“Only in Macedonia have I been thanked at the end of an interview for giving all applicants The Back Pages an equal chance!”

Primary Care in Eastern Europe, Peter Toon, page 74 viewpoint

What is a referral? A personal reflection “They disparaged HE NHS Plan expected that, by April 2001, all PCG/Ts would have a mechanism for French wines apart monitoring GP referral rates. Referral is one of the possible outcomes from any from Bordeaux, though Tconsultation in general practice. In terms of its impact on the rest of the system it may be the most significant outcome, yet it has been a relatively neglected area of academic admitted to drinking inquiry. A flurry of activity in the early 1990s,1-4 corresponding to the introduction of champagne ‘but only if fundholding, drew the conclusion that there was a wide range of referral rates from primary unwell’” to secondary care with no convincing explanation. On entertaining the Bordelais, I was appointed a GP Referrals Adviser in City and Hackney in November 2000, with the Stefan Cembrowicz, page 78 task to identify current GP referral habits and facilitate change in the light of best practice, thus keeping inappropriate referrals to a minimum. “The images are seared The cracks in this model quickly became apparent. Which practices were making inappropriate referrals? Were small, under-resourced and badly organised practices over- into our collective referring because they were unable to handle the demands they faced? No: Large and small memory — airliners practices appear to be spread evenly across a spectrum of referral rates. Similarly, practices coming out of a clear with large numbers of ancillary staff and well-developed infrastructures are scattered blue sky ... But, in throughout this spectrum. And who were the GPs who made inappropriate referrals? No GP ever believes that it was inappropriate to refer that patient in those circumstances at that time every sense except the and bearing in mind his own knowledge, experience, and practice capability. He then literal, the sky was considers local and national guidance, together with local hospital attitudes and facilities, and anything but clear and all referrals become appropriate. blue. The backdrop to It is clear that there are as many reasons for referral, as there are consulting styles. One GP’s the outrage was black watchful waiting is another’s irresponsibility. My borderline decision is someone else’s barn door case. Is it just the ability to live with uncertainty? Is the required outcome of the referral with hatred, green with clear in the GP’s mind, and how often is that outcome delivered? How often during a dollar bills, blood-red consultation is a referral considered and then rejected? with history ... ”

We need to consider when a referral opens the door to the range of expertise and facilities Behind the Lines, available in our hospitals and when it only succeeds in exposing the patient to additional Roger Neighbour, page 83 anxiety, resulting in care which could, ideally, be provided outside the hospital setting. The model we use for referring patients dates back, at least, to the inception of the NHS in 1948. GPs, who were mainly single-handed with no practice facilities, referred to consultants who had access to staff and resources. Of course general practice and primary care today has changed dramatically since 1948. The advent of NHS Direct and Walk-in Centres means that general practice is not the first point of contact for all patients. GPs will find themselves receiving referrals from other professionals, as well as making them. Within practices, the development of primary health care teams means that much chronic disease management is contents now referred to other practice members. The advent of GP specialists, nurse specialists, and extended scope physiotherapists opens up the opportunity for an intermediate level of care 72 news Overseas GPs, ... plus trefor between primary and secondary care. Additionally, the growth in subspecialties within the roscoe hospital has resulted in the loss of the secondary care generalist. Will GPs fill this role as physicians who take a holistic approach? Will GPs become as familiar with referrals from 74 Eastern Europe — Peter Toon and one primary care setting to another as across the primary–secondary interface? Yvan Fontanel 76 Kosovo — Robert MacGibbon Referrals remain at the heart of the GP consultation. They influence clinical decision making 78 Party time — Stefan Cembrowicz and are a fundamental part of the clinical governance agenda. However, changes in referral practice are also the key to successful modernisation and redesign within the NHS. 80 digest Medicine and humanity, Gillies GPs are in a unique position to influence this debate. Definitions about what is a referral will Racism, Hopayian determine the role and influence of Referrals Advisers. As primary care continues to develop, ... plus graham worrell referrals will be seen as part of the continuum of care, with outcomes measured in terms of 82 reflection quality of life, rather than referral rates or waiting times. The Sopranos, Hunter Women’s health, Cameron References ... plus roger neighbour... 1. Department of Health. The NHS Plan: a plan for investment, a plan for reform. London: The Behind the lines Stationery Office, 2000. 2. Coulter A, Seagroatt V, McPherson K. Relation between general practices’ outpatient referral rates 84 matters arising and rates of elective admission to hospital. BMJ 1990; 301: 273-276. UK Council 3. Roland M, Bartholomew J, Morrell D, et al. Understanding hospital referral rates: a user’s guide. 85 diary and BMJ 1990; 301: 98-102. goodman on NICE 4. Knottnerus J, Joosten J, Daams J. Comparing the quality of referrals of general practitioners with 86 our contributors high and average referral rates: an independent panel review. Br J Gen Pract 1990; 40: 178-181. plus miller on democracy

The British Journal of General Practice, January 2002 71 2TheBritishJournal ofGeneralPractice,January 2002 72 news doctors. training willberelaxedforthese leave theUKatendofGP interim period,therequirementto community healthservices.Inthe training inthehospitaland that currentlyextendtodoctors within thepermit-freearrangements bring generalpracticetraining amending theImmigrationRules,to Home Office withaviewto is currentlyconsultingwiththe training. The DepartmentofHealth them toleavetheUKatendof Experience Schemethatrequire the Trainingand Workunder training relyonpermitsissued for themselvestogothroughGP Overseas doctorscurrentlypaying in Februarynextyear. training vacanciesandpostsstarting recruitment exercisetofillexisting step, theywillberunningaone-off arrangements. As animmediate potential applicantsonthe medical Deanerieswilladvise Educationinthepostgraduate GP training. DirectorsofPostgraduate selection proceduresforGP to thenationalrecruitmentand Applicants forpostswillbesubject training. paying toputthemselvesthrough thought thatonlyahandfulare career ingeneralpracticeanditis put potentialtraineesoff pursuinga (trainee GPsareexcluded). This has training tobecomehospitaldoctors doctors onlygetfindingiftheyare Under thecurrentsystemoverseas the firsttimesincemid-1980s. funding totrainbecomeGPsfor Overseas doctorswillreceiveNHS to getNHSfunding Trainee GPs fromoverseas First Primary Care Sciences Week

ORe than 1000 primary care physicians and nurses are expected Mto attend the first Primary Care Sciences Week which will take place in Birmingham from 3–6 July 2002.

The conference, organised by the new Federation of British Primary Care Societies (FBPCS), will be the largest clinical meeting specifically for primary care ever organised in the UK.

