TAKING PRIMARY CARE SERIOUSLY           

Julian Tudor Hart

Opening lecture to 4^th annual history of nursing conference Swansea 13.11.07

Though this is a conference of experts on history of nursing, I’m neither a professional historian nor a professional nurse.  However, I’m 80 years old, and have worked, studied and thought around primary care for more than 60 years.  All thoughtful 80 year-olds are primary-source historians.  And all health workers in primary care have, or ought to have, at least some nursing responsibilities.  So that’s my inexpert justification for speaking to this conference of experts in both fields.

I decided to head for medicine in 1945, when I was 18.  Three years earlier I had started to read Marx and Engels.  We had defeated fascism and begun to construct a new world fit for everybody, not just those who had always ruled.  Illness is an indiscriminate injustice not only for patients, but for everyone round them.  Nature is blindly unjust, justice is a human construct, and requires intelligent struggle to bring it about, an aim unique to our species which will grow throughout its history.  Doctoring seemed a good way to apply that idea in material reality.

At the same time as I chose doctoring, I chose also to become a GP.  GPs worked at the bottom of the medical hierarchy, closest to patients where they led their lives and earned their livings.  Whatever currently fashionable historians may pretend, sustained progress has always come from below, because that’s where pressure for it always begins.  The most powerful resistance comes from above: not from popular unreason, but from the intelligent calculations of the rich, and all who depend on them.

While I was a medical student, from 1946 to 1952, the NHS was being born.  The landslide Labour majority of voters was its mother, Nye Bevan was its midwife.  Leaders – or more correctly, misleaders – of the BMA did their best to ensure a stillbirth, but they failed.  Too late, they discovered they were pushing with all their might against a historic process that was already irresistible.  The ideological battle raged throughout my student years, with almost all our teaching consultants proclaiming the imminent collapse of medicine as a dignified profession.  Doctors would lose all incentives to practice conscientiously, and committees would consider for weeks on end whether a patient with acute appendicitis should have a laparotomy.  Even today, with care in England divided into tradeable and regulable fragments connected only by consumer choices and wants, no such committees exist, but if you look at the editorials and correspondence columns of the BMJ for 1947 and 1948, this is the sort of nonsense you’ll find.  Evidently, most ordinary people then had more sense than most of the doctors.  They took another decade to discover from their own experience that once fees were removed from the complex equations of medical judgement, they could act more effectively, more rationally, and with greater integrity.

Fortune favours the prepared mind.  When I was still a student, patients admitted with severe, accelerated hypertension (malignant hypertension) all died with either brain haemorrhage, kidney failure or heart failure within a year or two.  Soon after I qualified, with new treatments almost as bad as the disease, some began to survive.  A couple of years later, while I was still working in London, George Pickering published his seminal papers on the continuous distribution of arterial pressure in the general population.[1]  When doctors knew almost nothing about the causes of a disease, they still had to give it a name, so hypertension of unknown cause (that is, more then 99% of high blood pressure as found by screening a community) was called Essential Hypertension – “of the essence.”  Mysticism personified.   

Pickering showed that arterial pressure was a personal characteristic variable, distributed continuously, with no clear dividing line between normal and abnormal states.  Like all biological distributions, it was skewed, with a short tail to the left (low values) and a much longer tail to the right (high values).  A colossal pile of subsequent studies has confirmed over and over again that for this, and for most other chronic so-called diseases, there is no abrupt shift from normal to abnormal values for any biological measurement.  There is rarely a clear distinction between disease on the one hand, and normal health on the other, until organ damage has already occurred, often irreversible.

For doctors thinking within the paradigm of private medical trade, Pickering’s perception was devastating.  Sir Robert Platt led a large majority of consultant physicians defending their right to define disease in the ways required to divide worried people who didn’t need doctors from sick people who did need doctors.[2]  Pickering won the intellectual argument, but Platt’s paradigm still holds the field for discussion of disease in general, fortified by medical tradition and reinforced by commercial interests which require that biological and social problems brought to doctors be divided into neat diagnostic subsets, each having its own pills or surgical procedures as its appropriate commodity solution.  It is a paradigm incomprehensible in biological terms, unless these include political economy, which accounts for more human behaviour than most people care to imagine.

