I hate mornings. The delights of the rosy-fingered dawn are not for me unless I'm seeing it through a vague noisy haze, wondering if it is excessive to open another bottle of wine. Occasionally though, life and nature can produce a surprise. In deep December, on an overnight COOP shift, we set out in the dark on a late call to a quarry village on the edge of our area. Neither the driver or I knew it well. We became frustrated driving aimlessly around various unpromising-looking streets, lit in a drab orange glow by street lamps working late on a winter's morning, just like us.
Suddenly, as we turned another corner the light changed dramatically. Out of range of the lamps the real world was already awake and bathed in a beautiful early morning light that the sodium lamps were hiding. We realised the road was now on the edge of the limestone crag on which the village is perched and unfolding in front of us was a spectacular view extending for miles down the beautiful Gwendraeth Valley. A ribbon of mist clung to the river and snaked its unbroken way to the deep blue calm of a glassy Carmarthen Bay clearly visible in the distance. A few miles downstream the ancient Norman Cydweli castle stood proudly as if it were arising mysteriously out of the mist itself. The valley below is supposed to be the site of a legendary battle. The beautiful princess Gwenllian, in the absence of her husband, had led troops out against the invading Normans and died in the ensuing battle. Her body is still said to roam the area looking for her head buried near the river. The whole scene had a cinematic splendour that left us speechless for a few minutes before we turned around to get back to our work.
Lighting up the landscape of general practice seems to be troubling the minds of many of my elders and betters. Recently, Baroness Young has suggested using the various guidances issued by NICE as shining searchlights that will show up every deficiency.1 She has threatened severe punishment for any GP caught in the harsh beams trying to jump the fence of clinical regulation.1 Meanwhile, Ben Bradshaw wants the combined view of patients gathered on rating style websites to give a sort of general glow that will also bring to light the good the bad and the ugly among us.2 Any opposition to this is viewed as a backward attempt to close professional ranks. Maybe it is, but maybe it's because it takes years in a profession to understand its subtlety and complexity. Over time I've realised that the landscape of general practice is richly varied and unpredictable, occasionally routine and drab, sometimes frustrating but at other times wonderful and life enhancing. People looking in expect a sort of simplistic order like some mythical Pleasant Valley suburb, all the houses looking the same with white picket fences and uniformly manicured lawns.
The landscape is shifting and sometimes conflicting. I would have failed my finals, not that long ago, if I suggested treating someone with heart failure with a beta blocker. Patients views can reveal a lot, but what about the times when they are unhappy? The times when what they want is against the Baroness's nice advice;1 for example, concerning antibiotic or hypnotic use? What sort of light would their opinions shed if they posted on Ben's website? Perhaps Ben and the Baroness can slug it out periodically for our entertainment.
Scrutiny is the spirit of the age but the scrutineers need to realise when it is harmful. They need to know that not all opposition is reactionary and that the people involved are not always trying to protect themselves but trying to preserve something that they know, from hard earned experience, to be valuable.
Artificial light is good at exposing areas of darkness but sometimes it can hide the beauty and splendour of what is there naturally.
- © British Journal of General Practice, 2009.