The agenda will include clinical sessions reviewing recent developments in the trefor roscoe management of cardiovascular diseases; respiratory illnesses, including asthma; HE image most people have of in a particular parish. Many local metabolic disorders, including diabetes and someone researching their family tree authorities, such as Cheshire, have been lipid abnormalities; gastroenterology; Tis of a bespectacled spinster grubbing working with their local genealogists to put rheumatology; oncology, and mental health. around in a graveyard, trying to decipher a as much of their information online as weathered inscription on a badly tended possible. Much of one branch of my family The agenda has been developed by a grave. Such family research also used to comes from Cheshire and I can search for consortium of representatives from the require many trips to local authority both marriage and death registration in the major primary care groups participating in archives and parish churches to leaf 18th and 19th century online at the FBPCS including: through dusty volumes of births, marriages, www.chesirefamilyhistorygettheurl.org and deaths. An ability to read Latin was • Association of Community Cancer Care useful for research before 1750. Like all There is also a large online community of • British Cardiac Patients’ Association things involving large amounts of people doing similar searches, as well as • British Hyperlipidaemia Association information, computerisation has altered professionals engaged in genealogy full- • General Practice Airways Group the process beyond recognition. The time. Bulletin boards, such as • Primary Care Cardiovascular Society Church of Jesus Christ of the Latter Day www.ancestry.com can put you in touch • Primary Care Mental Health Saints, more commonly known as the with fellow enthusiasts all over the world. Education/Mental Health Research Mormons, have been building up archives Many enthusiastic amateurs have built up Group of information about past generations since websites with thousands of names • Primary Care Rheumatology Society the end of the 19th century. In the past ten interlinked, the largest collection of such • Primary Care Society of years this has increasingly become links are to be found at Gastroenterology computerised and it is now all available www.cyndislist.com, which is rather online at www.familysearch.org. Like American-orientated but still very useful. The conference will also incorporate the most things on the net it is free, and there is Alternatively, a quick search in Google Annual Meeting of the Association of plenty of help available. If you’re lucky (www.google.co.uk) for your surname and University Departments of General Practice enough to have a slightly unusual surname the word ‘genealogy’ will usually be (AUDGP - see BJGPs passim), and a family that moved around very little, useful, unless your name is Smith. Even representing the clinical academics in every it may only take a couple of hours to trace then, if you put the surname and a county university department of primary care in your family back to about 1650. you could well strike lucky. I have also Great Britain and Ireland. found it useful to put the parish names into Information for the last century is patchy a modern-day mapping site, such as Full accreditation for PGEA, CPD and but, provided you know the name and www.multimap.com, which will give you PLPP is being sought. approximate birthplace of family members a detailed map of the area, allowing you to born before 1890, you can usually follow look up the names of adjoining parishes to Under the theme Quality Care Through the trail backwards. Other useful sites are find out if your relatives moved down the Clinical Evidence, the conference will be GENUKI.org.uk, the home of the road from generation to generation. Even held at the International Convention Genealogy Societies of Great Britain and if, like my forebears, they were very Centre, Birmingham. Registration will be Ireland. The site has detailed information mobile (one branch moving from Exmouth £120.00 (plus VAT) for delegates booking contributed by individuals all over the to Croydon and on to Rochdale!) The before 30 April 2002 and £150.00 (plus country on structure of parishes, the dates family search site allows you to look for all VAT) for delegates booking thereafter. of Censuses and current location of the people with the same name in the UK born parish records. Links are given to each or married within a few years. Abstracts and proceedings will be local authority who all have information published in a peer reviewed journal. departments where the archives are kept. If Be warned however, like many aspects of you get stuck trying to work out the internet, this can become rather Further information: relationships you can ask the archivist by e- addictive and you can easily spend hours [email protected] mail to do a quick search for the presence wandering down the highways and by- [email protected] or absence of a marriage or birth certificate ways of your long-dead relatives!

The British Journal of General Practice, January 2002 73 Primary Care in Eastern Europe

T is easy for those within the UK’s strong his own way through the medical Minos tradition of general practice to assume labyrinth, or finding himself pushed into it Ithat this is how primary care is delivered. by the territorial doctor.’2 (though for how much longer even here looks increasingly uncertain). The The Stampar Model Communist world approached health care Most Warsaw Pact countries copied the FSU very differently, and visiting Eastern Europe system with minor modifications. In challenges many such assumptions. Yugoslavia, however, Andrija Stampar, public health guru and founder of the World These countries cover a quarter of the globe, Health Organization, developed a slightly and each is different. There has been little different model. His vision was a ‘hospital systematic study and interventions are often without walls’, a multidisciplinary primary unevaluated. In some places things are health care team of specialists in internal developing rapidly, while elsewhere change medicine, paediatrics, gynaecology, school is slow, and not always for the better. Our medicine (caring for all in full-time generalisations are based largely on personal education up to university level) and and partial impressions and must therefore occupational or labour medicine. be viewed with caution, but perhaps they will give some idea of the problems doctors The reality was unfortunately often rather in these countries face. different. All doctors had a common basic training, but this was usually more The Former Soviet Union theoretical and less practical than in the The FSU had distinct health care systems for Soviet Union or Western Europe. After this children and adults, with separate training they became ‘general practitioners’ and from medical school onwards. The socialist could work in primary care. Postgraduate desire to provide accessible primary care to training was often secondary care-oriented, everyone was met in the 1920s in typical unpaid, involving few duties and little communist fashion by dividing the country practical experience, and funded by their into ‘territories’, each with its local health authority, as a reward after several polyclinic, often numbered rather than years service rather than as a preparation for named. District specialists in internal work. Many primary care doctors had no medicine, paediatrics, and obstetrics and specialist training; for example, 40% of gynaecology replaced the former zemsskii doctors are still caring for children in vrach (analogous to general practitioners). Macedonia. As usual, the inverse care law The initial idea was that ‘home care is applies, and they were more likely to work carried out by a single physician’ but the in remote areas or with deprived ‘territorial doctor’ responsible for those populations. Although continuing education living in part of a district did not have a programmes are now being introduced, the gatekeeper function, and patients could and limited appropriate postgraduate training did access specialists directly. In a that there was — such as the pioneering technologically-oriented society, family medicine scheme in Zagreb — was specialisation was valued and the holistic struggling for lack of funds. With such values of generalism overlooked. In time, limited educational provision and problems polyclinic specialists in psychiatry, of drug and equipment supply, the doctors venereology, and psychoneurology were faced, and still face, huge obstacles to introduced, more recently joined by providing a good service. cardiologists, endocrinologists, and neuropathologists. While the training and Country doctors expertise of these specialists grew, the Under either system, in rural areas the territorial physicians — seen, as Lord population does not justify such overblown Moran viewed British GPs — to be ‘those collections of specialists and primary care who have fallen off the ladder’,1 remained doctoring is closer to the traditional rural without postgraduate training. Many came model. As in remote and unpopular areas References 1. Moran, Lord. Evidence to the to be triagers, dealing only with minor, self- everywhere, you will sometimes find Royal Commission on Doctors and limiting illnesses themselves. Half of their inexperienced, incompetent or drunken Dentists Remuneration Minutes of contacts led to specialist referral (compared practititioners in villages, but there are also Evidence 3-4. London: HMSO, with about 10% from UK GPs). committed, caring doctors doing their best 1958: page 193. for their community — truly fortunate men3 2. Toon PD, Southgate LJ, One Russian doctor commented that ‘a (or more often women, as doctors in Gubachov Y, Simbertsev S. In the person is cut into pieces for different communist countries tend to be female, footsteps of Peter the Great. Eur J specialists. The authority of the primary except in the more prestigious and powerful Fam Med 1996. positions!) 3. Berger J, Mohr J. A Fortunate physician was lost, and the patient did not Man: The Story of a Country know who was responsible for his health- Doctor. Harmondsworth: Alan care. The patient himself had to decide what Out-of-hours care Lane/The Penguin Press, 1967. specialists would take care of him, finding Communist philosophy viewed illness europe 1

