May Focus

David Jewell

Reviewing an account of a celebrated Victorian murder, in The Guardian, Ian Rankin quotes the author describing pioneering detectives as taking over from priests and prophets the task of bringing order out of chaos.* On page 355 of his Pickles lecture, Sean Hilton introduces the idea of ‘chaordic organisations’ that exist in between order and chaos, of which the NHS is a prime example. There's an echo here. Some years ago David Metcalfe presented a diagram showing general practice occupying the space between the hard-edged world of hospital medicine and the messy world our patients inhabit. Trying to make sense of the disorderly way in which our patients experience illness is another way in which we try to create order; and so, in a different way, is conducting and publishing research.

Hilton also quotes the Physicians' Charter of 2002 in its statement that the requirement for medical professionalism in the new millennium rests on three fundamental principles (patient welfare, patient autonomy, and social justice), and on a set of professional responsibilities. Medical professionalism defies easy definition, but is essential for the trust between professionals and society, without which practising good medicine becomes impossible.

The supposed loss of trust is rarely out of the news, and in the UK is regularly linked to the recent high profile enquiries that followed various scandals. On page 307 Richard Baker revisits the recommendations of the Shipman Inquiry to assess how far they have altered medical practice. Some changes have occurred, most notably in the composition and processes of the GMC, but there are many more new regulations on the way. One of them was to promote mortality monitoring, and the paper on page 311 concludes that no system is likely to identify another murdering GP, not least because of the frequency of partnership changes within practices. Perhaps mortality monitoring should be divorced from the idea of identifying murdering doctors, and thought of as just another indicator to help focus on quality (page 316). The prospect of more regulations has a baleful ring to it and is unlikely to induce overwhelming optimism among UK GPs (page 376).

We're not the only ones dancing to the tune being played by the Department of Health. Ashley Liston describes his move from a comfortable practice to work in a ‘needy area’ (page 368). Having reinvigorated a struggling practice as a salaried doctor, he found himself competing with commercial organisations for the privilege of running it. He managed to get the PCT to recognise the value of what he was doing, but he acknowledges that the PCT were required to follow the procedures set out by the Department. He anticipates that when we come to compete, the commercial organisations will concentrate heavily on customer satisfaction.

However, in the study on page 346 analysing data from practices using the General Practice Assessment Questionnaire, the authors sound a note of caution. They conclude that measuring enablement may be a reliable indicator of quality, but report that: ‘satisfaction and enablement are only modestly related’. Patients with long-term illness reported lower enablement scores, while those from ethnic minority groups had higher scores. Oddly, patients in the middle age bands reported lower enablement scores while the older ones had similar levels to those in the youngest age groups. All a bit mysterious.

And just as mysterious is the illness behaviour reported on page 318. For years we have lived with the notion of older patients being more stoical and less likely to consult than younger ones. In response to a single vignette of a patient with chest pain, older participants were more likely, not less, to consult a doctor. This is inconsistent with other research showing lower rates of access to cardiological services among older patients. One possibility is that older patients experience less severe symptoms, and presenting a single scenario obscures the difference. At any rate, with such conflicting evidence it becomes a challenge to create order.