Chapter Two

 

Collintrae

 

The sleepy village of Collintrae lies on the south-west coast of Scotland, and stretches along a long shingle shoreline, its southern border being the mouth of the River Stinchar. Seen from the sea, there is a row of fisherman’s cottages bordered to the west by a solid sandstone harbour wall. Behind the cottages, more protected from the winter storms, is the heart of the village, where the landsmen, farm workers and foresters live. Where the village road meanders eastwards up the River Stinchar’s north bank towards the higher country, there’s a smattering of bigger houses for teachers, bankers, lawyers and businessmen – the commuters to Girvan thirteen miles to the north. In its single main street stands Collintrae’s one church, three pubs (the Ayrshire Scot has his priorities right), and three shops.  

Seven miles up river, along that meandering road, lies Kilminnel, the centre for the local dairy and arable farmers, cosily settled into the valley floor, alongside rich alluvial fields and looking across at low, green, rolling foothills. Eight miles further on is Braehill, higher still, nestling in the valley between steeper, browner, heather-clad hills, where the sheep and beef cattle, grazing there all year round, have been enough to keep families reasonably comfortable for hundreds of years. 

These three villages of Collintrae, Kilminell and Braehill made up my practice, which stretched twenty miles along the coast road from north to south, and thirty miles eastwards from the shores of Collintrae – six hundred square miles in all. With just eighteen hundred human inhabitants, that’s just three people per square mile. They were all my responsibility. There were also around a hundred thousand sheep and twenty thousand beef cattle. Thankfully they were the vet’s domains – or so, in my initial innocence, I thought.  

It had been my wife Mairi who had found the advert in the British Medical Journal about the vacancy in Collintrae.. It’s a long way from Birmingham – both in miles and in atmosphere. To be frank, I had seen my future in the Midlands. The usual house jobs in big busy hospitals, followed by a first GP appointment in a big practice in the northern outskirts of the city, were typical career moves for a young doctor on the way up.  

Three things got in the way of that ambition. One was my wife, Mairi, an island Scot. She was never going to settle so far from the sea. We once drove from Birmingham to Aberystwyth and back in a day, just so she could see it. What we actually saw was rain – all the way – and an absolute absence of parking spaces when we got there. We drove along Aberystwyth esplanade, stopped for a few seconds to buy an ice cream from a van, causing a traffic jam as we did so, and headed home. But Mairi had seen the sea, and her mind was resolutely made up.

My senior partners, Dr Dai and Dr Owen, were the second block to my advancement in Birmingham. They had qualified in Wales at the beginning of the war, had joined the army together, served in North Africa together, and had been captured together when they had volunteered to stay behind to tend the injured when the British had to retreat from Rommel. Their experience, they thought, had forged a lifetime friendship, so that when the war was over, they decided to go into partnership together. They were so close that they would willingly share, without the proverbial paddle, a canoe up the Orinoco. 

Sadly, by the time they decided to employ me, in 1964, their friendship had long been lost. They were paddling in opposite directions and the canoe had sunk without trace. No longer speaking to each other, it was their habit to communicate, and then only when absolutely necessary, by hand-written notes. Until I arrived, the note-carrier had been one of the receptionists, but the job, along with many others that I had never been trained for by my teachers in medical school, fell to me. 

They were short notes, usually referring to patients and their mistrust of each other’s diagnoses, the part that I was permitted to know about being written in English. The rest was written in Welsh, and was evidently even less polite. I never found out exactly why they were so hostile to each other, but I assumed it was something to do with their wives, and the way their incomes were split.  

It all came to a head for Mairi and me one week during my third month in the practice, when my first pay cheque was due. Mairi and I were wet behind the ears. I should have read the warning signs - the arguments between my partners and the huge extra load of work that I was expected to do in comparison to them. Our verbal agreement had been that I would be given a small advance each month to tide me over until I received my share of the practice income after three months. My gross pay was to be £2,500 a year – a colossal sum in those days – paid in three-monthly instalments from then onwards.  