74 The British Journal of General Practice, January 2002 mechanistically and saw clinicians as unjustly used. underpinning to the financial reform, so interchangeable units of labour. Doctors doctors tended to work as before, caring for worked in shifts, and 24-hour responsibility The post-Communist world the same groups of patients, so they had all was rare. The doctor–patient relationship is Following the collapse of Communism, the disadvantages of isolated single-handed undermined, rather than supported by this plans for health service reform were made practice with none of the initiative and system. So strong, however, is the need of as the countries entered ‘transition’. Like all autonomy that it can offer. patients for personal doctoring, and so countries, they faced escalating health care rewarding is it for the doctor, that despite costs, while social upheaval created new In other places, such as St Petersburg and these antagonistic institutional arrangements health problems, and economic collapse Macedonia, education without such relationships do develop. destroyed the scanty information sources — organisational or managerial change led to such as journals and books — that they had frustration, as doctors could not implement In Russian towns there are two emergency had previously. the changes they saw were needed. In many services, one for urgent problems in people’s countries the nettle of unemployment — homes and the other for emergencies that In both the Soviet and and Stampar systems, which any serious health service reform arise in the street — akin to GP deputising the large number of primary care and would generate — has proved too hard to and ambulance services, but with slightly hospital specialists, general practitioners or grasp, even after ten years. different boundaries. In both services teams territorial doctors, coupled with an consisting of a doctor, nurse, and driver go employment philosophy of ‘we pretend to The extent of the cultural and legal changes out (since few doctors drive and the role of work and they pretend to pay us’ had led to and the time needed for health care reform our paramedics, like those of many a vastly overstaffed health service, with were often underestimated by both locals ‘professions allied to medicine’), is huge bed numbers and long stays in and foreign advisors. One advisor was performed by doctors. Services for minor hospital. Costs were therefore high, despite reported to us as expecting that the Russian trauma and acute illnesses are separate from low wages. As one Russian doctor put it health service could be changed in six major accident and emergency units run by ‘our health service is obese!’ months! Both East and West saw democracy specialists in intensive care. This is rather as a political system, but it is also a state of more logical than the UK system, where ‘Experts’ from abroad were asked for advice mind. Changes tend to have gone better in ‘minors’ may be dealt with badly and and key figures from ex-Communist countries such as Poland, Hungary, and the grudgingly by A&E doctors whose interest countries taken on study tours to Western Baltic states, who saw Communism as is life and death emergencies. countries, from which they often came back externally imposed, than in Russia where full of enthusiasm for what they had seen. reform was associated with loss of empire. In contrast, in Yugoslavia the emergency Reforms were introduced, often hastily and In some parts of the Balkans, wars, ethnic service was part of primary care, again often piecemeal, importing Western models hatred and ‘Yugostalgia’ — a nostalgic staffed by inexperienced doctors without without considering a different society’s mourning for the past — have hindered postgraduate training. This dealt with all needs, or how systems, institutions, and change. problems out of hours, from a febrile child cultural values interrelate in a complex web. to a ruptured aortic aneurysm. What of the future? It was common to see the future of primary One thing is clear — in many of these The social position of doctors care as generic family medicine (just as we countries, change will take a generation. To Western doctors, used even now to a seem poised to abandon it). A few pioneers Power still lies largely with those whose good income and respected social position, were sent on study tours to Western Europe thinking was formed under Communism, one of the most striking features in many or the USA, returning to work in ‘model and autocracy and bureaucracy is second Communist and post-Communist countries practices’ often glistening with Western nature to them. There are encouraging signs is the low pay and popular esteem of money. This was understandably resented of openness to new ideas among the young, doctors. Incomes are, of course, generally by doctors working in crumbling buildings fuelled by the most powerful engine for lower in these countries, but even in relative under the old system. Primary care change in the 21st century: the Internet. terms doctors are badly paid. Their specialists, some with a low level and small ‘Grand plans’ are unlikely to succeed in commitment in these circumstances is range of skills, were deeply threatened by countries still ambivalent about democracy extraordinary. For instance, one paediatric these ideas. Impotent to achieve their vision, and capitalism and where the basic concepts surgeon in St Petersburg moonlights as a taxi these disillusioned pioneers often emigrated underlying them are not widely understood. driver, because the money is better — but to the countries they had previously visited It is more likely that change will be still operates when he can. or moved to the private sector, caring for incremental, an accumulation of small wealthy ‘New Russians’, or analogous advances. Personal friendships between Networks tend to be even more important nouveau riche groups. people from East and West which introduce than in the UK, promotion often depending individuals from both sides of the former more on who you know than what you Privatisation and compulsory insurance Iron Curtain to new ideas seem to be the know. In some countries, medicine is a systems were widely implemented, often at most powerful promoter of change. It will ‘family business’ and the most important the behest of institutions, such as the be ironic if these succeed in helping them criterion for entry to medical school is to be International Monetary Fund and the World achieve a health service based on personal the daughter of a professor! In Macedonia Bank, without the cultural or regulatory doctoring, just as we lose it in a flurry of we were thanked at the end of an interview changes needed for accountability. Thus in walk-in centres, primary care specialists, for giving all applicants an equal chance! parts of Croatia primary care doctors were and telephone triage systems. Since managerial and ministerial positions made independent contractors, but ‘medical are usually held by doctors, and not lay directors’ were retained from the previous managers or non-medical politicians, the hierarchical system, though they now had Peter D Toon power of patronage is enormous and may be no clear role. There was no educational Yvan Fontanel

The British Journal of General Practice, January 2002 75 The personal experience of a British GP teaching doctors on a CPD course to 'establish a comprehensive family medicine service' (WHO, 1999) in Kosovo

The CPD Course in Family Medicine from their own personal bereavements. I Against the background of the history of the have been living and working in a previous 10 years, it was clear that a predominantly Albanian town, Gjakova, in completely new professional medical the far west of Kosovo. Eighty per cent of register was needed with a policy on the old town was destroyed in a few educational needs and an approach to unimaginably violent days and nights soon continuing professional development, both after the NATO bombing campaign started. for the doctors already working in Kosovo Serb soldiers and police reduced houses and and for future doctors. shops to burning rubble, while NATO bombs picked out and destroyed Serb The doctors who had trained and worked military targets from the air. Thousands of during the 1990s providing primary care in people escaped over the border into Albania the ‘parallel system’ needed to adapt and but every family has experienced the death develop their knowledge and skills to of close family members or friends. practice family medicine in the new health Hundreds, particularly young men, are still service. ‘missing’, possibly alive in Serbian prisons but more probably now dead. By February 2000, the World Health Organisation had responded to this need by Everyone has their own story to tell and proposing a CPD course designed for the memories to learn to live with, somehow, situation. each in their own time.

In the situation in Kosovo, as it was in the During my time there, people had only just Spring of 2000, only a year after the war, been able to enjoy their first celebrations; a these were brave aims with a remarkable birthday perhaps, weddings too, and the vision and much to ask of one course. return of 150 prisoners of war to a small town where everyone had personal I joined the course as an international connections, either of family ties or close clinical supervisor at the end of September friendships. 2000 when it had been running for three months. The mood was high and both staff The speed and energy of the physical and participant doctors were full of energy rebuilding of the old town has been and enthusiasm for this major new initiative remarkable, with new houses and shops and venture. I committed myself to stay appearing and opening every day. until the end of the first phase of the course ( June 2001) as I felt from the beginning that However, the fragile infrastructure of continuity for the participants doctors was transport and power supply has made day- going to be an important factor for a people to-day living and working difficult at times, who had lived through many extremely particularly during the long winter of cold unstable years, both personally and nights and snowfalls. One snowfall lasted professionally. two days, and movement within Gjakova almost came to a standstill. In our Experience apartment, we had a wood burning stove for My personal experience has been twofold; heating and cooking and a gas bottle heater, first, the opportunity and luxury to work as well electricity, and we often used candles full-time with mature doctors developing and portable electric storage lamps during their professional futures over an extended the frequent power cuts. We were relatively period; and secondly an opportunity to live independent of electric power for our and work abroad with my partner in another comfort but for others who could not afford culture at the edge of the Europe I thought I these extras, and at the teaching centre, life knew. was more difficult.

Inevitably, the whole experience has been Teaching and learning dominated by being in Kosovo at a time I worked as a full-time teacher, planning when some two million people are ahead but also responding to issues and recovering from the horrors of a civil war. problems of the moment — very much like The professional development of the day-to-day general practice! This experience doctors has been part of their recovery from seemed very luxurious compared with all a prolonged period of ethnic and the teaching I have done in the past, which professional repression and also to recover has been ‘fitted in’ to days of full service europe 2

