Reading Glyn Elwyn's editorial on page 403 reminded me of Chesterton's comment on Christianity: ‘The Christian ideal has not been tried and found wanting. It has been found difficult; and left untried.’ The current scene in primary care is of valiant efforts being made to improve the ways in which we work, in lots of different areas, but finding the task more difficult than expected.
For instance, it ought to be right, for lots of reasons, for patients to take more control of their own problems, but somehow it doesn't happen, even in the field of mental health (page 415). Both here and in the study on page 407 some of the barriers are familiar (not enough time, not enough explanation), but others are less comfortable: doctors finding it difficult to give up control, and patients feeling that they need more attention paid to the underlying reasons for their behaviour.
Elwyn's editorial fears that the UK's GP contract, with the introduction of powerful incentives to achieve specified targets, has pushed patient–centred care further away. The fear is echoed in the account of a conference examining the effects of the contract (page 464), where specifically the consultation rates for depression and anxiety have fallen. This is despite a substantial increase in the rates of prescriptions for antidepressants over a different time period (page 423). It raises the spectre that whatever our high ideals are, our collective behaviour may still be driven more by commercial interests than by science, a point made powerfully in a book review we published in July last year.1
On page 474 Emyr Gravell compares modern medicine to playing the tables in a casino — a comparison that some of our patients might find a little shocking, but it's one of the criticisms that complementary therapists level at conventional medicine all the time. The study on page 444 is another valiant attempt, this time to assess the effectiveness of spiritual healing in asthma. The study was unable to produce clear evidence of effectiveness, but it raises lots of questions about what spiritual healing is, and whether it can be standardised. Herbal remedies (page 437) lend themselves much better to the randomised controlled trial approach, for obvious reasons.
The editorial on page 404 discusses the fate of comprehensive screening for the elderly, another one of those ideas that seemed to hold out so much promise in the past: the authors pronounce it dead, but the pronouncement has not deterred them from wanting to pursue the search for an assessment instrument to be used more selectively.
Then on page 466 Norman Beale discusses another of the Holy Grails, a means of reducing social inequalities in health. He has chosen not to put it all down to a failure of political will, as many of us do, but blames it partly on the very blunt methods currently in use for assigning social status, arguing instead for the use of the Council Tax Band to provide data more closely linked to individuals' needs.
Here in the UK there has been much public debate about euthanasia and assisted suicide, prompted by Lord Joffe's bill in the House of Lords. At the time of writing this the bill has just failed to get its second reading, effectively condemning it to an early death (Lord Joffe has said he intends to reintroduce it, but why it should take up parliamentary time when it has been so comprehensively rejected is beyond me).
On page 450 there is a report of the views of Welsh GPs on euthanasia and assisted suicide, and as a group they are very firmly against either. Many will be encouraged by this strength of feeling, but I feel uneasy. Opinion polls tell us that the public is increasingly willing to consider having such acts legalised. Is the profession simply, once again, showing itself to be more conservative than the general public? Or, more worrying, are we telling the public that we know best, and that their views count for nothing? Or are we, in aligning ourselves with the Anglican Bishops (back to Christianity again) taking a responsible moral stand in holding back the morally relativistic tide? To discuss this further visit our discussion forum: http://www.rcgp.org.uk/Default.aspx?page=3495
- © British Journal of General Practice, 2006.
