IELTS Academic Reading Practice Test 338

In the middle years of the twentieth century, dying in a British hospital was often a lonely and painful experience. Patients whose treatment had been exhausted were sometimes moved into side wards, where staff had little time for them and doctors visited rarely. Pain was treated with injections of morphine given only when a patient complained, and because the drug's effect wore off before the next dose was due, many people spent much of each day waiting for relief. It was against this background that a young medical social worker began to argue that the care of the dying deserved the same attention as the treatment of those who might recover.

Cicely Saunders was born in 1918 and went to the University of Oxford, where she studied politics, philosophy and economics. The outbreak of war interrupted her studies. She trained as a nurse at the Nightingale Training School at St Thomas's Hospital in London, but a back injury forced her to abandon clinical nursing, and in 1947 she qualified instead as a medical social worker, or almoner. The post took her back to St Thomas's, where she was responsible for patients' practical difficulties: housing, money, and the arrangements that had to be made when someone could no longer be looked after at home.

Among the patients she visited was David Tasma, a Polish refugee who was dying of cancer and had no family in England. Their conversations convinced Saunders that he needed more than physical care: he wanted to be listened to, to be taken seriously as a person, and to feel that his life had mattered. Tasma left her five hundred pounds in his will and told her that he would be a window in her home, a phrase she later treated as the founding gift of the hospice movement.

She decided that she could do more as a doctor than as an almoner, and at the age of thirty-three she began training at St Thomas's Hospital Medical School, qualifying in 1957. A year later she took a research post at St Joseph's Hospice in Hackney, east London, which was run by an order of nuns and cared for large numbers of terminally ill patients. There, recording what happened to several hundred patients, she worked out the ideas for which she became known.

Her most important observation concerned the timing of pain relief. Instead of waiting for a patient to ask for an injection, the staff began giving morphine by mouth at fixed intervals, including during the night, so that the level of the drug in the body never fell far enough for the pain to return. Patients who had been drowsy and withdrawn became alert enough to talk to their families. Saunders also insisted that pain had emotional, social and spiritual dimensions as well as a physical one, and she used the term total pain to describe the combination: a patient worried about money, or frightened of dying, might need help with those fears before any drug could work.

St Christopher's Hospice opened in 1967 in Sydenham, south London, on a site bought with donations. It was designed from the start as more than a hospital. Patients could go outside, keep their own possessions around them and receive visitors at almost any hour, and families were drawn into their care, sleeping in rooms beside them if they wished. The building also contained space for teaching and for research, because Saunders believed that the new approach had to be studied if it was to spread.

From its early years St Christopher's sent nurses into patients' homes, supporting families who wanted to care for a relative until the end, and it trained doctors and nurses from other countries who then returned home to set up services of their own. Volunteers were given a defined and valued role, and the hospice relied heavily on them; this was one reason why hospices came to depend less on public money than hospitals do.

The idea travelled quickly. The first hospice in the United States opened in Connecticut in 1974, and similar services were established across Europe, Canada and Australia, and later in parts of Asia and Africa, often in much poorer settings and with far fewer resources. In Britain, palliative medicine was recognised as a medical specialty in 1987, which made it possible for doctors to train and be examined in the field. The World Health Organization now describes palliative care as an approach that improves the quality of life of patients facing life-threatening illness.

Saunders herself was a committed Christian, and she spoke of the work as a response to what she had seen in her patients rather than as a campaign. She continued to write, lecture and travel into old age, and she died at St Christopher's in 2005, in the hospice she had founded. By then the movement she had started had grown into an international network of services, professional associations and academic departments.

Not every problem was solved. Hospices were initially built around the needs of cancer patients, and people with other long-term conditions, such as heart failure or dementia, were slower to benefit. Even today, most deaths in Britain still occur in hospitals. Inpatient hospice care is expensive, and many services rely on charity shops, legacies and fundraising to remain open. Yet the principle Saunders insisted on, that dying people are entitled to expert, unhurried care, is now accepted in most of the world's health systems.

