I have rich memories of general practice, and I mean general practice rather than primary care 1. My earliest memories centre around a single-handed GP, who looked after my family until we left Wales in the early 1970s. His practice was in his house, just off Whitchurch village in Cardiff. You entered by what once may have been the back gate or tradesman’s entrance. Around the corner and a few steps up, you found the waiting room. Originally, I guess, it might have been a washroom or utility room for a maid or housekeeper. By the standards of the Rees abode the house was large.
The external door to the waiting room was opposite the door into the main part of the doctor’s house, and on the adjacent sides were two long benches. They were fun for a little boy to sit on because since your legs couldn’t touch the floor, you could shuffle along as spaces became available. When you did this adults tended to smile at you; I now know why. If you were immobile for too long your thighs might stick to the faux-leather surface; pulling them away fast resulted in a fart like noise, although in those days I was too polite to think out loud.
Once you were called — whether it was by the doctor or his wife I cannot remember— you entered his ‘rooms’. The consulting rooms was by my preferred unit measure — how far I could kick a ball — large, with higher ceilings than we had at home. The floorboards creaked and the carpet was limited to the centre of the room. If there was a need for privacy there was what seemed like a fairly inadequate freestanding curtained frame. For little boys, obviously, no such cover was deemed necessary.
I can remember many home visits: two stand out in particular, mumps, and an episode of heavily infected eczema where my body was covered in thousands of pustules, and where I remember pulling off sheets of skin that had stuck to the bedclothes. The sick-role was respected in our home: if you were ill and off school you were in bed. Well, almost. Certainly, no kicking the ball against the wall.
Naturally, the same GP would look after any visitors to my home. Although my memories are influenced by what my mother told me, on one occasion my Irish grandmother’s valvular heart failure decompressed when she was staying with us (her home was in Dublin). More precisely, I was turfed out of my bed, so she could occupy it. The GP phoned the Cardiff Royal Infirmary explaining that the patient needed admission, and would they oblige? The GP however took ten years-or-so off her true age. Once he was off the phone, my mother corrected him. He knew better: if I had told them the truth they would have refused to admit her, he said. (This was general practice, not state medicine, after all). The memory of this event stuck with me when I was a medical student on a geriatrics attachment in Sunderland circa 1981. Only those under 60 with an MI were deemed suitable for admission to the CCU, with the rest left in a large Nightingale ward with no cardiac monitoring 2. I thought of my father who was then close to 60.
I was lucky enough to be able to recognise this type of general practice — albeit with many much needed changes — as a medical student in Newcastle, and to be taught by some wonderful GPs, and even do some GP locums when I was a medical registrar. And although I had never met the late and great Julian Tudor-Hart face-to-face, we are linked by a couple of mutual Welsh friends, and we exchanged odd emails over the years.
So, why do I recall all of this? Nostalgia? Yes, I own up to that. But more out of anger that what was unique about UK general practice has been replaced by primary care and “population medicine”, and many patients are worse off because of this shift. Worse still, it now seems all is viewed not through the lens of vocation, but by the egregious ‘its just business’. Continuity of care and “personal doctoring” is, and has been, lost.
I write after being provoked by a comment in the London Review of Books. Responding to a terrific article by John Furse on the NHS, Helen Buckingham of the Nuffield Trust states — as many do — that “The reality is that almost all GP practices are already private businesses, and have been since the founding of the NHS.” (LRB 5/12/2019 page 4).
Well, for me, this is pure sophistry. There are businesses and businesses. If you wish, you might call the Catholic Church a business, or Edinburgh university a business, or even the army a business. You might even refer to each of them as a corporation. But to do so, misses all those human motivations that make up civil society. Particularly the ability to look people in the eye and not feel grimy. There is no way on earth that the GP who looked about me would have called what he did a business. Nor was he part of any corporation. And the reason is simple: like many think tanks, many modern corporations — especially the larger ones — have no sense of morality beyond the dollar of the bottom line3, often spending their undoubted skills wilfully arbitraging the imperfections of regulation and honest motivation. It does not have to be this way.
