Edward do Bono once said that the basis of all science is lumping and splitting. The split we have chosen to make is between ‘Interpersonal’ professionalism and ‘Technical’ professionalism. This corresponds to the two meanings given by the Collins English Dictionary:

‘Interpersonal’ corresponds to ‘the methods, character, status, etc., of a professional’.

‘Technical’ corresponds to ‘the pursuit of an activity for gain or livelihood’.

Donald Schön, who contributed so much to the theory and practice of reflective professional learning, describes the inescapable problems of rationalising clinical practice thus:

In this area he says problems can be described as ‘difficulties’. He continues:

So – using Donald Schön’s terminology, our grey professionalism deals with ‘difficulties’, while red professionalism deals with ‘messes’. To Schön difficulties have a rational solution, while messes do not. Thus grey professionalism inhabits the ‘high, hard ground where practitioners can make effective use of research-based theory and technique’.

In contrast red professionalism inhabits Schön’s ‘swampy lowland’. There, Schön continues, practitioners ‘…deliberately involve themselves in messy but crucially important problems and, when asked to describe their methods of inquiry, they speak of experience, trial and error, intuition, and muddling through.’ This kind of talk doesn’t cut much ice in the ‘grey’ world, but the difference is crucial: to repair a car is to resolve a difficulty; to devise a policy to improve the quality of care in a health service is ultimately, at the end of all the complex, systems-led science, to tackle a mess.

To Schön’s analysis we would add the following: the grey professional focuses in detail on parts, while the red professional (and here the GP provides the classic example) deals with integrated wholes. So the grey approach isexclusive, while the red is inclusive. The first is, or can be,closed, finished, and certain; the second is open and provisional, and will always remain so. Far from being unscientific, as many non-scientists believe, this uncertainty is the very hallmark of science. This was made clear by the great philosopher of science Sir Karl Popper who showed that one of the few things science can be certain about is that scientific knowledge will for ever remain uncertain.

So grey professionalism deals with the simple, the linear and the predictable, while the red deals with the complex, using that term in its mathematical sense to mean non-linear and unpredictable. Again these differences correspond to those between the Enlightenment conception of art, which was all rule-driven technique, with the artist as a technician who focussed on the emulation of classical forms, and the utterly different Romantic conception of the artist as a genius, acting as an intermediary in mankind’s search for a permanently elusive reality beyond. These differences could not be more profound.

Now we come to the kind of relationship implicit in each role. Our grey professionalism corresponds closely to the relationship defined by the influential twentieth century theological philosopher, Martin Buber as I-It, or rather, in his native German,Ich-Es) while our red professionalism corresponds to his Ich-Du.

Ich-Du is usually translated as I-Thou, as for example in the English title of Buber’s book: I and Thou. But this translation is unfortunate and may explain the failure of such a valuable concept to penetrate beyond specialist theological circles – at least in the English-speaking world. The German du, like its French equivalent tu, cannot be translated accurately into English. Du was rarely spoken in Buber’s Germany. It implies an intimate closeness; a relationship with a past, a present and a potential for a future. You cannot say Du until you know the other person feels the same about the relationship. It implies commitment, and being there for the other person, no matter what. Applied literally to general practice this wording is an unrealistic idealisation, and probably always has been, but this does not lessen the force of the distinction.

Unfortunately the word thou is not merely a weak translation of this concept, and a pretentious and off-putting one to modern ears at that, but it conveys a sense of remoteness and alienation which is the opposite of what Buber was talking about. But properly understood, we believe Buber’s Ich-Du relationship becomes a powerful and accessible description of something that happens, sometimes, and to some extent, between a general practitioner and his or her patient. This relationship is one of mutual respect and exchange, in which both parties are open and vulnerable to the humanness of the other. It is difficult if not impossible to define, but we recognise it without question when we experience it. Perhaps the most successful attempt to describe it has been John Berger classic portrait of a West-Country GP, A Fortunate Man, of which Jean Mohr’s photographs were such a crucial part.

From what I hear of Tom Stewart, he was ‘acknowledged to be a good doctor’ in exactly this sense.

