IPNOSIS: a journal for the Independent Practitioners Network

Conversations towards the Rally of Impossible Professions, London 20th September 2008

George Freeman, GP, talks to Janet Low (14 May 2008).

George Freeman is a Professor of General Practice and was one of three key figures engaged in an initiative at Imperial College that brought together medics, humanities, and epidemiology to address the social and personal dimensions of health and sickness. By the middle of the decade that project was shipwrecked in the storm whipped up by the prospect of the Research Assessment Exercise. I had worked with George for a few years at the end of that era on some Continuity of Care projects, and when I got in touch with him again this spring, he very kindly invited me along to his West London surgery between sessions to catch up on the current climate.

JL: so, what are you up to these days?

GF: well, I’m talking a lot to the press – I had someone ring me up from Channel 4 asking about ‘Access’, but I managed to talk about Continuity of Care as well.

JL: that sounds great, and are you still attached to the College?

GF: No. No, they got rid of me. This relates to that article you sent me, the one by Andrew Sparkes (1). They invited Konrad (2) to leave too. It was the Research Assessment Exercise: basically they looked at everyone that they thought would be weak by their criteria, and called them in for a very unpleasant interview. At the same time the Registrar of the Faculty, which is a very powerful administrative position, was trying to get rid of the people who ran our undergraduate GP training. It was horrible. They invited the women administrators to re-apply for their own jobs – and only one succeeded and it was all very nasty. Anyway, I was given this interview and told that I would be set an academic target for the RAE vesting date and that if I didn’t achieve it, then I could be dismissed for breach of agreement. Or, they could pay me off now – making me quite a generous offer. It was a shock at the time, and it was nasty. So I left. But I still work in my practice, and have a new position at St George’s one day a week, and I’m still linked to some very interesting research projects on Continuity of Care.

JL: What do you do at St George’s?

GF: I was asked to come and lead the GPs, so I set up a group and we run seminars, do mentoring, and I’m part of a research group about the quality of the consultation. The atmosphere is very different. The other place has improved now, tho, as so many of those people from that bad time have moved on. There has been a huge turnover of staff. Our experiment was destroyed: all that stuff you spent a lot of time on - the joint seminars and so on - all that was swept aside. I ended up thinking that they weren’t terribly interested in the humanities. We didn’t fit their model of the world.

JL: Yes, there was a kind of wave of hostility against all those things that didn’t quite fit the brave new regime. Well, something similar is happening in the ‘psy’ field. My colleagues and I are organising a rally in response, a rally of the impossible professions. It’s a rally of the spirits to get ‘beyond the false promises of security’ and it is set against the backdrop of audit culture.

GF: Audit! There’s a lot of that going on here in the NHS at the moment. We’re being driven along. Not entirely good, not entirely bad, but too often it misses the point - it doesn’t have the desired effect, and sometimes it has perverse effects. The box ticking is particularly focused in a narrow sense on the system called Quality and Outcomes Framework or QOF for short. You could call it a desire to practice with evidence, evidence based practice – it’s a change in management culture, a desire to manage the health service directly. But the Primary Care Trust doesn’t really understand what we do, so it does odd things to get us into line. I’ll give you an example. [opens his desk drawer]. Here is a prescription pad…

JL: … so it is …

GF: … if you were to steal that and attempt to forge my signature, you could write prescriptions for this that and the other for patients that might or might not exist, and then you might sell them. Alternatively there’s that [reaches to the paper tray in the computer printer] it doesn’t even have anything printed on it except for a serial number, and again, apparently it has a market value. Obviously you are supposed to keep these locked – when I’m not here I lock them away. But there are concerns about the safety, and we have a fifty-one page document now from the PCT about the safety of these things, and it’s really like Securicor! When they are unloading them from the van they’ve got to have a witness, they have to go into a room with grills on the windows, and someone has to witness them being locked up - and it take 51 pages to say that. That’s an example of the bureaucratic effort that’s going into administration these days: it’s disproportionate and it’s happening across the board.

JL: You remind me of when I first worked in psychiatry, we moved from one of the old hospitals to a new purpose built ward. Each patient was to have his or her own private room with a little wardrobe and so on in each. Just before we opened, the regional managers came to have a look round. For some reason the wardrobes roused their anxiety. Each had a little bar in it on which you could hang a few coat hangers – it was a little tiny space really, barely fit for the purpose, but just enough to create a nice impression. But the managers ordered the carpenter to unscrew all the ‘U’ shaped brackets in which the bars were resting, and turn them upside down! This created the impression that the wardrobe functioned, but as soon as you tried to hang anything on the bar, of course it just fell out!