So Mairi and I were looking forward to our £600 or so. We had a mortgage and a car loan to pay, and the overdraft had been growing apace since we had left the hospital residency. The cheque that arrived, however, was for £300, which would make my salary £1,400 a year. That evening I was in the branch surgery, which was attached to the senior partner’s house. I got there early, to ask about the discrepancy. The senior partner, Dr Dai, wasn’t there, but his formidable wife, Miriam, was. Miriam was the self-appointed practice manager and treasurer and as the senior partner’s wife, she was well aware of her dominance over a new junior GP.  

She put me right. There were a few things to come off my salary, she said – didn’t I know about them? Because Dai owned the buildings of both the main and branch surgeries, Owen and I had to pay him rent for using them. We also had to pay our share of their cleaners’ and gardener’s pay for keeping the practice premises neat and tidy. And there were all sorts of other practice expenses that had to be shared among the three of us. So the gross of £2,500 was quite legitimately whittled down to £1,400 – and that was before income tax. She reminded me that as the years progressed I would, step by step, earn a larger share of the profits, but I had to be patient. One day, she implied, I would be just as respected in the district as her saintly husband. 

She then handed me the draft partnership agreement, (which had taken three months for her to draw up). Could I take it home this evening and study it? All parties could sign it later in the week.

 I started that evening’s surgery in a suppressed fury. I hope it didn’t show on my face as I entered the waiting room to greet around forty car body workers and tyre makers all hoping to have their private sick notes signed. It was a Thursday evening. They had all signed off work sick on Monday morning: to get a full week’s wages from the car or tyre plant they could miss Monday to Thursday, but they had to get back to work on Friday, so this was the evening for their back-to-work notes. If they were really ill, and were off a whole week, they only got half pay. These patients knew how to manipulate the system to a nicety.  

I have no reason to suppose it was any different in any other industrial practice. In the English Midlands, the vast majority of work sickness absence stretched from Monday to Thursday. Friday was apparently a day of amazing good health. Manufacturing employers must have known that this was a tad odd, but had no answer to the power of the unions who had negotiated the rules, or indeed to the connivance of doctors like Dai and Owen, who were doing very well, thank you, from the sick note fees. 

I struggled through that evening surgery, slowly simmering with the injustice of my pay and the waste of my time with people obviously on the ‘take’. My first patient had had ‘backache’ on Monday and had been signed off by doctor Dai. It was better now, doctor, he said. So could he have a note to go back to work tomorrow, please? 

Anger must have clarified my mind. I decided to examine his back. No one had done that before. He protested: there was no need to do that, his back was perfectly OK now. It must have just been a muscle strain, he suggested, helpfully. I insisted: I wouldn’t be a good doctor, I said, if I didn’t examine him properly. After all I might miss a slipped disc or arthritis, or even kidney or prostate trouble. He lay down on the couch. I bent and stretched him, pummelled him and prodded him.

It’s easy to make a back feel sore, even when it’s normal. A judicious prod here, a bit of pressure there, and you can make your patient yelp. Of course, it isn’t ethical or moral, but it sure is satisfying. My patient yelped. 

‘Oh,’ I told him, sounding suitably serious. ‘Your back obviously isn’t right yet. Especially as you have such a heavy job in the factory. You had better stay off until we can sort out the cause and get it completely better. I’ll arrange for some X-rays. In the meantime I’ll sign you off for another two weeks.’

He was thunderstruck. He knew, and he knew that I knew, that he was having me on. His back was as good as mine. Yet etiquette didn’t allow him to admit it. He protested again that the pain was nothing. I prodded him again just on the spot where the sciatic nerve emerges from between the third and fourth lumbar vertebrae. He yelped again. 