But there is another key point here: Buber insists that the I-It is every bit as necessary as the Ich-Du – the I-Thou. Both kinds of relationship are essential and the two are in continual dynamic flux. One is not better than the other. Indeed any such comparison is meaningless, a class error – in other words it is an attempt to compare two things of entirely different kinds. Not chalk and cheese – chalk and, say, happiness. For Buber, confrontation has no place whatsoever; the thing he calls for so urgently is dialogue.

So the I-It relationship provides the objective, the mechanical, the infrastructure – utterly essential to life, and perhaps all that is required in the GP-patient relationship for a large proportion of the time. The Ich-Du brings in what we might call the ‘squirmy notions’ of mutual recognition, mutual vulnerability, empathy, engagement with emotion. In a word, compassion.

The two sides can come together when for example I-It objective science provides evidence of unexpected Ich-Du phenomena, such as patients having better clinical outcomes when their doctors adopt a positive outlook in a consultation. (As in Bruce Thomas’ classic studies from general practice.) But where the two sides do not come together is in the issue of continuity of care. In the grey, I-It kind of professionalism, continuity with the same GP is unimportant. Indeed, the contemporary wisdom holds it to be self-evident that, thanks to sophisticated treatment protocols and medical record systems, ‘any doctor will do’. Personal continuity of care is not merely thought unnecessary but sometimes actually undesirable. Just as OFSTED inspectors who have personal knowledge of a school they are inspecting are described in the internal jargon as ‘contaminated’, so prior knowledge of a patient may also (it is argued) seriously compromise a doctor’s judgement, however much they seek to maintain professional objectivity.

In complete contrast to this, continuity is not merely essential to the Ich-Du relationship; without it there cannot be an Ich-Du relationship. The red professional can never be a ‘replaceable part’ in the way that the grey professional certainly can. So the red side of a doctor’s professionalism continues to regard the client as patient while his or her grey side increasingly sees the patient as client. And in grey professionalism liking a client has (in W.S.Gilbert’s words) ‘nothing to do with the case’.

From the establishment of the NHS in 1948 general practice acknowledged the fundamental commitment of one individual to another by insisting on a formal link between a named doctor and a named patient. In the new contract of April 2004 this was replaced by a contract between patients and organisations, a change that has made little or no practical difference so far, but is indicative of the profound shift that has occurred in principle. It is also a change of which few patients are so far aware. We think it is likely that if they were aware of it many would regret it.

Doing a thing for the money, especially making your living by doing the thing, is perhaps the characteristic which is most commonly seen to define professionalism. But again this is simplistic – there is another kind of motivation, sometimes seen to be every bit as clearly defining of professionalism, which is almost exactly the opposite. In this latter kind the desire for money takes second place to the desire for self-respect; for the satisfaction of feeling valued and needed; for the pleasure gained from living in a just society; and to the desire to avoid the unhappiness of witnessing injustice and inhumanity. Altruism, notoriously difficult to prove, may also take its part.

A good example of this second kind of motivation is seen in Citizens Advice Bureau volunteers: they display a high level of professionalism in their work, are highly trained and relentlessly audited, work under enormous pressure (not at all unlike a GP surgery) yet give their time and services entirely free of charge. If all professional motivation were ultimately mercenary this kind of thing would surely never occur. In fact we know it is commonplace.

The traditional scientific community is another example. For professional scientists peer-respect rather than money is the crowning reward of success. The birth of the British National Health Service, an institution which may have been more unusual and precious than those of us who grew up in it realised, allowed many doctors to detach their dealings with patients almost entirely from financial considerations. Practitioners were liberated by the assurance of good salaries, working conditions, pensions and job security.

So in this analysis grey professionalism corresponds more to the ‘market economy’ in which status is accorded to those who have the most, while red professionalism corresponds more to the ‘gift economy’, in which status is accorded to those who give the most to others. We should at the same time, however, recognise that grey professionalism achieves much of its dynamism and effectiveness from the human fascination with mechanical problem solving and also from the human satisfaction derived from the achievement of targets.

