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AN ACCOUNTABLE GENERAL PRACTITIONER
1012
Occasional Book AN ACCOUNTABLE GENERAL PRACTITIONER A New Kind of Doctor1 is an exceptional book. On the dust John Horder describes it as "powerful and disturbing", while Sir George Godber sees it as "a major contribution to the future of the NHS". It is the personal testament of an idealistic but essentially practical doctor working (literally) at the coal face of general practice almost since the inception of the National Health Service. It is warm, it is self critical, and it is well researched. The book follows a broadly chronological sequence, moving from a brief autobiographical description of life in an urban industrial general practice in the 1950s ("20 to 30 patients came each morning, about the same number in the evening and between these two sessions I was supposed to fit in about 15 house calls. I would finish by 7.30 if I was lucky, by 9.00 if I was not. I did all the night work for the first year") to an analysis of the future of general practice and the National Health Service in the 1990s ("serious plans must be based on the real people we have, produced by the society we have"). The bulk of the intervening text carefully documents and references the advances and retreats of general practice during the past three decades. The Lloyd George heritage, Lord Moran’s ladder (off which aspiring physicians fell to become general practitioners), the 1966 GP charter, the rise and fall of the Royal College of General Practitioners, the influence of Balint, the advent of vocational training, and the present crisis of accountability are described "as they happened". As a social history of general practice since 1950 this description is unmatched, and I suspect will remain so. So what of the passionate socialist idealism for which the wild man from Glyncorrwg is well known? The book is passionate but never wild. It is precisely this which makes it exceptional. Hart leaves us in no doubt of his own belief that general practice will only move forward if it can encompass a more scientific methodology (in his terms "deal with doubt") and if it can accept patients as partners in promoting the health of the whole community. The expression of these ideas frequently involves words such as "participation", "democracy", and "community care", terms used loosely by demagogues. In this book these words are used neither loosely nor uncritically. In discussing patients’ participation groups, Hart notes that "the rate of formation of new patient groups is only slightly greater than the rate at which the old ones collapse ... my guess is that progress would be quicker if we gave higher priority to organising special interest groups addressing practical tasks". Similarly, in discussing the reasons for opposition to a salaried service, he agrees that fears of bureaucracy and loss of initiative are real and deserve to be taken seriously. Nevertheless, he is prepared to be trenchant in voicing his fears: "unless we can develop a new social alliance to extend medical professionalism in new ways ... only increasingly bankrupt and unconvincing traditions will delay passive privatisation by the apparently inevitable processes of decay in public, and growth in private, services. More than sentimental outrage will be necessary to preserve the welfare state in the health sector". Perhaps the reason why I think doctors of all political persuasions will take this book seriously is that it has its roots
cover,
1. A New Kind of Doctor.
Julian Tudor Hart. £11.95. ISBN 0-850362997.
London: Merlin Press 1988
Pp
in clinical experience. One of the most powerful examples in the book is his description of the medical care and history of Hopkin Morgan-a fictitious name for a big coal miner who rarely missed a shift until a runaway tram gave him a compound fracture in one leg in 1964, and killed the man working beside him. As the author says, this story is the "antithesis of episodic battles with acute disease" but it is a real story about a real person and it probably sums up his reasons for writing the book. The most surprising aspect of the book for me is the total lack of bitterness. For a young man with socialist ideals the medical profession is not the easiest place in which to find fulfilment. The history of the NHS during the past decade of "new conservatism", and Hart’s own experience of Glyncorrwg (where a thriving community based on the coal and steel industry has over 20 years experienced unprecedented loss of services, population, and employment) are hardly the stuff of optimism. However, rather than agreeing wholeheartedly with the coal miner whom he quotes as saying that "things might be getting better, but people are getting worse", he argues that British doctors are beginning to realise that the only credible choices are between accountability for cash to a centralised or multinational government corporation, and for health care to the local accountability population. He no doubt the that, given expresses opportunity, they will choose the latter. One way in which doctors can show they are worthy of this optimism is by reading the book. Department of Community Medicine and General Practice, University of Oxford
DAVID MANT
Round the World From
our
Correspondents
Israel COMPLAINTS ABOUT TREATMENT OF DETAINEES
ON Feb 8 this year a 19-year-old Palestinian youth, Khader Fuad Tarazi, died after he had been arrested by the Israeli Defence Forces (IDF). After a post-mortem examination by the IDF, heart failure was given as the cause of death. He came from a prominent Christian family in Gaza City, who did not accept the IDF version of the circumstances or the cause of his death. They pressed for an investigation and seven months later, after an inquiry, two private soldiers are to be tried by a military court on charges of "causing bodily harm" and a military doctor in the reserves will stand trial for neglecting his duties at the Beach Army Camp, where Tarazi was detained.l Staff at Soroka Hospital, to which he had been admitted, told investigators that he had severe external head injuries, which could have been caused by gunfire, by a blow with an instrument, or by a fall. The IDF statement released on Sept 8 maintained that the "main cause" of death was a fall as he tried to escape arrest. "He fell on a fence and was injured ... Soldiers arrested him and drove him to the Beach Camp installation. While being driven there he was hit several times, and when he was received at the installation he was unconscious." Tarazi was admitted to hospital at 11.15 pm on Feb 8; he had not been seen in his neighbourhood since 2.30 that afternoon. This incident illustrates some of the concerns of Palestinians living in the West Bank and Gaza. There are reports of brutal treatment of detainees and of failure of the medical services in the detention camps to provide basic medical care. There is also evidence to suggest that some doctors are directly involved in the ill treatment of detainees and in the use of torture during interrogation.