As with HIV, “an epidemic reveals the fault lines in society. The big one this epidemic has revealed is how we treat the elderly. We often park them in pre-mortuary type institutions and give a bit of money and hope it is OK”.
When the tide goes out you see who is not wearing bathing costumes…
Even those who liked it at the beginning are becoming wary of the creeping clapping fascism,
One of the pleasures of retirement from medical practice is not being on the General Medical Council (GMC) register. If you were able to listen in on many doctors private conversations, and run some Google word analytics, the word you might find in closest proximity to the term General Medical Council (GMC) would be loathe. There would be other less polite words, too. As the BMJ once wrote: there is very little in British medicine that the GMC cannot make worse. It is a legalised extortion racket that fails to protect the public, messes up medical education and makes many doctors’ lives miserable.
The following are quotes from the Lancet and the FT. They are about the horrendous crimes perpetrated by a surgeon, Ian Paterson. The full Independent Inquiry report can be found here. I am not surprised by anything I have read in the investigation into these crimes and the attacks on those who attempted to draw attention to them.
Health-care workers reporting concerns often come under substantial pressure from health-care management, and sometimes have to justify their own practice and reasons for speaking out. Four of the health-care professionals who did report Paterson were subject to fitness to practice scrutiny by the GMC during the later investigation because they had worked alongside him
The FT draws up some lessons. Here is number four:
The fourth lesson is that those who speak up are likely to suffer. Some of Paterson’s colleagues were worried about his practices. When six doctors raised concerns with the chief executive of the NHS trust where Paterson worked, four were themselves investigated by the General Medical Council because they had worked with him.
Maybe after clapping this Thursday evening people need to take a long hard look at the culture of NHS governance and its proxies in the UK. Pandemics just open up the cracks of incompetence that are hidden in plain sight.
Dr Chris Day writes:
Two weeks ago, I swabbed my first positive Covid-19 patient during an A&E Locum shift. I must say back then, I hadn’t fully taken in what we as a country will have to face over the coming months. The reports from colleagues in Italy and China are beyond belief.
The UK has been left to fight Covid-19 with half the Intensive Care beds per capita of Italy. Back in 2014, the trigger for my whistleblowing case was my attempt to try and secure more ICU resources for South East London (see Private Eye).
Instead of spending 5 years and £700k fighting /smearing me and damaging whistleblowing law, the NHS could have just fixed the problem. There has never been a more important time for the public and the politicians to understand Intensive Care resourcing and what is decided on their behalf by NHS leaders.
The following is from Janan Ganesh of the FT. The title of the article was “The agony of returning to work in September”.
A personal ambition is to reach the end of my career without having managed a single person.
It seems to me a very sensible ambition, one which used to be the lot of many academics — usually the better ones. He goes on:
Friends who have been less lucky, who have whole teams under their watch, report a quirk among their younger charges. It is not laziness or obstreperousness or those other millennial slanders. It is an air of disappointment with the reality of working life. They will be among the people described in Bullshit Jobs by the anthropologist David Graeber….
A generation of in-demand graduates came to expect not just these material incentives but a sort of credal alignment with their employer’s “values”. The next recession will retard this trend but it is unlikely to kill it.
At one time the words ‘manager’, ‘management’, or worst of all, ‘line-manager’ were alien to much of medicine or academia. Things still got done, in many ways more efficiently than now. It is just that our theories of action and praxis have been ransacked by Excel spreadsheet models of human motivation and culture. It is the final line from the quote that those controllers of ‘managers’ should be scared of:
The next recession will retard this trend but it is unlikely to kill it.
I am generally nervous about doctors or academics working for the government. Not that I think the roles are unnecessary, far from it. But what worries me is when instead of resigning from their academic role, they end up working for more than one master. So, I tire of the use of university titles when the principle employer does not subscribe to the academic ideal. I think if you have been at Stanford and you go to Washington it should be as a regular civil service post. I think the Americans get it right.
But the retiring CMO, Dame Sally Davies, in an interview in the RCP in-house journal ‘Commentary’ speaks some truths (Commentary | October 2019, p10).