The knowledge base of ‘red’ professionalism, which is used as the basis for practical decisions, is open, provisional, and forever incomplete. It is under constant review throughout the entire career of the practitioner. It is acquired by the open, life-long process of education rather than the closed, defined process of training. Potentially, any information and experience whatsoever can contribute to it. No fixed curriculum can ever encompass it. One crucial corollary is that in any given situation there is likely to be legitimate disagreement amongst colleagues about the correct way forward.

In the case of the GP, this personal knowledge base includes a working representation of the whole of medical knowledge, integrated of course with an awareness of psychological and social issues. This knowledge base is educated by textbooks, journal articles, colleagues, specialists, protocols, guidelines – in a word by ‘evidence’ – but it is never blindly controlled by any of them. So, red professionalism, in an enormously demanding and life-long process, avidly seeks out advice, information and experience and so builds up and maintains a personal understanding upon which to base its decision making.

In contrast, the knowledge-base of the extreme kind of technical, ‘grey’, professionalism – for example the knowledge base of the professional soldier – is acquired by training rather than education. It consists of techniques, rules and protocols which are the accepted stock of that particular trade. This stock can, at least in theory, and at least at one particular time, be closed, final and complete. It is not part of the role of the individual to change or adapt it, only to follow it. Failure to follow these rules will render the offender prima facia culpable, regardless of the outcome, even when the outcome of such ‘off-piste’ behaviour turns out to be good. And heaven help the offender if the outcome turns out to be bad. And here again the crucial corollary: there will be agreement between everyone – colleagues, instructors, rank and file – about the correct course of action that should be followed in any particular case.

Again, in principle, to the technical, ‘grey’ professional ‘targets’ are binding; to the red-blooded, interpersonal professional they are advisory. Again, when a ‘grey’ professional achieves such a target the job is at an end; but if ‘red’ professionalism reaches a target it has been set (or more likely one it has set for itself) responsibility to the next client, or patient, is not reduced in the smallest degree because that target has already been met. In other words, to ‘grey’ professionalism rules and targets are absolutes; to ‘red’ professionalism they are relative – things to be taken into account in the understanding of the situation, never aims to be pursued blindly. ‘Working to rule’ is therefore in ‘grey’ professionalism, the theoretical ideal; in ‘red’ professionalism it is abdication.

The deeper point here is that mechanistic, rule-following behaviour and independent, evidence-informed behaviour will normally be indistinguishable. In other words, the GP dealing with a particular problem on the basis of his wisdom, experience, and knowledge of his subject will normally deal with it in more or less exactly the same way as would be prescribed by a sophisticated expert system or treatment protocol. Indeed, as rules and protocols improve, this ought to become progressively more and more the case. Nonetheless, however similar the surface appearances, the underlying decision-making process of understanding-based, interpersonal professionalism will always be an entirely different kind of thing from the strict working to rule of technical professionalism. ‘Red’ professionalism operates independently, albeit within the bounds of a wide but fixed code of conduct, and it will certainly make use of protocols and information systems of many kinds. But it uses these tools-of-the-trade, and here I especially mean the knowledge-base of the trade, as a servant, never as a master.

In the modern world it is increasingly assumed that motivation comes from outside the individual. Thus we have targets, protocols and audits, annual reports, mission statements, and a burgeoning army of workers to oversee jobs instead of actually doing them. This trend is often thought to be an inevitable part of progress. It is a trend towards the kind of professionalism which is associated with soldiers, in which it is ‘professional’ to subjugate large areas of decision-making to officers, and away from the kind traditionally associated with doctors, in which individual freedom and autonomy were violated only in the most exceptional circumstances.

There are many aspects of this change which are to be welcomed. Much of it follows from the raising of standards and the fact that medical knowledge has now been assembled and catalogued into a body which is larger, more complex and based on more evidence than can be held reliably in one human mind. Indeed, once it becomes possible to base professional actions on a super-human body of knowledge it becomes culpable, almost automatically, not to do so. With no sign of a slow-down in the exponential growth of IT power this trend is certain to continue and perhaps accelerate.

