The Back Pages viewpoint

EBM and the future general practitioner VER since evidence-based medicine (EBM) erupted onto the scene in the mid-1990s it has evoked strong passions, both for and against. Among general practitioners, there “The central idea of an Eare enthusiasts (with whom I unashamedly identify)1,2 and sceptics (with whom I am happy to debate).3,4 The resulting dialogue has played an important part in moving forward ecosystem is that ideas about how to integrate the process of EBM into our practice while preserving a humane, organisms living in an patient-centred approach.5-7 For enthusiasts, the integration of EBM into general practice area ... should be now seems essential for its future development.8 Yet, sceptics sometimes seem to reject the idea that any good can come of it at all. considered together with other organisms I agree unreservedly that the doctor patient relationship and the art of medicine are essential and their environment components of good general practice. I also agree that it would be a disaster if clinical practice was reduced to ... a mechanistic rulebook [following] evidence-based guidelines .9 as an integrated However I profoundly disagree with the conclusion that the practice of EBM by GPs would interacting system of lead to such a dire outcome. co-evolving elements.”

EBM at the individual patient level is a process in which ... knowledge of epidemiological The NHS as an ecosystem principles [sheds] light both on the illnesses of patients and on the diagnostic and Peter Dick, page 248 management behaviour of their clinicians [and that] applying these epidemiological principles ... to the beliefs, judgements, and intuitions that comprise the art of medicine might “ substantially improve [clinical management and the teaching of medicine] .10 In other words, what ten non-medical it is an addition to our established clinical skills, not a replacement for them. There remains, books (to) recommend of course, much work to be done on how to integrate these new skills into the consultation, to aspiring GPs but that would be so for any innovation. today?...” 9 Nevertheless, Charlton s nightmare scenario is by no means a figment of his imagination. Osler’s Books There is currently a plethora of top-down guidelines imposed upon GPs by expert groups and John Gillies, page 251 organisations, such as the National Institute for Clinical Excellence (NICE). The fiasco of the zanamivir (Relenza) guideline is a demonstration of what the editor of the BMJ called the “ corruption of EBM .11 The appropriation of EBM by such groups, that take a population an indispensable rather than an individual patient view of clinical effectiveness, is a real threat to humane information source for clinical practice, as it puts pressure on clinicians to fit patients into predetermined categories the cultured traveller” rather than listening to them to take account of their unique needs and values. Benny Sweeney finds solace, page 252 The necessary (but probably not sufficient) condition to protect patients from impersonal, bureaucratic, clinical management is for clinicians to learn the skills of EBM themselves contents rather than leaving it to the experts . This is partly a matter of using evidence in such a way as to make better and more focused clinical decisions in the context of the patient s needs and 242 news values ( bespoke rather than off-the-peg medicine), but it is also a matter of power. The Pesticides/human nutrition/Belfast ability of GPs to practice EBM represents an enhancement of their expert power relative to 244 miscellany guideline-generating bureaucracies , and thus their ability to act as advocates for their Cuban general practice 2,12 John Waller and Graham Watt patients and practice Cum Scientia Caritas. 246 postcards from the Toby Lipman 21st century Supra-practice organisations References Geoff Meads 1. Dawes M. On the need for evidence-based general and family practice. Evidence-Based Medicine 248 essay 1996; 1: 68. Beyond markets and government: 2. Lipman T, Rogers S, Elwyn G. Evidence-based medicine in primary care: some views from the 3rd a Third Way for Primary Care UK workshop on teaching evidence-based medicine. Evidence Based Medicine 1997; 2: 133. The NHS as an ecosystem 3. Sweeney K. How can evidence-based medicine help patients in general practice? [Editorial.] Fam Peter Dick Pract 1996; 13(6): 489-490. 250 digest and reflection 4. Jacobson LD, Edwards AG, Granier SK, Butler CC. Evidence-based medicine and general practice McWhinney on neo-Balintism, (see comments). Br J Gen Pract 1997; 47(420): 449-452. Howie on patterns of work in 5. Greenhalgh T. Narrative-based medicine: narrative-based medicine in an evidence-based world. primary care, Osler’s books, BMJ 1999; 318(7179): 323-325. Thistlethwaite assesses two 6. Elwyn GJ. So many precious stories: a reflective narrative of patient-based medicine in general novels on extreme disability, practice. BMJ 1997; 315(7123): 1659-1663. Minns drooling over Caravaggio, 7. Lipman T. Evidence-based medicine. [Letter; comment.] Br J Gen Pract 1997; 47(422): 591-592. Sweeney gadding about...plus 8. Lipman T. The future general practitioner: out of date and running out of time. Br J Gen Pract 2000; tales from newfoundland 50: 743-746. 254 matters arising 9. Charlton R. The future general practitioner. Br J Gen Pract 2001; 51(462): 66. January Council 10. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology: a basic science for clinical 255 diary and medicine. 2nd ed. Boston (MA): Little, Brown & Co., 1991. goodman on being read 11. Smith R. The failings of NICE. BMJ 2000; 321(7273): 1363-1364. 256 our contributors 12. Lipman T. Power and influence in clinical effectiveness and evidence-based medicine. Fam Pract and Thistlethwaite 2000; 17(6): 557-563.

The British Journal of General Practice, March 2001 241 4 TheBritishJournal ofGeneralPractice,March 2001 242 news organochlorines, theclassofchemicalthat Dr Howardthendescribed how measured. single lineardose-responseeffect is conventional modeloftoxicologyinwhicha systems, basedastheylargely areonthe not beingtestedforintheregulatorycontrol chemical combinationsandtheireffects are s Dr Howard local authorities. farms, butinhomesandgardensby exposed. Pesticidesareused,notjuston seeshasbeen seminar, everypatientaGP University ofLiverpool)describedatthe (Foetal andInfant Toxicopathologist atthe delegates. Infact,asDr Vyvyan Howard pesticide poisoningwasnotacceptedby The argument that doctorsrarelyseecasesof profession. not beingeffectively disseminatedtothe epidemiological evidenceaboutpesticidesis much neglectedarea.Emerging NPIS Londonitselfadmitsthatthisisa assessed iftoxicovigilanceiscarriedout: term effects of exposurecanonlybe envisaged isinanycasequestionable.Long- Whether theNPISfulfillsexpertrole Service (NPIS). network: theNationalPoisonsInformation might haveformedthebasisofsucha funding oftheonlyexistinginstitutionthat Department ofHealthhasnowcutthe also acknowledgedwereneeded? The supporting doctorsthattheRoyalColleges And whatofthecentresexpertisefor ignored. Psychiatrists. However, thishasbeen Physicians andtheRoyalCollegeof Joint Working PartyoftheRoyalCollege recommendation inthe1998reportby organophosphate poisoningwasa pesticide cases. Training fordoctorson equipped eithertoinvestigateordiagnose acknowledged thatGPsarenotwell Health andtheRoyalCollegeshave medicines. However, boththeDepartmentof any exposurestopesticidesandveterinary at regularintervalsthatGPsshouldreport The ChiefMedicalOfficer issuesreminders September, wasborneoutoffrustration. The seminar, whichwasheldinLondon Network UK,anon-profit-makinggroup. organised lastyearbythePesticide Action A Pesticide-related illhealth pesticide-related illhealthwas the diagnosisandtreatmentof seminar forgeneralpractitionerson main concernwasthat URL: Action NetworkUK,tel020 7274 6611; pesticide useinyourarea, contactPesticide If youwouldlike more informationabout framework. within theHealthImprovementProgramme Care Groupsandotherhealthprofessionals which canbeusedbyindividualPrimary More coursesandmaterialsareplanned . breast cancer they areseeingmanycasesof,forexample, ThiscouldbeusefultoGPsif available. pesticides usedinaparticularareais Survey, fromwhichinformationonthe Ministry of Programmes. Hedrewattentiontothe forthcoming HealthImprovement surveillance systemstobeembeddedin argued for betteroccupationalhealth Environmental HealthResearchGroup, sOccupationaland University Professor Andrew Watterson, ofStirling . fruit onthewrongsortofday reference doseiftheyatethewrongsortof receive sixorseventimestheacute Childrencould individual itemsofproduce. particular pesticidesfoundondifferent underestimated becauseofvariations for onemealorday)couldbegrossly that theacutereferencedose(thesafe Pesticides SafetyDirectoratewhichfound was basedonworkcarriedoutbythe sexposure.It vegetables, toreducechildren guidance toparentspeelfruitand He remindeddelegatesofthegovernment ,saidDrHoward. chain mustbeconsidered endocrine-disrupting pesticidesinthefood risk fromthedeliberateroutineuseof through avarietyofroutes,primarilyfood. 72 hours. We comeacrossthemeveryday carbamates, relativelyquickly, withinabout chemicals, suchasorganophosphates and The bodyisabletogetridofother the bodyburdenincreasesaswegetolder. more slowlythanwetakethemin,sothat body, whichmeansthatwemetabolisethem doctors nowwork: so, hedescribedthecontextinwhichfamily globe, includingourownbodies.Indoing 1940s, nowcontaminateeverypointinthe was firstwidelyusedasapesticideinthe Persistent chemicalshaveahalf-lifeinour Whether ornotchildren,inparticular, areat www.pan-uk.org giutr s Agriculture Pesticide Usage Alison Craig Intercollegiate Course on Belfast hosts RCGP Spring Meeting 2001 Human Nutrition