I hear non-stop stories from unhappy juniors. In my day, we (consultants) made up the rotas for the juniors, but now administrators do it without understanding all of the issues. I’m told you can’t go back to the ‘firm’ structure because there are so many doctors in the system, but whenever I meet a roomful of young doctors I ask: ‘Does your consultant know your name?’ It’s rare that a hand goes up. We have depersonalised the relationships between doctors and that can’t help the workings of the medial team, or with the patients.
Your mileage may vary, but when I was a junior doctor it was us — not the consultants — who came up with the rotas. But the point she makes is important, and everybody knows this (already). At one time junior doctors didn’t work for the NHS, rather they worked within the NHS for other doctors, for good and bad. I find it hard to imagine that the current system can deliver genuine apprenticeship learning. Training and service may often have resembled a bickering couple, but there was a broader professional context that was shared. I am not certain that this is the case anymore. Whenever people keep pushing words such as ‘reflection’ or ‘professionalism’, you know — pace Orwell — that the opposite is going on. Politics is a dominant-negative mutation.
Shortage of GPs will never end, health experts say | Society | The Guardian
OK, maybe the subeditor is to blame, but spare me the cartel of health think tanks and their pamphlets. Enticing people into general practice and keeping them there is not rocket science. When I was a junior doctor getting onto the best GP schemes around Newcastle was harder than getting the ‘professorial house-jobs’. Many people like, and want to be, GPs. If general practice is dying , it is in large part because the NHS is killing real general practice.
A few years back I wrote a personal view in the BMJ, arguing that an alternative model for dermatology in the UK would be to use office dermatologists, as in most of the first world. It is likely cheaper and capable of providing better care as long as you consider skin disease worthy of treatment. The feedback was not good or in some instances, even polite. The more considered views were that my suggestion was simply not possible: how would we train these people? Well jump on a ferry or book Ryanair, and look how the rest of Europe does it.
There are some general discussion points:
Two personal examples:
I received an orthopaedic operation under a GA at a major teaching hospital. I was in the my mid 50’s, and previously fit. At the clerking / pre-op assessment by a nurse, my pulse and BP were recorded, and my urine was tested. I was asked : “Are your heart sounds normal and do you have any heart murmurs?” (There was no physical examination). My quip — that how could you trust a dermatologist on such matters — was met with a total lack of recognition. I recounted the story to the anaesthetist as a line was inserted in my arm. I also mentioned, for effect, that they didn’t ask about my dextrocardia….( I achieved the appropriate response — to this untruth). Subsequent conversations with anaesthetists confirmed that their opinions were in keeping with mine, and this “was management” and ‘new innovative ways of
As a second year medical student, with a strong atopic background (skin, lungs, hay fever etc). I came out in what I now know to be widespread urticaria with angioedema. On going to the university health centre, the receptionist triaged me to the nurse, because it was ‘only skin’. I didn’t receive a diagnosis, just an admonition that this was likely due to not washing enough (which may have been incidentally true or false…). A more senior medical student provided me with the right diagnosis over lunch.
The latter example chimed with me, because DR Laurence in his eclectic student textbook of Clinical Pharmacology lampooned the idea that nurses had ‘innate’ understandings of GI pharmacology, a delusion that remained widespread through my early medical career. Now, sadly, similar prescientific reasoning underpins much UK dermatology. The public are not well served.
General practice has been undergoing a quiet revolution in recent years that has had little fanfare: it is now an overwhelmingly part-time profession.
Official figures suggest almost 70% of the workforce work less than full time in general practice – the highest proportion ever.
Did the NHS save your life, or did Doctors and Nurses save your life?
It’s an earnest question. A comment on an excellent FT piece: “Is Britain loving the NHS to death?”
This was a quote from an article by an ex-lawyer who got into tech and writing about tech. Now some of by best friends are lawyers, but this chimed with something I came across by Benedict Evans on ‘why you must pay sales people commissions’. The article is here (the video no longer plays for me).
