Visiting Julian and Mary Hart at Glyncorrwg in South Wales in the 70s and 80s, as hundreds did, and experiencing their rich mixture of hospitality, fine food, and brilliant conversation, was to live life temporarily on a higher plane.
As a visiting medical student in 1975 on my first night out, listening to men in a pub singing ‘Delilah’, ‘Myfanwy’, and Verdi’s ‘Chorus of the Hebrew Slaves’, I got an early taste of the strength in depth of a mining community.
Dr ‘Art (without an H) lived in such a community with his patients:
‘From many direct and indirect contacts, in schools, shops and gossip, I have come to understand how ignorant I would be if I knew them only as a doctor seeing them when they were ill.’
(1973)
Julian hated when bad things happened to his patients, especially when they could have been prevented. He embodied the ‘worried doctor’, seeing his job as anticipating and avoiding patients’ problems, not waiting for them to happen. He described a 42-year-old man, invalided by a leg fracture. He had become obese, had high blood pressure and cholesterol, got gout, and was drinking too much. After 25 years, 310 consultations, and 41 hours of work:
‘… intially face to face, eventually side by side, the most satisfying and exciting things had been the events that had not happened: no strokes, no heart attacks, no complications of diabetes.’
(1988)
Years later we asked Julian what had happened to this patient. He had died of something else, but, when Julian told us this, there was a tear in his eye. His patient had become his friend.
Julian was the first doctor to measure the blood pressures of all his patients. What he did for patients with high blood pressure, he did for other patients, delivering unconditional, personalised continuity of care. After 25 years, premature mortality was almost 30% lower than in a neighbouring village; a rare example of what a GP can achieve in a lifetime of practice.
With Medical Research Council funding, Mary and Julian carried out a series of practice-based epidemiological studies in which everyone’s contribution was important and the study wasn’t complete until everyone had taken part. He applied the same approach to clinical care.
Julian was embedded in the present but thought, wrote, and talked about the future, as a tireless advocate of what health care could and should achieve. He was at his brilliant, exhilarating best in impromptu, unscripted exchange. He could argue until the cows came home and in his younger years took no prisoners.
Many people quoted his Inverse Care Law (described in 1971) without seeming to understand its meaning, so he put it more simply: people without shoes are clearly the ones who need shoes the most.
Standing for election to RCGP Council in 1983, Julian topped the poll. He offered GPs an image of themselves as important members of the medical profession — alongside specialists, not beneath them.
He saw health care as a way of producing social value, achieved by doctors and patients together, transferring knowledge, building confidence, learning to live better and longer.
He argued that the NHS is not a business to make money but a social institution based on mutuality and trust: the ultimate gift economy, getting what you need, giving what you can, a model for how society might run as a whole. In rebuilding society, cooperation would trump competition, not marginally, but as steam once surpassed horsepower. The Glyncorrwg research studies showed glimpses of that social power.
My daughter who met Julian many times said that losing him as a person was like the burning down of the Mackintosh Building at Glasgow School of Art — we had lost someone dear, a big part of our lives, an institution, a one man School of ‘Art, full of life, light, and creativity.
Julian’s gift to general practice is not the example he worked out in the microcosm of a Welsh mining village over 25 years ago; it is the challenge of giving practical expression to his values in local communities in the future. In honouring his memory, there is work for all of us to do.
- © British Journal of General Practice 2018