N 1996, an Intercollegiate Working HE Waterfront Hall in Belfast is the a grand banquet in the City Hall, preceded Group was set up to address the venue for the Royal College of by a civic reception. Trips have been Iperceived need for postgraduate training, TGeneral Practitioners Spring Meeting, organised to some of the many rich cultural, primarily for medical practitioners, in the to be held in April this year. This is the first heritage, and natural history sites for those broad discipline of nutrition. Over the past time that Northern Ireland has hosted the overwhelmed by the academic programme, four years, representatives from 11 medical event, and preparations are well underway including the Giant s Causeway, and the Royal Colleges, with financial support from for what promises to be a spectacular event. famous Bushmills Distillery. Rank Prize Funds and other sponsors, have Between Friday 6 and Sunday 8 April participated in developing an intercollegiate around 500 delegates are expected to enjoy Valerie Fiddis, Norther Ireland Regional course on human nutrition. a very full programme of academic and Manager for the RCGP, has been involved in practical interest, with an imaginative social organising the conference and seen the It has been a substantial challenge to component. efforts of the produce such a course for an Symposium interdisciplinary group drawn from many Taking Pride in Committee and medical specialties. The emphasis of the Primary Care is the professional course has been on basic principles of the theme of the conference nutrition that have common elements across conference, and planners, Project the life-cycle, across the range of disease an internationally Planning states, and in both primary and secondary renowned list of International, health care settings. The topics covered speakers has come together in include the assessment of nutritional status, been called the past 18 nutritional requirements in health and in together to help months. prevention and treatment of disease, the accentuate the Following the assessment and management of nutritional positive . success of the abnormalities, and ethical and psychological Professor Chris last RCGP issues, using an evidence-based approach. Van Weel of the Spring University of Symposium in Two courses were held in 1999 and three Nijmegen will Crieff, Scotland, were held in 2000, in Southampton, look at the delegates are Dunkeld, and Nottingham. A further three impact of science expected to are planned for 2001, using the same five- on the future of attend the day residential course format which has medicine. An The Waterfront Hall, venue of the Spring Symposium Belfast meeting proved very popular. Twenty to 30 American in Belfast. from all over the participants attend each course. flavour will be UK, and also given by Professor Larry Culpepper of from Denmark, Sweden, Canada, and the The Intercollegiate Group on Nutrition and Boston, with a response from RCGP United States. delegated College representatives have Chairman Professor Mike Pringle. A host of played a key role in the development and local speakers will also be present, speaking The Waterfront Hall, situated alongside the delivery of the course, with valuable extra on subjects as diverse as telemedicine, River Lagan, has plenty of excellent hotel input from a dietician, a pharmacist, and a conflict resolution (a local speciality), sports accommodation within easy walking nurse. There is now an experienced cohort medicine, emergency care, joint injections, distance of the venue. Two international of College-approved trainers. Ongoing and rural medicine. airports and several ferry terminals are close support for new trainers has enabled the by for easy access. Project Planning course to be franchised to each site, with Among the highlights: Liam Farrell will International have already negotiated virtually the same course being given on give his recipe for how to make a fortune discount rates for travel. each occasion. For this, universal take- and kill the cat if he doesn t suffer from home messages has been prepared. A course writer s cramp beforehand! Dr Michael Brochures and registration forms can be management team that includes an Boland, president elect of WONCA, will obtained from Project Planning experienced medical educationalist has been gaze into his crystal ball with a look at the International, by writing to them at established to review the programme, the future world of medical education. Montalto Estate, Spa Road, Ballynahinch, materials, and the details of the course Revalidation inevitably gets a mention, and Northern Ireland BT24 8PT, or telephone administration. Ann-Louise Kinmonth will be delivering the +44 (0)28 9756 1993; fax +44 (0)289756 William Pickles Lecture. 5073; E-mail: catherine@project- Participants receive a certificate of planning.com; URL: www.rcgp2001.com. attendance, and where relevant, CPD/CME The social programme will include a tour of credits. There are, as yet, no formal the Stormont Parliament buildings, now Barry Mitchell arrangements for an intercollegiate used for the new Assembly, and there will be qualification, although there have been some preliminary discussions regarding how attendance at the intercollegiate course RCGP Annual Meeting — a correction might contribute towards a diploma qualification in certain areas of nutrition. In last month s issue of the BJGP (page 166) we announced that the RCGP AGM would Further information regarding future be held at the Spring Symposium on 8 April in Belfast. We would like to point out that courses can be obtained from the website this announcement referred to the Spring General Meeting, and not the Annual General www.icgnutrition.org.uk. This site also Meeting, which will be held at the normal time in November. For more details of the carries links to other nutrition sites, as well as to the websites of participating colleges. formal events during the Spring General Meeting, please turn to the Diary on page 255.

Colin Waine

The British Journal of General Practice, March 2001 243 A day in the life of a Cuban family doctor

MAGINE what would life be like if you manner to British GPs. The scripts are only had 600 patients? Yolaynee Deliz normally taken by the patients to the Idoesn t have to, because that is roughly neighbourhood state pharmacy. Sometimes how many patients she, and another 20 000 the patient will come back with a note saying Cuban family doctors like her, have to care that the drug is not available, or that the for. pharmacy have substituted for a similar drug. Cuba is a Third World country trying to run a At eight o clock in the morning she leaves her First World health service, and some flat, which has been provided by the Ministry medicines are expensive under foreign of Health, and goes downstairs to her exchange. Others are simply unavailable consulting room. Like most of her colleagues because they are produced by US she lives above her job, often in purpose-built multinational drug companies, and for them to accommodation. The advertised surgery hours sell even an aspirin to socialist Cuba is illegal are from 8.00 am to 12 00 pm, Monday to under the US trading with the enemy act. Saturday; for one day a week there is a late afternoon/early evening surgery for people However, there are always alternatives. The who work full time, though workers may also pharmacy has herbal medicines and Yolaynee visit a family doctor near, or even at, their has had training in their use, but when in doubt workplace. In this four-hour period she will she refers to the specialists in alternative see 10 to 15 patients in consultations (principally Chinese) medicine at the averaging about 10 minutes each. There is no polyclinic. receptionist and no appointments. Patients drop in as they please and regulate their own Laboratory tests? The patient takes along a queue, which is rarely more than one or two note from the doctor and visits the polyclinic people. They can always drop back later since between eight o clock and 11 o clock in the in this city practice, they all live with five morning. Once there, the technicians do the minutes walk. test or tests, 95% of which are analysed on-site the rest go to a hospital. The clinical workload would be familiar to any British GP, since Cubans suffer from Outpatient referrals? Once again the patient much the same illnesses as British people; takes along a note from the doctor to the however, the style is somewhat different. polyclinic reception and receives a booked Yolaynee is focused and business-like, but not morning appointment for some time within pressured for time. The patients are relaxed, the next seven days! Most specialties run acting as if they are in the house of a friend. outpatient clinics weekly at the polyclinic. Useful Information about Cuba She has worked there for five years and knows Gynaecologists, obstetricians, paediatricians, The best source of information them all very well. and specialists in general medicine are based directly from Cuba is the website permanently there. For a few specialties it of Granma International One old man walks in and gives his young may be necessary to go to hospital; however, www.granma.cu doctor an affectionate kiss patient-initiated the principal of weekly appointments is the physical contact is not uncommon. Another same. In this case, the patient would drop by For information from the Cuban woman arrives, initially angry and agitated, the surgery before the appointed time, to Ministry of Health go to www.infomed.sld.cu This Spanish but calms down during the consultation and collect his or her clinical history and the language site is linked to the eventually departs with a hug and kiss. A referral letter to take to the specialist. English language US Infomed site mother consults about her nine-year-old Occasionally, Yolaynee will go for a joint daughter. Mother and doctor sit in classic consultation, which is often a learning For two opposing sources in positions around the table, but the girl experience for the family doctor. Britain contact wanders round and leans on the doctor s Cuba Solidarity Campaign, shoulder to see what she s writing about her. So, what kind of beast is a polyclinic? It is 129 Seven Sisters Road, something with its origins in Eastern Europe London N7 7QG Confidentiality? Yolaynee routinely reminds but with a distinctive Cuban flavouring. 020 7263 6452, www.cuba-solidarity.org.uk her patients to close the door behind them, and Serving 30 000 people, it combines the US Embassy, 5 Upper Grosvenor they routinely ignore her. A woman pops in resources we would expect in a large general Street, London W1A 2JB during a consultation to remind the doctor that practice with hospital outpatients, community 020 7499 9000. she has to visit her mother later. Nobody health clinics, dentists, opticians, alternative bothers about my presence, not even the practitioners, social workers, and Further reading about Cuba’s teenage girl with an unwanted pregnancy. environmental health. All under one roof, one Health Service Compared with the British way of life, management and all free to the patient. It is Waller J. Cuba - health for all - Cubans live their lives in public. invariably managed by senior doctors their what difference does a revolution make? London: Cuba Solidarity technical management skills are variable but Campaign, Oct 2000. There s no computer. Yolaynee fills in the their commitment to the service is Theodore MacDonald. A patient s clinical record, which is in book unquestioned. developmental analysis of Cuba’s form, and also a workload sheet. At lunchtime health care system since 1959. she takes this sheet to the polyclinic a few Yolaynee, meanwhile, is salaried and doesn t New York, NY: Edwin Mellon blocks away where the workload data will be have to employ anybody. She only has with Press, 2000. entered onto computer. The data set is small her a practice nurse who does similar work to but is collected in the same way by every British practice nurses of five to 10 years ago Reference family doctor everywhere in Cuba. vaccinations, smears, diabetes, 1. Washington on trial - the people of Cuba versus the US government. hypertension, sterilising equipment, and Melbourne: Ocean Press, 1999 Yolaynee writes scripts, laboratory tests ordering supplies generally within strict (Dengue fever and the CIA) requests, and referral letters in a similar protocols and limited clinical autonomy. miscellany

