It’s just business

by reestheskin on 19/11/2020

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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.

  1. Here I am echoing the arguments made by Howie, Metcalfe and Walker in the BMJ in 2008: The State of General Practice — not all for the better. Comments on this article effectively said: the halcyon days of general practice were over. Get used to it! I am not convinced. What has happened is that ‘government led population / public health’ has gobbled up ‘personal doctoring’. For the latter, it appears, you will need more than the NHS.
  2. Many epidemiologists argued that there was no need for CCUs as no RCTs had shown their benefit. Ditto for parachutes, renal transplantation , no doubt.
  3. You can insert your own favourite de jour: Pfizer and Flynn for raising the price of an anti-epilepsy drug by up to 2,600 per cent, or GSK, or Crapita, Test and Trace etc. The list goes on, well before we get to the likes of Facebook or the Financial Services Industry