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Politics and policies within the NHS
David L Beales MRCP MRCGP
J R Soc Med 2000;93:487±488
`What the [modernization] plan will illustrate is the
degree of change that is necessary and I think the
problem will not be people saying, ``so what?''. The
problem will be making sure that those in the health
service, who we need to work with in order to get these
changes done, buy into the change. Really I think that
will be the biggest problem'ÐTony Blair, Times, 26 May
2000.
Once more, general practice ®nds itself at the forefront of
change in the National Health Service (NHS), accelerating
rapidly without adequate consultation. The Prime
Minister's sincerity in promoting his new vision is beyond
doubt. But where is the considered debate? Where is the
forum to bring about informed discussion so that NHS staff
can `buy' into the change? Within society there are now
more pressures than ever before on the individual and
family, promoting fragmentation and isolation. We have
escalating divorce rates together with increasing rates for
depression and functional somatic syndromes of all kinds
1
.
Within existing primary care there are protective strategies
that could be destabilized by introduction of new policiesÐ
particularly NHSDirect and walk-in surgeriesÐwithout
pilot studies and subsequent debate with those concerned.
In this paper I move from my personal experiences as a
general practioner to urge a formal consultation process
that is ongoing and ®rmly bedded into the multidisciplinary
culture of the NHS.
Individual practice
My approach to practice was shaped by the de®nition in The
Future General Practitioner
2
. This can be summed up now in
the words of Luke Zander when retiring from thirty years
of practice:
`I'm a personal doctor and generalist who looks after all
the conditions a patient may present: medical, social or
psychological . . . I provide continuity of care to
individuals and to familiesÐpeople related physically,
genetically and emotionally'
3
.
The context in which I work calls for an understanding of
the predicament of my patients, and often for skills to help
them in the reattribution of their somatic symptoms to the
effect on them of the stresses of their everyday lives. As
many as 30% of general practice consultations can be seen
as functional
1
. The purely mechanical investigation of
physical symptoms is likely to be costly as well as
inappropriate. Overinvestigation and the subsequent ®xity
on the underlying search for this mechanistic explanation
then proves expensive and futile. But renegotiation, away
from the mechanistic interpretation, demands trust between
clinician and patient.
Teamwork
To make connections with other facets of patients'
problems, my practice has developed an extended team
including a practice counsellor, an attached psychologist and
a community psychiatric nurse. Our programme of
anticipatory care to elderly people has led to the award
of NHS Beacon status. We have founded a charitable trust
to offer services not available within the NHS but important
for the development of self-esteem and self-managementÐ
courses on stress management, meditation and stopping
smoking and joint working with complementary practi-
tioners. Our consultation rates are low (despite good access
to services), as are prescribing and referrals to secondary
care. The ability to work together and plan services depends
on the ability of the team to communicate and to respond to
need. It also depends, within primary care, on knowing
each other's ®rst names and meeting not only formally but
also over coffee and in the corridor. Bion has de®ned an
effective team as `a planned endeavour to develop in a
group the forces that lead to a smoothly running co-
operative activity'
4
. This is much easier at a small team level
but still necessary within the larger organization.
Making connections
We have therefore done a great deal to broaden our
approach and to improve our internal communications and
ef®ciency. Worrying anomalies still remain, however. In
particular the gap between the NHS and local authorities
has not been wholly bridged. Local authorities are still
responsible for community care of the mentally ill and
handicapped and the residential care of elderly people, and
decisions about the care of patients in these categories are
still dogged by ®nancial and organizational complications.
These often make it dif®cult to decide whether a patient
487
JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 93 September 2000
Phoenix Surgery, 9 Chesterton Lane, Cirencester GL7 1XG, UK
should move into or out of hospital or be provided with
some form of halfway house. The very different forms of
training received by doctors and social workers do present
further obstacles. There are several ways to bridge the gap
but in Northern Ireland a successful model is already in
place. There, health and social workers operate within a
common ®nancial framework, and it seems urgent to
consider whether similar arrangements could be extended
to the rest of the UK.
A re-engineering of the organization, where health is
seen in a broad context, builds from the early visions of the
Peckham experiment
6
. Healthy-living centres are already
developing, as are joint educational initiatives with schools
and use of the Internet. These are all means to increased
wellbeing for people, but they need to be coordinated.
Political and clinical
Matters of this kind could be examined in depth at a Staff
College of the kind lately proposed in the JRSM by Duncan
Smith
5
. He called for a college where frontline staff would
be more closely involved in shaping new patterns of health
care. Politicians, as Smith suggested, often choose to take
the advice of management consultants, civil servants and the
Royal Colleges. A Staff College, embracing training,
interdisciplinary debate, and the development of strategy,
could act as a sounding board for all elements within the
service, whether in the settings of primary, secondary,
tertiary or social care.
REFERENC ES
1 Wessely S, Mimnuan C, Sharpe M. Functional somatic syndromes: one
or many? Lancet 1999;354:936±9
2 The Royal College of General Practitioners. The Future General
Practitioner, Learning and Teaching. London: RCGP, 1972
3 Times. Is this the end of the family GP? 18 May 1999:18
4 Bion W. Experiences in Groups and other Papers. London: Heinemann,
1961
5 Smith D. The National Health Service needs a voice of its own. J R Soc
Med 2000;93:217
6 Pearse IH, Crocker LH. The Peckham Experiment. London: Allen &
Unwin, 1943
488
JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 93 September 2000
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Article
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We review the concept and importance of functional somatic symptoms and syndromes such as irritable bowel syndrome and chronic fatigue syndrome. On the basis of a literature review, we conclude that a substantial overlap exists between the individual syndromes and that the similarities between them outweigh the differences. Similarities are apparent in case definition, reported symptoms, and in non-symptom association such as patients' sex, outlook, and response to treatment. We conclude that the existing definitions of these syndromes in terms of specific symptoms is of limited value; instead we believe a dimensional classification is likely to be more productive.
Book
A classic study which, by synthesizing the approaches of psychoanalysis and group dynamics, has added a new dimension to the understanding of group phenomena.
Is this the end of the family GP?
Times. Is this the end of the family GP? 18 May 1999:18
The Royal College of General Practitioners. The Future General Practitioner, Learning and Teaching
The Royal College of General Practitioners. The Future General Practitioner, Learning and Teaching. London: RCGP, 1972
The Peckham Experiment
  • I H Pearse
  • L H Crocker
Pearse IH, Crocker LH. The Peckham Experiment. London: Allen & Unwin, 1943