Anyone who has argued with a friend about the exact shade of a paint knows that colour naming is imprecise. For most people, however, the underlying sensation is much the same. Roughly one man in twelve and one woman in two hundred sees certain pairs of colours as unusually similar, and a small number cannot tell them apart at all. The everyday term for this is colour blindness, although the phrase is misleading: very few affected people see only in black and white.

Colour vision begins in the retina, the layer of light-sensitive tissue at the back of the eye, which contains two kinds of photoreceptor. Rods, far more numerous, respond to dim light but cannot distinguish wavelengths, which is why colours fade at dusk. Cones, of which a typical eye has about six million, work in bright light and come in three varieties, each containing a different photopigment that responds best to a particular range of wavelengths: short (blue), medium (green) or long (red). The brain compares the relative activity of the three, and it is this comparison, rather than the signal from any one of them, that produces the experience of colour.

The genes that build these pigments have been located. The instructions for the blue-sensitive pigment lie on chromosome 7, but those for the red- and green-sensitive pigments sit close together near the end of the X chromosome. Women have two X chromosomes; men have one. A man who inherits a faulty copy of a red or green pigment gene has no second copy to compensate, whereas a woman is normally unaffected because her other X chromosome carries a working version. This explains the striking imbalance between the sexes in the commonest forms of colour deficiency.

The X-linked pattern also helps to explain why the condition takes so many forms. The red and green genes exist as a tandem array, a short sequence repeated several times, and errors during the formation of sperm and eggs can shuffle them. A person may end up with one green gene, with several, or with a hybrid that responds to wavelengths between the two. Someone whose pigment is merely shifted along the spectrum is called an anomalous trichromat and usually has difficulty telling reds, oranges, yellows and greens apart. Someone who lacks a whole cone type is a dichromat and sees fewer distinct hues.

Because the array varies, two people with the same label may not see alike. A colour-naming test in a clinic cannot capture this, and instruments such as the anomaloscope, in which the observer mixes red and green light until it matches a yellow standard, are needed. Researchers who have tested large numbers of men have found a continuous range of settings rather than a few tidy categories, which suggests that mild differences in colour perception are far more widespread than the standard figures imply.

For screening, most clinics rely on plates devised by the Japanese ophthalmologist Shinobu Ishihara and published in 1917. Each plate shows a circle of dots in shades of a background colour with a numeral or a winding path hidden in dots of another; a person with normal colour vision reads it easily, while someone with red-green deficiency may see nothing or a different figure. The plates are quick and cheap, which is why they remain in use more than a century later, but they are designed to detect a problem rather than to describe it.

In everyday life the condition is usually a minor inconvenience. Traffic lights can be distinguished by position, and labels, symbols and patterns can substitute for colour coding. Difficulties become more serious when colour carries information that nothing else does: a chart, a warning light or a resistor marked with coloured bands. For this reason some occupations, notably flying, driving trains and working with electrical wiring, are closed to applicants who fail a colour vision test, a restriction that those who apply it regard as a matter of safety.

There is no treatment. Because the cones themselves are altered or missing, no pair of spectacles can restore a signal that the eye never sends. Glasses marketed for colour deficiency work by filtering out certain wavelengths so that overlapping signals become easier to separate; some wearers report an improvement, particularly when they use an accompanying test chart, but independent studies have produced mixed results, and the effect is a change in contrast rather than a return of normal vision.

The most striking recent development has come from animal research. In 2009 a team in the United States reported that two adult squirrel monkeys, which normally lack red-green discrimination, had acquired it after a gene for a long-wavelength pigment was delivered into their eyes. The result was notable less for the technique than for what it showed about the brain: the adult visual system could make use of a new channel of information. Whether the same approach could ever be justified in people is another matter, since the condition is not dangerous and any treatment would carry risk.

