General practice adaptation

In 2001 Richard Smith, then editor of the British Medical Journal (BMJ) wrote an editorial titled, Why are doctors so unhappy?  and found the source of their unhappiness in a bogus contract in which medicine promised too much and delivered too little to the mutual disappointment of doctors and patients.

In 2013 John Launer responded in an essay titled, Doctors as Victims in which he called for doctors to reflect on how powerless they felt despite being in possession of far more power than their patients.

Returning to the theme, and linking these two pieces together, Smith has responded with a much less sympathetic blog for the BMJ this week,

General practitioners have replaced farmers as the profession that complains the most.

I have no sympathy for them. I want them to stop being victims and become leaders, people who solve problems rather than complain about them and expect others to solve them. I’ve preached this message to meetings of GPs several times in the past, which has not made me popular, but the current orgy of moaning has urged me to put finger to iPad.

When I was editor of The BMJ I seemed always to be reading studies of stress in doctors. Why, I wondered, were there so many studies of stress among doctors but few among single mothers, the unemployed, schoolteachers in rough areas, aid workers, rickshaw drivers, asylum seekers, or the billions living on less than $1.25 a day?

Seeing yourself as a victim, he says, is unedifying when others are so much worse off than you are.

Smith never practiced clinical medicine. Disturbed as a medical student by the realisation that medicine can do serious harm as well as good, he avoided having to personally take responsibility for others lives. He doesn’t know, as I do, what it feels like to kill someone when you were trying to save them. As an aid-worker in Afghanistan in 2004 I was evacuated after several of my friends and colleagues were shot dead. I’ve always worked in rough areas and every day I listen to the stories of asylum seekers, victims of torture and domestic violence. Despite my happy childhood and financial security, I have a pretty good idea what stress feels like. Faced with a depressed patient, the last thing you do is tell them that they’ve got little to be depressed about because you’ve just seen someone whose situation is far worse who is coping much better. One thing most depressed people suffer from is the guilty feeling that they don’t deserve another’s sympathy because they don’t have enough to be depressed about.

Faced with a patient (or a profession) that is in distress, the first thing to do is acknowledge and explore their emotions, and your own. GPs are feeling depressed, anxious, angry, exhausted, confused, despondent, miserable, hopeless, powerless even. Smith is feeling frustrated, impatient, angry even. The next step is to try to understand the emotions. Acknowledging and understanding  feelings are the affective and cognitive aspects of empathy. The next, compassionate step is to try to identify needs. According to the recent BMA survey, the majority of GPs want to spend more time with their patients, less paperwork and better continuity of care. Recent articles in the Journal of the American Medical Association and BMJ Quality and Safety have argued for the importance of finding joy in medical practice through professional autonomy, meaning and respect. Penny Campling has clearly articulated the need for professionals to work in a culture of ‘intelligent kindness’ if their work with patients is to be also kind and caring. I guess Smith wants medicine to be more humble with regards to its science and more radical in its politics. He wants doctors to be more like him.

Demanding solutions without exploring feelings and needs is a form of violence, according to Marshall Rosenberg, who has pioneered ‘non-violent communication’. People with feelings and needs need to be heard without criticism or demands. Smith’s conclusion,

a moratorium on moaning and a festival of ideas for reinventing general practice.

will not be taken up by a profession whose distress is dismissed.

Having said all that, I have spent some time thinking about what might enable GPs to find more joy in our work. The following is a sketch of some of the things that we could consider if we are to thrive in future. It is not a prescription to be swallowed hole, but a menu of suggestions, there should almost certainly be more options and some that are unpalatable. But it is my response to Richard Smith’s challenge, and I hope some of it will help.

General Practice adaption

GPC Chairman, Chaand Nagpaul’s 2015 LMC conference speech received a long, standing ovation from the assembled GPs last month as he described ‘the triple whammy of morale, workload and workforce pressures’ and quoted the Health Education England Taskforce review  describing a ‘GP crisis’ because present numbers of GPs are unable to meet current demand. Numbers of GPs per head of population are set to decline with up to 10 000 planning to retire in the next five years, many training places unfilled, and one in five trainees planning to emigrate.

General practice clearly needs mitigation to attract more doctors to the profession and the case for this is clearly stated by Dr Nagpaul  but it also needs adaption to cope with a future in which there are significantly less GPs per head of population than there have been before.

The following are suggestions about how General Practice can adapt. There is almost certainly a bias towards urban General Practice, because that is where I have worked, and these are suggestions, not a prescription. But there is no doubt that we will need to change, wherever we work.

Rethinking the gatekeeper role.

The GP gatekeeper role should be reserved for situations of medical diagnostic uncertainty and clinical management support. In most other cases and especially when patients want self-management support, they ought to be able to refer themselves to a specialist. In many instances patients can already self-refer to the services listed below, but this is not the case everywhere and I have referred patients to all the listed services in recent years. I would suggest that patients should be able to refer themselves directly to these services without having to make their case to a GP. The services would have to adapt by having their own effective triage system so that patients are supported on a spectrum from advice to specialist intervention as appropriate. Patient education and self-management support should be part of every service at every level.

