AUTHOR’S FOREWORD
In 1977 the World Health Assembly of the United Nations agreed that:
The main social target of governments and WHO in the coming decades should be the attainment by all the citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life.
This was further elaborated at the WHO Alma Ata conference in 1978, with a declaration endorsed by the British government, which spelled out that this ambitious target could never be achieved by medical action alone, centred on hospitals. It depended on adoption of health-oriented policies on incomes, housing, transport, nutrition, education and sport, but above all on development of primary health care as the foundation and principal focus of future health services.
The British government later endorsed the 38 regional targets set by WHO Europe to implement the Alma Ata declaration. Despite all the rhetoric no British government has yet made any substantial changes in health policy to translate the slogan of Health For All into a reality. Government welcomed the implied de-emphasis on hospital services, because they are expensive; but the emphasis on environmental and social improvement was first ignored, and finally opposed. As for primary care, British governments have assumed that this simply means the work of general practitioners, plus some dentists, chemists and opticians as a peripheral afterthought. As all of these are in Britain still private entrepreneurs, albeit in loose contract with government to provide public services, their work is unplannable and the government has no plan. The central actors are the GPs; they occupy the stage, and without their consent, the play can’t proceed.
The medical profession has until recently insisted on its unique responsibility for maintaining the health of nations. There are of course many other ways, often much more important, in which health can be either damaged or conserved, but so long as doctors retain this unique role, other people who want to take effective action on health are prevented from doing so, and governments are provided with a credible excuse for inaction. One solution, much written about but not as yet put into practice anywhere, is to bypass the doctors and construct primary care systems without them. A curious feature of this strategy is that none, so far as I know, who have advocated it for other people, have ever accepted it for themselves. Another, the one advocated in this book, is so to change the clinical and social orientation of the medical profession that it can accept teamwork in primary care as a central and obligatory rather than peripheral and optional role.
Indignant descriptions of what’s wrong with society, and the doctors’ role in it, are increasingly superfluous and irrelevant; few of us need convincing that there are more and more reasons for despair, not only about our own society, but about the future of mankind. Somehow we have to find rational, historically credible foundations for renewed optimism, convincingly supported by evidence, with positive programmes for something better, which do not depend on defensive faiths in obsolete solutions. There is now a large medical literature of denunciation listing the major errors of medical professionalism, but because nearly all of it comes from observers in academic community medicine rather than from clinicians in the field, it often lacks realism. Though a transformation of the social direction and mode of thought of medical professionalism is certainly necessary, this does not mean that all our problems will disappear, only that we shall face a new but still very difficult agenda, hopefully more relevant to health than the one we have now, but demanding even more work by more people. We need a more positive critical literature which draws more from the many examples of work already going on in primary care, which give us the first working models of a new approach. These are of much greater value than schematic approaches which try to build new worlds from political drawing boards, deriving what is useful and possible from first principles often held with a fierceness and indifference to real experience, suggesting religion rather than science. One of the most hopeful features of medical science is its combination of theory with practice, particularly in primary care, where if it is not also streetwise it might as well not exist; we need a critical literature that reflects this very positive feature, and respects everyone who, however mistakenly, actually works in the health service.
Though I have used many examples of clinical evidence to support my argument, I have tried to make their presentation simple; anyone who can read this rather unexciting foreword should be able to manage the rest, and also find it a lot more interesting because it is more concrete. The book is aimed at students, doctors, other health workers, and non-medical people interested in the National Health Service (NHS), regardless of their political affiliations. Though the different social assumptions from which people begin in trying to make sense of their work are important, more important are their attitudes to the work itself. Doctors, other health workers, patients, and their caring relatives, who loyally slog away day after day, night after night, month after month, year after year doing the best they can in usually difficult circumstances, are the audience I want; I have tried not to make my argument inaccessible to them by assuming that their social and political points of departure are the same as my own. This has not been easy, because central to my argument is the view that medical care has always been a highly political subject, though only recently has this begun to be generally recognized, and I cannot pretend to believe in other than socialist solutions of some kind. However, just as I have learned as much from non-socialists and even anti-socialists as I have from people who share my beliefs, so it is possible that readers who are not socialists will find material which helps them to work out other solutions.
General practitioners dominate primary care by right of inherited tradition, because they are there. This situation won’t last; if doctors are to retain a leading role in the future, they’ll have to earn it, and if some other kind of health worker can do better in terms of measured health outcomes, good luck to them. The present dominance of doctors is a fact, but this in no way excuses the failure of so-called general reviews of primary care, as for example the government’s Green and White papers on primary care have purported to be, to take account of other primary care workers. That problem has been dealt with excellently by Linda Marks in her King’s Fund paper, ( Marks, L., Primary health care on the agenda? A discussion document. Primary Health Care Group, King’s Fund Centre for Health Services Development, 125 Albert Street, London NW1 7NF, 1987.) but my book is not intended to cover that ground except incidentally. I have set out to examine the way that doctors, and particularly doctors in primary care, have come to regard their relation to society, and how society has come to regard the function of doctors; once this matter is settled, it will, I hope, be easier to sort out the functions of the many other kinds of primary health workers, many of them as yet scarcely born or thought of, who are needed for effective maintenance of health in whole populations.
I have relatively little to say about hospital specialists, because I don’t believe a solution to the crisis in the NHS and in medical professionalism can depend on change at this level. Any effective hospital specialist service must rest upon general practice, because its efficient function depends on appropriate selection of cases and adequate continuing care before and after episodes of hospital care. General practice is both the largest and the most obsolete part of the NHS, and is probably also the most susceptible to fundamental reform.
My argument is based on general practice and its historical development: because in Britain general practice has been the often creaky foundation on which all the rest of the NHS has been built; because general practice is both its main present weakness and main potential strength; because it is the most credible means of renewal of the NHS, of medical professionalism, and of medical science; and perhaps most of all because general practice is what I know, having practiced it for over 30 years in my own country and observed it in 17 others.
I have also concentrated on the development and problems of general practice in urban and industrial areas, because it’s here that problems are most serious and solutions most difficult, and again because this is what I know: the South Wales mining valleys are the inner-city of Wales, the Appalachia of Britain, the nearest we come to the problems of the Third World.
As the book went to press a government White Paper on primary care at last appeared, together with the announcement of what purports to be a major Bill to be put into law in the 1987-8 session of parliament. More people need to know and think about primary care and about general practice than at any time since the NHS began in 1948. My impression is that few either of the public whose lives will be affected by this legislation, or of the politicians who have devised or will criticize it, are well-informed about developments in British general practice over the past 30 years and the large discussion and research literature it has built up. For most people most of the time, above all for most politicians, the NHS has been the hospital service.
I have not aimed to describe British general practitioners as people, a task done very well by Jonathan Gathorne-Hardy, (Gathorne-Hardy, J. Doctors: the lives and work of GPs. London: Weidenfeld & Nicolson, 1984) but to explain the nature of their work, how it came to be as it is (different in many ways from general practice in other countries) and how change in this work could alter the whole of medical practice, in hospitals as well as in the community, so that it might become feasible fully to apply continued advance in medical science to the whole population; and how change in medical practice might contribute to profound and positive changes in the whole of our society. It is no secret that I am unable to conceive of a society in which medical science is fully applied, which would not be some form of socialism. People who share Mrs Thatcher’s belief that socialist ideas of any kind are now un-British as well as un-American, an alien infection to be purged from clean minds, will find this book irritating. Everyone else, whether or not they agree with my solutions, may nevertheless find my definition of our problems helpful in devising alternatives of their own. If we are permitted to have it, time will tell.