76 The British Journal of General Practice, January 2002 commitment as well. However, towards the were to receive full recognition as specialist end of my time I realised that I needed to get GPs, without having to participate in further Recent History of Kosovo CPD. Morale finally rose to a realistic and back to practice myself, to keep in touch During the 1990s the political apartheid policy with the reality of general practice and to optimistic level. of Yugoslavia in Kosovo led to increasing maintain my credibility. economic and cultural decline. In a well- For me, one of the best achievements was to established town, such as Gjakova in the west The doctors were very good at learning from see and participate in the development of an of the province, factories fell into disuse, lectures and were used to having very little active local branch of the Kosovo Family vineyards were left untended, and sports access to textbooks. The course text was Doctors Association. Centrally, this embryo facilities and cultural centres deteriorated with basic and there was a hunger for new books organisation seemed rather quiescent but, in lack of maintenance. During the civil war that and journals after the years of deprivation. Gjakova at least, an increasingly confident culminated with the intervention and bombing group of doctors decided to move forwards. by NATO in March 1999, major installations Over the year, ways of teaching appropriate of the infrastructure were finally destroyed and for experienced adult learners were They developed their own aims and even the land itself became unusable because introduced — learning new ways of objectives and a programme of meetings. of the extensive laying of land mines. learning. It took time to convince the They addressed both professional doctors that their level of knowledge was contractual issues about terms and At the same time the health service, very good and to have the confidence to conditions, and strategies for promoting and particularly for Albanians, declined because of spend more time on exploring ways of developing the role of family medicine in lack of funding, and also because Albanian applying their knowledge. The value of their own municipality. The group were staff were progressively removed from truly building a base from which to working in the service and denied training in asking questions and problem solving in undergraduate or postgraduate institutions. peer groups was stressed. The tools needed participate in the future health service. They Hospitals were not maintained; windows were for problem solving, such as consultation had gained self-value and confidence from not repaired, light bulbs not replaced, heating technique and basic clinical skills, were the course and had become innovators and systems and plumbing were left leaking. identified and learned about. leaders in their speciality and among their professional colleagues, both in primary In response to this, Albanian doctors organised By the end of the year, the doctors were care and in the secondary hospital services. the ‘parallel’ system for medical education and developing their own lecture sessions and primary care which developed without state running their own groups. Clinical skills Personal reflections funding or support and it was subjected to My partner and I have had the privilege and intermittent harassment by the police. Many were exchanged and improved among the doctors trained during the 1990s in back doctors themselves. pleasure of living and working completely rooms and without official access to patients. immersed in another culture in the very By March 1999, despite this remarkable Earlier in the year I had set my own goal, Albanian town of Gjakova. We have lived response, very little was left of a Yugoslavian which was to make my supervisory role in with a people who are recovering from a health service which, 20 years before, had the teaching/learning process redundant. By horrific civil war and an extreme apartheid been comparable and reciprocal with the the end I really felt that I had achieved this. policy of ethnic cleansing. Even if we can British NHS. I spent more and more time in the last weeks not quite imagine what recent life had been like, we were received there with great At this stage the United Nations and NATO silently watching from the sidelines! intervened, and when KFOR troops secured warmth and trust and perhaps shared some the province in June 1999 the United Nations Progress and achievements of the grief. We lived there long enough to Mission in Kosovo (UNMIK) was set up to re- The initial excitement of a new future observe some remarkable recovery, both establish all levels of civil life, such as a legal promised by the course inevitably went materially in the rebuilding of the old town system, a police force, and a municipal through highs and lows. At the six month and also more subtly and movingly, in the structure to organise local services. Recreating stage, in the depths of the winter with the rebuilding of individual lives and the future a health service was also a priority. added logistic problems, morale was so low of families. at times that participants often talked of By October 1999, UNMIK had developed an We marked our time in Gjakova and our ‘Interim health policy guidelines and six- leaving. At this time too the course had still month action plan’ (UNMIK, 2000) as their not been accredited towards achieving departure by giving a dinner party for 30 official strategy for health in Kosovo. The specialist status in family medicine by the Albanian friends. It was an evening full of policy was built on ‘European Health 21’ Kosovo Ministry of Health. The doctors joy, laughter, and indeed love. I did not developed by the World Health Organisation were still working with low professional understand the words of much of the (WHO, 1998) and the key aspect was to re- status and for only 350 Deutsche Marks a conversation (although some of the talk orientate what had been a hospital and month (about £120 sterling) with little belief was in English!) but I certainly understood specialist driven system, to one more focused in a future for themselves in the new and experienced the mood and feelings. My on family medicine and prevention in primary primary care health service. We clinical partner and I were truly privileged to be so care. supervisors spent time and energy working accepted and included by a people whose With an estimated population of about on this, both with the participants and by culture and history are both physically so 2 000 000, at least 700 family doctors were stressing the importance of accreditation to near and yet also so different. We all live in going to be needed to establish the base of the doctors working with the Ministry of geographical Europe but have far to go to family medicine as soon as possible, before a Health. By the end of the year the course understand each other. mixture of private and public specialist- had become officially recognised and orientated health services grew irrevocably. accredited. In addition, the doctors with more than ten years previous experience Robert MacGibbon

The British Journal of General Practice, January 2002 77 How to set up an international exchange group

ENERAL practice is an international way to a reception with the Mayor of Bristol phenomenon. Although ‘doctors of at his official residence (impressing our Gfirst contact’ overseas have different guests, whose mayor — controversial working conditions from GPs in the UK, resistance warlord and politician Chalbon there is always common ground — as well Delmas — was far less accessible) and drug as contrast — to be found in other people’s companies helped sponsor evening systems. meetings. Rather a mistake, though, was a wine tasting; our guests were gravely A group of Bristol GPs assembled 12 years disconcerted to be presented with powerful ago to visit a similar group of French Californian and Australian wines, let alone a doctors in Bordeaux for a week. One of us Chinese Riesling. At home they disparaged had a friend in Bordeaux, and since the two French wines apart from Bordeaux, though cities are twinned, it enabled us to gain they admitted to drinking champagne ‘but support from our City Council. only if unwell’.

Our first exchange started with a home On the return leg our hosts were not to be fixture. Our guests stayed in our houses, and outdone. The French generally entertain shadowed us at work. Their programme away from home and we were clearly guests included visits to different aspects of of honour to be staying in our hosts’ houses. primary care and there was plenty of emphasis on the social side. Shadowing our French colleagues we saw how the open-ended French system catered The Bristol–Bordeaux link smoothed the for citizens’ wishes. Doctors were paid per consultation, partly reimbursed by the state. Record keeping was minimal and medicolegal problems seemed rare, as the doctor–patient relationship was courteous and dignified and patients had free choice of doctor. Our Republican colleagues were certainly not going to be ruled by the centre, and freedom of the individual was central to their culture. Doctors had higher incomes but less holiday; this might be funded by les laboratoires. Multiple prescribing was prevalent, and less work was delegated to non-doctors.

Perhaps the contrast between English and French cuisine is an analogy; in England you get sound, if unpalatable, nutrition; in France, every nuance of your palate would be catered for. Since our visit the Ministry of Health has tried to curb expenses, with a Bordeaux group, visiting in Bristol. national record system and complex penalties for over-investigating, overdiagnosing or overtreating, to prevent overclaiming. However, our French colleagues remain very independent practitioners. Our exchange was great fun, and led to persisting friendships and family contacts.

Our Prague exchange was quite different. A reliable personal contact in Prague recommended her two young family doctors. They turned out, fortuitously, to be President and Treasurer of the fledgling Czech Association of GPs. We got on well, and planned a group exchange visit.

Family medicine in the Czech Republic was then being reborn. Under the Soviet regime, GPs had been replaced with deskilled street doctors working in large polyclinics, to whom patients were allocated. Ambitious Dr Vaclav Smattah with his nurse, in Prague doctors specialised and general practice was europe 3

78 The British Journal of General Practice, January 2002 described as a dumping ground for the politically unreliable and alcoholic.

From beneath these ashes, diamonds emerged. When the Communist regime fell in Havel’s velvet revolution, the intelligentsia emerged from the prisons and boiler rooms where thay had been shelved, and started to rebuild democracy. Free choice of an independent, trustworthy doctor was one aspect of this, and a part of Czech culture that had not been forgotten.

Shortage of up-to-date medical information was a problem — it was not so long ago that state paranoia had placed an armed guard by each photocopier. With help from the (then) Knowhow fund, the British Council, and the British Embassy, we presented a seed-library of current GP-related books. Our hosts fell hungrily upon these well- produced and illustrated textbooks. This was a salutory reminder of the value of knowledge. When I got home I arranged for my copy of the BMJ to be diverted to my friend’s Prague address.

One scene comes to mind; the new Polyclinic Director saying goodbye to his ousted boss from the former regime, who had been relocated to ‘the countryside near the cement works, where he will be able to keep a pig — if he wishes’ (his expression implied that he wouldn’t wish ...)

As Czech salaries were a few dollars a week at that time, we raised funds from pharmaceutical reps for our group of doctors to come over. Our groups have kept in touch by e-mail, letters, and visits, and family exchanges have taken place.

We subsequently made contacts with family doctors in Denver, Colorado, and Odense in Denmark, and further exchanges ensued. More (Cuba and Turkey) have been mooted, though progress has been slow. Successful exchanges seem to depend on a single dependable contact abroad, a language in common, and a coherent group.

General practice is a culture-bound phenomenon. GPs are deep inside each country’s culture, a very central part of it. High-tech hospital medicine is much the same around the world, but each country’s family doctors relate to the public on most intimate terms.

Seeing others working lives and health systems helped us reflect on the strengths and weaknesses, challenges and rewards of our own.