  • Abortion
  • Alcohol services
  • Ante-natal care
  • Audiology including paediatric
  • Dietician
  • District nursing
  • Exercise/ gym
  • Falls team
  • Family planning (contraception)
  • Family support services
  • Health trainers (see below)
  • Health visitors
  • Occupational therapy
  • Palliative care
  • Physiotherapy
  • Podiatry/ foot health
  • Psychology/ counselling/ bereavement counselling
  • Rehabilitation (after major illness, e.g. heart attack/ stroke etc.)
  • Sexual health
  • Smoking cessation
  • Social prescribing
  • Social services
  • Speech and language therapy (paediatric and adult)
  • Specialist nursing, e.g. asthma, copd, dementia, diabetes, epilepsy, heart-failure, stroke, wound care etc.
  • Substance misuse

Patients should also be able to refer themselves back to hospital after a missed or cancelled appointment. A considerable and infuriating amount of time is spent re-referring patients back to hospital with the same problem.


When a patient presents with a problem, for example stomach ache, they may not know whether they need to see a GP, a nurse, a pharmacist, a gastroenterologist, a general, urological, gynaecological or vascular surgeon, a hepatic or renal physician or whatever. An expert generalist at the point of first contact can minimise the steps required to solve the problem. This is why many practices are choosing to phone patients before they book appointments so that if possible they can deal with their concerns immediately and where not, they can make arrangements for their patients to be seen. At present, this system still relies on receptionists taking the initial call, and making a basic triage decision: can they wait for the GP to call them back, or do they sound so sick that the GP should be immediately informed? Furthermore, with this system, GPs might find themselves spending a lot of time signposting patients to services or giving simple advice, a role that health-trainers (or similar) could do very well. If the first point of call was to a clinically trained receptionist, such as a health-trainer who had immediate access to GPs in case of concern, then GPs could spend more time with patients who need them.  Where possible, every point of contact should have some clinical training so that, for example instead of making an appointment for a blood pressure check, everyone who works in a GP surgery can check a patient’s blood pressure and teach them how to do it themselves next time.

The GP team.

The traditional GP team has expanded over the years from a GP and a receptionist/ manager to include practice nurses, nurse practitioners, health-care assistants and more. Not long ago health-visitors and district nurses were based in GP practices and many GPs wish the close working relationships could be re-established. The advantages are better continuity of care and clearer lines of communication. The extent of the team will vary according to the size and needs of the practice, but larger (>10k patients) practices could include:

  • Auditors, at practice and CCG level to regularly audit practice, guided by GPs to choose the areas to be audited, but not to waste time on the audit process itself.
  • District nurse
  • Health trainers/ community health workers to support self-management of chronic diseases, including hypertension, diabetes, asthma, COPD and lifestyle change including: weight loss, smoking cessation, exercise, alcohol reduction etc. They could also proactively follow up vulnerable patients who are not good at attending appointments and visit housebound patients. Here is a good guide to Brazil’s Family Health Strategy and use of Community Health Workers (Agents). One of their most important roles is to pro-actively engage people who are in need of care but do not choose to go to their GP.
  • Health visitor
  • Legal and financial advice
  • Pharmacists to support medication reviews, polypharmacy rationalisation, prescribing audits, repeat prescription requests, changes in prescribing guidelines. Excellent blog by Ravi Sharma, a GP based-pharmacist explaining his roles
  • Physiotherapist
  • Psychologist/ counsellor
  • Social worker

GPs should not be spending time on human-resource management (HR), occupational health, and finance-management. A lot of this work could be carried out at scale for federations of practices with patient-populations of >100 000


Patients should have online access to their medical record. This can improve the accuracy of the record and will enable patients to show it to every health-professional they meet and keep it safely updated. This is not without risks; consider for example an adult that discovers that they were once subject to a child-protection order, or a woman in an abusive relationship whose partner forces her to disclose her record. Risks need to be mitigated and shared between GPs, NHSEngland and patients.

Social media.

Secure online platforms for patients and professionals should be set up so that expertise can be shared. Self-care protocols could be set up and time-tabled specialist presence so that patients and professionals know when to look for answers with effective moderating and curating so they know where to look.

Community specialist teams.

We need teams in areas of high need such as nursing homes / homeless / mental health with the commissioner working with providers and third sector organisations to design contracts that stimulate innovation. Nursing homes are in a parlous state with providers squeezed desperately as a result of government cuts to local authority funding. When nursing home care fails, patients end up in hospital. Joint health and social care budgets might force commissioners to fund care where it is most cost-effective, which is almost certainly in nursing homes with expert-medical support. GPs, working in teams with geriatricians, psychiatrists and specialist nurses are in an ideal position to work here. But many hospitals are carrying enormous debts from the reduction in payments by tariffs and PFI costs and cannot cope with any further loss of funding.

Team working.

One of the greatest dangers in general practice is professional isolation. Older GPs remember a time when they would have weekly meetings at the local hospital and knew many of the consultants personally. The intensity of their workload now means that many GPs are isolated not only from their hospital colleagues, but also one-another. It is vital that time is made and protected at least weekly, both online (as suggested above) and face to face for GPs to discuss the patients that they and their colleagues are concerned about. Almost all the changes above increase the size of the teams within which GPs work and effective teams need good lines of communication.

Relationship-based care.