‘There you are,’ I said triumphantly. ‘You still have pain. You can’t go back to work yet. Here’s your official sick note. You don’t have to pay for it, so that’ll save you paying us for a private one.’ I tore a sheet from the NHS pad, rather than the thicker one for private notes, and started writing. Official sick notes from the NHS didn’t cost a penny – they were used for longer spells off work, and were free. He and I both knew, of course, that it wouldn’t save him money to be off for another week – he would be on half pay. That would seriously limit his drinking funds over the weekend.  

‘I don’t want it,’ he raged at me. ‘I’ll go back to work tomorrow anyway. And I’ll see Dr Dai in the future.’ He pushed himself off the couch with amazing agility, flexibility and speed for someone with such a bad back, stood up straight as a ramrod, and stomped out.

 

I wrote up his notes meticulously, suggesting that we should investigate the repeated back problems that had kept him off work so many times in the previous year, stacked them away on my out-tray, stood up and walked with a sigh to the door, to usher in the next patient.

I was surprised to see that half of the people in the waiting room were getting up to go. Patient number one had tipped off patients numbers two to twenty that I ‘was an examining doctor and didn’t hand out work notes to order’. I was no use to them, and they had decamped, grumbling into the Birmingham night.

 

The evening surgery continued in a better mood, until close to its end. As I was talking to my last patient, a commotion from the waiting room interrupted us. I excused myself, and went to see what it was about. Lying on his back across three seats was a tramp, attended by two policemen. He was a stranger to me, which was unusual, as by this time I had got to know most of our small colony of homeless and vagrants.  

One of the officers apologised for bringing him in. They had found him slumped on a bench in a nearby park. They had thought he was drunk, but he was complaining about a stomach pain, and they felt they had better bring him to me before taking him in for a night in the cells, where they could at least give him food and warmth. The police, incidentally, were like that wherever I have worked, in Birmingham or Ayrshire. Their main aim was to help this man, not to bully him or charge him. 

The man himself looked around fifty years old, though he could have been thirty. Homeless people, like prime ministers, age faster than the rest of us. They probably have similar levels of stress. He was filthy, hadn’t washed or shaved for weeks, and had obviously starved for several days. His cheeks were sunken and flushed, he was breathing heavily, and didn’t smell, even faintly, of drink. He was pleased to see me, again an unusual reaction in a down-and-out. 

Down and out he certainly was. One of the policemen helped me to undress him. He was in a lot of pain, and his stomach was as stiff as a board. As I felt his abdomen, he winced, and the muscles below my fingers tensed into a hard solid sheet. His pulse was fast and thready and his blood pressure low. 

It took seconds for me to recognise that he had peritonitis, either from a ruptured appendix or from a perforated stomach ulcer. My only option was to get him straight to hospital from the surgery. There was a blanket on a chair near the couch, so I asked one of the officers to make him comfortable by wrapping it around him, while I reached for the phone.  

Within a quarter of an hour, he was on his way by ambulance. I thanked the policemen, and looked at the time. The surgery had taken from five-thirty until nine o’clock. I phoned home, to apologise for being so late, and left the surgery with the blanket folded on the couch. Mairi was used to my late arrival in the evenings, and wasn’t upset. I don’t know how she did it, but there was always hot food ready whenever I arrived after surgery, along with a small whisky and water. There were times when I was so tired that all I wanted was the drink.

 

After supper, we sat together to study the practice agreement. It was full of the usual restrictions prevalent at the time. If I were to leave the partnership, I could not practise within the surrounding fifteen miles. That was to stop me ‘poaching’ patients from them. It would take ten years for my pay to achieve ‘parity’ with that of the other partners, but the work would be equally shared amongst us. Except that the senior partner would take three fewer surgeries per week, to manage the finances and organise the practice and the buildings. The senior partner would not have to do evening surgeries more than once a week, and would have two weekends off per month. That was apparently because he was older and had spent many years building up the patient numbers, and deserved a little extra. The clauses about us paying part of the gardeners’ and cleaner’s wages were included. It was also interesting that although I was to be paid a lot less than the others over these future ten years, I was expected to pay a full third of the practice expenses. So the proportion of my income taken off for all these expenses was much greater than for the other two partners. 