244 The British Journal of General Practice, March 2001 Targets? Financially, they don t have any. In any case this is not an issue, since smear and Learning from Cuba ... vaccination rates are usually in the 99% The Cuban family doctor system has been the subject of increasing UK interest in the region. Members of the neighbourhood past few years, partly because Cuba has become easier to visit but mainly because of the associations and the local Women s achievements of the Cuban health care system, boasting the best health statistics, Association are involved in encouraging including infant mortality and life expectancy, of any Third World country and putting uptake. You can refuse, and some do, but you its plutocratic and hostile neighbour, the United States, to shame.1 have to be pretty strong to resist the combined medical and peer group pressure. People here In Wim Wenders film, Buena Vista Social Club, Ibrahim Ferrer comments that the trust their doctors. achievement of the Cuban revolution has been to protect its population both from having too little and having too much. As such, their impressive health gains may be similar in A husband and wife couple enter the surgery, nature to those achieved in the UK during World War II when most commodities were to be seen in turn. The woman mentions that, rationed. earlier that same morning, the polyclinic It s not clear to what extent the Cuban health care system is responsible for fumigation team had visited to spray for the improvements in public health, but their investment in maternal and child health has mosquito that carries dengue fever been substantial and comprehensive. Such early benefits were not enjoyed by most (introduced into Cuba by the CIA in 1982, Cubans born before the 1959 revolution, however, and perhaps this group has had most killing 150 Cubans in the process1). Yolaynee to gain from socialised health care. explains for my benefit that collaboration with The quality of the primary care system is hard to judge, but lists are low (about 600 per this eradication programme is compulsory. GP), home visiting rates are high, protocols abound, what we would call significant Quite right too, says the husband. In Cuba event auditing is standard, and there is strong local support from specialists.2 The system there is no freedom to breed mosquitoes on lacks resources, particularly since the US economic embargo began in the early 1990s, your property. but is rich in people. The afternoon is for home visits, but acute Modelled on British general practice and starting from scratch less than 20 years ago, visits are the exception. Mothers and new- the 30 000-strong Cuban family doctor system is a huge achievement, matched by an borns get regular visits from the doctor or equivalent number of practice nurses. With monthly salaries of $26, the system is hardly nurse (there are no community midwives or transportable, nor is the extent to which doctors and nurses are distributed evenly health visitors), as do patients discharged throughout the country, or the readiness of Cuban family doctors to accept prevention under the hospital-at-home scheme. There are and public health responsibilities as key aspects of their role. no district nurses either. Since people often Perhaps the most impressive aspect of the system is the extent to which shared social live in three-generation extended families, values supersede the usual medical interest in specialisation, centralisation, and much basic nursing care is undertaken by the commercialisation. This is achieved largely via the political system, but another factor family or, more correctly, the women in the may be the rigorous selection system for 15 medical schools, in which evidence of a family. Other visits are for routine three- commitment to community service and values is based on school reports over many monthly checks on, for example, diabetics. years. Patients who haven t been seen for a year get Cuba is no utopia its lack of democracy remains a blight, and there are uncertainties a visit too. about what will happen after Castro s death but its survival so far, unlike the rest of the communist world, and its health prosperity, compared with countries following the The style is casual. Yolaynee dispenses health model of development favoured by the World Bank, suggest that the Cuban example is promotion advice as she goes and receives not important. In its social values, systems approaches, and investment in people, Cuba so healthy but delicious Cuban coffee in provides a rare, important, defiant, and successful alternative to the American way. return. Occasionally she pays an early morning visit to the grandparents circle a t Graham Watt half-past eight in the morning, in parks and References squares across Cuba, groups of elderly 1. World Health Organisation. The World Health Report 2000 - Health Systems : Improving Performance. Geneva: World Health Organisation, 2000. women, and some men, do physical exercises. 2. Craig M. Viva Cuba! Br J Gen Pract 1999; 49: 1020-1021. Sometimes this is followed by a celebration of somebody s birthday or maybe a minibus visit to a place of interest. It boosts their well being and lowers the incidence of chronic disease and the prescription budget. Can we have some please?

Night calls? In principle she is permanently on call all the time. In practice, out-of-hours work is fairly rare people look after their friend the doctor. The polyclinic runs a 24- hour casualty unit and all family doctors do an all-night turn roughly every three weeks. Holidays are four weeks a year. Family doctors are teamed up in groups of three, so for eight weeks a year you have to help cover for a colleague.

Fancy the job? The wages are very poor but costs are low and the free flat is a big perk. The job satisfaction is high, the patients adoring and the weather wonderful!

John Waller Yolaynee on a home visit

The British Journal of General Practice, March 2001 245 Postcards from the 21st Century At the end of the tunnel

T a recent workshop for members of inexorable and global policy pressures for This is the second article in our both effective resource management and continuing series, Postcards from Primary Care Group (PCG) boards in the 21st Century, commissioned Asouth London, the first speaker began public health improvement require as much. and edited by Alec Logan (Deputy with a reference to the Scottish decision to The British General Medical Practitioner is Editor, BJGP, London) and Paul do away with Primary Care Trusts (PCTs) as having to recognise that organisational Hodgkin (Primary Care Futures). separate corporate entities, and locate the change is a legitimate tactic for modern public accountabilities for health and health health policy development and implement- care, not now residing with the new national ation; even to the extent that such change parliament, at future supra-district levels may take statutory form. (e.g. NHS Grampian). He went on to mention that, in Wales, the Cardiff-based It is, of course, what is commonly felt to be Assembly has also indicated its intention not the bewildering speed of such organisational to pursue the PCT path and that its Local change that has affected the morale of not Health Groups, with their co-terminous NHS just GPs, but also many other health care and local authority boundaries, are already professionals more than any other factor well placed to become among the early over the past decade. The NHS itself has not versions of integrated health and social care kept up with progress in organisational organisations in the UK theory and practice. Its reliance on such simple, closed organisational forms as the The response was dramatic. The shocked hospital institution, the unidisciplinary expressions on some of the faces of the profession, and the administrative primary care professionals attending the bureaucracy, now seems suddenly and workshop are now firmly logged in the quaintly outmoded. Conceptually modern memory, if not quite to be cherished there organisations are adaptive socio-technical was too strong a sense of pathos for that systems. Practically, their informal then certainly to be retained as a cautionary relationships are as significant as their reminder of the continuing distance between formal structures. This is the age of the central policy and local practice when it Virgin-style virtual organisation, the comes to contemporary primary care stakeholder enterprise (in Manchester organisational developments. Several GPs in United s image), and, above all for primary particular simply could not credit the care, the multi-membership National Trust - implication that, in setting up their own new type community organisation. PCT, they may once again be putting their (considerable) energies into an organisation- Each of these three terms virtual, al structure pre-destined to self-destruct. stakeholder and community are now in common parlance among PCG/T members, The reaction of GPs at this PCG, which is an each one acquiring a currency in different event typical of many others now taking territories. place around the country, mirrors that of local counterparts across the UK as the In those parts of the country, such as the process of continuous organisational Shire counties, where the individual practice development in primary care continues is still sovereign, the virtual organisation apace. Despite their awareness that the likes holds sway. Its theory of a brand name of Total Purchasing Pilots, multi-funds, GP organisation comprising many, disparate commissioning groups, and consortia not semi-autonomous units with their own to mention GP fundholding itself have operational styles and strengths, all signed already come and gone, the workshop up to a (very) few overarching and highly participants could scarcely believe that NHS visible goals (or slogans), seems ideally Primary Care Trusts might represent yet suited at this stage of their development to another passing phase. A little over a year those PCG/Ts where subsidiarity is the ago they were having to adjust in similar principle and a federal approach is required. learning events to the dawning awareness that Primary Care Groups were organisations In many of the more affluent suburban areas in transition. Now, as their response to the outside our larger cities it is the stakeholder speaker illustrated so vividly, the prospect of model that is preferred. It fits well with the a further novel collective identity just local cultures of commuting, competitive seemed too much. sport, and consumerism. Here, the primary care organisation represents a new Historically, GPs have been used to a stable, opportunity for mixed investment. The and sometimes static, form of organisation. theory is that its accountability, scope and, They have also expected to control its above all, resource base will each be fortunes, determining its shape and increased by its multiple interests. strategies. Manchester United is as important to clothing manufacturers and the media as it is The legal partnership has been both a simple to the Stock Exchange and its soccer and single form of organisation. The supporters. imperative in modern care systems, however, is for complex and, above all, genuinely Similarly, the future Primary Care Trust can dynamic organisational types. The prospectively draw on a wide range of local futurology

246 The British Journal of General Practice, March 2001 and external contributions, in addition to the public purse.

Finally, especially around inner-city areas there is the community organisation. The Trust us — we’re just doctors! fundamental concern of GPs and others in these parts is local, neighbourhood-level legitimacy very often among socially and Shipman — Bristol — Alder Hey. Whatever next? More of the same, ethnically mixed populations for their clearly, for the world has shifted and being a doctor no longer of itself own roles and responsibilities, for their commands confidence. Instead, patients’ trust is becoming conditional, services, and, most important, for the contingent on our performance. difficult decisions on resource usage priorities that lie ahead. These PCGs operate as communities themselves in their When we trust someone we understand both that their actions may relationships and focus externally on the have an impact on us and are not under our control. Trust also implies maintenance of as much interest and support a degree of choice — too ill and I become dependent, not trusting. from other community organisations as possible. Finally trust implies risk — if the outcome is already assured the relationship is mundane, not fiduciary. In most situations — General practitioners have had tunnel vision relationships, business, sport — trust is also mutual. In medicine it is when it comes to NHS organisational development in England. Internationally, of peculiarly asymmetrical: patients have to trust me, but in what sense course, the opposite has often been true, do I trust patients? In what sense do their actions put me at risk? Inter-sectoral alliances remain one of the In health care, trust has other dimensions too: that doctors act in World Health Organisation s key principles patients’ best interests, are competent, command the resources in its promotion of primary health care. Many developing countries have developed necessary to do good medicine, maintain confidentiality, and disclose their equivalents to the NHS applying this all relevant information. tenet. Dissect trust in this way and it is immediately clear that patients have In the UK, the days when general practice was the name of the building, the profession, good cause to trust us less: at times we all place the good of the the organisation, as well as the service and balanced budget above their needs, frequently we cannot command the clinical discipline are fast coming to an adequate resources, and daily we fail to be honest about these end. For the last two those that GPs really compromises. Given the asymmetry of trust to start with, it is hardly care about this is good news. Their whole-person principles mean that they have surprising that patients reach for their lawyers. long been used to operating effectively across boundaries. Each of the new primary So what can be done? Firstly we might be less dewy-eyed about trust. care organisational types transcend past Perhaps it is a good thing that patients trust us less — standing on a conventions of public and independent roles, and provide them with fresh opportunities pedestal for 30 years not only makes for pomposity, it is also damn for demonstrating anew the service value of uncomfortable. Next we could get much better at disclosing all that their clinical discipline. relevant information: We need to be comfortable about discussing the There is positive evidence of these costs of treatment, and about when and why we are not doing certain opportunities being taken. The networks things even though they may be indicated. And while we are getting nurtured and developed by the first wave of used to doing these big, difficult things, we can make a start by Personal Medical Service pilot sites, serving disclosing the easy, cost-free things — routinely dictating referral people with with problems such as drugs misuse, homelessness and mental illness, letters with the patient, displaying the monthly practice drug budget in grow ever more impressive as time passes. the waiting room. Finally we could increase patient choice by being In one, the GP s count of his 17 primary care more transparent about who we are and what we are proficient at: team members now includes hostel, hospital, video clips of the partners in the waiting room might sound far-fetched and health centre staff. In another it is the parallel church charity which is co- but quick summaries of what we are good at, and what we are less ordinating with the GPs the primary care confident about would help patients select who is right for them. team s training programme. Above all, at Deteriorating trust leads to a vicious circle of defensiveness. several sites new nursing specialisms are Paradoxically, restoring trust demands openness and vulnerability. releasing general medical inputs by GPs, rather than replacing them. [email protected] It is an encouraging picture. The organisational change is clearly favouring Davies H, Rundall T, Managing patient trust in managed care. Millbank modern general medical practice. Perhaps there is a light at the end of the tunnel. Q, 2000; 78: 609-624.