For almost all patients, and especially those at the end of life and those with serious, chronic illnesses, complex multi-morbidities and enduring mental health problems, continuity of relationship is essential. Although most patients will be cared for by teams, continuity within teams should be a priority and every patient should have their own named, responsible GP. Health care is a moral practice that involves people treating people, and yet we are in danger of treating medicine as if it were science treating disease by protocol. If we let it go that way even more than we already have, then we will dehumanise our patients and ourselves, to say nothing of recklessly ignoring the complexity of human lives and human suffering.

Estate change.

Chaand Nagpaul quoted the LMC survey showing that 40% of GP premises are inadequate to provide essential care and 70% do not have space to expand. NHS England has secured a £1bn infrastructure fund which will benefit 1000 English practices this year. We need fewer, bigger GP practices providing more services with space for specialists to work in the community where they can train and leave legacy. BMJ podcast on buildings for health: GP practices  should be community centres.

Patient-centred care requires buildings that are easy to access and navigate, promote care and recovery for patients and good health for everyone in them. They are not only places for work, but must also provide peace, natural light, healthy food and time and space for everyone in them to meet, learn, reflect and rest.

GP training.

This should be a ‘better fit’ for the needs of the future GP (RCGP 2020) with a greater emphasis on elderly care, palliative care, multi-morbidity etc. There should be much more attention to patient-centred care, in particular shared-decision making and self-management support. Training should reflect the shift from a GP as an independent practitioner to a multi-disciplinary team player.

Out of hours and 7 day a week general practice.

There are not (and will likely never be) enough GPs to keep every surgery open 8-8 , seven days a week operating as the presently do. However in places like Hackney that have taken back responsibility for out of hours care with a locally run GP co-op, the quality of out of hours care and patient satisfaction levels are very high. The infrastructure: phone-lines, receptionists and clinicians is already in place, and with a little more investment could be set up to offer patients appointments with GPs and other members of the primary care team, at weekends.

Less is more.

Finally, there is a global coalition of medical professionals, journalists and patients who have realised that a great deal of modern medicine is not effective and that cutting down on waste requires that patients and professionals are given the right information and enough time to make the right decisions about care. We could start be stopping unsolicited health-checks and dementia screening as well investigations like MRI scans for the vast majority of patients with back pain and headaches.

BMJ Too Much Medicine

Innovation, evaluation and emulation.

General Practice is a hot-bed of innovation, but innovation is incredibly patchy, poorly evaluated and rarely emulated. The Royal College of GPs should support innovation, evaluation and emulation so that good practice is backed up by good evidence and shared so that patients and GPs everywhere can benefit.

Further reading:

RCGP Blueprint for general practice May 2015


I heard a voice coming from an answer-phone but I couldn’t make out the words. I recognised the tones of concern and it was obvious they weren’t just leaving a message. Not entirely sure where my parents kept their phone I followed the sounds until I heard, “Hello?! Is anyone there? Mr Tomlinson, are you all right? Can you hear me?”

I picked up the receiver, “Hello, it’s Jonathon, Mr Tomlinson’s son, how can I help?” “Mr Tomlinson has pressed his emergency call button.” My dad was upstairs and I was downstairs but we were close enough to hear one-another. I guessed he had pressed it by mistake.

My immediate reaction was to feel embarrassed and apologise and immediately reassure them that he was OK and apologise again for wasting their time. All without checking on my dad. One thing carers are afraid of is being a burden on others or wasting anyone’s time.

I hung up and ran upstairs. He was in the bathrooms on his hands and knees, groaning with a mixture of pain and shame. “Are you OK?” I asked. “No, not really.” He struggled to get the words out. A series of strokes has combined with Alzheimer’s dementia to undermine his ability to find the right words and join them together in the right order. He was in a mess. A huge nappy, full of watery diarrhoea was tangled around his ankles, the diarrhoea was smeared all over his legs and hands, the bathroom floor, the toilet, everywhere. My mum – 70 years old, his full-time carer, called from downstairs, “Are you OK up there? Do you need any help?”

“We’re fine thanks” I called back, “Just give us a few minutes.” I knew this kind of thing happened to my dad quite frequently, but it was the first time I’d been in this position, the first time I’d seen him like this. I looked around for wipes and gloves. I found some wipes on the window sill but no gloves. The wipes had dried out in the unseasonably warm early spring sun, so I had to wet them under the tap. For about 15 minutes, carefully, gently, firmly, thoroughly I washed him, starting with hands and feet, working my way gradually towards his bottom. To my surprise neither of us seemed embarrassed. I’d seen him in tears before, sobbing and saying sorry for being useless and for being too much trouble when he couldn’t help with household tasks. I think I was more afraid of that, an emotional outburst, than the mess and the foul smell. I was expecting him to be beside himself, tearfully and shamefully apologetic, but he was almost cheerful. This helped enormously. He stood up and hung onto the sink as I washed between his thighs and buttocks. “Thank you … very … much”, he managed to say with a bit of a struggle. “It’s fine”, I replied, “no problem. You’ve cleaned my bum many more times than I’ve cleaned yours!” We laughed together, “Oh yes!” he agreed, smiling.