The opening quote poses a question:
I felt a little odd writing that title [ why you must pay sales people commissions]. It’s a little like asking “Why should you give engineers big monitors?” If you have to ask the question, then you probably won’t understand the answer. The short answer is: don’t, if you don’t want good engineers to work for you; and if they still do, they’ll be less productive. The same is true for sales people and commissions.
The argument is as follows:
Imagine that you are a great sales person who knows you can sell $10M worth of product in a year. Company A pays commissions and, if you do what you know you can do, you will earn $1M/year. Company B refuses to pay commissions for “cultural reasons” and offers $200K/year. Which job would you take? Now imagine that you are a horrible sales person who would be lucky to sell anything and will get fired in a performance-based commission culture, but may survive in a low-pressure, non-commission culture. Which job would you take?
But the key message for me is:
Speaking of culture, why should the sales culture be different from the engineering culture? To understand that, ask yourself the following: Do your engineers like programming? Might they even do a little programming on the side sometimes for fun? Great. I guarantee your sales people never sell enterprise software for fun. [emphasis mine].
Now why does all this matter? Well personally, it still matters a bit, but it matters less and less. I am towards the end of my career, and for the most part I have loved what I have done. Sure, the NHS is increasingly a nightmare place to work, but it has been in decline most of my life: I would not recommend it unreservedly to anybody. But I have loved my work in a university. Research was so much fun for so long, and the ability to think about how we teach and how we should teach still gives me enormous pleasure: it is, to use the cliche, still what I think about in the shower. The very idea of work-life balance was — when I was young and middle-aged at least — anathema. I viewed my job as a creative one, and building things and making things brought great pleasure. This did not mean that you had to work all the hours God made, although I often did. But it did mean that work brought so much pleasure that the boundary between my inner life and what I got paid to do was more apparent to others than to me. And in large part that is still true.
Now in one sense, this whole question matters less and less to me personally. In the clinical area, many if not most clinicians I know now feel that they resemble those on commission more than the engineers. Only they don’t get commission. Most of my med school year who became GPs will have bailed out. And I do not envy the working lives of those who follow me in many other medical specialties in hospital. Similarly, universities were once full of academics who you almost didn’t need to pay, such was their love for the job. But modern universities have become more closed and centrally managed, and less tolerant of independence of mind.
In one sense, this might go with the turf — I was 60 last week. Some introspection, perhaps. But I think there really is more going on. I think we will see more and more people bailing out as early as possible (no personal plans, here), and we will need to think and plan for the fact that many of our students will bail out of the front line of medical practice earlier than we are used to. I think you see the early stirrings of this all over: people want to work less than full-time; people limit their NHS work vis a vis private work; some seek administrative roles in order to minimise their face-to-face practice; and even young medics soon after graduation are looking for portfolio careers. And we need to think about how to educate our graduates for this: our obligations are to our students first and foremost.
I do not think any of these responses are necessarily bad. But working primarily in higher education, has one advantage: there are lost of different institutions, and whilst in the UK there is a large degree of groupthink, there is still some diversity of approach. And if you are smart and you fall outwith the clinical guilds / extortion rackets, there is no reason to stay in the UK. For medics, recent graduates, need to think more strategically. The central dilemma is that depending on your specialty, your only choice might appear to be to work for a monopolist, one which seeks to control not so much the patients cradle-to-grave, but those staff who fall under its spell, cradle-to-grave. But there are those making other choices — just not enough, so far.
An aside. Of course, even those who have achieved the most in research do not alway want to work for nothing, post retirement. I heard the following account first hand from one of Fred Sanger’s previous post-docs. The onetime post-doc was now a senior Professor, charged with opening and celebrating a new research institution. Sanger — a double Laureate — would be a great catch as a speaker. All seemed will until the man who personally created much of modern biology realised the date chosen was a couple of days after he was due to retire from the LMB. He could not oblige: the [garden] roses need me more!
“Certainly, for frontline doctors like us who are used to wrestling with clunky NHS IT systems, the biggest surprise of the malware attack was not that it happened but why it had taken so long. It is an irony lost on no NHS doctor that though we can transplant faces, build bionic limbs, even operate on fetuses still in the womb, a working, functional NHS computer can seem rarer and more precious than gold dust.’