Geoff Meads Anthony Riley

The British Journal of General Practice, March 2001 247 The NHS as an ecosystem

References of these has had its successes and failures; 1. Lakoff G, Johnson M. Metaphors ‘The real significance of the metaphor: We Live By. Chicago, IL: University “Life’s … a tale told by an idiot”, is that, each has its advantages and disadvantages. of Chicago Press, 1980. in getting us to try to understand how it 2. Aristotle, Rhetoric 1410b. The could be true, it makes possible a new Medical men and women have for the most complete works of Aristotle. understanding…’.1 part not played this game. A focus on the (Revised Oxford trans.) Princeton, individual relationship with one s patient, a NJ: Princeton University Press, HIS essay very briefly explores a lack of interest in and a scepticism about grand 1984. metaphor. As with all metaphors, it social schemes and often a rather low social 3. Royston G, Dick P. Healthcare status yielding a lack of power or influence Ecology. Br J Health Care Tresults from the bringing together of two Management 1998; 4(5): 238-241 distinct areas of experience and of treating one over fellow members of society has meant 4. Greenhalgh T. Change and such area of experience as if some of the than those in the health professions are more complexity - the rich picture. Br J characteristics and features of the other applied likely to be victims of organisational schemes Gen Pract 2000; 50: 514-515. to it. The metaphor considered here is that than to be initiators. This is particularly true of 5. Golley FB. A History of the which results from applying ideas about those working outside the more formal Ecosystem Concept in Ecology. natural ecosystems to primary care institutional structures of university hospitals. New Haven, CT: Yale University The appearance of Primary Care Groups, Press, 1993. organisations, their staff and patients, and collaborative communities of such Primary Care Trusts, and Local Health Care 6. Axelrod R, Cohen M. Harnessing Co-operatives however seems likely to change Complexity: Organisational organisations and individuals. Implications of a Scientific Frontier. this. Free Press, 2000. Our thinking is essentially metaphorical in 7. Lewin R, Regine B. The Soul at nature. We form our ideas within a framework, The dominant metaphors of social Work Unleashing The Power Of model or picture of the world about us and, organisation in the 20th century have been that Complexity. Science For Business since we then often act on our ideas, these of the machine and the market place. Success. London: Orion Business frameworks are a significant, although often Following the model of the machine is seen as Books, 1999. hidden, part of our lives. In particular, the a route to efficiency and effectiveness: each 8. Petzinger T. The New Pioneers: part has a pre-defined function which The Men and Women who are ability to use novel or different frameworks or transforming the Workplace and metaphors allows us the freedom to act contributes to the overall purpose of the Marketplace. New York, NY: Simon differently. Twenty-five centuries ago, the machine. The parts relate to one another in & Schuster, 1999. Greek philosopher Aristotle wrote that well-defined ways and it is thought possible to 9. Clippinger III JH. The Biology of ordinary words convey only what we know pull a lever in one part of the machine and the Business: Decoding the Natural already; it is from metaphor that we can best whole machine will respond in the intended Laws of Enterprise. San Francisco, get hold of something fresh .2 manner .3 Much of our language about CA: Jossey-Bass Publishers, 1999. organising uses terms implicitly or explicitly Since even before the time of Aristotle, the taken from descriptions of how machines A fuller annotated bibliography on operate. Central government is seen as, and the application of a complex question of how we should organise ourselves dynamic systems perspective to and our activities so that we can most sees itself operating as, a vast, complicated but organisations is available from the effectively live and work together has ultimately feasible machine. Laws are author at: occupied the minds of our greatest thinkers. proposed and enacted and in some distant part [email protected] We know that, at our best, we can achieve of the machine behaviour is expected to much more by working with our fellow men change in the predicted manner. This paper expresses the personal and women rather than in competition with views of the author and should not them or in isolation from them. The difficult The metaphor of the market place where be taken as representing the position goods and services are bought and sold is a of the Department of Health. question is how best to co-ordinate our collective life as a society so that we are more more recently prominent model; however, it than simply a vast collection of more or less too underlies much of our discussion about isolated individuals. how we should co-ordinate our activities. Important relationships should be based on The answers given by the philosophers to this (usually short term) contracts to buy and sell question have been diverse, often very services or to provide labour because, it is dependent upon the focus of the collective believed, in the absence of such legal contracts achievement and the interests of the nothing will be achieved. philosopher. Political thinkers seeking a moral society have suggested that power be held and Within the health service in the UK and in exercised by wise other countries, these models or metaphors guardians and that the continue to affect the way we think of our rest of us are organised work and our professional relationships. to serve their interests. Revolutionaries seeking However another organisational model has a just society have put recently been given some prominence in everyone and no-one in scientific and business circles and some charge. Military men discussion of the application of this model to seeking a victorious public organisations such as the NHS has society have emphas- taken place.4 This is the biological metaphor of ised rigorous training, an ecology or an ecosystem. Ecosystem is a specialist tasks, and relatively recent idea used in studying the obedience to orders. natural world that emphasises the inter- Economists seeking connected and dynamic aspects of the living efficiency have tried to world and its environment.5 The central idea of organise us so that we an ecosystem is that organisms living in an mirror the workings of area cannot be understood as isolated elements the market-place. Each but should be considered together with other essay

248 The British Journal of General Practice, March 2001 organisms and their environment as an wider environments with which resources are where no one person or institution can be integrated, interacting system of co-evolving exchanged, and an ecosystem perspective thought of as being in control , which is held elements. draws attention to these exchanges. Often the together by a framework of common values, ecosystem and its environment can be thought and which seeks to be responsive to individuals Systems with properties like those of of as a larger ecosystem itself and so the ideas and at a very local level. Local health ecosystems are of a particular type, known in of ecosystems within larger ecosystems, of ecosystems have multiple goals and objectives, the scientific literature as complex adaptive ecosystems having sustainable sub-systems, some of which are long term and some short systems.6 These have been extensively studied and of hierarchies of ecosystems, become part term. They therefore need to include a long- in recent years in the developing sciences of of a useful complex of concepts drawn from term focus and this puts a premium on strategic complexity with applications to ecology, discussions of natural ecosystems. Social management (management across the biology and, importantly for our purpose, to organisations need to recognise that the ecosystem and into the longer term future) at organisations.7-9 Examples in the natural world working environment is often a complex set of all levels of the local health and social care include not only ecosystems but also the embedded, overlapping networks each with economy. immune system, the central nervous system, their own functions and purposes. Any one and communities of social insects, such as ants system or network needs to remain aware of The ubiquitous nature, the complexity and the or bees. Human organisations which may be changes in these other systems and be flexible rapidity of change itself, driven by the regarded as complex adaptive systems include enough to respond. opportunities presented by new technology and villages, towns and cities, or firms, industries, the expectations that these opportunities be and national economies. Markets themselves An important feature of complex adaptive seized form the staple diet of many are complex adaptive systems of a limited systems and a productive way of viewing management books. The general-purpose kind. Such systems are highly dynamic, ecosystems, both natural and health nature of the industries changing most rapidly continually developing in the way in which ecosystems, is to see them as learning systems, (computing, telecommunications, finance) they are structured internally and in the ways adapting to and co-evolving with their means that such rapid change is not restricted they interact with their environment. environments and each other. To be more to these industries. The complexity of change precise, ecosystems are embedded hierarchies means that past change often becomes As an organisational model, the significant of learning systems in which individuals, embedded in the system structure and thus lives features of ecosystems and other complex groups of individuals, organisations, and on, while expectations of future change affect adaptive systems are that: they emphasise a groups of organisations develop by learning the current performance of these same systems. systemic perspective where the effectiveness what works and what doesn t work. of complex, rich, and dynamic relationships Increasing interdependencies and connectivity are as important as the performance of Successful open systems must be learning in physical form (from inexpensive, fast individuals or individual institutions; they are systems. Closed systems (such as machines or telecommunications), in functional and open to the environment; they evolve and learn unresponsive bureaucracies) can be designed problematic terms (from the overlap of through interaction between the elements of to cope with well-defined and foreseen boundaries of responsibilities and problem the system and with the environment; a rich problems. The intelligence of the designer is areas), and in moral terms (from knowledge of diversity of elements, of relationships, and of incorporated into the structure of the machine. interdependencies and sensitivity to the processes is important to sustain the In contrast, open systems that interact with consequences of them) combine to produce a ecosystem ; no-one is in charge, and power their environment cannot anticipate the range more complex situation than previously existed and influence are distributed throughout the of problems with which they will be required for organisations inside and outside the health system; and finally the organisational focus is to deal. They must, therefore, evolve solutions sector. long-term and strategic rather than short-term on the basis of experience; that is, they must and tactical. learn. In open systems, the intelligence A new (or newly acknowledged) diversity, both resides, not in the machine structure, but in of the workforce and of the attitudes and The operational implications of a change in the individuals and groups that make up the expectations of patients and the public, present perspective towards such a biological model ecosystem and that must respond to novel management problems for those with could be extensive. changing contexts. responsibility for managing a local health economy. The dynamic system perspective implies that Machines may be complicated and ingenious attention be paid to relationships and the but any diversity they have is static and For government and the public, limited management of relationships. Machines are designed in to the machine. Fast moving resources and a general unease about public simple systems whose parts have fixed, pre-set markets may surprise us with their offerings spending, increasing demand in part driven by relationships with one another. Once the but the structure of the market or the processes demographic factors, the complex nature of machine is up and running there is no need to of buying and selling remain very much the seemingly intractable public problems, and an be concerned with how the parts fit together, same. In the natural world, however, the expectation that the user-friendly services unless the machine stops working properly. diversity of the living and non-living parts, of provided outside of the public sector will be In an ecosystem, however, maintenance of the multitude of ways these relate together and matched inside, together lead to a degree of effective relationships, the monitoring of of the processes of exchanging food, shelter, difficulty and complexity for public services changing relationships, and the encouragement protection, and other necessities is critical. not often seen elsewhere. The problems of of a diversity of types of relationships are Organisational ecosystems need to public sector management are often highly central tasks for all the living creatures encourage, monitor, and work with a diversity context-dependent, requiring specific solutions concerned. The need to avoid locking oneself of people, structures, processes, skills, and for specific situations. in to any sort of rigid structure and to look out ways of working if they are to be effective. for and exploit emerging sets of relationships is All these factors suggest that a conceptual important. A similar dynamic perspective In a market, power accrues to the larger framework different from that embodied in applies in markets; however, since the players and, in general, power and influence either the machine or the market place relationships are relatively simple, always are responsive to the magnitude of resources, metaphors may be productive. To look at the based on contracts, and often short-term, the financial or otherwise. For a machine, the way nature organises herself may be a useful strategic implications are often not power resided with the designer, and the first step in the creation of a framework and emphasised. machine responds only as it was designed to even make possible a new understanding .1 do. Neither of these models is appropriate to Ecosystems are always embedded within situations, such as a local health economy, Peter Dick