In this tradition of medical trade, diseases have been defined backwards.  Their definitions start from death, life-threatening illness, or qualitative shifts in biological variables that establish an abnormal physiology, adapted to new conditions for survival.  From these they work backwards, with diminishing interest and investment, toward the progression (or, more often, regression) of illness, finally reaching their always multiple causes – the births of illness, when most of these causes fail to produce anything recognisable as classical diagnosis. “Good teaching cases”, typical examples cherished by teaching hospitals, have advanced or end-stage disease, usually with gross symptoms and signs, or at least grossly deviant physiological values.  In a developed economy, these cases are seldom seen in primary care.  When they are seen, nearly all get referred to hospital-based specialists. 

Teaching hospital specialists therefore assumed that most of general practice, and most of primary care (which they saw as just a different way of describing general practice), was about nothing, except selection of real clinical problems for solution by real doctors.  The rest was a pile of unsorted minor complaint, of little or no clinical interest.  In fact, it was composed of everything they didn’t want or couldn’t do, much of it very important.

Specialist care and judgements deal with converging probabilities of these end-stage states, with their clearly defined labels.  The main agenda for primary generalists is entirely different.  They deal not with converging probabilities, but with diverging possibilities.  Most people don’t have the end-stage problems described in the Oxford Textbook of Medicine.  Even if they do have them, but at a much earlier stage in their natural history, in a developed economy, most will recover through their own body defences. 

However, these patients who don’t have classical diseases certainly do still have problems, because people without problems don’t go to doctors.  When patients first feel sufficient fear to open their lives to a doctor, they always have a problem. 

Left to themselves, Platt-paradigm doctors would have been content to deal with the real problems of end-stage disease, and left the rest in an unsorted heap of unwarranted fears, worries, self-limiting trivia and so-called neurotic illness which as good clinicians were not their concern.  However, they were not left to themselves, because at the bottom of the professional heap there is no escape from patients’ problems as they feel them.   The NHS ended consultations as sales opportunities for doctors, but GP consultations remained an increasingly profitable sales opportunity for the pharmaceutical industry, as long as doctors could be helped to stick with the Platt paradigm rather than become human biologists.  For every ill to attract its pill, the ills of primary care must have names.  They must be seen as diseases equally worthy of scientistic treatment.  For this reason, the pharmaceutical industry still spends more on brainwashing, and to a smaller extent on bribing, doctors to find names and therefore pharmacological treatments for all the problems they meet.  If the European Commission has its way, they will soon also have direct to consumer advertising for prescribed medications, to ensure that our entire society accepts this irrational set of assumptions.[3]  And so we walk blindfold toward the present situation in USA, where 15% of Los Angeles schoolchildren are on continuous medication for Attention Deficit Hyperactivity Disorder,[4] and childhood depression is attracting medication similar to that used in adults.[5] WHO experts now issue recommendations that would result in about one quarter of all adults having lifelong treatment with antihypertensive drugs,[6] and some expert authorities have even advocated continuous statin treatment for the entire adult population.[7] 

It’s surprising that the concept of graded response to graded risks made any headway at all, considering the forces ranged against it.   However, this increasingly rational strategy has been the dominant paradigm within which every university department of primary care now operates, simply because it reflects the daily needs and experience of all primary care staff who think critically about what they do, and because this is the way we think about all the rest of biological science.  For human biology, we recognise that diseases have no separate existence from the people who have them, and that most ill-health, at the stage when we can deal with it most effectively, is still a quantitative deviation from normal physiology, not a qualitative shift into what may usefully be categorised as disease.