GF: and then there’s the evidence base. You are always being asked for evidence, and ‘evidence’ always means something countable. Then there’s the more focussed bit that carries the money: the Quality and Outcomes Framework, (QOF). It involves not just sitting here waiting until the patient brings you a problem, but actually going out and bringing to the patients things they must do (it’s usually them who must do something), but also things we can do for them. It’s what we call pro-active rather than reactive, and it’s about preventable diseases – preventable by changes in lifestyle. Each little thing is very small, but taken collectively it takes up time and makes us inaccessible. We are less available for reactive care because we get chronically booked up because of all this proactive stuff…

JL: there’s no room for the unpredictable things - the computer is very good at regimenting this …

GF: … certainly computers are in there with it, and computers make proactive care much more doable: they are very good at routine, they epitomise routine. But we’re much better now at helping people treat their blood pressure and their diabetes and much better at persuading people to stop smoking, and treating their asthma, but too much insistence on these ongoing problems can make us completely forget the person in front of us, and the needs that they have as people. I think I have an advantage here, being older. I was brought up in a different paradigm, and I can say ‘!**!QOF’ to myself, and just concentrate.

Things took a turn for the worse with the Advanced Access Scheme, this came from California, USA, where there was a different Health Care system and much more resources to cope with the demand. Here it’s different: we act as a kind of rationing system, and with a system that’s free at the point of access that’s always going to be true, no matter how you dress it up. Yet it is politically impossible for a government to admit that it is a rationing system. The way we deal with it is by negotiating and getting people to wait for appointments that don’t seem essential. The Government gets round it by trying to beat sticks over our head with access targets, and making the Chief Exec of the PCT fear for his job if access targets are not met. But now they also provide other services for patients: NHS Direct, Walk-In centres, Primary Care Units in A&E, and Polyclinics. The question is, will it get rid of the GP as a perverse outcome?

JL: that’s rather an important question.

GF: yes, there are quite a lot of difficulties going on at once: there’s polyclinics, and the fact that every Primary Care Trust in London, has been told they must set up a new health-centre practice catering for 50,000 patients. Every PCT is supposed to plan and build one in the next three years, and the private sector can bid for them. To run a thing for 50,000 patients is beyond the administrative capacity of any GP practice, so the private sector has a great advantage. It is really about privatising the health service, but it’s done by stealth.

The back-drop is the contraction in the economy and in the world economy, and this has got much worse in the last few months. So there isn’t any money in the kitty, and the government is getting increasingly anxious to get elected, so there’s a lot going on there. But all these initiatives tend to fragment care. You are either persuading the patient to go to a different place or getting a different doctor. None of it is about an ongoing contract with a doctor you can trust. That isn’t rewarded, it is not valued, and it doesn’t fit.

JL: there is a huge wave of commodification, a kind of factory-isation flooding over a lot of different areas. It seems unstoppable, but I suppose we can try to find bits of shelter and new ways of forging relationships.

GF: yes, there are many forces making personal care less available. But there are counter forces, and people still want to be people. And it is important that we keep on teaching this - it makes a big difference.

JL: Yes, I remember a presentation I heard by Sally Hull (3), a GP in the East End I think. She was part of a team who had done some interesting statistical research on the propensity of GPs to prescribe anti-depressants. They had thought it would correlate to the ethnicity of the doctor, but in fact they were surprised to discover that it was correlated with the medical school the doctor had attended. Those who had gone to British med schools were more likely to prescribe, no matter what their cultural background.

GF: There was a report that recently came out that said that the new anti-depressants don’t work. That was amusing, because many of us have suspected this for some time - although now and again you see people get amazingly better on them, like a miracle. But now of course there are all these new drugs (which cost a lot more) and we’ve been subjected to this new campaign from 1995 called Defeat Depression. So there has been a big push, and the drug industry was right behind that one of course. But people here and in other practices were always pretty sceptical – depression is not a useful concept. It doesn’t fit the medical model very clearly. But a lot of people want to take pills. It’s a very difficult area.