Stefan Cembrowicz

The British Journal of General Practice, January 2002 79 0TheBritishJournal ofGeneralPractice,January 2002 80 digest Understanding ofGeneralPractice’ Institutes forKnowledgeand 2 HAIKUGP–-‘Headsof Academic nature, orthenatureoflife 17–25 syllables,usuallyreferringto 1. HAIKU—aJapanesepoemof Add up The numbersdonot 30 professors 30 000GPs 50 millionpatients HAIKU 1 GP Amanda Howe 2 and dyingwell’,‘healthinthecity’. conformity andmentalhealth’,‘livingwell freedom orpublichealth?’,‘culture, and justice’,‘stayinghuman’,‘personal Millennium. The lecturescovered‘health held inLondonlastyeartocelebratethe based onaseriesoflecturesanddebates and this,hiseditedcollectionof12essays,is management meetingsformanyyearsnow, look upfromourprescriptionpadsand Marshall Marinkerhasbeenimploringusto but mostoftherightquestionsarethere. There arenosimpleanswersinthisbook, decides whatmedicineisfor? makes therules? Who enforcesthem? Who obligatory. Howdoweproceed? Who immunisations suchastheMMRshouldbe and ourchildren,thosewhobelievethat choose whatwethinkisbestforourselves we areautonomousindividualsfreeto battleground betweenthosewhoargue that backwater ofpublichealthhasbecomea become evenbigger. Eventhequiet fertilisation, foetalselection),theissues and possibility(contraception, glucose) andtheexpansionofhumanchoice factors (raisedbloodpressure,cholesterol, disease toincludethetreatmentofrisk from itstraditionalterritoryoftreating It isnosmallsubject. As medicineexpands relationship. and theambiguitiesuncertaintiesof interstices betweenmedicineandhumanity, more slowly. This bookisaboutthe beings andtheirsocieties,however, adapt more isalwaysbecomingpossible;human science ofmedicinechangesbytheday— available tothosewhocanpayforit. The virtually anymedicaltechnologyis states. This happensinaworldwhere the contextoflocalcommunitiesandnation- in consultingrooms,clinicsandhospitals acts andtransactionsofmedicinetakeplace consumers orco-producersofhealth. The They maybecalledpatients,clients, practised on,orwith,otherhumanbeings. PB, 152pp,£14.99,1857174410 King’s Fund 2001 Publishing, Edited byMarshallMarinker Medicine andHumanity M by humanbeingscalleddoctors.Itis or profession,practisedprincipally EDICINE is ascience,orart,craft, in vitro even moreuneasy. Ifyoufeelthatit’s the conformity andmentalhealth’. You willfeel Jonathon Glover’s essayon‘Culture, read ‘antisocial personalitydisorder’ Secretary’s wishtolockupindividualswith If youfeeluneasyabouttheformerHome Hart andKennethMinogue. pieces onhealthandjusticegivenby Tudor values andindividualismisreflectedinthe necine warfarebetweencommunitarian health tofindaplace. The continuinginter- healthcaresystem,itishardforpublic USA is thatittooweak.Inthemarket-obsessed has toomuchpower, andtheUSperspective the UKperspectiveonpublichealthisthatit On publichealth,it’s notinsignificant that in Greece1836byhisdoctors. since Byronwasbledandclysteredtodeath death. Notmuch,hesuggests,haschanged technology, morphine-assistedpeaceful eventual rescuebyhisfamilydoctortoalow biochemistry inateachinghospital,andhis organs and rampantlyabnormal asabagofdiseased father’s ‘management’ letters. BertKeizerwritesmovinglyofhis This isautonomywritlarge, incapital freely availabletothepublic,asalcoholis. psychotropic drugssuchasantidepressants travel. BruceCharltonsuggestsmaking essays inthisbookdevelopdirectionof Many masters ofmedicine,notitsservants.’ that ‘we[thepublic]mustbecomethe of 1980,entitled‘UnmaskingMedicine’, Ian KennedysuggestedinhisReithlectures isakinderwayofstatingwhat doctors.’This merely aformofself-expressionfor on wastotheeffect that‘medicineisnot and society. Oneremarkthatwasmadeearly exploring someissuesconcerningmedicine series ofmeetingsinScotlandwithagroup Over thepastyear, Ihavebeeninvolvedina links thethemestogether. an excellentintroductoryessayinwhichhe very wellknown.Marinkerbravelyprovides Robert Winston, andRichardHarries,are ethicist authors.Many, suchas Tudor Hart, religious, academic,medical,economic,and There isaspreadofperspectivesfrom Racism in medicine: graham worrall an agenda for change Edited by Naaz Coker King’s Fund Publishing, 2001 Atlantic crossing PB, 241pp, £15.99 1 85717407 0 ET another intrepid team of voyagers has failed to complete the journey Yfrom Newfoundland to the Old World. Two young Americans, in a boat not much longer than a bath tub, had to give up their journey two days out of St John’s, because of high seas and unfavourable winds. Their unsuccessful fate was the right thing to do, there is even more reason HIS is a book that needed to be written. to read it. Kay Redfield Jamison has a brave As Rabbi Julia Neuberger states in the same as that of the balloonists who and honest piece on life as a psychiatrist Tintroduction, ‘Racism is one of the attempted the trek in summer 2000, only to with manic depression. I may be wrong, but most difficult and painful words in the be fished out of the water by a fishing boat I can’t imagine a British psychiatrist writing English language. It both describes and on the Grand Banks. such a piece. Are American doctors more creates barriers between people. Not honest and less covert about their disorders surprisingly, then, it is a word that gets a Because eastern Newfoundland is the than we are? great deal of use but which is rarely nearest part of North America to Europe, it discussed openly, dispassionately and with has often been the start of voyages. For I would have liked to see a debate on neither malice nor dismissiveness.’ example, when in 1913 Lord Northcliffe of medicine and the media in this volume. The the Daily Mail offered £10 000 for the first media are central to public perceptions of This book does discuss racism in medicine continuous non-stop transatlantic flight, the medicine and increasingly shape openly, dispassionately, without malice or island became abuzz with hopeful aviators Government policy. An essay on medicine dismissiveness. It weaves together (in addition to the proximity, they hoped and the media would certainly have raised discussions of concepts, descriptions of the that the prevailing easterly winds would controversial issues and perhaps cast some current state of institutionalised racism, and help them along). light as well. Developing world issues, suggestions for practice. You might think increasingly important in our shrinking that starting the book with a discussion of In April 1919, the British aviation team of world, are given only a brief mention in the concept of race and racism is Woods and Wylie attempted a western Peter Budetti’s essay. superfluous, since anyone bothering to read crossing from Kent, but their plane crashed the book would be aware of these issues. But in the Irish Sea. By the following year, However, any of these essays would make Shahid Dadabhoy’s personal account several groups were hard at work clearing for a stimulating and fruitful GP registrar demonstrates that such self-assurance is ground and assembling their crated aircraft workshop, perhaps to discuss both the goals unjustified. His perspective on how of the in fields near St John’s. By that time an and the limits of medicine. Illich revisited, College’s 1999 discussion document, additional 2000 guineas prize had been but with less polemic and more substance. Tackling discrimination in general practice, added by the Ardath Tobacco Company read much more like a defence than an (sport sponsorship by ciggies has a long A few years ago, the term ‘post-modernist’ agenda for change, holds up a mirror — not history) and a gentleman by the name of would have hung over this collection of only to the health service generally but also, Lawrence R Phillips Esq donated a further essays, but I can’t recall seeing the term and more importantly for us, to the RCGP in £1000. anywhere and was glad not to. What it does particular. illustrate, however, is what Alasdair Two flights took off on 18 May, 1919. A MacIntyre describes as the impossibility of Personal accounts such as this and the one Sopwith piloted by Hawker and Grieve securing moral agreement in our culture, or by Aneez Esmail, who describes the early managed to fly 1050 miles, before it was the interminable character of contemporary controversial work that he and Sam forced by engine failure to ditch into the moral discourse. Marinker accepts this in his Everington published on discrimination in Atlantic. The Martynsyde of Raynham and introduction in saying that the purpose of the selection for medical school places, make Morgan has even less luck; it crashed in the exercise is to initiate a debate, and frame the this a highly readable book. However, facts same field it was taking off from! questions in a way that allows illumination and proof of discrimination at all levels of of the issues. Moral certainty in the 21st training and career progression are provided Three weeks later, on June 14, John Alcock century, it seems, is only given, or taken by too and the book contains a substantial body and Arthur Brown in their Vickers-Vimy those such as Osama bin Laden. of evidence. took off from Lester’s Field on the outskirts of St John’s. Like the other aviators, they I go fishing with a friend who tells me that The second part of the book is titled, had no reliable weather forecast and their one of his main aims in life is the avoidance ‘Agenda for action’. Disappointingly, it navigation and in-flight instruments were of dullness. A good way of achieving that is starts with a very short description of the very simple. When ice and snow began to to read and argue about this book. inequality of health service provision obscure the fuel gauges and clog the engine experienced by minorities. This was out of air intake valves, Brown had to climb out place in the section and would have on the wing of their mile-high plane and John Gillies benefited from a chapter of its own. Practical scrape them clear by hand. After 16 hours suggestions are given for policy and 57 minutes flying, mostly navigating development, such as assessing needs of by the stars (when these could be seen), hard-to-reach groups, enhancing they arrived near Clifden on the West Coast communication, recruitment of doctors, and of Ireland. They selected a flat green field harassment policies. They are good starting for their landing, and were soon nose down points for organisations, such as PCGs and in a bog! Fortunately, they were not hurt, Trusts which do not yet have policies; given they claimed the cash prizes, and both were the evidence in the book, they are the knighted by King George V. majority.