The British Journal of General Practice, March 2001 249 5 TheBritishJournal ofGeneralPractice,March 2001 250 digest atfri wait forit exposØ, andcomebacktofind fasciitis toanemergency tabloid an obviouscaseofnecrotising of leave yourcarlisteningtotheend Radio 3 know. Then, outoftheblue, for allI is advertisingurostomyaccessories, FM at half-time.Meanwhile,on after beingencouragingly8-0down with alast-minutedisputedpenalty man ManchesterUnitedwinagain Live direction, andlistenersto memorable radio. afternoons, haveneverenjoyed On-call GPs,lateonSunday in brief... it ...? does itsplitintwowhenyouopen Medicine Concise Oxford Textbook of Next month saGP uncle Her better latethannever. Sheisastar! until theracehasfinished.But about howmuchweadmiredher review hamperedourtellingreaders come second.Delayswithpeer and thatwepredictedshewould know atEdinburgh dinnerparty), (Deputy Editormeetsman-in-the- MacArthur backinNovember reveal thatweknewallaboutEllen The performance inthe Vendee Globe. MacArthur’s Then homewards,tosalute cantellyou. funded broadcasting,I to restoreyourfaithinpublicly Basil hollering re Care carry-outcurryfacility. We local emergency on-callPrimary carriageway, careertowardsthe sword-fighting onthedual and I,dodgingOldFirmfans son Ricks) asaseminalinfluence. A Among thePoets neck with Which timeshallneverfalsify There isatruth Within yourkiss Which ageshallneverfade There isalight Within youreyes Love Un Balloinmaschera someone calledNatalie Wheen BJGP are becomingjaded,asasix- to astridentFMbeat.Enough comes uptrumps. You Isabella; Or, ThePot of ? Fabulousbook,butwhy John Keats can nowexclusively Bob Dylan Howconciseisthe astonishing Colin IanJeffrey , bytheway. , Christopher Radio 4 ( Dylan Alec Logan , dispatch neck and Radio 5 loses all Ellen Classic PB, 174pp,£19.95,1857754077) Radcliffe MedicalPress,2000 Southgate John Salinsky, PaulSackin,MarieCampkin,MichaelCourtenayandLesley Identifying andavoidingdefensivepatterns intheconsultation What areyoufeelingDoctor? T the possibilityofadefensivereaction having enabling thegrouptobemore open about case provedtobeasignificanteventin challenge. After someinitialhesitancy, one temptation tooffer comfortratherthan intrusiveness, andondealingwiththe avoidance ofsensitiveissuesandundue reflections onachievingabalancebetween Discussion ofthecasesprovidesinteresting project. conceived asaground-breakingresearch Like Balint awareness mighthavechangedtheoutcome. of hisorherdefences,andhowself- sdistress,thenature reasons forthedoctor developed aseriesofquestionsaboutthe To focusthediscussion,group doctors. probably nothavebeendifficult forother that wereupsettingforthem,butwould physicians, memberstriedtoselectthose presenting casesrecognisablydifficult byall case thathadupsetthedoctor. Ratherthan starting withtheverbalpresentationofa group followedtheBalintprocedure, were GPs,includingthetwoleaders. The had attimesbeengroupleaders. All ofthem seasoned membersofBalintgroups,andall patients. The membersofthegroupwereall their owndefensivereactionsinresponsesto doctors thatdeliberatelysetouttoexplore and evaluatestheexperienceofagroup This bookhasbrokenthetaboo.Itdescribes in therapyforhisorherpathologicaltraits? self-knowledge withoutbecominginvolved s that agroupcouldcontributetomember always thatthegroupmightbecome sdefences? The fearwas group ofthedoctor unless therewassomeexplanationbythe responses topatients.Howcouldthisoccur, negative emotions,andstereotyped into theirowndefencemechanisms, heightened self-awarenessprovidinginsight undergo achangeinpersonality, a seminar, thememberswouldneedto taught that,toachievetheobjectivesof has becomeataboo. At thesametime,Balint and inthecourseoftimesuchanexploration spersonalhistory, exploration ofthedoctor steered thediscussionawayfromany or herpersonallife.Manygroupleaders semotionsinhis on thesourceofdoctor focus wasexplicitlyontherelationship,not his orherprofessionalendeavours. The the patientandworkwithitinserviceof semotionalreactionto to revealthedoctor therapy HERE original aimoftheBalintseminarwas s Michael Balint for thedoctor. Was itnotpossible is acontradictionattheheartof s originalgroup,thisonewas teaching. The a notablecontribution. does notneglecttheemotions. This bookis in theirfinalchapter, fromaneducationthat think not.Itcomes,astheauthorsmaintain the abilitytolistencomesonlywithage?I mirrors myownexperience.Isthisbecause how tolisten,butIwasnot.Itexactly experienced doctorsweresolateinlearning might havebeensurprisedthatthesevery required apersonalchangeinthedoctor. I For Balintlisteningwasthekeyskilland especially anewwayoflisteningtopatients. feelings,and greater toleranceofpatients found curiosityabouttheirownreactions,a In theinterviews,doctorsspokeofanew- doctors. observer, andincludingpatientsaswell ethnographic methodsandanexternal the pathisnowopenformoreresearchusing experience ofthisground-breakinggroup, method wasappropriate.Buildingonthe the project,arelativelylimitedqualitative impractical. Giventheexploratorynatureof considered, butreluctantlyrejectedas findings. Interviewingpatientswas s and afocusgrouptodiscusstheobserver on aninterviewwitheachgroupmember, group usingparticipantobservation,based The projectwasevaluatedbyoneofthe . too much keepcalmandnotlettimefrightenus we already emotionallyupset. They suggestthat Time pressureismuchgreaterifweare observe, thereisasubjectiveaspecttotime. counsel onthetimeproblem. As they this, thechapterdoesoffer somewise arrived atbydifferent methods.Havingsaid hazards ofcomparingconsultationtimes statements, andthereisnothoughtforthe correct. Noreferencesaregivenforthese times citedforGPsinCanadaarenot doctors inNorth America. Consultation the pointofcontact. Time isaproblemfor doctors seetheirpatientsfreeofcharge at the onlyhealthcaresystemwherefamily some majorfactualerrors. The NHSisnot pressure? Unfortunately, thischapterhas this waywhenweareundersuchtime of time.Howcanweattendtopatientsin One chapterisdevotedtothehardquestion not necessarilyso. spersonalself,but have abasisinthedoctor thatmay patternsofavoidance see themas defences deployedbythedoctors,comingto book goesontolookmorecloselyatthe important factorinthisbreakthrough. The level oftrustinthegroupwasobviouslyan spersonalhistory. The roots inthedoctor Ian McWhinney General Practice: Demanding Work Understanding patterns of work in primary care osler s books John Waller and Paul Hodgkin HEN I went to medical school in Radcliffe Medical Press, 2000 1969, a family friend gave me a PB, 177pp, £17.95, 1 85775447 6 Wbook of essays by Sir William Osler, BT, MD, FRS (1849 1919),1 the HIS is a little gem! Subtitled increasing too. They note that the seasonal great Canadian physician, who was Understanding patterns of work in increase in workload is much less significant successively Professor of Medicine at Tprimary care it weaves a story in three than doctors usually think, and find only a McGill, Pennsylvania, Johns Hopkins, and parts: first, it uses data from a study of modest connection between working in a Oxford Universities. I never read it at workload and morbidity to address questions deprived area and increases in consultation medical school, of course, but it is a often asked about why general practice rates. They suggest that the problems of non- handsome volume and lent an Osler-ish seems so busy and demand so difficult to attenders and of high attenders pose a gravitas to my shelves. manage; secondly, it subtly persuades the problem that is more an irritant than reader to question some of the traditional anything worse. As others have found, they Osler s place as the last guardian of pre- assumptions about how work is patterned; conclude that work patterns between and technology, bedside general medicine is and lastly, it puts the earlier issues into a within practices vary widely and with analysed by Tauber2 in his challenging reflective and philosophical framework. The hardly any detectable rhyme or reason . analysis of the dehumanising effect of success of the authors lies in their being able Most importantly, they face up to the reality, technology on modern medicine and on to present the three themes in a single that it is supply (how available doctors make doctors, the high priests of the discipline. continuous narrative, that is easy to read, themselves to their patients) which is as Osler wrote at the time of the paradigm and manages to make statistics and ideas often the problem underlying perceptions of shift from observational to scientific seem comfortable bedfellows. overload, as is demand and they rightly medicine, and saw the ascendance of the say that supply is a quality issue. scientific model of practice as potentially The main content of the book is derived sacrificing the important humanistic from the Sheffield Practice Data Paul Hodgkin writes the 20th and elements of medical care. He was not Comparison Project, which collected penultimate chapter on his own. Sensing opposed to science applied to medicine, but information from 33 practices in the late admirably the anxieties GPs feel about their was worried that scientists who learnt 1990s and had available continuous data roles in a modernised Health Service at the medicine in laboratories, not wards, would from 17 practices for three years and from start of the 21st century, he argues that make poor physicians, orientated to illness four practices for five years. The 16 core people most want a fast, efficient, courteous alone, unable to understand or relate to chapters are all short and start with the kind service from competent people ... who patients. His fears were well founded. of everyday question practice staff ask about discuss fully what can be done and why At the end of his book, first published in their work. An engaging introduction leads sometimes things will not be done. He 1904, he put down, as a recommendation on to analysis of the relevant Sheffield data suggests that, on the surface, what the for reading for medical students, a list of (generalisable within the limits the authors generalist does better than the specialist is to ten books. He suggested that students set themselves). A focused discussion diagnose normality. However, he also argues should try to get the education, if not of a stimulates the reader to think both in straight around the importance of holism to patients scholar, at least of a gentleman. Osler s lines and often laterally as well, there is a and describes the kind of concerns that books were: key points box and finally a what others patients want their doctor to answer, have found item with references and pointing out that for many of them there are 1. The Old and New Testaments comment about recent relevant literature. no easy answers and no guidelines. He 2. Shakespeare This body of work stands alone in its own finishes by reflecting on what made John 3. Montaigne right as a good read, offering a starting point Berger s Sassall A Fortunate Man, quoting 4. Plutarch’s Lives to any primary care worker interested in that Sassall is nevertheless a man doing 5. Marcus Aurelius comparing their own working practices and what he wants Sometimes the pursuit 6. Epictetus experiences with those of others. involves strain and disappointment. Like 7. Religio Medici anybody who believes that his work justifies 8. Don Quixote However it was the second of the three his life, Sassall by our society s 9. Emerson strands that marked this text out as miserable standards is a fortunate man. 10.Oliver Wendell Holmes (Breakfast Table something different for me. Whether series). consciously or not, the core chapters The authors start by suggesting that their repeatedly question the received wisdom of book can be used for reference or read from It is easy to mock a selection of books the general practice culture which says that cover to cover. I strongly recommend the written by dead, white males, who range it is patient demand that makes the job so second option. Whether for a new registrar, from 1st century Stoic philosophers to a difficult, and that solving the problems is for an established principal, for a nurse, or near forgotten 19th century medical everybody s responsibility but our own. for a manager at any level, from practice to polymath. The list contains not a single Waller and Hodgkin note that general PCT, the whole tells a better story than the scientist. What he was perhaps trying to practice workload does not in fact appear to parts do on their own. It is a story that do was to help his students put their be increasing if surgery consultation rates mirrors reality, promotes thought and burgeoning scientific knowledge in are taken as the yardstick. They note that reflection and, in the end, should provide perspective and, by looking backwards as home visit rates are declining, although they encouragement and a way forward. What well as forwards, temper that knowledge argue correctly that the complexity of more could we ask? with wisdom and judgement. consultations is increasing and that Perhaps medical teachers might consider expectations of patients and managers are John Howie this: what ten non-medical books would they recommend to their students today? >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> What ten non-medical books would you John Gillies 1. Osler W. Aequanimitas with other addresses. recommend to aspiring GPs today? London: Lewis & Co, 1941. Suggestions to [email protected]. 350 words maximum. 2. Tauber AJ. Confessions of a medicine man. We ll try to rustle up a prize for published entries London: MIT Press, 2000.