This was not how I had thought it would be. I was expecting  us both to feel upset, ashamed, angry perhaps and disgusted. As a 17 year old working on an elderly care ward at Winchester hospital, a demented man had got really upset when I was washing him and started fighting and I had been frightened and upset. The memory has stuck with me. But this time, with my dad, we discovered affection and humour bound together by intimacy. It was the closest we had been, not just physically but emotionally, for a long time. I steadied him out of the bathroom into his bedroom and helped him dress, washing his hands once more, last of all. Then I went back and cleaned the bathroom. Then we went downstairs together. This act of intimacy made me realise, once again that a medical education and nearly 20 years of medical practice has taught me almost nothing about care-giving. Having worked as a care-assistant on an elderly care ward in my holidays when I was a medical student, I wasn’t entirely naive, but I was sad to discover that 20% of carers say that their GP practice is not carer friendly. I’m not even sure you can teach someone about giving care, you have to learn about caregiving by doing it, and you do it because you have no choice. Caring is a moral and practical obligation. For me though, in many ways it was easy, it was just the once. I am not my dad’s carer, I was just visiting for the weekend. My mum is my dad’s full-time carer. About once a month she pays a carer to cover while she has a break or my sister comes and helps. Caring full-time is far more physically, practically and emotionally complex than my single encounter. Psychiatrist Arthur Kleinman, who cares for his wife with Alzheimer’s explains,

I am not a naive moralist. I’ve had far too much experience of the demands, tensions, and downright failures of caregiving to fall into sentimentality and utopianism. Caregiving is not easy. It consumes time, energy, and financial resources. It sucks out strength and determination. It turns simple ideas of efficacy and hope into big question marks. It can amplify anguish and desperation. It can divide the self. It can bring out family conflicts. It can separate out those who care from those who can’t or won’t handle it. It is very difficult. It is also far more complex, uncertain, and unbounded than professional medical and nursing models suggest. I know about the moral core of caregiving not nearly so much from my professional life as a psychiatrist and medical anthropologist, nor principally from the research literature and my own studies, but primarily because of my new life of practice as the primary caregiver for Joan Kleinman.

At the same time that the number and proportion of elderly people is rising and people with disabling chronic diseases are living longer, our government is cutting social care and underfunding the NHS. And so the burden of care is falling, and will continue to fall, on families, neighbours and informal networks of unpaid volunteers. David Cameron’s rhetorical ‘hard-working families’ will have to give up their jobs to care for their families. Their ‘hard work’ will be providing unpaid, personal care for their families, providing the social care that a low-tax economy cannot provide. Sooner or later, most of us will be carergivers or cared-for.

This is a good time to think about Carer’s week and the kind of society we want.

Further reading:

“Unendurable” cuts threatening vital home care Adult social services press release

Crisis? What Crisis? Roy Lilley blog about Saga withdrawing from nursing homes

Arthur Kleinman on Caregiving

What are we afraid of? Growing old without social care.

Listening and Learning from people with dementia and their carers.

A Perfect Storm. The impact of welfare on healthcare

Giving and receiving

Several years ago, I was packing my panniers with presents that patients had given me for Christmas. I felt embarrassed by their generosity. My patients then, as now, were for the most part pretty impoverished, and yet some had gone to considerable trouble to buy me gifts and wrap them carefully. Troubled by this I spoke to one of the other GPs who had been there for several years.

“I think of it like this”, he said. “First of all, sometimes of course a gift is just a gift, a straightforward expression of gratitude. But don’t forget too, you’re in a powerful position: all day long people who need help come to you and you do whatever you can for them. They give you their stories and share their pain, their worries, and their misery and then apologise to you for being a burden, and they mean it. No matter what you say, a lot of patients feel guilty for giving you nothing but grief all year and this is an opportunity for them to give you something different for a change. If you refuse, then you’re basically saying to them that you’re the one who dishes out the sweets and they’ve only got sour grapes and that’s the only way it can be. Accept the presents graciously, it means a lot to them and it should mean a lot to you too. Your patients care about you, and caring for others is one of the things that makes a hard life a bit more bearable. For some of course, you’ll have gone the extra-mile or diagnosed them with something really important, and for others there’s precious little kindness in their lives and you’ve been a part of that. For you perhaps it’s just business as usual, but look at it from their perspective, it’s anything but business as usual, it’s incredibly important, and giving you a present is their way of letting you know that.”

“I can’t help but feel uncomfortable though …” I started.

“Well that’s hardly a surprise,” he continued, “If you read the medical journals or the tabloids, you’ll be bound to think that presents are incendiary devices that you should treat with extreme caution because they’re loaded with the assumption that patients cannot be trusted and your moral integrity can be bought. And for what? A box of Turkish delight? It’s interesting and more than a little depressing to see the misanthropic fog of mistrust that hangs over us.”

“But I’ll grant you, It can be difficult for some of us to accept presents, I used to feel like that myself. It starts off with feeling inadequate, ‘what did I do to deserve this? I’m only doing my job!’ We propagate the idea not only that we’re not deserving, but that we don’t need affection, as if that’s a weakness that afflicts patients, but doctors are immune. We’re even uncomfortable using our humanity. It’s a sad fact that modern medicine instils in us the idea that it’s OK to treat patients with dangerous drugs, but somehow unprofessional to treat them with kindness, empathy and compassion. If these things leak into our practice, then we’re almost apologetic. As if that’s what homeopaths do, but not ‘real doctors'”.