A related puzzle concerns women who carry a gene for red-green deficiency and may, in principle, possess four different cone pigments rather than three. A few individuals have been reported to make colour distinctions that others cannot, but the number confirmed is very small and the claims remain disputed. What is clear is that colour vision is not a fixed property of a species but a family of slightly different arrangements, most of which cause no trouble at all.

Every appointment system has its ghosts: the patient who does not arrive, the slot that stays empty, the letter that is never answered. In England, several million appointments in general practice and in hospitals are missed each year, and the proportion has remained broadly stable in recent years despite repeated attempts to reduce it. Campaigners often attach a price to this waste. A figure frequently quoted is that a missed hospital appointment costs the health service around £120, and a missed consultation with a family doctor perhaps a quarter of that. Such figures are estimates rather than measurements, but they explain why proposals to charge patients have reappeared so regularly.

The argument for a charge rests on three claims. The first is that a fee would make people take appointments seriously, so that some of those who currently forget, or change their minds, would either attend or cancel in time. The second is fairness: an unused appointment is a place that another patient, perhaps in pain and waiting weeks, could have had. The third is financial; if even a fraction of the money lost could be recovered, it might pay for extra clinics or staff.

Health economists tend to accept the logic but question the arithmetic. A charge has to be explained, billed, collected, chased and accounted for, and each of those steps costs money; a fee small enough to be acceptable may raise less than the administration consumes. The more serious point is that a charge is only one way of changing behaviour, and it should be judged against the alternatives. If reminders sent by text message achieve as much at a fraction of the cost, the economic case collapses. On this view, the question is not whether waste exists, but which remedy removes it most cheaply.

Patient organisations answer differently. Their case is that most people who miss an appointment do not do so lightly. Illness can make the journey impossible; a parent may have no one to leave a child with; a shift worker may be unable to ask for time off; a patient with a mental health problem may lose the courage to walk through the door. A charge, they argue, would be heaviest for exactly these patients, who often have the least money, and the effect would be to deter some of them from making a further appointment at all. The cost of that, in untreated illness, is not counted in the £120.

Doctors' representatives raise a different objection: the relationship. General practice depends on patients telling their doctor the truth about their symptoms and their circumstances, and a system that treats every absence as a debt risks turning a consultation into a transaction. A patient who has been charged once may hesitate to book again when the next symptom appears. Some doctors also doubt that they should be the ones to police the scheme, pointing out that the consultation in which a fee is explained takes time that could be spent on care.

Practice managers, who deal with the consequences, are less interested in principle than in what works. Many report that a reminder sent a day or two before an appointment reduces non-attendance noticeably, and that a second message asking patients to cancel if they cannot come recovers places that would otherwise be lost. Longer opening hours, online booking and systems that allow patients to give up an appointment without speaking to anyone have all been credited with modest improvements. None of these measures is dramatic, but together they address the problem without penalising anyone.

Research in behavioural economics suggests a further option. People respond more strongly to a small sum they have already paid and may lose than to a larger sum they might one day be asked for. A refundable deposit, or a clear commitment made at the time of booking, can therefore change behaviour more effectively than a threat of a penalty. The same research warns, however, that any charge, even a refundable one, deters some people from using a service, and that the deterrent is strongest among those with the least money.

Underlying all of this is a question of principle. Health care in Britain is funded through taxation and is free when it is used, an arrangement that has survived for more than seventy years. A charge for missing an appointment is not a charge for treatment, and its supporters can reasonably say that the two are different. Yet the money would come from the same pocket, and the patient asked to pay would be the one who was ill.

My own view is that a national scheme of charges should not be introduced now. The evidence that it would reduce waste is thin; the evidence that it would fall on the vulnerable is not. What the health service lacks is not a deterrent but capacity: appointments that cannot be booked, letters that arrive late, clinics that close before working people can reach them.

If a charge is to be tried at all, it should be in a small number of practices, with an exemption for anyone on a low income or living with a condition that makes attendance unpredictable, and with the results published. Until then, the fairest reading of the evidence is that missed appointments are a symptom of a stretched system rather than a moral failing of the patients inside it, and that the remedy should be found in the system.