Kevork Hopayian

The British Journal of General Practice, January 2002 81 2TheBritishJournal ofGeneralPractice,January 2002 82 reflection of Channel4Television Lorraine Bracco). Dr JenniferMelfi(playedby Courtesy Channel 4,Thursdayevenings The Sopranos T makes bravemenofusall.Mainly, weare we knowhisweaknesseswhich,ofcourse, ourselves verymuchon Tony’s side.Partly, presume, ourfinernatures—wefind So, againstourbetterjudgement—and,we he isacompletejerk. paragon ofrectitude,but,in any normaldrama,theboywouldbea towards hisdaughter’s blackboyfriend.In cliché. Tony, forexample,isvirulentlyracist so bythewritersavoidingeverychanceat discomforting, andconsciouslymademore injudicious federalagents. The ambiguityis devious mobsters,andincompetent him againsttheserriedranksofenviousand we likehim,andareencouragedtosupport he hasfewredeemingcharacteristics.But disloyal, self-indulgent,andplainhomicidal, repelling. Racist,unforgiving, callous, Even foranantihero, Tony ispretty holding ustogether. holding himtogether. And, byimplication, gradually cometocomprehendthestrands his psychotherapy, throughwhichwe and hispsyche. The integratingelementis Tony Soprano’s familylife,hisMob the early20thcentury. Herethethemesare of psychoanalysisandphenomenologysince Interpenetrating themeshavebeenthestuff HE deeper level. takes Mafiafantasytoanaltogether Sopranos is challengingdramaand The Sopranos , own. steam. Tony’s fateawaits,andwithit,our far, therearenosignsitisrunningoutof there arepromisesforatleasttwomore.So The thirdseriesishalf-waythroughand Sometimes itisvainandarealshow-off. comedy, orasendupofsuburbia? making upitsmind.Isitsatire,aLynchian and therearetimeswhenithasdifficulty different episodeshavedifferent authors, all deconstructionists. The stylecanvary, as critics,and dream foramateurfilmand TV mostly itworksperfectly, andtheshowisa and theartcanintrudeonnarrative,but Work’. Occasionally, thatcanbeoff-putting, sings alonginthecartoSteely Dan’s ‘Dirty connection unmade. Tony, forinstance, shows. Virtually noreferenceismissed, major studentoffilmandtelevision,it impossible. The creator, DavidChase,isa To dojusticetotheformisalmost psychopath thantherestofus. than whatwewere. Tony isnomorea father. We maybemorewhatwebecome to berathermoreaboutthesonthan Godfather son isgentlygoingoff therails.Like as achildathisfather’s business.Hisown that hisneurosishasitsseatinrevulsion In recentepisodes,wehavecometolearn our understandingof Tony, andofourselves. Nevertheless, thetherapyisvectorfor symbolism ifevertherewasone. psychiatrist’s couch,anelementarypieceof minimalist, andcontainsadouble and herconsultingroomisclinical, mixture ofcooldisregardandmildterror, Her consultingstyleisanunderstandable she describesasa‘charmingpsychopath’. something arguably unwisewithapatient model atGaultier, anddressesthatpart, viewers willsympathise.Braccowashouse at me’,shepertinentlyobserves.Manymale delights intellingher, ‘likethrowingarock dreams aboutDrMelfi,somethinghe And punishmentitwouldbe. Tony haswet improve, asifthatwerepunishment. with referraltoabehaviouristifhedoesn’t cognitive therapyandeventhreatens Tony psychodynamics, shemeandersthrough best whenstickingtoconventional,focused (unlicensed) forhispanicdisorder. At her Prozac” says Tony, asitisprescribed elsewhere as‘eclectic’:.“herecomesthe ambiguous, fromaschoolreviewed drugs.Hertherapyissimilarly ‘prescription’ particularly dependenceonalcoholand demons leadhertosomedissolution, Jennifer Melfi’s own(asyetunrevealed) figure. PlayedbyLorraineBracco,Dr Even hispsychiatristisanambiguous socialisation. upbringing, oureducation,and ourselves rendereddormantbyour encouraged toseein Tony thatpartof , The Sopranos may wellturnout Stephen Hunter The Handbook of Women’s Health: an evidence-based approach roger neighbour — behind the lines Edited byJo Ann Rosenfeld OFFEE poured, I’m ready to begin what was once called ‘writing’. An intimidating Cambridge University Press, 2001 white screen, labelled ‘New Blank Document’ and destined to become this, my HB, 631pp, £47.50, 0 52178833 1 Cinaugural column for Back Pages, is mouse-clicked into existence. Inconsequential thoughts arise, tantalise, evaporate — ‘In the beginning was Microsoft Word …’