“I suspect you’re the kind of person who feels uncomfortable with praise.” I nodded, “That’s because we think that people should only get what they deserve and we don’t deserve our patients’ kindness. Patients don’t deserve colitis or cancer, epilepsy or infertility either, though goodness knows they often think they do, and sometimes we even feed into that. And I’ll bet that if you try to reassure them and tell them that they’re wrong, that it’s not their fault, nine times out of ten they don’t believe you.” I nodded again, “That’s because we’re bought up in a culture in which just deserts are what you get for doing something bad, but being good is just how we ought to be, so it’s not deserving of attention. And the healthcare professions have made kindness a professional competency instead of celebrating it as something wonderful, which we should do, because it is.”

“Kindness is a choice we make. When we choose to listen and attempt to understand what our patients are feeling and what they need, then we’re choosing to be empathic. We demean this by saying that it should just come naturally when in fact it’s bloody hard work, especially when you’re at the end of another twelve hour day and in receipt of so little kindness or empathy yourself.”

“So think about what these presents mean to your patients and what they mean to you, be kind to yourself and be grateful.”

Wonderful lecture/ workshop on Non Violent Communication that inspired this blog

General Practice after the election

General Practice after the election. (First published on the LMC Newsletter)

In 2008, Professor Don Berwick wrote in the British Medical Journal,

Reinvest in general practice and primary care—These, not hospital care, are the soul of a proper, community oriented, health preserving care system. General practice is the jewel in the crown of the NHS. Save it. Build it.

His advice was ignored. The NHS has an unprecedented funding-gap of this governement’s own making and it has no credible plan to fill it. General Practice is in a parlous state: one in three GPs are planning to retire in the next five years, one in three training posts and one in six vacancies unfilled. Older GPs are retiring early and one in five younger ones are emigrating and many more are choosing to work part-time. The loss of MPIG could force dozens of practices to close. The consequence is that the remaining GPs cannot cope. Something has to give.

What GPs want, according to the recent BMA survey is more time with patients, with 80% ranking continuity of care as essential. They said they needed more core funding, longer consultation times and a reduction in bureaucracy. GPs are attempting to practice relationship-based, patient-centred care in an increasingly performance and guideline-centred NHS. This is in the interests of neither GPs nor patients.

In 1992, Julian Tudor Hart asked rhetorically,can contexts for clinical decision-making be structured so that doctors’ interests coincide with those of patients individually and society collectively?  He knew that the solution would “require revolutionary changes in the way care is conceived, organised and resourced.”

GPs are still reeling from the last revolutionary re-disorganisation that was the 2012 NHS Act and there is very little appetite for radical change. Having said that, British General Practice has been, in large part because of its independent contractor status, favoured by 82% of BMA respondents, incredibly innovative and new models of federating and networking are actively growing. The vast majority of GPs, despite their political differences, are deeply committed to their patients and still find great satisfaction in spending time with their patients. Our future resilience depends on the quality of this time.

It is very unlikely that there will be enough GPs to continue working the way we are. We could work a lot more efficiently by being better prepared for the patients we see, either by speaking to them on the phone or by employing community health workers/ health trainers/ physician assistants. Patients who need help with housing, benefits, hospital appointments, lifestyle changes, minor illnesses, a blood test, blood pressure check or other weights and measures could get help with all these things without having to make their case to a GP. There was a pilot project in Wales for community health workers, physician assistants are being trialed and Turntable health makes good use of them. But it is not yet clear how they can best work with primary care teams, whether they represent good value for money or whether sufficient numbers could be trained. Experimentation needs to be combined with evaluation.

What then do we want from the new government?

  1. Trust and support. As Don Berwick said in his report on Mid Staffs, “[the government] should foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work”. Money presently wasted on inspection and regulation should be spent on education, research and support.
  2. Outcomes that matter. In her essay, Arm in Arm with Righteousness, Iona Heath warns that “we risk destroying quality in healthcare in our attempts to measure it”. We should stop measuring things that don’t matter and start measuring those that do.
  3. Fair funding. For one thing, funding should reflect workload. For another, “Despite being an oft-repeated command to dying institutions, the ability to do more with less is an inherent impossibility”. The government’s pledge of 8am to 8pm seven day a week GP access is an inherent impossibility.

There is nothing the government can do to increase the numbers of GPs, but it can help to make general practice a more attractive career. Then the new GPs will come.

Power in the consultation

I called in my next patient, Jane and she sat down in front of me and we shook hands. Instead of letting go, our hands slipped back a little and our fingers interlocked, our thumbs raised …

“I’d like a referral to see a specialist”

She came out straight with it before I’d had a chance to ask her how she felt or how I could help. Her thumb twisted around the back of mine and pulled it down. One-nil.

“Ok” I replied, not being committed into an outright refusal or straightforward acceptance. Our thumbs circled, she pulled hers back defensively. “How did the FODMAP diet go?” I asked.

“I didn’t try it”, she replied brusquely, “You don’t even know what’s wrong with me and you said the blood tests were normal” Her thumb snapped down, but I pulled mine back just in time.

There was a sharp tug on my left arm, twisted behind my back. “Fill in the alcohol template,” a voice behind me hissed. A box in the corner of the computer screen listed the boxes I had to tick before Jane left the room.

“So, um, how much alcohol do you drink on an average week?” I asked and the grip on my left arm relaxed slightly.

“well …” Jane paused, I circled my thumb clockwise sensing she was getting off-guard. “I’ve been drinking a bit more lately, things have been pretty difficult at work and John and I have been arguing quite a lot since he did his back in and hasn’t been able to work”.