362. 1. Jerusalem Post
Sept 9, 1988.
Occasional Book AN ACCOUNTABLE GENERAL PRACTITIONER A New Kind of Doctor1 is an exceptional book. On the dust John Horder describes it as "powerful and disturbing", while Sir George Godber sees it as "a major contribution to the future of the NHS". It is the personal testament of an idealistic but essentially practical doctor working (literally) at the coal face of general practice almost since the inception of the National Health Service. It is warm, it is self critical, and it is well researched. The book follows a broadly chronological sequence, moving from a brief autobiographical description of life in an urban industrial general practice in the 1950s ("20 to 30 patients came each morning, about the same number in the evening and between these two sessions I was supposed to fit in about 15 house calls. I would finish by 7.30 if I was lucky, by 9.00 if I was not. I did all the night work for the first year") to an analysis of the future of general practice and the National Health Service in the 1990s ("serious plans must be based on the real people we have, produced by the society we have"). The bulk of the intervening text carefully documents and references the advances and retreats of general practice during the past three decades. The Lloyd George heritage, Lord Moran’s ladder (off which aspiring physicians fell to become general practitioners), the 1966 GP charter, the rise and fall of the Royal College of General Practitioners, the influence of Balint, the advent of vocational training, and the present crisis of accountability are described "as they happened". As a social history of general practice since 1950 this description is unmatched, and I suspect will remain so. So what of the passionate socialist idealism for which the wild man from Glyncorrwg is well known? The book is passionate but never wild. It is precisely this which makes it exceptional. Hart leaves us in no doubt of his own belief that general practice will only move forward if it can encompass a more scientific methodology (in his terms "deal with doubt") and if it can accept patients as partners in promoting the health of the whole community. The expression of these ideas frequently involves words such as "participation", "democracy", and "community care", terms used loosely by demagogues. In this book these words are used neither loosely nor uncritically. In discussing patients’ participation groups, Hart notes that "the rate of formation of new patient groups is only slightly greater than the rate at which the old ones collapse ... my guess is that progress would be quicker if we gave higher priority to organising special interest groups addressing practical tasks". Similarly, in discussing the reasons for opposition to a salaried service, he agrees that fears of bureaucracy and loss of initiative are real and deserve to be taken seriously. Nevertheless, he is prepared to be trenchant in voicing his fears: "unless we can develop a new social alliance to extend medical professionalism in new ways ... only increasingly bankrupt and unconvincing traditions will delay passive privatisation by the apparently inevitable processes of decay in public, and growth in private, services. More than sentimental outrage will be necessary to preserve the welfare state in the health sector". Perhaps the reason why I think doctors of all political persuasions will take this book seriously is that it has its roots
cover,
1. A New Kind of Doctor.
Julian Tudor Hart. £11.95. ISBN 0-850362997.
London: Merlin Press 1988
Pp
in clinical experience. One of the most powerful examples in the book is his description of the medical care and history of Hopkin Morgan-a fictitious name for a big coal miner who rarely missed a shift until a runaway tram gave him a compound fracture in one leg in 1964, and killed the man working beside him. As the author says, this story is the "antithesis of episodic battles with acute disease" but it is a real story about a real person and it probably sums up his reasons for writing the book. The most surprising aspect of the book for me is the total lack of bitterness. For a young man with socialist ideals the medical profession is not the easiest place in which to find fulfilment. The history of the NHS during the past decade of "new conservatism", and Hart’s own experience of Glyncorrwg (where a thriving community based on the coal and steel industry has over 20 years experienced unprecedented loss of services, population, and employment) are hardly the stuff of optimism. However, rather than agreeing wholeheartedly with the coal miner whom he quotes as saying that "things might be getting better, but people are getting worse", he argues that British doctors are beginning to realise that the only credible choices are between accountability for cash to a centralised or multinational government corporation, and for health care to the local accountability population. He no doubt the that, given expresses opportunity, they will choose the latter. One way in which doctors can show they are worthy of this optimism is by reading the book. Department of Community Medicine and General Practice, University of Oxford
DAVID MANT
Round the World From
our
Correspondents
Israel COMPLAINTS ABOUT TREATMENT OF DETAINEES
ON Feb 8 this year a 19-year-old Palestinian youth, Khader Fuad Tarazi, died after he had been arrested by the Israeli Defence Forces (IDF). After a post-mortem examination by the IDF, heart failure was given as the cause of death. He came from a prominent Christian family in Gaza City, who did not accept the IDF version of the circumstances or the cause of his death. They pressed for an investigation and seven months later, after an inquiry, two private soldiers are to be tried by a military court on charges of "causing bodily harm" and a military doctor in the reserves will stand trial for neglecting his duties at the Beach Army Camp, where Tarazi was detained.l Staff at Soroka Hospital, to which he had been admitted, told investigators that he had severe external head injuries, which could have been caused by gunfire, by a blow with an instrument, or by a fall. The IDF statement released on Sept 8 maintained that the "main cause" of death was a fall as he tried to escape arrest. "He fell on a fence and was injured ... Soldiers arrested him and drove him to the Beach Camp installation. While being driven there he was hit several times, and when he was received at the installation he was unconscious." Tarazi was admitted to hospital at 11.15 pm on Feb 8; he had not been seen in his neighbourhood since 2.30 that afternoon. This incident illustrates some of the concerns of Palestinians living in the West Bank and Gaza. There are reports of brutal treatment of detainees and of failure of the medical services in the detention camps to provide basic medical care. There is also evidence to suggest that some doctors are directly involved in the ill treatment of detainees and in the use of torture during interrogation.
362. 1. Jerusalem Post
Sept 9, 1988.