HIS is a comprehensive, well- Some good advice comes to mind — ‘Write about what matters to you.’ OK, so what referenced text written almost matters? Revalidation? The College’s Working Party on cradle cap? No; since the Texclusively by women for use in cataclysmic events of 11 September, hardly anything has seemed to matter as much as the primary care. The authors’ aim is to ‘provide concatenation of atrocity that began that day in New York and Washington. a clear and comprehensive evidence-based primary care guide to the care of women in The images are seared into our collective memory — airliners coming out of a clear blue ambulatory practice — intended for GPs, sky and bringing down the emblems of America’s domination of the world’s agenda. But, nurses and all those who practice primary in every sense except the literal, the sky was anything but clear and blue. The backdrop to care of women’, with an emphasis on the outrage was black with hatred, green with dollar bills, blood-red with history. prevention and screening. They partially succeed. The book is handsomely presented Hollywood knows that, for a movie to feel like it matters, the characters, even the bad in a logical fashion, with recommendations guys, must have a back-story — a past that makes sense of their behaviour — and the Act easily identifiable and small summaries of III climax must catapult them into an unseen but all-too-imaginable future. It’s drummed important points highlighted throughout the into every aspiring screenwriter: ‘Think the big picture before you write the small one’. test. The subject matter is presented as a That is (or should be) what President Bush’s friends are telling him now. We have little to series of lists and tables which makes the send but love to those who grieve amidst the rubble of Manhattan. Instead, our contribution text easily accessible. to the healing process should be informed with the best thoughtfulness we can muster, and that means thinking the big picture. There is one excellent chapter on ‘Woman battering’, which gives a full and detailed Some commentators on both sides of the Atlantic have found the courage to wonder why account of this difficult subject, including the USA — land of the free, the self-fulfilled and the self-obsessed — should find itself so rigorous forensic examination techniques — violently loathed. And if there is to be any healing power in friendship, America’s friends likewise for sexual assault and rape. should help her dare to see a picture big enough to contain the answer. It will have to be done gently yet insistently; for any answer will come in terms of that nation’s reputation as But after that things go downhill. The a bully and a know-all — cosmopolitan, vibrant and creative by all means, but, at least as emphasis is so dominated by American far its conduct abroad is concerned, a bully and a know-all nevertheless. models that one wonders why Cambridge University Press bothered to bring it out on It is, I suppose, progress that the definition of ‘enemy’ has been expanded beyond this side of the Atlantic. Take, for example, particular individuals. I suppose it makes a bigger picture for the war to be against an Chapter 2 and recommendations for annual abstract noun, ‘terrorism’. Yet the dead in America and Afghanistan surely deserve better smear tests and vaginal examination for all than to be thought of just as ideological casualties, collateral damage in a philosophical women between 21 and 70, annual breast war-game. These particular dead should not have needed to die at all. In a war between examination by a clinician, annual abstractions, better weapons than airliners, B-52s, and smart bombs would be other mammography for all women between 40 abstractions — listening, humility, generosity, mutual regard, and even the apparently and 75, and annual blood pressure screening forgotten religious virtues of compassion and forgiveness. for all women over 40. The authors have the good grace to admit that there is little ‘Only connect …’ wrote E M Forster. I’m afraid talk of bullies and know-alls inescapably evidence to support such zealotry, so why do reminds me of the present British government, and indeed of all our recent governments. it? Why medicalise life to this extent? For if sabotage and subversion are the politics of the powerless, the extremities to which the unheard and the desperate are driven when their aspirations are overridden by a And a further recommendation — again complacent Establishment, then maybe some of our own institutions, notably the NHS, are without evidence — that ‘all women of at risk of catastrophic attack out of a seemingly clear blue sky. child-bearing age should take a daily multivitamin’ (in the richest nation on Doctors and patients alike know to their cost that the shameful inadequacy of Britain’s earth!) is simply absurd. health service has not been cured by cosmetic surgery to its management structure or by homeopathic doses of money. They also know that their protestations are systematically Moeover, there is little discussion of the ignored, denied, belittled, and dismissed by our bullying know-all governments. well-known discrepancies in health care provision across the social divide in General practice has been called ‘the art of managing uncertainty’. If only it were that America. And why is there almost no simple. In the consulting room and in our wider professional lives we are having to acquire mention of termination of pregnancy? a new skill — managing disappointment and desperation: our patients’ and our own. And Politically incorrect, or just too dangerous? with that new skill may have to come a new role — the GP, if not as social terrorist, then as freedom fighter. I began reading Handbook of Women’s Health anticipating a medical textbook from The College, like the NHS, is in danger of withering for lack of resources. Many young a feminist perspective, but I was doctors who pass the MRCGP exam don’t continue as fee-paying members. Why? Because disappointed — the largely female they don’t see the College as standing for the things that really matter. And what matters authorship seems, ultimately, coincidental. supremely, I believe, is that the impoverishment of Britain’s emasculated health service is, The most interesting aspect is the different on behalf of its consumers and its providers, exposed and rammed home to Government social and cultural attitudes in the USA, before damagingly confrontational tactics become the only option for the disillusioned. The highlighted as much by what is not College has the people and organisation to lead creative protest. Has it the nerve? discussed as what is. I am not convinced this will add anything more to already available We are in the early months of David Haslam’s Chairmanship of Council. David is my good texts in UK practice. friend, and I know him to be a man of unsurpassed compassion, energy and common sense. So, David — let’s make sure the College is seen to stand for the things that matter. Let’s Linsey Semple think the big picture.

The British Journal of General Practice, January 2002 83 uk council, december 2001

Chairman of Council groups and working parties. Additionally, Council paid warm tribute to the huge lay members of the PLG are invited to achievements and contribution made to the contribute their views and comments on College by Mike Pringle, who handed over responses to consultation documents, which the Chair of UK Council to Professor David we prepare, and to be involved in developing Haslam at the beginning of our meeting. policy. This work is all done voluntarily and Mike’s energy and productivity have been we are grateful for the huge amount of effort truly amazing and the College has a very and time that lay members of PLG in great deal to thank him for. His influence on particular put into this work. David will be the College will last, as we are in a better looking at how best we might be able to position than ever before to influence the support and develop this work in the coming primary health care agenda and with a months. Council was also keen to explore much-improved profile. how more explicit involvement of the RCGP President, Officers public, as opposed to patients, might be and Chairs 2001-02 50th Anniversary of the College taken forward. The AGM marked the start of the 50th President Anniversary of the RCGP. This will be an Modernising the NHS Professor Dame Lesley Southgate opportunity not only to celebrate the past but At Council we had the usual updates on the how we can support members effectively modernisation process across the UK which Chairman of Council Professor David Haslam through the many changes and challenges as ever shows the diversity of the NHS as that are being presented to them. See well as the common themes in the four UK Vice-Chairman http://www.rcgp.org.uk/50th/index.asp countries. In England, the introduction to Dr Mayur Lakhani Parliament of the NHS Reform Bill sees the Vice-Chairman Simulated surgery and MRCGP proposals for restructuring the NHS given Dr Tina Ambury A motion from the North East London legislative shape. The strength in the College Faculty on this subject was debated, and will in having firmly established bases in the Honorary Treasurer be considered by our Quality Network, country capitals is again being demonstrated Dr Tony Mathie looking at the feasibility and resource by the information we glean and can discuss Honorary Secretary Dr Maureen Baker implications of offering candidates a choice by means of these reports. of using video or simulated surgery. The Chairman of Scottish Council Network will report back to Council in due Workforce and morale Dr Bill Reith course. Comments welcome. A recent survey by the GPC and the Chairman of Welsh Council Department of Health’s General Practitioner Dr Terry Davies Chairman’s strategy Recruitment, Retention and Vacancy Survey Chairman of Northern Ireland David Haslam brought a paper to Council, set out very clearly the difficulties of Committee explaining his two main themes. First the attracting doctors to work in general Dr Peter Colvin greater support for and involvement of practice, retaining them in active and Chairman of Quality Network members in the work of the College. This effective service, morale problems, and Dr Has Joshi will be demonstrated by a number of ideas to avoiding undue early retirement, as well as Chairman of the Examination be developed over the coming months. The the problem of the growing number of GP Board second plank of his strategy is to look at how vacancies. Dr Valerie Wass even more effective involvement of public Chairman of Clinical and Special and patients in the work of the College, with These are all alarming signs. Our debate Projects Network GPs and in primary care can be achieved. focused on the issues to which we have Dr Joe Neary Council offered David Haslam many ideas drawn attention over the last few years. We Chairman of Education Network Dr Steve Field and aspects which could be woven into these have repeatedly pointed out to the Chairman of Research Group themes. Departments of Health the folly of failing to Prof Amanda Howe continue to build the training numbers for Chairman of Publishing Network Other activities and papers before Council the GPs, to recognise the way the GP Professor Ruth Chambers are linked with these themes. workforce is changing, and the need for an Chairman of International effective and comprehensive training regime Committee Council was pleased to support the concept for GPs. While announced increases in GP Dr John Howard proposed by David Haslam of developing a numbers and training places are welcome, Chairman of Ethics Committee Dr Iona Heath virtual e-mail discussion group alongside these will all take time to feed through. Chairman of Patients' Liaison the existing routes for feedback and ideas Group (PLG) through faculties. Council, guided and We have particular concerns that when the Mrs Eileen Hutton supported by CEC, will of course remain the Medical Practitioners’ Committee ceases to College’s policy-making body. The concept function, from April 2002, there will be no As you know, these Council of a virtual discussion group will be body with the responsibility to ensure summaries now appear in the open developed and we shall advertise for equitable distribution of the workforce on a area of the Website volunteers in the BJGP soon. national basis. This is likely to reinforce (http://www.rcgp.org.uk/rcgp/cor existing health inequalities, as areas of porate/council/coun_index.asp). We are now putting on the website There was a paper from David Haslam and greatest deprivation already have the a list of the College responses to the Chair of our Patients’ Liaison Group greatest difficulties in recruiting and consultation documents on a (PLG), Eileen Hutton, looking at the way retaining GPs. In Sunderland — the most monthly basis that patients and the public could be more understaffed PCTs in England — there are (http://www.rcgp.org.uk/ effectively involved in the work of the only 30 GPs per 100 000 patients — rcgp/corporate/viewpoint.asp). College. Already, as the first College to compare and contrast with Hounslow in This links the relevant College web introduce a PLG from 1983, we have lay Middlesex, where there are 70 GPs per pages and website across the four involvement not only at Council and at 100 000. In Liverpool alone, 84 additional UK countries. Executive Committee level but also on many matters arising GPs are required to bring the area up to