Yet there are some things which human minds can do which codified information systems cannot. This is certainly true at the present level of IT sophistication, but some argue, as for example the distinguished Oxford mathematician Sir Roger Penrose, citing Gödel's incompleteness theorem, that it will always be true that there will be functions automatic systems cannot perform, however advanced those systems become. Whether or not this is so, it is certain that for the foreseeable future there are qualities of the human mind which are essential and indispensable for the general practice of medicine and for other activities of a similar nature in other walks of life. They enable, for example, the reconciliation of incompatibles, irrationalities and impossible expectations, the very stuff of general practice expertise.

GP’s are often faced with logically irreconcilable conflicts such as the one which commonly arises between the needs of a individual patient and the needs of society in general. In the phrase coined by Iona Heath, the GP copes in such seemingly impossible situations by adopting an ‘oscillating gaze’. In some mysterious way both aspects of the dilemma are entertained in full force in the mind of the practitioner, who employs a constellation of resources, not least expert advice, so that on the vast majority of occasions a satisfactory resolution is achieved, or at least a satisfactory compromise. It is at our society’s peril that it forgets the importance of nurturing people who use such priceless abilities in their daily work.

Years ago one of my certificates to state that a patient had reached 26 weeks in her pregnancy was returned to me by a faceless official because I had signed it one day early. Aware, as you are, of the extent to which the period of gestation is an approximation, I couldn’t resist sending it back, with its now valid signature and date, with a note saying: "People who behave like computers will inevitably be replaced by computers.". There was no reply, so they probably already had been, computers have no sense of humour.

For these ‘red’ abilities to operate they must have freedom. And while this freedom must have strict boundaries, those boundaries must be much wider and freer and must allow more room for manoeuvre than grey-squirrel policy-makers and theorists would like. The notion that, thanks to technical advances, complex human activities like general practice can now be codified into systems of rules, is simply wrong. The idea that the model of grey professionalism is capable of eliminating risk (and therefore blame) from life, is a mistake.

That is about as far as we can go with our red/grey analogy, because taken any further it leads to a very serious misunderstanding – it creates a false polarisation and implies that professionals have, like squirrels, to be either red or grey. On the contrary, the two can and must be brought together, and it is now time to consider how this can properly be done.

From the grey side it simply isn’t possible; technical professionalism, by its very nature, cannot incorporate the fuzziness of the red. It is inclined, as has been said above, to treat the red with contempt – to treat it as obsolete, irrelevant, or even harmful. Emotion, for example, is commonly seen to be the enemy of efficient professionalism. Moreover – grey professionalism views any attempt to qualify it – to colour it even slightly red – as an attack on its virtue. There is an element of Fundamentalism in the grey.

But from the other viewpoint things could hardly be more different; red professionalism can certainly incorporate the grey. But not in any sort of muddy compromise, it can do so whole-heartedly and to the fullest potential. The red professional can make full use of protocols, guidelines, books of instructions, recipes, but does so only when appropriate, always as tool, never as master.

And this is where Tom Stewart once again provides such an extraordinarily fortuitous example. I didn’t know him personally, as far as I can remember, although I knew of Sonning Common Health Centre and of course I knew of John Hasler. But my brother, Andrew, as the co-author of their book, did know him well. He remembers him as a revered trainer, and a family doctor who was the perfect epitome of the best traditions of the old school. As far as Andrew can remember, everybody loved him, which is a dangerous thing to say about anyone, ‘love’ being the last remaining taboo four letter word, but it is about as ‘red’ as you can get. At the same time Tom Stewart was one of the first to see the staggering potential of computers. The book they published in 1989 was one of the first on the use of computers in general practice. It was called ‘Computers: A Guide to Choosing and Using’. So while Tom was ‘red’ to the core, his effectiveness as a doctor was enormously enhanced by the enthusiasm with which he assimilated the ‘grey’ approach.

His pattern of enlightened professionalism applies far beyond medicine, but general practice is the best example of all. Here we have some of the most highly selected, most highly trained, and most powerfully-motivated members of our society – nothing beats the responsibility you feel towards the human being sitting opposite you who trusts you. But the ascendancy of the ‘grey’ approach, and its espousal by the Royal College of GPs during the crucial years at the end of the last century, has left general practice bewildered, and as I said at the time, ‘forced to express itself in terms which deny its very nature’.

