Yes, I’m still in shock. After a year at the Children’s Hospital, I am now safely ensconced in a north London suburb, doing my final year of GP training. Gone is the stifling heat, the dust, the endless parade of near-dead toddlers. Instead I am working in a friendly, well-ordered practice. I only need hit “print” for my patient to miraculously receive the optimum medication for their condition, for free. It’s amazing!
 
Moreover, I have been over the moon the past few weeks since a wonderful nurse, Rebecca Cridford, won the Vodafone “World of Difference” competition. After a gruelling Facebook showdown with strong competitors, she has been awarded funding to spend a year working for the Welbodi Partnership.
 
There were a few minor visa hiccups (a passport declared lost at the Embassy, but later found), but Becky arrived in Freetown last Wednesday, flung into the torrential downpours of a West African wet season.  She will be helping the hospital management in various ways to improve the performance of hospital staff in tough conditions.
 
One initiative is a brand new disciplinary committee aimed at establishing and enforcing minimum levels of acceptable behaviour for doctors, nurses, and others.  It sounds amazing from planet NHS, but until now the hospital management have been unable to enforce attendance, let alone basic care. Despite reasonable staff levels on the rota, wards may be manned by a small band of hardy souls by day and often by hardly anyone at night.
 
The hospital doesn’t have the power to fire people, as appointments are controlled by the Ministry, so that the disciplinary process is indirect and largely ineffective. 
 
Unfortunately, it is not uncommon for critically sick children to die because basic observations and drug rounds aren’t done.
 
All this makes me wonder what motivates healthcare workers generally to do their job in the best interests of their patients.
 
Perhaps rather naively, I always used to feel that it was my morals that kept me awake at 4 in the morning when, truth be told, I quite powerfully did not wish to be pacing the corridors of Barnet Hospital. Part of me wants to believe that, but I have recently started to wonder how much of this comes from external factors, such as the likelihood of bad practice being noticed by others (not least the patients) and the fear of being reprimanded, fired, or struck off the medical register.
 
It was actually the issue of drink driving that brought it home to me.
 
I would never drink and drive in the UK; I am outraged and disgusted by it and will openly berate anyone who I believe to be over the limit who plans to drive.
 
In Freetown, however, the traffic police don’t have breathalyzers and they don’t seem worried about alcohol.  As in many countries, the culture amongst many foreigners and elite Sierra Leoneans is that a few (or more than a few) drinks on a Friday night needn’t stop you driving home. To my shame, I almost immediately fell into the same attitude and began to think that driving under the influence didn’t matter; it seemed normal, rather than unforgivably irresponsible as it does at home.
 
I wonder how much our attitudes to our patients work in the same way.  In general practice, there are many things that you can check a thousand times and never get a positive answer.  How many people with a headache actually have a brain tumour?  In many such scenarios, the diagnosis is the common, benign condition that first came into your mind when you heard the symptoms.  Yet, I still do the checks.  Every time.  Is it really because I care about this individual patient? Or is part of the motivation the fear of what will happen to me (not them) if they are the one with the brain tumour?
 
Thinking about the drink driving example, I’m inclined to be slightly less damning of the nurse at the Children’s Hospital who sleeps through her night shift.  She undoubtedly juggles multiple responsibilities in domestic circumstances that we spoiled Westerners can barely imagine.  Forget the chore of putting on the washing; it’s fetching the water from the public tap up the road in order to do the family’s washing by hand when you get home from your shift…

Emily Spry is a doctor from London who took a year out of her general practice specialty training programme to live and work in Sierra Leone, West Africa. She worked for the Welbodi Partnership, a charity which supports the main government children’s hospital in a country where more than one quarter of children die before their fifth birthday. She has recently returned to London