“I’m sorry to hear that”, I replied, genuinely sorry. “How bad has it been?” I could have beaten her then, thumbs-down, but it didn’t seem fair.

“You don’t know anything! She could have cancer!” several voices screamed through the window, a copy of the Daily Mail was pressed up against the glass. I jumped in fear and surprise and Jane nearly caught my thumb under hers again.

I quickly composed myself and tried to ignore the din outside and focus on Jane instead.

I tried to concentrate on her answer, but the door flew open, and several patients were stood outside, “I’ve been waiting for twenty minutes”, “You’ve got my prescription wrong”, “My sick-note’s run out”, “When are you going to visit my mum?”

I turned back to Jane, just as my left arm was yanked higher up my back. “She’s overdue a blood-pressure check, that’s £3k you’ll lose for the practice if you don’t hit the target for this year”, the voice behind me growled.

“Could I just check your blood pressure?” I asked. Patients rarely object to have their blood pressure checked even if it’s entirely irrelevant to their presenting complaint. We let go of each other’s hands briefly while I fitted the blood-pressure cuff.

“You’re only in it for the money! You don’t care about patients!” The taunts from outside had reached a hysterical pitch and copies of the Express and Telegraph were shoved through gap at the top of the window. “A nurse could do your job!”

I straightened up and tried to ignore them. “I guess you’ve read some stuff online about what might be causing your symptoms?” I suggested to Jane as I unwrapped the blood pressure cuff.

“Actually, I haven’t”, she confessed, “You know what it’s like, whatever you put into Google, before long you’ve come up with cancer, and that just gets you worrying. You must hate it when your patients look things up online”.

I laughed gently, it’s funny how often patients say that to me. I replied,

“No, no – really I don’t, but sometimes I think it’s like a law of the internet that whatever symptom you’ve got, you’re never more than six clicks away from cancer”

Our thumbs hovered, neither sure whether to strike.

Someone had pushed their way through the crowd of patients at the door, “You’re needed now, at the commissioning meeting” they barked angrily, pointing at the clock on my wall.

A pain shot through my shoulder as my arm was twisted even tighter, “You need to document their blood pressure and a five year follow-up on the other template and give them smoking cessation counselling”

“Thirty year old woman DIES from bowel cancer after seeing her GP THREE times!” Someone outside the window shouted.

I couldn’t think clearly. I looked at Jane and struggled to think of what next to say. Our thumbs hovered. “What do you think I should do?” She asked. Her thumb rested on my index finger in submission. “You know what I’m afraid of, I don’t want it to be cancer, I just want to feel better”.


Now is a good time to be thinking about power in the consulting room. Patients are learning to be assertive consumers, NHS England and commissioners are demanding evidence that we are ‘performing’, the government is devolving public health interventions from the state to the consulting room and the media is whipping up resentment towards professional power. It is easy for doctors to think of themselves as victims, but as John Launer warns,

Even in the era of shared decision making, the vast majority of consultations are led by the doctor’s beliefs about what it is right to investigate, how it is best to treat the patient, and when to make an onward referral. All of this power may be different to the kind of power exerted upon us by governments and managers. But it is still power, of a special and privileged kind. If we cannot recognise that it infuses most of the encounters we have during our working lives, we may be at risk of abusing it.

In the scene I described above the only battle the doctor could possibly win was with the patient. Unable to do anything about the bureaucratic burden imposed upon us, we may be at risk of venting our frustration on our patients.

Another reason we might blame our patients is because, as Richard Smith pointed out in 2001, we’re still hanging on to a bogus contract,

The bogus contract: the patient’s view

  • Modern medicine can do remarkable things: it can solve many of my problems
  • You, the doctor, can see inside me and know what’s wrong
  • You know everything it’s necessary to know
  • You can solve my problems, even my social problems
  • So we give you high status and a good salary

The bogus contract: the doctor’s view

  • Modern medicine has limited powers
  • Worse, it’s dangerous
  • We can’t begin to solve all problems, especially social ones
  • I don’t know everything, but I do know how difficult many things are
  • The balance between doing good and harm is very fine
  • I’d better keep quiet about all this so as not to disappoint my patients and lose my status

The new contract

  • Both patients and doctors know:
  • Death, sickness, and pain are part of life
  • Medicine has limited powers, particularly to solve social problems, and is risky
  • Doctors don’t know everything: they need decision making and psychological support
  • We’re in this together
  • Patients can’t leave problems to doctors
  • Doctors should be open about their limitations
  • Politicians should refrain from extravagant promises and concentrate on reality

At last week’s inspired Imperial college GP training day, author and lugubrious self-confessed addict Will Self and I talked about doctors and power. If there was a ‘bottom line’ to Self’s presentation it was about this bogus contract. “Imagine”, he asked us, “if instead of billboards over the North Circular exclaiming, ‘We’re going to win the war on cancer!” we were more honest and said, “We’re all going to get cancer if we live long enough, and we’ve all got to die eventually!”

Part of the reason the bogus contract still exists is because of, as Self put it, the deep reverence with which many patients hold their doctor. Our earliest experiences of the medical profession are often as a frightened, febrile child bought by an anxious parent to a calm, authoritative figure who makes things better.