But as Iona Heath pointed out, in one of the most famous tracts of modern general practice literature, there is an element of ‘mystery’ in General Practice, and perhaps that means an element which cannot be logically reconciled, cannot ever be reduced to a formula. But to say that is not for one moment to deny science, or to join the perverse fashion for irrationality and ignorance which is now so prevalent as to amount almost to a counter-Enlightenment. On the contrary, it has never been more important for modern doctors to be bastions of science, just as they are empowered by science. When a GP talks of ‘intuition’, or of using his ‘art’, he is not saying that he acts on those abilities alone, what he actually does is to use them as a guide and short-cut (of quite literally incredible accuracy and efficiency), and then to disprove, modify or confirm by means of scientific tests before taking action. So what we are really saying is close to Shakespeare’s, ‘There are more things in heaven and earth, Horatio, than are dreamt of in our philosophy.’ Or in more prosaic terms, ‘we don’t know all the answers yet, and thank heaven for that’.

The discussion above, which I fear may appear rather abstract in places, can be brought into focus by consideration of the New Contract for NHS general practitioners which came into force in April 2004. This contract codified a style of practice which is radically different from that which was normal during the latter decades of the last century.

I must emphasise that we believe many of these changes to be welcome, but our purpose is to argue that they also threaten something which is unique and precious and which in consequence is now in danger of being lost. The 'red', Ich-du, flavour of professionalism does not fit in to the new, ‘grey’, way of doing things. From the macro-political perspective it appears insignificant and when noticed at all, it is treated with contempt.

But at the interpersonal level it is precisely this aspect of professionalism which is most valued; everyone senses its fundamental importance. And that includes the politicians themselves in their own (possibly infrequent) interactions with their personal GPs. The story of the parliamentary candidate mentioned at the beginning of this lecture is a case in point.

Currently GPs are seeing primary care being used as a crude instrument of public policy, with little debate about the underlying values of that policy and their freedom to dissent. There is a very real danger that the trend towards detailed political control (or 'micro-management') of clinical care will continue if a stand is not taken by doctors on behalf of their patients. Hitherto unprecedented information technology has given politicians  historically unprecedented powers of control. They, of course, regard their motives as benign, but we should remember that the Nazis in their day were very keen on public health and hygiene – and they did not have the micro-chip! The emphasis in public health policy on eliminating smoking and tackling obesity may be laudable, but it must not be allowed to exert a tyranny within the consulting room, with primary care staff as its agents.

Never has it been more important for GPs to assert the independence of their role and the unique validity of their point of view. That is why GPs should use, and be seen to use, the ‘exceptions’ in the Quality and Outcomes Framework of the new contract conscientiously to protect individual patients from dictatorship by targets. That is why they should never use, or be seen to use, pounds-for-points as the main focus of their role, and never encourage or require colleagues to do the same. That is why they should demonstrate a critical awareness of the vested interests that influence clinical guidelines and practice: vested interests that include professional bodies such as the Royal Colleges, powerful patient groups, and above all the pharmaceutical industry. That is why they should protect the central values of compassion and confidentiality from the incursions of managed care and information sharing. Above all, that is why they should fight to retain the right to say ‘no’ when they believe something to be wrong, and why they should stand together as professionals to defend that right when they can see that the greater good requires it.

If general practice has the courage to do such things, and stand up to the unqualified and untrusted bureaucrats and politicians who have gained such bizarre ascendancy in recent years, it can reclaim its heritage and the role expected of it by patients. Then we can celebrate this mysterious ability of ‘red’ professionalism to use all the different modes and capabilities I have listed above, and many more that I haven’t, and somehow manage to oscillate sensitively between them, and at the same time to immeasurably enhance that ability with the power of modern technology. But as we celebrate it, we must also protect it. For one thing is certain, left to nature the red approach, like the red squirrel, doesn’t stand a chance. So we have to persuade our society that feelings count, and then we can start to compensate and deliberately balance the fight. But to do that – to even begin, we have to find the necessary words. That is exactly what I have attempted to do tonight: by distinguishing two colours of that deeply ambiguous word, ‘professionalism’: ‘red’ and ‘grey’.