The British Journal of General Practice, March 2001 251 5 TheBritishJournal ofGeneralPractice,March 2001 252 reflection equivalent. traveller. IknowofnoBritish information sourceforthecultured guide, whichisanindispensable Path Off theBeaten European Museums delightfulessayonsmaller A Centre. the CambuslangCommunity attend wereittoarrivetomorrowat Houston. Personally, Iwouldnot New York, Minneapolisand Yes ,visiting Yokosection is Ono .Curiously listedinthesame Rome TheGeniusof the unmissable Royal Academy, currentlyhosting Matisse Masterpieces fromIngresto Triumph ofFrenchPainting: Frick CollectioninNew Y one ofmyfavouritegalleries,the Gallery ofScotlandappearingin Master DrawingsfromtheNational London earlyin2002,andOld coming totheNationalGallery landscape artist, Albert Cuyp, obscure 17thcenturyDutch listed, includingthesomewhat Major travellingexhibitionsare sculptor SirJacobEpstein. Walsall bythewidowof Art donatedtothepeopleof contains acollectionofEuropean the New Art Galleryin Walsall s each gallery Arkansas. Inaddition,itdescribes world, andalsoinLittleRock, T PB, 500pp,£10.95,0810967243 Abrams, 2000 Art MuseumExhibitions2001 Traveller's Guideto alone justifiespurchasingthis HIS year anywhereinthecivilised every exhibitionstagedthis arrives thissummeratthe book givesdetailsof permanent collection: Benny Sweeney ork. The flowers orbeingbittenbylizards,and of unhappyyouthsholdingbunches series ofsexuallyuncomfortabledepictions see. You mayknowhisworksonlyfromthe what makethisexhibitionworthcomingto Caravaggio areabsolutelydominantand as Artemisia Gentileschi,buttheworksby some whomoneispleasedtoseeagain,such notablySimon V the firsttime whom oneisgladtohaveencounteredfor There are,tobefair, afewfinepaintershere judgment canaccordinglybeclouded. level somefewfeetaway look atthemproperlyifwestandthesame be seenhunghighbehindanaltar:wedonot meant tobelookedatcloseup,butrather Of course,someofthepaintingswerenot true natureofaperiodistobeunderstood. artistic endeavourmustbeincludedifthe of curatorialphilosophythatthefullrange Academy galleries,itisnowacommonplace sblockbusterinthemainRoyal year ,last 1900 the conclusionthat,justasin and somearesofeeblethatoneisforcedto Many oftheartistsaredistinctlysecondrate, of theirsshownheredonotthemjustice. Elsheimer, suchasRubensand here accurate. Somegreatnamesareincluded ,itwouldhavebeenmore contemporaries some OKpicturesbyofhis TheGeniusofCaravaggioand christened A This exhibition has been organised by the Royal Academy of Arts, London, and the and London, Arts, of Academy Royal the by organised been has exhibition This Caravaggio: Dublin. the lateDrMarieLea-Wilson.Photocopyright©courtesyofNational GalleryofIreland, National GalleryofIrelandandJesuitCommunity, Dublin,whoacknowledgethegenerosityof The Royal Academy, London,20January–16 April 2001 The GeniusofRome1592–1610 Soprintendenza per i Beni Artistici e Storici di Roma Roma di Storici e Artistici Beni i per Soprintendenza nature ofthisshow. Haditbeen t doesn S il, TheGeniusofRome a title, o xml butthepaintings for example The Taking of Christ, of Taking The represent fairlythetrue n n s , andone ouet and c.1602; oiloncanvas133.5cmx169.5cm Adam Sharps Card s copy ofahatdepictedinCaravaggio be enjoyedbythosewiththedesiretobuya consumption onanalmostpapalscalecan into theshopoutside,whereconspicuous atmosphere of17thcenturyRomepersists capricious figuresiswellexplored. The relationship withthesepowerfuland their insecureandevendangerous patronage thatthesepaintersenjoyed,and suitably enoughgiventhehighecclesiastical The paintingsarehungondeepredwalls, the Westerncanon. Caravaggio isoneofthegreatestmastersin you haveseenit,willbeconvincedthat be movedbythePassionofChrist.Once even themostnon-religiouswouldhaveto paintings Ihaveeverseen,beforewhich of theseisamongthemostmagnificent the T magnetism. Strikingasthisis,itpalesbeside of roomstolookatitproperly, suchisits you wanttowalkthelengthofsequence room thatyouenter:assoonseeit, other endofthegalleryfromsecond Baptist National GalleryinLondon. in the SupperatEmmaus such asthe sworksintheUK, accessible ofCaravaggio prepared forthese,evenbyperhapsthemost the religiouspaintings.Oneisnotreally included here.However, thetriumphsare rightly, someofthesevirtuosoworksare nobetfrom the V Entombment kn fCrs fromDublinorthe Christ of aking for some£1500. from KansasCityisvisibleatthe atican. The latter atican. The The John the Frank Minns The Diagnosis — Alan Lightman Tantalus Bloomsbury, 2000 graham worrall HB, 369pp, £16.99. 0 74754932 X Edward Hall, Peter Hall and John Barton Yours eponymously The Officers’ Ward — Marc Dugain Which of us does not wish to have a new (trans. Rory Mulholland) Salford Quays, The Lowry syndrome named after him? Weidenfield & Nicolson, 2000 27 January–3 February 2001 HB, 135pp, £16.99, 1 86159176 4 Imagine my excitement, then, when a Then: Nottingham, Milton Keynes, middle-aged man came to see me recently, WO very different novels with a Newcastle, Norwich, and The Barbican, complaining of a bald left leg! Sure common theme: the reaction of men to London (May) enough, examination revealed that his left Toverwhelming disability and their leg was much less hairy than his right one, treatment by healthcare professionals. The and it was completely smooth below the Diagnosis is set in modern day America, a CY blasts of late winter turn thoughts to knee. My pulse quickened was I on the land of competition, where stability is only Ionian shimmering sands; very different threshold of discovering a new disease? achieved by conformity and meeting Iemotions played through the minds of the deadlines. Bill Chalmers, an outwardly Athenian army, camped on the beach before I remembered the bald patch we found last successful trader in information, is stricken the walls of Troy in Tantalus, the gigantic summer on the back of our faithful family by a mystery illness that slowly paralyses production of John Barton s Greek tragedy pooch s neck caused by friction as he him. His search for a diagnosis among the now touring the UK (Royal Shakespeare squeezed under our verandah to escape the nightmare of the American healthcare system Company information: 01789 403440). sunshine. But what could have caused becomes increasingly Kafkaesque as he unilateral lower leg friction in a human? undergoes blood tests, scans, and psychiatric Gigantic is the only word that can describe assessment at the hands of seemingly the scale of the production which, with all As usual, the patient provided the answer. unempathic doctors. The situation is ironic, in three parts lasts ten hours, and took place in He told me that he d had deep venous that a man whose company s motto is The the magnificence of the Lowry Centre thromboses in that leg about 10 years ago, maximum information in the minimum of Salford s answer to the Guggenheim. and ever since then, because of poor time receives no explanation about his tests Fortunately, each part, which each consists venous return in his left leg, his calf is and treatment, nor recognises that his of three plays, is self-contained: your slightly swollen all the time. He also physicians are reluctant to face uncertainty. reviewer chose Part 2, War , which begins mentioned that his left leg had been as They are always confident that modern on the last day of the Trojan War. The hairy as his right, last summer, when he medicine will triumph in the end. How often weariness and pointlessness of this conflict was wearing shorts most of the time. have our patients been left floundering after a is reminiscent of Vietnam (is the Asian tiger trip to their doctors, unsure of what has been economy really America s Trojan Horse?). Eureka! It was clear that his swollen left said and in despair at their helplessness? leg was tight inside his long trousers in the The second play takes the Trojan s view and winter, and the trouser lining was rubbing The impersonal nature of Chalmers world is is dominated by their spindly King Priam, off the hairs. The exhilaration of making and his prophetess daughter, Cassandra. highlighted by the fact that one of his main this diagnosis was balanced by the Despite her warnings, the Trojans bring the means of communication is e-mail. Even his disappointment of not discovering a new legendary horse into the city and their fate is son, increasingly distressed at his father s disease after all. I kept a straight face, sealed. condition, talks to him in cyber space more however, and suggested that either he buy eloquently than he can face-to-face. Bill s baggier pants, or he let the inner seam of The third play which takes place with the story is intercut with that of Socrates. I found his existing ones out an inch or so. this intrusive but I suspect the reader is meant gory remains of the previous night s killing to make comparisons between the lives of the strewn about the stage and all over the body *** ancient Greeks and their thirst for knowledge, of Neoptolemus, the young son of Achilles The school roll calls have been much and our own society overloaded with often has all the tribal ingredients of the Balkan diminished of late. Many children get an meaningless facts. conflicts more familiar to contemporary illness which seems more than a cold, and eyes. For all his savagery, Neoptolemus less than true influenza. They stay off In contrast, Adrien, the narrator of The remains the little boy, too small for his school for a few days, apparently recover, Officers’ Ward, knows exactly what is wrong armour, as Hecuba, Priam s wife go back to school, and then soon fall ill with him. He has suffered mutilating head contemptuously remarks; even as he again with what seems to be the same injuries at the onset of the First World War threatens to strip and brand her, a fate which infection. Given that the initial viral and spends the next five years in hospital as has already befallen the rest of the Trojan infection should have produced immunity, surgeons attempt to reconstruct his face. The women. it was difficult to understand what was doctors are matter of fact and professional in going on. I weakly explained to the parents their approach. It is a time of experiment in In a few minutes the audience became of one such child it was possible that, still plastic surgery and skin grafts; however, attuned to the features of Greek tragedy; debilitated from the first infection, he had many operations are unsuccessful. Adrien actions taking place offstage enable the picked up one of the many other viruses eloquently describes a life devoid of the many drama to explore the dilemmas and emotions that swarm through our institutes of pleasures that he hitherto took for granted. He of characters heightened by masks. Soon education at this time of the year. I don t feels an outcast, cloistered away from the they were roaring at the sometimes know whether the parents were any more people for whom he volunteered to fight. contemporary quips of this ironic and witty convinced by this explanation than I was. script supported by a timeless eastern The doctors do not appear to recognise the musical accompaniment. It was left to my son, then eight years old, psychological scars these victims bear. The to give the definitive name to this puzzling physical healing process is secondary to the It took $8 million, an 88-year-old Denver cyclical disease, which he d had himself. I mental recovery that the soldiers gain through philanthropist, the Royal Shakespeare was discussing the sickness with my wife contact with each other, an early example of a Company, six months of rehearsals, and a over dinner, when he leaned over his plate self-help group. The book encourages the mega-row between John Barton and Peter and said, Dad, I know what that is it s reader to reflect on the nature of disability and Hall to bring about this production. Only one the Coming and Going Flu! Everyone at our responses to it. word describes it tantalising. school has it. Jill Thistlethwaite Jim Ford Can we call it the Worrall Syndrome?