Before I entered primary care in South Wales, I worked under Archie Cochrane and Bill Miall in their MRC Unit attached to the MRC Pneumoconiosis Research Unit at Llandough.  The MRC paid very badly, so in my vacations I worked as a GP locum, first in Maerdy and later in Ferndale, both in the Rhondda Fach.  My earlier London practice had been in Notting Dale, then border country between gentry and slums.  All were very hard work, but a GP’s work in the South Wales valleys was much harder than in London.  There was about twice as much of everything except time and money.[8]  I had to deal with around 60 patients in the morning, then do around 20 to 25 home visits, and then see another 60 or so in the evening session.  Like other industrial practices at that time, the nominal duration of each session was one hour.  After this the entrance door was locked, but it actually took at least 3 hours before the last patient went out.  That allowed an average 3 minutes for each consultation, including turn-around time. 

Many of these patients were very sick indeed, with uncontrolled heart failure, untreated pernicious anaemia, unstable or undetected diabetes, untreatable lung failure with continued smoking, untreated major depression and so on.  Their expectations were low.  Most came either for certificates of incapacity to work, or for token bottles of medicine to sustain the illusion that somebody was treating their illness.[9]

GPs doing this hard but clinically futile and professionally humiliating work seemed to seek escape by three different routes.  The best of them assimilated to the very strong mining communities they served, becoming highly respected characters in a society of other respected characters, each one of them unique: but they pretty well abandoned any attempt to work within the paradigm of evidence-based medical science.  The weakest of them took to the bottle; the incidence of alcoholism among South Wales valley GPs was huge.[10]  The worst of them blamed their patients, assuming that trivial demands and expectations, for pieces of paper which did at least provide useful money, were not associated with often gross treatable disease.[11]  These were sick communities, as their generally premature deaths testified.  GPs’ anger was often vented on the nearest target, least able to fight back, not on the system that created this conveyor belt of pretend care.

What was that system?  By the time Nye Bevan’s 1945 plans were nearing fruition in 1948, paying for the recent war and preparing for the next one had almost bankrupted the UK economy, and BMA opposition to state-funded general practice had ensured that secondary care would become the only field for innovation for the next 18 years.  From 1948 to 1966, hospital-based specialists were appointed to serve the whole of the UK, roughly according to population needs.  This was a huge advance from prewar chaos,[12] not achieved even today in USA, which still relies on market distribution of resources rather than rational planning.  Like everyone else, Nye Bevan seems to have thought that only specialist care from hospitals needed to be taken seriously.  Anyone who really needed a real doctor would be referred to a specialist at the hospital.  Everyone else would make do with their GPs, quasi-doctors defined not by knowing their own field of primary care as human biologists, but by their failure to become real doctors, hospital-based specialists.

GPs were left to survive as best they could.  With roughly three times as many patients as before and no fees to obstruct demand, they had to cope with an avalanche of consultations, backed only by the resources of their own cottage industry, starved of investment because everything spent on care came from their own pockets.[13]  By 1966, experience in USA and Sweden was showing that without GPs as gatekeepers, hospital specialists couldn’t really specialise.  Huge A and E departments had to grow ever faster to cope with people whose problems had not been filtered or defined as appropriate to hospital care.  The UK would lose what was at last becoming recognised as a colossal asset, gatekeeper GPs.[14]

The NHS was a vehicle with a powerful engine, real doctors (specialists) working with the effective tools and teams which only hospitals could provide.  This vehicle connected with all of the people and all their unsorted problems, through four sturdy wheels providing free care of some kind to the whole nation no matter how rough the road.  These wheels had to move at whatever speed this whole population with free access demanded each Monday morning, but the engine had to move at speeds of its own, demanded by specialists as the most they could reasonably achieve.  Reconciling these two quite different speeds was the clutch – GPs whose choices between cursory diagnosis and treatment by themselves for about 95% of their consultations, or referral to specialists for about 5%, made the difference between sustainable progress or collapse.

This role of UK general practice, as a clutch that allowed the specialist engine first to survive and then to grow within an NHS gift economy, was implicitly understood by governments until the 1980s, and accepted throughout the world as the key to Britain’s uniquely cost-effective NHS.  It was never explicitly admitted, either by government or professional organisations, but I doubt if even my fiercest opponents would now deny it.