The proposed agreement was so unfair that we began to laugh. Not in a million years were we going to stay. But the biggest laugh was in the final paragraph. It ran something like this:

 

‘If the sons of the senior partner and of any subsequent partners qualify in medicine and wish to join the practice, then the senior partner’s son will have seniority’.

 

I had an extra whisky on the basis of that one. The next day, we decided, we would look for a practice in Scotland. Preferably one without partners and, of course, near the sea.

The third thing that sent me packing happened first thing the next morning, and made my mind up once and for all. Just before setting out for the morning surgery, a man came to the door carrying a large brown paper parcel. A label on it stated it was for ‘Dr Smith’s Wife’. Mairi was excited. The outside label didn’t list the sender, but it was obviously a gift of some sort, perhaps from someone who knew that she was expecting our first baby. This was the first sign of thanks from anyone in the practice in the three months we had been there. 

Just as pleased, I stayed behind for a few minutes to see what it was. It was the blanket the tramp had been wrapped in the evening before. Miriam had sent a note with it. There were no pleasantries such as ‘Dear Mairi’. I remember the exact words today, forty years on. They were in capital letters, perhaps to indicate the writer’s anger.

 

YOUR HUSBAND HAS ALLOWED THIS BLANKET TO BECOME INFESTED WITH FLEAS. I HAVE NO INTENTION OF LAUNDERING IT MYSELF. WE NEED IT CLEAN AND UNINFESTED FOR NEXT MONDAY MORNING SURGERY

 

There was not even a signature, or ‘kind regards’, although I suppose kind regards would be hypocritical under the circumstances. Luckily Mairi has a sense of humour: she just laughed it off. I, by this stage, was beyond incandescent.

The blanket was laundered and delivered on time. I didn’t ever have a conversation with Miriam again, nor did I sign the agreement. I still spoke to Dai, who was strangely subdued with me. I suspect he was deeply ashamed of his wife’s behaviour, but neither of us broached the subject. He wasn’t surprised when I didn’t sign and return the proposed agreement.  

He did, however, try to remonstrate with me about sick notes. Apparently he had been wakened at seven-thirty that morning by about a dozen men wanting sick notes to go back to their morning shift work that day. They couldn’t wait until the surgery opened at nine a.m., because by then the shift would have started, and they would have lost half their week’s wages. They had accused me of ‘not co-operating’ and being an ‘examining’ doctor when all they wanted was their usual note. I looked at him, sitting comfortably in his big leather consulting armchair. In his mid-fifties, he had long since stopped wanting to rock the boat. The income from work notes was a good extra for the practice, from which he stressed I would assuredly receive my share. If I didn’t toe the line with them, we would lose a lot of patients to the McKelvie practice down the road. After all, they were doing the same thing, so that wouldn’t do, would it?  

I wish I could write here that I stood on a matter of principle and argued the toss with him, but I didn’t. Instead I came to a compromise.  

‘If you like,’ I said, ‘I’ll do regular Friday evening surgeries instead of the Thursday ones. Then you can collect all the work note money and you won’t need to share it with me – you and Owen can keep it all to yourselves.’  

Amazingly the insult implied in the last suggestion washed over him. He was delighted by both propositions, and we stuck to them until I left. I didn’t bother, either, arguing about the salary. I put it down to experience and accepted the loss. 

I didn’t take long to leave. Mairi found the advert and we applied for it. At the interview it turned out that there were two adjoining practices – Braehill and Collintrae – that were both currently without doctors. The Braehill doctor had left to join a city practice, and the Collintrae doctor had left for the great surgery in the sky. My interviewers asked me if I would consider combining them, and I responded with the enthusiasm of the young, keen and wholly inexperienced. The other interviewees were clearly older and wiser doctors looking for an easier time, for I was given the job.