Three recent examples of the application of the ideas in this book to confrontations with centralised regulation
URCHFONT - THE VIDEO
Many GPs disagree with me and video is widely used as a tool in GP education. Trainee GPs on courses of the kind I used to run are often asked to bring in videos of their consultations and all sorts of techniques have been developed for assessing them to help them improve their communication skills.
On our course I always made a point of insisting that this kind of thing was voluntary and (being one myself) I respected the position of the conscientious objectors. The videoing of simulated consultations with actors playing the patients was another matter and I found this useful and completely unobjectionable. I actually scored rather well on this myself, so I could see that it was a valuable technique.
So. The years went by without me actually letting the cameras roll on a real patient in a real surgery. Nobody seemed to mind, and my communication skills, in spite of being thus un-honed, were generally held to be more than adequate for the job in hand. Then came confrontation.
It was after I had resigned as a course-organiser in despair at the changes imposed on the National Health Service by Margaret Thatcher’s government, but while I was still an accredited trainer. One of the requirements for continued accreditation was an occasional attendance at a residential course at Urchfont, a comfortable retreat in the Wiltshire countryside, which I had enormously enjoyed when I went there on first becoming a trainer.
The problem now was that the course I was being asked to go on required me to bring a video of some of my consultations.
I got on the telephone —
‘Please tell Bob that I don’t video my consultations. Does it matter?’
‘Oh yes, quite a few people object, but we do require it. Bob says that they all come round in the end.’
‘Oh does he! Well he’s just found someone who won’t’
I withdrew my application and didn’t go to the course. And from that instant onward the statement, ‘They all come round in the end’, became untrue and could never again be truthfully made. A small point you may think, but not entirely insignificant. Who says individuals can’t change the world? We can all be Popper’s one black swan that disproves, absolutely, the statement, ‘All swans are white’.
I would certainly never go as far as to say that a GP who is prepared to video his consultations isn’t fit to be a trainer, but I was in this very simple way able to take a stand against it becoming compulsory! I am sure we need some trainers who have this view of their relationship with their patients.
The changes to the NHS brought in on April Fools Day 1990 included unprecedented centralised controls on the priorities of GPs in their daily work, just as the sections of this book written prior to that date predicted.
They included requirements to visit all patients over seventy five years of age at home once every year and carry out a list of specific checks, and also to carry out a routine medical check on all adults once every three years. Careful readers will immediately realise that I was doing both of these things already, at least to some extent. From now on, however, the details were actually enshrined in the law of the land.
I was required, for example, to measure the height of every adult every three years. This, I can tell you, makes a very dull graph. Electrocardiogram (ECG) paper, being long and narrow, has been suggested as a suitable format for a life-time’s record, though with the danger that a cursory glance might lead an unwary physician to declare you dead.
As far as the over seventy five year checks were concerned, I had almost unique experience having visited and checked all my own over seventy five year old patients in order to write my BMJ papers about chronic visiting and dependency assessment. I had done it once, as far as I know the only GP to have done so, but the law of the land now required every one of us to do it every year. I knew that the law of the land was requiring the impossible. Just like a contractual obligation to practice without your feet touching the ground — a superficially attractive idea which does not stand up to close examination.
In view of these absurdities, and many more, I wrote to the local employing authority. Popper, again, was the key. ‘I will consider doing all these new things when you have told me what I must stop doing in order to make time for them. My time and energy are fully occupied. If I do these new things I will have to stop doing other things that I am doing at the moment in order to make time. Thinking up new things to do is easy and fun. Sorting out priorities is the difficult bit and the basis of my professional expertise. When you have told me what to stop doing I will be able to judge whether I would be justified in abdicating my traditional professional role to you.’
The reply came back that they could not tell me what to stop doing and that is how the matter rests four years later. I have continued to decide my own priorities and I have never conceded that any manager has the right to dictate to me.
Just to put the matter on an official footing I recorded the whole correspondence and the outcome in our first annual report (another new requirement — but as I have always held that my practice was open to any inspection I had no particular quarrel with that). I think it is extremely unlikely that anyone has actually read the report, but should there ever be a need to refer to it, there it is in their files, set out just as I have written it here, my justification for continuing to decide my own priorities in caring for my patients.
POST GRADUATE EDUCATION ALLOWANCE
Another 1990 April Fool was a new system of Postgraduate Accreditation, reputedly invented by Kenneth Clarke (Minister of Health) himself. GPs get an allowance of about £2000 a year if they attend a certain minimum of postgraduate education — not an unreasonable arrangement you may think.
My first experience of the new system was at the Royal College of General Practitioners Spring Meeting in Harrogate in April 1990. The claim sheet which accompanied the programme indicated that of the total of twenty four lectures (in two simultaneous programmes — the ‘academic’ and the ‘scientific’) only eighteen had been judged to be of educational value. In each case the regional postgraduate adviser had indicated into which educational category, in his opinion, the subject would fall. So each item on the list had either an ‘A’ for health promotion/prevention of illness, a ‘B’ for disease management or a ‘C’ for service management. Each lecture counted for one quarter of a day’s credit in the assigned category and at the end of the weekend we were to circle the credits we had amassed and send in the form with a cheque for three pounds for each quarter day.
Having grasped the rules of the game, a closer study of the list began to reveal a number of curious anomalies. For example, the Saturday afternoon session in the ‘scientific’ programme consisted of six papers, only five of which had been approved for quarter-day credits. (The lecture that did not count was the one by a Canadian guest — a foreigner, demmit!) So somebody who sat through that lot got four A credits and a B.
If on the other hand a delegate did what I did and spent the same afternoon in the ‘academic’ session things were quite different. We heard Sir Roy Griffiths on ‘Management in General Practice’ — a C, Christian Schumaker (yes, the son of the great Fritz) on ’The Good Manager’ — another C and Professor James Howie on ‘The Measurement of Stress in General Practice’ — an A. In other words, we got three quarter-day credits while the others got five. So some delegates had experienced one and a quarter days and the others three quarters of a day, all in the same afternoon. I had thought that this kind of time-dilation effect was only possible during journeys over inter-stellar distances at close to the speed of light. This in itself seemed to me to be a phenomenon of great academic and scientific interest, yet it passed unremarked. Nor did the fact that the two best addresses by far at the conference didn’t get any credits at all.
I think it is very demeaning to our profession that anyone should think we only go to academic activities in order to get these ridiculous credits. In fact it is often said that this is the case. But it is now just as untrue as saying that all GPs eventually give in and video their consultations:
I do still take part in educational activities in spite of the fact that I’m not claiming my allowance at all this year. It is worth every penny. I am in the happy position of being able to afford it (partly because better off people pay so scandalously little tax in Britain today) and I now have the luxury of completely bypassing the absurdities of the accreditation process and choosing what I want to do for myself. I am spending this Friday at a day’s course on Microsoft Access, for example, (which, by avoiding the need for a commercial practice computer system has saved us many times £2000) and I spent my week’s study leave last year sitting here at my desk planning my own session for the 1994 RCGP Spring meeting which achieved the first standing applause I have ever seen for a speaker at a medical meeting.
I called the session ‘The Paradox of Progress’ and subtitled it ‘An exploration of the problem of retaining respect for human values in an increasingly systematised world’. Alan Pattison, retired headmaster, put the solution as follows for the benefit of a roomful of spellbound doctors:
‘Teaching is very much a matter of having enough freedom, within a reasonable structure, to exercise gifts and judgement. Surely that is what you as GPs must retain: the freedom to exercise personal judgement and to relate to each patient in a personal way.’
That is what this book has been about and I hope it has struck the same chord that we struck in that conference room. Just in time for the millennium.