The British Journal of General Practice, March 2001 253 5 TheBritishJournal ofGeneralPractice,March 2001 254 matters arising Princes Gate,London Saturday 17March Date ofnextmeeting organisation. to continuebeingthelead which NICEhasinvitedtheCollege Primary CareCalibratingCentre is inprogressonestablishinga programmes. Inthemeantime,work appraisals andotherNICEwork activities intheareaofmanaging s intend torationalisetheCollege appraisal workoftheCollege. We with NICEtofundsupportforthe hassecuredagreement The RCGP Calibrating Centre Excellence andthePrimaryCare National Institutefor Clinical reservations: expressed someimportant extending nurseprescribingCouncil While weweresupportiveof (England) consultationdocument. Council discussedthisDoH College Response Extension ofNursePrescribing: in March. detailed budgetwillcometoCouncil will risefrom£650to£670. A remain unchanged.Fellowshipfees -otherrates subscription rateonly of inflationinrespectthefull 4.9% increaseslightlyovertherate full rateof£321. This representsa subscription shouldbesetatanew Council agreedthattheannual Annual Subscriptions College Budget2001-2002and of theShipmaninquiryisknown. palliative careuntiltheoutcome controlled drugsorthoseusedin to theprescribinginrespectof That nochangesshouldbemade to operationwithintheNHS; the proposalsshouldberestricted implemented there,andtherefore the privatesectorbeforeitis necessary controlsshouldexistin governance systemsandother That thesafetyandclinical implemented; attention beforetheprocessis workforce andstructuresneed That theimplicationsfor prescribing rights; nurses whohaveextended doctors shouldbeappliedto equivalence ofrevalidationfor Governance arrangementsandthe That appropriateClinical effectively; continue toprescribesafelyand education toprescribeand right peersupportofprofessional That nursesconcernedhadthe agreed localguidelines; That prescribingwaswithin areas concerned; to prescribeinthetherapeutic should havebeenproperlytrained extended prescribingrights That nursespermittedtohave UK Council,January purporting tobe number ofdetailedprovisionswhile document wasnolongerclear:itcontainsa More seriously, manyfeltthepurposeof properly integratedwiththeexistingtext. felt thattheadditionalmaterialhadnotbeen Council wascriticalofthelatestversion,and and guidanceissuedintheinterimperiod. incorporate variousotherGMCpublications of material,thedocumenthasbeenupdatedto some ofthechangesonlyinvolvereordering members toprepareourresponse. While conducting aconsultationexerciseamong Medical Practice consultation arevisedversionof You mayknowthattheGMChasissuedfor Good MedicalPractice operation possibletotheInquiry. undertaken togiveallsupportandco- will beverytightandtheCollegehas looms. The timetableforproducingevidence s Shipman sauditofHarold Following RichardBaker Shipman PublicInquiry Spring Meeting/AGMin April. place fordiscussionintimetheBelfast Proposed changestobyelawsshouldbein the creationofaNorthernIrelandCommittee. to theCollegeconstitution,Councilapproved Council oftheCollege.Pendingamendment establish, induecourse,aNorthernIreland Northern IrelandFacultyformovesto Council supportedproposalsfromthe College inNorthern Ireland Council lookforwardtoworkingwithhim. from November2001. The Officers of David HaslamwaselectedChairmanElect, Chairman Elect complex andsupportsbothformative and a singleappraisalprocess,which istheleast but wassupportiveofourapproach toaimfor changing. Councilfoundthisacomplexissue of theformativemodel,thatpositionmaybe Wales andScotlandappearedtobe supportive Although theChiefMedicalOfficers in that appearstobesummativeinnature. consultants toamanagementstyleappraisal complicated byanagreementthe England aboutthis. The positionisnot advisers attheDepartmentofHealthin in manydiscussionswithministersand Chairman ofCouncil,MikePringlehasbeen which servesbothpurposes. go throughoneappraisalprocesseachyear, cycle ofrevalidationsothatGPsshouldonly same timecanformpartofthefive-yearly formative, educationalprocessandatthe that, whenintroduced,appraisalisa revalidation. We havebeenatpainstoensure significant concernssurroundingtheissueof well knownthatithasbeenoneofthe This wasamajorissueforCouncilanditis Appraisal position asadocumentofprinciple. that itshouldberecastandreverttoits Council wasmindedtoproposetheGMC activities, thepublicenquiry a principles and Iamcurrently document. Good College isproducingjointlywith General responding totheEnglishNHSPlan thatthe subject ofmodernisation. The seriesofpapers Council consideredanumberofpapersonthe Modernisation oftheNHS Colleges. appropriate withothermedicalRoyal of theseconcerns,alsoworkingas The paperwillbeworkedontotakeaccount the detrimentofgeneralists. if class doctors second sure thatGPswouldnotbeviewedas above wereevident.Councilwantedtobe by Councilwhenthetensionsreferredto these issuesfromMikePringlewasdebated intermediate care. The firstdraftpaperon are alsolookingatthelinkageswithin with theRoyalCollegeofPhysiciansandwe have beendiscussingsomeoftheseissues preserving thespecialityofgeneralism. We here betweendevelopingspecialinterestsand but thereisadifficult balancetobeachieved years andweareveryencouragingofthat, interests inmanyareasofpracticeoverthe .GPshaveofcoursehadspecial interest generalpractitionerswithaspecial term specialism ofgeneralpractice. We preferthe wish tomaintaintheethosandpurposeof term isnothelpfulfortheCollegegivenour proposal tocreate1000specialistGPs. This In theNHSPlanforEnglandtherewasa Interest General PractitionerswithaSpecial comments comingbacktoCouncilinMarch. to dothisinFebruarywithmoredetailed Council ExecutiveCommitteewillbeasked We needtimetoanalysethedocument,and negative inrelationtoitscontentandtone Quality ofMedicalPractice s Council appraisal, asabove,remainsunresolved. issue hasbeenacknowledgedthequestionof rather thanaformativetool. While thefirst under theseprocesseswouldbeamanagerial inappropriate process.Further, appraisals environment andresultedinafalse concerns awayfromtheirworking would haveassessedGPswheretherewere for asupportandassessmentcentre. This Patients analysis in of MedicalPractice one ofthekeyparts National Clinical Assessment Authority is Supporting Doctors, Protecting Patients following hisconsultationdocument document producedbytheCMO(England) Assuring theQualityofMedicalPractice Readers mayhaveheardofthedocument, National ClinicalAssessmentAuthority was theaimofNHSPlanforEngland. by this April, itwillnotbefullyinplaceas introduction ofasystemappraisalforGPs while theremaybeprogresstowardsthe summative outcomes.Itisquiteclearthat, itseemedtoperpetuateablamementality. , ourmajorconcernwastheproposal first reactionto Supporting Doctors, Protecting specialist GPsdevelopedto . While supportiveofthe Assuring theQuality Assuring the was very . The , a neville goodman Practitioners Committee (and in some cases other primary care organisations) is nearly Of articles and authors completed. These papers will explore some T must happen to journalists and of the issues already referred to including novelists all the time, but it s never GPs with Special Interests and Intermediate Iknowingly happened to me before. The Care. The document on the Primary Care man sitting opposite me on the train was Workforce has already been published. reading an article of mine. I knew he was a doctor from his previous reading matter, The NHS Plan for Scotland has already been but nothing else had kept my eye. His issued and contains many positive proposals briefcase was stuffed with journals, folders, though there are some negative aspects as and files. Some of them had been shuffled well. In Wales, the Plan is due to be debated over to my side of the table and I d politely in February. In Northern Ireland, there is no but pointedly had to push them back. He d modernisation document planned, although half-smiled apologetically but we d not two documents on the future of medical spoken. Then, he riffled through a section regulation at local level and on primary care of the case and brought out my article. have been issued and the Northern Ireland Faculty is responding to them. I have to admit it was not a Back Pages column. It was a serious article with which Health and Social Care Bill people are likely to agree unreservedly or A full brief on the Bill has been prepared by disagree wholeheartedly. He read it very our Information Services section and is slowly and carefully. Reading the later available via [email protected]. pages, he turned back on a couple of occasions to earlier sections. I found it One clause in the Bill is of concern, not only difficult to do anything except watch. No to the College but to the British Medical real expression crossed his face. He didn t Assocoation and others, namely Clause 59 nod, or tut, or look skyward, and he didn t dealing with patient confidentiality. This notice that I was taking an interest. gives the Secretary of State power to make regulations to prohibit or restrict the use of When he d finished, he put it down on the anonymised data, and also to enable table and looked out of the window for a disclosure of patient identifiable information little while. Then he put it back where it without the patient s consent. Iona Heath had come from in his case and started pointed out that this infringes overriding reading something else. principles of the Data Protection Act in some instances and could also infringe Human Should I speak to him? I couldn t help Rights provisions. Council was keen that the noticing what you were reading: what did College should be active in trying to amend you think of it? Or perhaps I should be these provisions or narrow them to specific more bold. Excuse me, but I wrote the needs rather than granting wide powers. The article you ve just read Then again, bill is having a very rapid progress through perhaps I should be more subtle, find Parliament as the Committee stage ends on something in my briefcase with my name 8th February after thirteen sittings. on, put it on the table and sort of slide it across. Out of Hours (OOH) Review: Implications for Primary Care But to what gain? If he agreed with me, Council expressed concerns about the ability then I could glow in a self-satisfied way. If of NHS Direct or its counterparts in Scotland he didn t, then there might be an argument and elsewhere to handle all OOH work its unpleasantness directly proportional effectively. The reduction in patient choice to our degree of difference. Even worse was criticised as many patients want to speak would be indifference: not hurrahs of directly to their GP or use a well known local congratulation or outpourings of scorn but OOH service rather than a nationally-based the opinion that the article was worthless. call centre. As the College has representation And what would happen after this on the OOH review implementation group, conversation? We were only halfway to our we will press these points during the coming destination and I had plenty to read myself. discussions. So I passed up the opportunity. I then Other matters discussed at January Council: reflected that when I d found myself standing next to Roy Hattersley, and on • NHS Plan for England: Implementing another occasion Clive James both the Performance Improvement Agenda writers whom I greatly admire I d not • Winter Pressures 2001–2002 said anything. Nor did I say anything to • RCGP Network Structures Jean Shrimpton (the 1960s supermodel • Advice for Air Travellers whom I eventually forgave for marrying • Spring General Meetings 2003–2005 fashion photographer David Bailey), when we were standing next to one another in the Full transcript via [email protected] taxi queue at Paddington, though perhaps for different reasons. Maureen Baker [email protected]