The clutch metaphor serves well enough to explain the historical function of GPs within the Platt paradigm, but it’s wholly inappropriate for explaining how primary care could function in a more rational NHS, planned to produce health gains as its measurable products, rather than processes as priced commodities.  Already within the clutch function, primary care teams were somehow making space to develop into something quite different and immeasurably superior.  Nigel Hawkes, health correspondent of the Times, wrote two weeks ago in the British Medical Journal  that “The NHS stifles the entrepreneur in us all.  Managers in the NHS do not innovate because there is nothing in it for them.”[15]  Perhaps that’s now true of NHS civil servants, after nearly three decades of uninterrupted descent into Thatcherist corruption, but it was certainly not true of GPs I knew who first created modern concepts of primary care, from the early 1960s to the late 1980s.  They were huge innovators, but generally had to operate against substantial financial disincentives, because their principal innovation was to allow themselves more imagination and give their patients more staff time, largely though not wholly out of their own time and their own pockets.  I deny that there is, or should be, an entrepreneur in us all, but there is indeed an innovator, unless or until it is crushed by the ignorant condescension of managers imported from commerce and industry.

Innovation in science has never depended on thirst for money, though often enough innovation is thwarted by lack of it.  What is not paid for at all will never be done, but the real barrier to innovation was not a lack of incentives, but a surfeit of disincentives.  Making life better for everyone in a community you know and where you are yourself known needs no incentive other than itself.  Within the NHS as its own economy, we can measure how seriously governments take their responsibility for different sorts of health care by comparing budgets for each.  Primary care as a clutch cost a small fraction of the cost of specialist care from hospitals.  I’m afraid we allowed many politicians and their consultant advisers to fool themselves that if much if not most of the function of hospital outpatient departments for assessing chronic health problems and monitoring their progress could be shifted to primary care, this cost advantage might remain.  If so, I have news for them.  Hospital care is cheaper than effective care in the community, and always will be.  That’s why hospitals were invented, both voluntary hospitals and workhouse infirmaries.  It was cheaper for governments, and more convenient for physicians and surgeons, to process patients in factories than in their own homes.  Decentralisation and rehumanisation will cost more money, not less, because it will require more labour.  Health care is a field in which human labour can’t be replaced on a significant scale by machines.  Least of all can it be replaced where care is continued through lifetimes rather than concentrated on brief episodes of body repair.

This higher labour cost should present no problem to a truly civilised, truly democratic society.  Development of intelligent machines has hugely increased productivity, leaving millions of people with innovative capacities not needed for commodity production, but desperately needed for health care, education, and any number of other useful tasks as yet neglected because they’re not profitable.

When we begin to take primary care seriously, we shall begin to value its health workers as generalists, working in a field demanding much wider imagination and more cautious judgement than anything now expected from specialists.  We shall need human biologists, not as informed observers of the human species, but as educated participants applying scientific knowledge within small communities of which they are themselves a part, to other people who will be their friends and neighbours.  They will have to live with their mistakes, so they’d better get their judgements right.  No doubt they will generally work within guidelines, crude indicators of boundaries within which these judgements will usually operate, set by the crude evidence so far available.  But within these guidelines they will have to think critically and creatively as innovators, because nobody has yet written the book of Glyncorrwg, or St.Thomas, or West Cross.  Even when the primary care staff serving these communities do create their own information base through their own research, within one generation somebody else will have to rewrite another edition.

Rebuilding community within the social wreckage wrought by thirty years of retreat from public service into market chaos will be very difficult, but in primary care we are accustomed to hard work in dire circumstances.  There’s more community left in Wales than in England, our Welsh Assembly operates further from Washington, and will continue to learn from the increasingly obvious consequences of inviting multinational corporations to run NHS England for their managers and shareholders.[16]  For us in the Nye Bevan tradition, who believe in solidarity and public service, our most potent enemy is despair: don’t fall for it.

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