'perfect end' has no place in the future of health care in Britain. Convalescence is a word that has all but disappeared from the vocabulary of the modern health service. A survey of nursing staff last month suggested that hundreds of patients are being discharged from hospital before they are better. Bed shortages and financial constraints imposed by the new internal market were blamed.

But this is also a question of deliberate policy. The future, as described earlier this year by Virginia Bottomley, the Secretary of State for Health, involves bedless hospitals which 'through-put' their patients as day cases. For patients with complications or those who cannot go home the same day, there will be 'hotel' accommodation - cut-price, short-stay NHS beds, with medical staff on call nearby. 'It is clearly better to be at home than in a hospital. Keeping people in hospital is costly for the NHS and inconvenient for them,' Mrs Bottomley said.

She has a point. Hospitals are unhealthy places; homes are preferable - but only if patients have someone to care for them, look after their children and pets, answer the phone and deal with all the other daily pressures, with the back-up of GPs, district nurses, and social services if necessary. But few of us will ever have this luxury of care. Being at home is equated with being well, of ignoring the signs that mind and body would benefit from a period of convalescence.

Mrs Bottomley's conveyor-belt approach would, in the words of an 1867 Times leader on the importance of convalescence, 'bring the poor man back from the gates of death and lead him with the utmost care over the first part of the journey, but . . . suddenly drop him at the most crucial part of the road'.

Florence Nightingale could not have endorsed Mrs Bottomley's vision either. In her Notes on Hospitals in 1863 she agreed that 'no patient ought ever to stay a day longer in hospital than is absolutely essential . . .' But, she added, 'what then is to be done with those who are not yet fit for a work-a-day life? Every hospital should have its convalescent branch and every county its convalescent home'.

Twenty-three years earlier, the first such home had been opened in London, the Metropolitan Convalescent Institution. By 1884 the Charity Organisation Society listed 237 homes, offering rest, good food and fresh air in pleasant surroundings with a minimum of nursing care.

In the 20th century, however, improvements in general health and housing conditions seemed to reduce the need for such homes; by the end of the Second World War hundreds had closed. In 1956, the Ministry of Health set up a working party to review convalescence. The main conclusion - that convalescence required a new approach and a 'much greater interest at all levels particularly by the medical profession' - was ignored, and overtaken by medical advances.

Sick people were recovering sooner as powerful drugs, particularly antibiotics, were developed; surgeons were more skilful and operations less hazardous. An appendectomy, for example, no longer required three weeks in a hospital bed. The buzz words were 'early ambulation' and 'rehabilitation'. Convalescence was deemed an old-fashioned idea, conjuring up an image of wan Victorian ladies reclining on chaises-longues.

But better treatment does not always compensate the body for the stress it has endured. People often return to work or resume normal life far sooner than they should, even after minor illnesses. They don't allow themselves time to convalesce because it is no longer an accepted part of being ill. As Dr Margaret Mitchell, reader in psychology at Glasgow Caledonian University, puts it: 'for most people, they are either sick or well, and that is it'.

Dr Mitchell's research has shown that pressure from the workplace - real or perceived - to return quickly, is also a factor. This attitude developed from the post-war period when workplace insurance against illness and injury became common. Insurance companies naturally wanted to pay out for as short a time as possible. In addition, the social security system refuses to recognise any intermediate phase between total incapacity and fitness for work.

Convalescent care - provided in hospital or the community - is an important feature of any health service. It should be given a higher priority by the primary health care team, by health educators and the social services - and funding allocated for them to do it properly. This seems unlikely.

A change in regulations governing the care of chronically sick elderly people last month signalled the end of a 'cradle to the grave' national health service. Increasingly, it looks as if we are left with a 'Kwik-Fit' service, offering just essential maintenance and repair of the human body.