“Core surgical training in the UK has been dubbed “core service training” because many trainees believe it does not provide enough surgical experience. At the southern tip of Africa, I felt I was being taught to operate, not to just watch and hold retractors. My commitment and progression were judged on hard work and merit, not on how many courses I had attended.”
Fairly dismal reading here and here. Much of what has happened in the UK is a result of a health service that is not based around clinical need, and in which most decision makers might as well believe in fairies. The mistake is to imagine that we got into this mess because of a lack of money. We got into this mess for much the same reason that much of UK industry has collapsed: the people making decisions have no technical competence in the relevant domains. If it was left to the NHS, BMW would not employ engineers (‘its just process management, isn’t it, so let’s reorganise the workflow, and set some targets?’).
‘Health policy is in tatters. Markets haven’t worked, inspection hasn’t worked, demand management has failed, morale at an all-time low and workforce planning botched. The sky is dark with chickens coming home to roost. The NHS is now all about muddling through’. Roy Lilley calls it right. But what is a young graduate or student to do? [link for this post]
So the English NHS is to stop paying GPs to diagnose dementia. The NHS supremo is quoted as saying, ‘I think it’s too early for hindsight. We need to look at the dementia diagnosis rate through the year before we do that. It is not driven by patient preference, but by different levels of focus on this topic. ‘ Well forget hindsight, a little foresight would have helped.
A long, long time ago, I was sitting in the biochemistry coffee room in the medical school in Newcastle. Roger Paine, a professor of biochemistry came and sat next to me. I knew of him, but he didn’t know me. He was a FRS, I was a dermatology research registrar taking my first steps in learning some wet bench science in the Medical Molecular Biology Group there. Coffee rooms work, as do Aeron chairs. Sometimes you need to talk, and ramble around what interests you; and sometimes you have to sit alone, and dream. If you don’t, you will do ‘kit’ science, or act out being an administrator by conducting randomised controlled trials.
We got chatting—we shared a mutual colleague—and he expressed his puzzlement to me about how medics managed to do any research. He pointed out what with seeing patients, and some undergraduate teaching and postgraduate training, how on earth could you hope to do any meaningful research. I listened, not wanting to hear what he said. And I should point out, he was a keen collaborator with medics, nor stand-offish in any way.
Many years later, in another setting, I was talking to another successful scientist, a geneticist, also a FRS. We knew each other reasonably well, and by this stage I had been working in wet-bench science for a dozen years or more. Some modest successes, and plenty of failures. He told me that because he knew the details of many clinical medics research careers very well, he would be loathe to ever approach any of them if he needed medical care. He had the highest regard for them as academics, and researchers, but he too couldn’t see how they could carry on all the various activities expected on them. (And no doubt be able to go to the cinema once in a while: Steven Rosenberg, a one time Chief of Surgery at NIH, in his autobiography, describes how he would struggle to leave Sunday evening free of lab and clinical duties, so that he could go to the cinema with his wife).
“What of attempts to improve skin cancer diagnostic skills in primary care, or to develop GP specialists as seen in Australia or the UK? There are various points to make here, and perhaps a lot of wishful thinking about how the problem could be solved if only ‘GPs’ knew more about this or that subdomain of medical knowledge. In truth, such blandishments, must be frustrating to many GPs: there are only so many hours in the day. There are studies showing that it is possible to improve diagnostic skills over the short term following organised tuition (cited in Rees (16)). To find anything else would of course be surprising: if we expose intelligent people to formal tuition or learning, we expect short-term performance to improve. But, the critical point is whether this improvement is maintained, and what aspects of performance suffer because they have been replaced by training in another domain (16). There is no free lunch. If we run a course on skin cancer, then the rheumatologists, cardiologists etc. will all want to run courses. And much of what we know about such one off tuition is that in the absence of consolidation and feedback, the benefits are short lived only. How many of us remember all the history and geography we learned at school?” Here.