As Edward Ernst recently explained, a great deal of what makes patients feel better is to do with power and personality including the therapeutic relationship with the clinician (empathy, compassion etc.), and social desirability (patients tend to say they are better to please their friendly clinician)

The therapeutic relationship was described by psychoanalist Michael Balint, who used the term, ‘doctor as drug’. Like any drug there are indications (where it can be used), contra-indications  (where it should not be used), risks (including tolerance and dependency) and side effects (including irritability and rejection or intoxication).

Used appropriately it is a potent force for good and as Foucault noted,

What makes power good, what makes it accepted, is simply the fact that it doesn’t weigh on us as a force that says no, but that it traverses and produces things, it induces pleasure, forms knowledge, produces discourse. It needs to be considered as a productive network that runs through the whole social body much more than a negative instance whose function is repression Foucault 1984: a 61. Quoted from DA Lupton

Physician Edvin Schei agrees,

The structural and symbolic power of doctors is what makes good and right healing actions possible. 

Doctors know that without power, they will lose their potency as therapeutic agents. Self argued that patients might resent this just as they secretly desire for their doctors to retain their magic. There is an ambivalence between reverence and scepticism in their regard for the medical profession.

Most of us agree that power is unavoidable and inevitably stacked in the doctors’ favour, not only over patients, but also over nurses and other health professionals and far beyond. Unfortunately we don’t do enough to teach medical students and doctors about power and how it is used. As Kathryn Montgomery agues in her wonderful book, How Doctors Think, we don’t do encourage medical students to challenge the philosophical assumptions which underpin the practice of medicine. Medicine is neither art, nor science, but an interpretive practice that makes use of clinical reasoning, but we teach it as if it were science treating disease rather than people treating people.

Sara Donetto studied medical students’ conceptions of power in the doctor-patient relationship and discovered that they were severely limited, viewing the imbalance as a consequence of patient ignorance that could be solved by professionals educating them. It was striking that my second-year medical student’s learning objectives included ‘giving lifestyle advice to patients’, but didn’t include anything about understanding values or interpreting narratives, in other words making sense of other people and themselves. Many medical students, and for that matter, doctors, are stuck on the second of Emanuel and Emanuel‘s four models of the doctor-patient relationship, ‘Dr Informative.’ Dr Informative’s conceptual development is stranded, as the authors noted back in 1992 and Self concurred today, on a model where both doctors and patients are rational consumers. It’s a thinking that underpins much of the policy thinking that shaped and continues to drive the recent NHS reforms and is a source of despair to those patients and professionals who know that there are higher levels to which we should aspire.

Patients and professionals as partners.

In 1998, GP Julian Tudor Hart wrote,

Progress in health care depends on developing professionals as sceptical producers of health gain rather than salesmen of process, and on developing patients as sceptical co-producers, rather than consumers searching for bargains.  Productivity in health care depends on complex decisions about complex problems, involving innumerable unstable and unpredictable variables.  These decisions require increasingly labour-intensive production methods, with ever deeper, more trusting and more continuous relationships between professionals and patients.

Doctors themselves have an ambiguous relationship with power. The reverence we enjoy can just as easily make us feel uncomfortable. Scepticism shared about, for example surgery for back pain, can be mutually reinforcing, but scepticism about the doctor’s clinical judgement is unsettling. My second year medical students described feeling uncomfortable with the trust and apparent reverence shown to them by a patient who revealed what it was like being severely depressed. They felt that they hadn’t earned the power that this trust conveyed. Bearing witness to intimate stories is a form of pastoral power. Handled sensitively and skilfully it can be enormously supportive and empowering for patients, but it can easily be abused.

Self raised the idea of the therapeutic state which is a form of Foucault’s idea of governmentality in which the state devolves responsibility for public health and action on the upstream social determinants of health like housing, education, nutrition and economic security down to individuals. Moral pressure is exerted on patients to behave in ways that fulfil public health objectives, so that obese individuals have to become thin in order to reduce the pressures on the NHS and contribute more to the economy. Pressure is exerted on patients who confess to their sins of being a burden, and then promise to repent by losing weight, returning to work and helping themselves.

It was interesting to watch the medical students reflexively slipping into role, most of them remembered their learning objective to give patients lifestyle advice at the same time as they interrupted their patients’ confessions. Like many more experienced healthcare professionals, they launched into this without exploring their patients’ priorities, or wandering too deeply about the efficacy of their advice, much less the philosophical basis of their practice.

Requiring the medical professional to put the needs of the state before the concerns of the patients in front of them undermines what could be an effective therapeutic relationship, but it’s not the only barrier to effective partnerships.

Because we don’t teach healthcare professionals to challenge the philosophical, political and economic foundations of their practice, they are insufficiently self-critical and sceptical about medicine’s role and purpose. This impedes their ability to be sceptical partners with their patients and makes them anxious and defensive when challenged, rather than interested and engaged. Insight is a teachable skill. Forced to act in an increasingly commercialised health-service patients are recast as consumers of health care rather than producers of health gain. The front line also becomes a battle-ground where clinicians are forced to protect limited NHS resources from demanding patients who want too much. Under conditions where patients pay for their care, they are encouraged to consume more medicine than they need. Commercial healthcare is incompatible with therapeutic alliances.