The British Journal of General Practice, March 2001 255 our contributors jill thistlethwaite Alison Craig isProject Officer for the Pesticide Action Network ‘Is this the beginning of the end, doctor?’ Peter Dick has a BSc degree in Mathematical OW if I were clairvoyant, would I be talking to this 92-year-old lady on the phone? Physics, an MSc in Numerical Analysis and MA No I would be lying someone warm where the sun shines for more than one hour a in Modern European Thought. In 1998-99, he day, courtesy of a large lottery win. was Fulbright Fellow at the Humphrey Institute N of Public Affairs at the University of Minnesota, Minneapolis, USA where he undertook research It s difficult to know what to answer when the patient is a fairly sprightly nonagenarian into the strategic management and leadership of with intact intellect and a few months history of (very) intermittent chest pain. Platitudes decentralised organisations, with the aim of are the easy option: of course not, you ll live to receive that telegram from the Queen (if learning lessons which might contribute towards she still sends them), see your great-granddaughter married, and celebrate the New Year. improving the performance of the Health Service You ve only had to use that headache-inducing spray once this week after all. But of course in the UK. Presently he is a team leader in reality I have no idea. I tussle with the idea of referring her for an exercise ECG, after all responsible for providing analytical and we under-investigate our female patients with possible ischaemia, but decide that old ladies facilitative support, policy analysis and advice to managers in the NHS Executive, Leeds on treadmills could be construed as some form of euthanasia if anything were to happen to [email protected] her. So I reply that I don t know, and she is glad I am honest. As I said, her intellect is Jim Ford is a medical civil servant at the intact. Department for Education and Employment, where he is Medical Director of the Job Do the worried elderly well lie awake at night fearing that every breath might be their last? Retention and Rehabilitation Pilots Some of my aged patients, similarly in their nineties, living alone, pottering about (www.dfee.gov.uk/nddp). He is also still an managing some housework, watching daytime TV, are just marking time. They tell me they occasional GP in Bootle are just waiting to die. There are no stigmata of depression, no sense that this is a morbid John Gillies is a GP in Selkirk in the Scottish fascination, simply the realisation that their work here is done. Death will be welcome, but Borders... [email protected] Neville Goodman has been writing elegantly it will happen when it happens and until then they will continue to potter and make jam and to the Observer rebuking that normally sensible wait for visits from their offspring and have the flu jab. newspaper s Barefoot Doctor for spouting nonsense. ( The ears are the flowers of the But other patients cling to an illusion of youth and gasp in amazement when that niggling kidneys etc etc etc) pain in the knee is diagnosed as osteoarthritis and that loss of hearing is not wax but John Howie has recently retired from the signifies the necessity of a hearing aid. They take as personal insults the creeping patina of chair of general practice in Edinbugh, but isn t age and vow to carry on as long as possible living life to the full. But then the doubts creep short of work, before you ask... in. Little lapses of memory are seen as the signs of full-blown dementia. God, I don t want Toby Lipman s talents continue to impress our reviewers. Naval history one month, EBM to die. I imagine them looking behind the curtains at night, ready to send the Grim Reaper for the next six or so, and Berlioz to come. Yet packing. (He will resemble the ghost of Christmas yet to come, as played by Alistair Sim in another Renaissance Man from Newcastle. You the film version of A Christmas Carol.) But, unless they are obviously dying, I have never have been warned asked my patients are you scared of death? I would not know how to carry on the Ian McWhinney OC, MD, was until recently conversation whatever the answer. director of the Centre for Studies in Family Medicine, at the University of Western Ontario, Perhaps it is fear of ageing, rather than fear of mortality. I see this in the much younger, Canada. He hails originally from the elegant middle youth, as some wit has described them. This is the group of adults who wish to be Lanarkshire spa town of Motherwell, Scotland seen as teenagers. They are up on all the latest music, buy clothes from trendy shops, go to Geoff Meads is Professor of Health Services Development, Health Management Group, City the gym to stay lithe and fit, and spend a fortune on retinol and other anti-wrinkle creams. University, Northampton Square, London, EC1V They like the sun, but not its direct rays. Their role models are Mick Jagger or Cliff 0HB Richard though they would rather listen to Robbie Williams or Britney Spears. The well- Frank Minns remains in the Navy informed woman s panacea is HRT, the well-informed man demanding equality wants Barry Mitchell practises in Coleraine testosterone patches, or failing that, Viagra. Anthony Riley is a Researcher, Department of General Practice and Primary Care, Queen Mary It all adds up to that familiar feeling: the inadequacies of 21st century medicine. I cannot College, University of London keep you young, I cannot predict when you are going to die and I cannot make your Benny Sweeney is a GP in Glasgow who owns large parts of Edinburgh. He has been hearing aid look any more appealing. vice-chairman of UK Council, and chairman of the RCGP s ethics committee Jill Thistlethwaite is based in the Academic Unit of Primary Care at Leeds University Colin Waine OBE is Director of Health Programmes & Primary Care Development in Sunderland John Waller is a health information analyst at the Centre for Innovation in Primary Care in Sheffield. He recently spent a couple of days in Cuba both shadowing a family doctor and observing what happens at the polyclinic to which she is attached. Graham Watt is professor of general practice in Glasgow Graham Worrall has been working in rural Newfoundland for 20 years. His major interests are primary care research, single malt scotch, baroque recorder playing and helping his patients, though not necessarily in that order

All of our contributors can be contacted via the Journal office

256 The British Journal of General Practice, March 2001