This month’s issue of the BJGP takes vulnerable people as its theme, with articles on the homeless, frail older people, asylum seekers and refugees, people with multimorbidity, and the socioeconomically deprived. Each of these groups can face challenges in obtaining access to high-quality health care, coping with everyday life, and pursuing fulfilling work and leisure activities ... but doesn’t that sound familiar? The reality is that we are all vulnerable people. Ill-health simply adds to the range of threats that we face on a day-to-day basis, whether from pollution or climate change, violence or terrorism, failing economies, or failing governments.
Aneurin Bevan, the architect of the NHS, understood much of this when he wrote In Place of Fear in 1952, in which he described the establishment of a national health service which removed the fear that attended sickness among people who could not afford to pay for medical attention. It’s almost impossible to overestimate the benefits of that breathtakingly imaginative and generous political act. It’s so important to remember where the NHS came from and what it meant, although I fear that we are beginning to forget.
Twenty or thirty years ago, altruism was hardwired into the system. There was a mutual recognition of patients’ needs for care and the willingness of their doctors to go beyond their contractual requirements to meet them. Patients were not seen as a bit of a nuisance — ‘Only one problem per consultation please’ — and although doctors could seem paternalistic and remote, by and large they didn’t watch the clock. This may not have been a golden age, but the NHS seemed a kinder, gentler place than it has become.
There are endless reasons for finding ourselves in a crisis of confidence in the NHS. Many are to do with a systemic failure to acknowledge that we have lost much of the social glue that has held the service together, through the erosion of partnership working in general practice and the gradual disappearance of continuity of care, the loss of the firm structure in hospital medicine, and the disappearance of the small comforts which made arduous work more tolerable. This dislocation unfortunately extends to the wider relationship between the public and the medical profession, which seems to me to have abandoned social purpose for a cool pragmatism, in which health policy no longer has a social conscience at its core. Commodification, competition, and ratings have replaced collaboration and trust, and we are now used to the languages of business and managerialism, where health care is delivered by providers, and service users access healthcare professionals in primary care settings. We sleepwalk into using the ugly lexicon of the Department of Health, and we do so at our peril.
Many clinicians completely understand this, and an impulse to achieve wider social benefits informs their thinking and their actions. In general practice the Deep End Movement is an example of this,1 and in specialist medicine, Richard Horton has pointed out that the Lancet Liver Commission showed that hospital specialists can be just as active in tackling deprivation, poverty, inequity, social exclusion, and stigma,2 although in the same article Horton calls to account the major UK health institutions, who are virtually silent on campaigning against health inequality and health injustice.
In this issue, Graham Watt’s editorial on this subject is essential reading. It is a call to action for general practice and offers a powerful way of inspiring the next generations of GPs and providing a metric which goes beyond the measurement of traditional health outcomes. Echoing the ideas of Julian Tudor Hart, Watt asks how publicly funded doctors can contribute to society:
‘Julian Tudor Hart maintained and demonstrated throughout his career that the NHS could and should be a model for wider society, as a gift economy based on giving as well as getting. Inclusive health care, excluding exclusions and building relationships, is a civilising force in an increasingly dangerous, divided, and uncertain world.’
- © British Journal of General Practice 2019