The toughest part of returning to general practice after a 4-year break is witnessing the crisis of trust in medicine that I helped precipitate. In 1992, I exposed the high mortality rates for complex child heart surgery in Bristol. Alas, it was in a satirical magazine under a pseudonym, but a belated public enquiry found that the columns reached the top table, yet no-one was prepared to investigate and protect patients from unnecessary harm. When I was called to give evidence, I said that all surgical teams should have their work independently audited, risk-stratified, and published because ‘doctors can no longer be trusted to regulate themselves in secret’.
I'm not sure why I'd become so pious. Certainly half a day in the witness stand had ruffled my feathers, particularly when I was threatened with a custodial sentence for not revealing all my sources. But the seeds of my doctor-baiting were sown much earlier, when I was at medical school. The hierarchy, arrogance, and ritualistic abuse of teaching hospitals were more than the Australian half of me could bear. So I laughed it off and left with a one-line reference: ‘Refuses to take medicine seriously; does not deserve a St Thomas' housejob’.
I decamped to the West Country and fluked my way onto the Bath vocational training scheme, in the days when people wanted to be GPs. In 1990, fluffy medicine was at the fore. Course organisers took new recruits for walks on Weston beach with paper bags on their heads. We'd role-play kings and queens and throw cushions at each other. I bought my first pair of hiking boots and wore tortoiseshell spectacles and a cuddly lambswool sweater. I even cut a hole under one arm so I could lean back and let patients know ‘hey, I'm not a God, I'm a doctor … and I'm human’.
OK, I wasn't quite that soft but I did buy The Inner Consultation and managed to keep a straight face when a very hirsute man lent forward in my MRCGP oral and asked ‘What does Michael Balint mean to you?’. In surgery, I saw old ladies who popped in on their way to Safeway's because they wanted a chat. My wise trainer explained that older people could go for weeks without anyone touching them, and 10 minutes' hand-holding was an entirely legitimate use of a GP's time. When he retired, he summed up his 40 years in general practice as: ‘Saved two, killed one … No, actually, it was the other way round.’
Fifteen years ago, we were trusted to provide an extensive, holistic, but largely unmonitored, service. We knew our value intuitively but could never prove it on a spreadsheet. We helped people through their lives and accepted them as they were because we'd learned the hard way how difficult it is to change someone who doesn't want to be changed. Or, as one memorable patient put it: ‘I just want to be well enough to do the things that made me ill in the first place’.
But Thatcher had other ideas. She demanded to know precisely what GPs did with their time, where all the money went, and why patients were still so unhealthy. My trainer advised me that the golden days of clinical freedom were over, and now was not the time to become a principal. So I decamped to the Edinburgh Fringe Festival.
In one sense, satirical comedy is a lot easier then medicine. You simplify and crystallise problems without ever offering solutions. You blow everything out of the water and leave others to pick up the pieces. But it's also a lot harder; many people would rather eat their grandmother than speak in public. You can be a dangerously bad doctor and still have a waiting room full of patients but if you're not funny on stage, you starve. Counting bums on seats is as accountable as it gets.
I did 5 years at the Fringe, gleefully taking a swipe at every possible target and working as a locum in between. But I was deluded into believing that satire can change things. When I started writing for Private Eye in 1992, I thought it might make a difference. In 1996, I went public on BBC2 , presenting Trust Me, I'm a Doctor, a sort of evidence-based medicine for the masses with the not-so-hidden message ‘don't trust them just because they're doctors’. The NHS was an easy target; there were huge ‘Bristol-type’ variations in the quality of care for just about every treatment you could name. We encouraged patients to shop around and ask ‘how likely is it that you'll kill me?’ Doctors had to earn their trust.
The audience figures were never huge, and the stockpile of remaindered books in my garage suggests this was an idea before its time. Patients found that if they asked difficult, awkward questions they got difficult, awkward answers, riddled with uncertainty and insecurity. And once they'd abandoned the cosy certainty of blind faith in their doctor, they couldn't get it back. It's ironic now that, as medicine is being sacrificed on the altar of accountability, patients are flocking to the magic and mysticism of complementary therapies. Doctors have become toothless magicians with all their tricks publicly exposed, so people seek the rabbit of the homeopathic hat.
A month after the Kennedy inquiry, my step-father had a heart attack, requiring urgent surgery at our local unit — Bristol. Now was the chance to practise what I preached. I accompanied him onto the ward, armed with my list of awkward questions, but before I could open my mouth, a nurse spotted me and said to the Professor of Surgery, ‘You know who that it is, don't you? You'd better not screw this one up’.
In her excellent Reith Lectures,1 Onora O'Neill hit the trust nail on the head: ‘Trust is necessary precisely where we can't be certain. If we had certainty, we wouldn't need to trust’. But has the plethora of post-Bristol accountability mechanisms helped to restore trust in doctors? O'Neill is unconvinced:
‘We seek greater trust by appointing supervisory bodies, ordering audits, stiffening professional codes, and publishing league tables of performance. But it is far from clear whether they achieve what they set out to do. In some respects they make matters worse.’
So now you spend half the day proving you can do the job you've been doing for 20 years. How can the GP tree flourish if you dig it up every day to check the roots? The managed care that now pervades general practice is an extension of this new accountability. Doctors can no longer be trusted to decided how best to spend the consultation, so risk management does it for us and nudges holism out of the window. As we aggressively treat older people with hypertension, they all end up in the falls' clinic. Nurses who used to have time for laughter and therapeutic gossip are now slaves to the GMS2 template. If you don't take on your enhanced services, they'll be farmed out to the supermarket at half price.
This splitting up, coding, and costing of medicine into marketable chunks may well be a prelude to full-scale privatisation. Everyone is now skilled-up, fit for purpose, and sent off to do their particular protocol-based chunk. In this model, it's hard to justify the cost of a GP when you could get two nurses, a healthcare assistant, and a new computer for the same price. But no-one has the world view and the wisdom any more. Just as surgeons now specialise in the north face of the gall bladder, family doctors will become marginalised computer buffs who spend the day wondering why every Lablinks result has a sodium level of 125 mM. Their only human contact will be complex over-medicalised patients who don't fit into an algorithm.
There's a real danger of collusion of anonymity, when no-one takes responsibility for conflicting parcels of care. And the government's ‘Red Army’ approach to NHS computing suggests these little parcels of care couldn't communicate with each other even if they wanted to. So, who will the confused and distressed older people turn to when the ASDA warfarin clinic has shut and they can't remember what dose to take? Us, I suspect. Or the out-of-hours call centre 20 miles away.
Patients are now supposed to be informed consumers armed with the power of choice, but the flip side of this is ‘if it goes wrong, it's your fault’. If they choose cherry-picking treatment centres for their hips and hernias, and force the closure of their local district general hospital, that'll be their choice, not that of the politicians. Shifting the balance of power cleverly becomes ‘shifting the blame onto patients’.
GPs I meet seem divided about this new direction. Some enjoy the simplistic focus of GMS2 and are busy hitting their targets in the hope that the PCT will have enough money to pay up. Others are optimistic that the focus on traditionally non-sexy areas, such as stroke, will improve the quality of care. But the coercive nature of targets is at odds with the mantra of informed choice. There is no time to inform patients about the pros and cons of treating mild hypertension or atrial fibrillation, and financial inducements favouring treatment have a nasty habit of clouding judgement: ‘I'm treating your blood pressure so I can send my kids to private school’. The new contract may make us richer, but I doubt it will make us wiser.
- © British Journal of General Practice, 2004.