We have to live in a real world where both reverence and scepticism can co-exist. Without trust we will have nihilism and adversity; without scepticism we have ignorance and abuse of power. Trust and scepticism can flourish in partnerships which themselves depend on consultation times that allow doctors and patients to educate each other and continuity of care to allow them to get to know one another. Given more time, we could do a lot more to help patients and more to help patients help themselves.

The real question is, can contexts for clinical decision making be structured so that doctors’ interests coincide with those of patients individually and society collectively?

Julian Tudor Hart

Other reading: 

Arm in Arm with Righteousness. Iona Heath

Why are doctors unhappy? Richard Smith

Doctors as victims. John Launer

Power and Powerlessness. John Launer

Unhappy doctors and what can be done. Nigel Edwards

Foucault on the case: The Pastoral and Judicial Foundation of medical power.

The idea for the thumb-war between doctor and patient came from the play Who Cares at the Royal Court

On (not) blaming patients

Should doctors blame their patients?

(edited version published as a debate piece on Pulse Today)

Working in Hoxton in one of Hackney’s most deprived wards, where the high rates of alcohol and drug abuse, cigarette smoking, domestic violence, child abuse and all kinds of other criminal behaviour may give me more reason than many GPs for finding fault and blaming my patients, I would like to argue, briefly, that blame is not helpful.

One doctor whose patients have more reasons than most to be on the receiving end of blame is Gwen Adshead, consultant psychiatrist at Broadmoor hospital. The violent crimes her patients have committed put our patients’ ordinary misdemeanors into perspective. She describes the dividing line between good and evil in an inspiring presentation for the Forgiveness Project.

There is, I think, a distinction between blaming someone and holding them responsible. Blame implies a finality, “You’ve bought this on yourself and you’re on your own now.” As doctors, we are bound to work with patients who may be blameworthy, but they may also be vulnerable and so it is not good enough for us to cast blame when we could be helping them take responsibility. This is what Adshead does by helping her patients move on from a position of “it wasn’t me, it was my illness”, to ‘it was me, but it was an old me and I want to engage with a new me”. Understanding why patients behave the way they do and engaging with them and helping them take control is hard, therapeutic work and it is part of doctoring. But this takes time and energy that many of us feel we are desperately lacking.

Adshead’s patients like many of our own patients are no strangers to blame, fuelled by media and political rage against the poor, the obese and now immigrants with HIV for being a burden on the NHS and the economy. Blame and shame are internalized and the harshest criticism is often self-imposed.

We should also be concerned by how blame affects us because blaming others is both symptom and cause of our own unhappiness. When we are overwhelmed we tend to blame our patients for demanding too much, but consultations where our patients are blamed leave both parties feeling miserable. Refusing to blame patients is a way of showing compassion for our own distress.

It is interesting, but unsurprising that one study of GPs who work in challenging areas found that,

Doctors were motivated by the belief that helping a disadvantaged population is the ‘right thing’ to do. They were sustained by a deep appreciation and respect for the population they served, an intellectual engagement with the work itself, and the ability to control their own working hours (often by working part-time in the field of interest). In their clinical work, they recognised and celebrated small gains and were not overwhelmed by the larger context of social disadvantage.

I recently reviewed some qualitative papers that looked at parents’ experiences of consulting with sick children. Parents were acutely sensitive to accusations of timewasting and hated being made to feel stupid for consulting either when their child was not sick enough to be worthy of the doctors’ attention or so sick that they had left it too late. The conclusion I drew from the papers was that what parents wanted from doctors was not just reassurance, but confidence. It was of little use to know that their child was OK at the doctors when what they wanted was the confidence to know that they would be able to cope with a sicker child later on. Giving confidence is empowering and empowering parents helps them take responsibility. Humiliated parents are disempowered and leave anxious and upset. The next time their child is unwell, they seek help elsewhere in the hope that their fears won’t be belittled or dismissed.

It is frequently claimed that there should be no rights without responsibilities driven by a steady rhetoric of the powerful telling the powerless how to behave. But it is with power that responsibility lies. The powerful can access what they need or desire through force, wealth or contacts without resorting to rights. Rights are to protect the powerless and are therefore unconditional. When we talk disparagingly about ‘the entitled masses’ or ‘rights without responsibilities’ we miss this important distinction. Our patients need empowerment not blame. The right to compassionate, empowering care is unconditional. It is at the heart of why the NHS is so precious. And if the NHS is to be sustainable for the future, patients and professionals need to be partners, not enemies.

Starving you back to work: Why Tory policy of cutting benefits if you refuse treatment is vile


Really important blog by Alex Langford. Worth reading with this paper about patient perceptions on patient-centred care and quality improvement:

Originally posted on The Psychiatry SHO*:

The Tory manifesto it out. Like many others I was immediately drawn to page 28, where David Cameron explains how he will ‘help you back into work if you have a long-term yet treatable condition‘. But their spellchecker must be on the blink because they obviously don’t mean ‘help’, they mean ‘threaten’.

‘We will review how best to support those suffering from long-term yet treatable conditions, such as drug or alcohol addiction, or obesity, back into work. People who might benefit from treatment should get the medical help they need so they can return to work. If they refuse a recommended treatment, we will review whether their benefits should be reduced’

The idea of starving sick people back to work was first raised by the Tories last year, but despite the fact that it went down like a sack of lead crap, they’ve stuck with it.

I viscerally…

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