At St Thomas’s when I was training we had the high priest of psychiatric drug taking there: William Sargeant. He was a charismatic personality, but he had no idea of his own impact. He was tall with a craggy and impressive face, a big shock of white hair – he would have been excellent on a film set. He was very interesting but he completely denied his own personality: he had a massive ‘placebo effect’ and he couldn’t see it at all, he said it was his medicines.

JL: how interesting - the epitome of the powerful man that is now so out of fashion. The only big names that stand out these days seem to be the ones associated with tragedy, and this is bound up in the increased auditing of the profession. I wonder what do you think about the CHRE(4)?

GF: I don’t think I know much about it. Is this the council that has taken all those other council’s under its wing? Yeah, well, it’s a waste of time really. The GMC is in difficulty; I think Doctors have always had mixed views about it. They are the people who strike you off. What’s happening now is that the criticisms from the Bristol Enquiry, the Liverpool Labs, and the Shipman case all purport to show the public that the GMC is not doing a good job. So it has reformed: there is a much greater proportion of lay members than ever before, it is much more bureaucratic, and of course it is much more expensive. Many more people are reported to the GMC than ever before.

But there’s also been another huge change, suddenly about 10 years ago they decided to expand the intake to medical schools. They nearly doubled the numbers in training since 2000, so a huge numbers of trained doctors are coming through with no jobs for them. It has completely depressed the market, and for the first time ever there are no jobs for doctors. There’s lots of argument about it. These private places now setting up can employ doctors on the cheap.

JL: this is related to the changes in university funding and the increased numbers of students in universities. It has had a knock on effect on the supply and demand in health care. But this is also something that Andrew Elder (5) spoke of at the Savoy Conference last year. He raised a question from the floor about the changes in British Higher Education Policy, how it made it increasingly difficult to teach the students the rudiments of relating the patient as another human being.

GF: and the GMC has to approve training in medical schools, they must inspect places and engage in ongoing arguments about revalidation and so on. But they are caught in between the changes in higher education and the rhetoric of ‘Shipman’.

The simple fact is, if you are practising anything then really you should try and review it. It’s all about judgement in the end, and it is the fear of judgement which leads people to try to take refuge in a system! But my image of the British is still that we’re very good about common sense, and I think that there’s still a great deal of wisdom out there. It will rise again. Actually I feel threatened as never before as a GP, but I’m also rather confident. It’s scary because of the political pressure: particularly the blend of pseudo-privatisation, and political diktat. The relationships between us and the Department of Health is bad at the moment, and the Government seems to be losing its nerve, lashing out in desperation. Governing is a complex business.

JL: Freud named it one of the Impossible Professions – alongside medicine and education. His point was that none can rely on evidence or rules alone, each must have men and women willing to step into the gap and to take the responsibility for the risks and uncertainties. I always thought this was relevant to Continuity of Care.

GF: But in the meantime the rising tide of bureaucracy continues to destroy judgement - and people keep taking refuge in the system. Sometimes I wonder if it is just my age! I do feel that I’ve seen it all before. Take this new Darzi initiative: Health Care For London. There are three GPs in the team of 35 advising Darzi, and they feel so exposed that they have created an advisory group. They invited me onto it because of my work in Continuity of Care.

JL: So, you keep on keeping on; continue with the continuity of care.

Notes

(1) Andrew Sparkes, professor of physical education at Exeter University, wrote a fictional account of life in higher education in the era of the RAE and submitted it as part of the assessment. It is published as “Embodiment, academics, and the audit culture; a story seeking consideration” in the Sage Journal: Qualitative Research, 2007, Vol 7, pp521-550

(2) Konrad Jamrozik, professor of primary care epidemiology at Imperial College. Imperial made him an impossible offer, which of course he declined. He is now doing very well as head of his Division in the University of Adelaide.

(3) Sally Hull, P Aquino, and S Cotter (2005) “Explaining variation in anti-depressant prescribing rates in east Loindon: a cross sectional study”. In Family Practice, Vol 22, No 1, pp37-42

(4) The CHRE – The Council for Health Regulatory Excellence was set up by the Health Professionals Order 2001 as a result of the Kennedy Report (written as a part of the Bristol Royal Infirmary Inquiry).

(5) Andrew Elder is a GP and was a GP teacher at Imperial College, he is also a member of the Balint Society. He attended the Savoy Conference (Nov/Dec 2007) where he asked some important questions about policy implications for the structure of health care delivery and medical training and its impact on the relationship between practitioner and patient