84 The British Journal of General Practice, January 2002 neville goodman national averages. NICE Workforce and morale need to be central HE House of Commons’ Health Com- issues to changes we expect to see in the mittee is undertaking an inquiry. It is future, such as the SHO Review, the Tasking whether NICE is doing its stuff. I Medical Education Standards Board, and the really don’t know whether to laugh or cry. emerging primary care structures across the UK. ‘Quick wins’ were unlikely to be Since Clinical Governance was introduced in possible and stop gap measures, such as 1998 as the way to save the NHS for the bringing in GPs from Spain to North West nation and from itself, scarcely a week has England, were inevitable provided that gone by without one of the big boys (Blair, standards are not compromised and the Brown or Milburn) announcing another doctors are effectively inducted to the NHS. reform, review, reorganisation or modernisation. I’ve lost count. Derek Revalidation and appraisal Wanless (surrogate for Brown) is the latest. We had further updates on the introduction He’s decided that the underfunding is worse of revalidation across the UK countries and than anyone thought and that general taxation how appraisal is being developed. The final remains the most effective way to pay for form of appraisal across the UK is still health. But there’s another review (for Blair uncertain, with different models being this time) in the pipeline, so that may change. proposed and tested. The School of Health and Related Research (of the University An editorial in the BMJ gives the clue to the Sheffield) (ScHARR) had produce a report Government’s difficulty with the NHS. commissioned by the DoH in England on Nicely understating, Smith, Walshe and appraisal. This is a formative approach to Hunter (BMJ 2001; 323: 1262-1263) wrote: appraisal and was generally supported by ‘Governments often regard a degree of Council. It remains to be seen if it will be medical disapprobation as a sign that their accepted by Government. NHS policies are generally heading in the right direction.’ It’s the Government’s Reforming emergency care difficulty with everything: transport, crime The DoH in England has issued Reforming and education, as well as the NHS. The Emergency Care, which looks at the spread government believes it knows more and of activity across primary and accident and cares more about everything than anyone emergency care and asks how admissions else. Anyone else includes not just those who and management of those processes can be actually run the service, but particularly and better controlled. Council expressed a wide especially those who run the service. Unlike range of views about the interface between politicians, whose every thought and deed is primary care and A&E services and the way altruistic, railways workers, policemen, in which these services were used by teachers, doctors and nurses serve merely patients. We discussed the tensions that exist their vested interests. This has now come to between the greater use that could be made include NHS managers who, according to of primary care services and the capacity to Alan Milburn, have ‘never saved a life’. It provide such services. Vice-Chair, Tina would be churlish to say that this cheap jibe Ambury, has been asked to lead a small is even more true of Mr Milburn. group looking at these issues. But where does NICE fit into all this? It fits eBJGP because all the problems with NICE that the It has long been a wish of the College to Health Committee will uncover were have an online version of the BJGP and foreseen. They were discussed at a fresh proposals came before Council which conference in 1999, which — whaddya appear to offer a good value way of know? — no-one from NICE was able to achieving this. Council was happy to attend. Take the myth that NICE could end support the proposal, which will now go postcode prescribing: if health authorities are forward to be considered alongside other forced to buy expensive cancer drugs from a demands on our limited resources during our limited budget, then some other drug, forthcoming College ‘budget round’. operation or service has to go. Different health authorities will restrict different things Next Meeting of Council (remember devolution from the centre?), so UK Council next meets on Friday, 25 access to treatments will still depend on January 2002 at Princes Gate. Also, the next where you live; the restrictions will simply John Hunt Lecture will be held on the be less obvious. And if the government evening of 24 January 2002. The speaker resists special interest groups as feebly as it will be Sir Alan Langlands. Details are resisted the multiple sclerosis lobby over β- available via [email protected]. If you interferon, then NICE might as well shut up require any further information on the issues shop. To set up a flawed review or committee above or on other matters discussed by and then ignore it is throwing out the baby Council, please contact the Honorary but keeping the bathwater. Treasurer at [email protected]. Miles A, Hurwitz B, Bentley P. (eds). NICE, CHI and the NHS reforms: enabling excellence or Maureen Baker imposing control? London: Aesculapius Medical

The British Journal of General Practice, January 2002 85 our contributors saul miller

Maureen Baker is Honorary Secretary of UK Democracy Council of the RCGP SIDE from the irony of the current anthrax scare in the USA (the citizens of that fine country freely stockpiling their own personal supplies of the wonder-drug, Stefan Cembrowicz is a GP in Bristol Aciprofloxacin, while here in Blighty my practice faces penalty if we prescribe more Yvan Fontanel was formerly a BBC than a handful of the stuff in a year). Aside from that, yet another example of America journalist, and was project manager for a CME failing to take note of Northumbrian health policy, the main disquiet I feel about current development project in Macedonia. He is world events is that democracy should be the concept our armed forces are claimed to be currently writing a book about his experiences defending in the Afghan offensive.

John Gillies practises in Selkirk. He was the I could cope with freedom, I can understand why it isn’t capitalism, but I do have my driving force behind the Medicine and Society doubts about citing democracy as the concept in need of such a defence. Bear in mind that Working Party, organised jointly by RCGP it was less than a year ago that George W Bush himself made it to the White House, the Scotland and the RCPEd. legal victor in a presidential election despite polling fewer votes than his opponent. Note Neville Goodman is a consultant anaethetist too that our own parliament has not been allowed the opportunity to debate the War on at Southmead Hospital in Westbury upon Trym, Terrorism before it was launched. Bristol Perhaps such inconsistencies as these merely serve to show that translating the democratic Kevork Hopayian is a GP in Suffolk ideal into practice is not easy. No doubt a part of the Queen’s security of tenure rests on the [email protected] fears of the British populace as to just who they might end up with as head of state if democracy were introduced. Amanda Howe is professor of Primary Care at the School of Medicine, Health Policy & Practice, University of East Anglia, Norwich, But I should come clean here and admit that my difficulty about what democracy really is, and chairs the RCGP Research Group also stems from events much closer to home; closer, even, than what goes on in London. It [email protected] is to do with all of the consultation exercises we are currently having to endure.

Stephen Hunter is a consultant psychiatrist The local primary care group is about to become a Trust. The local health authority is about in South Wales. He is one of few Scots who can to amalgamate with others and become even less local. And all stakeholders have to be sing in Welsh consulted about every such change (if I am a stakeholder at all, it is only in respect of a long pointed stick I carry in the hope of violence). Democracy in action. David Keene is based at City and Hackney Primary Care Trust, in London [email protected] Consultation exercises when I was a boy took the form of my mother asking me what I wanted for pudding before she had decided. Consultation exercises were not, of course, a Mayur Lakhani is a vice chairman of UK daily occurrence (far from it, if anyone is interested in my heart-rending stories of a Council, RCGP deprived childhood) but when they did occur I invariably got the pudding I wanted. If I were to relive my childhood under the current system, my mother would decide, canvass Robert MacGibbon is GP with 30 years of my opinion, and then produce a big glossy brochure at tea-time to inform me that what she bicycling experience in Islington, Norwich, has chosen for my pudding is what everyone wants for pudding. Cambridge and on the war torn roads of Kosova [email protected] More fundamentally still, the one question never asked in any of these consultation Saul Miller practises in Belford, exercises is ‘should we be doing this at all?’. Which sounds suspiciously like the question Northumberland — [email protected] that the House of Commons debate on the War on Terrorism will be too late to consider if such a debate ever takes place. Roger Neighbour is the Convenor of the RCGP Panel of Examiners and is based in I am not a great believer in direct action. Bit of a wimp really, if the truth be told. I have Hertfordshire [email protected] thoughts like these without ever actually doing anything about them. Although lately I do find ‘ciprofloxacin’ on more prescriptions than perhaps I ought. Trefor Roscoe is a GP informaticist from Sheffield

A Lanarkshire nine year old has desribed Linsey Semple as ‘short, strict and exquisite’. She is an associate advisor in the West of Scotland deanery, and a principal in Mosspark, Glasgow

Peter Toon is a non-principal GP. He has been the RCGP St Petersburg Fellow since 1992, and has worked on development projects in Macedonia, Croatia, Latvia, Uzbekestan and Russia. At present he is taking a break from working abroad to spend more time developing primary care from his computer in the Open Learning Unit at UCL and less at Vienna Airport.

Graham Worrall is a GP in Newfoundland, Canada, and is a member of both the UK and Canadian colleges of general practice [email protected]

All of our contributors can be contacted via the Journal office at [email protected]

86 The British Journal of General Practice, January 2002