It’s time to stop pretending the health service can answer all of life’s ills, says Dr Katie Musgrave
What is our health service for? GPs have traditionally provided services to help ‘people who were sick or perceived themselves to be sick’. But what about lonely people? Teenagers worried about exams? Toddlers with difficult tantrums? Babies with colic? Women suffering from premenstrual mood swings?
Somewhere along the line, our society has medicalised normal life. A patient’s grief after the loss of a spouse is diagnosed as ‘bereavement reaction’, while an insecure youngster is diagnosed with ‘anxiety and depression’. Are people not allowed to be sad any more? Are children not allowed to have meltdowns? Is life not allowed to be shit sometimes?
We farm out our patients’ problems to the professionals, hoping that an hour on the phone having CBT might solve issues from a difficult childhood, a broken marriage or long-standing financial stresses. We hope that social prescribers might help address our broken, disconnected communities (they largely can’t). The professionals don’t have the answers, yet we keep referring.
Ever more people are given the emergency mental health number and urged to read online manuals on mental wellbeing and have a course of CBT. But are they not generally left feeling disappointed – that the ‘fix’ isn’t there – when they find they are gently fobbed off by a clinician who has as much to offer as a chocolate kettle?
With every passing year, it seems the health service is managing an increasing range of conditions, yet clearly not all are essential medical services. This would be fine, perhaps positive, in a system that was functioning well: where a heart attack or stroke was swiftly assessed and conveyed to an acute hospital for urgent treatment; where worrying symptoms of cancer were quickly attended to by a GP with the time to ask the important questions, undertake an appropriate examination and make a referral.
But the system isn’t functioning, is it? Our ambulance statistics are worsening year on year. Our emergency department waits are atrocious. Our early cancer detection rates are extremely poor by international standards. And yet, I regularly find time to explore the minutiae of a lady’s menopausal flushes. I often counsel anxious parents on sleep training, reflux and weaning. It is very common that a slightly upset child is brought to me, where my only intervention is to urge the parent to get the child to school, consider getting out of the house more or take up some hobbies.
In a war zone, which the NHS is rapidly emulating, we should not be discussing tantrums or mood swings. I know I will offend some by writing this. Still, if they were my mood swings, or my child’s tantrums, I would forgive the offence – if I knew my mother or father had fallen, broken a hip, and were lying on a bathroom floor for 10 hours.
The time for niceties has passed. There are no magic resources in the NHS. Every minute spent discussing a moody teenager is a minute less spent seeing a palliative patient. I know some of the teenagers with mood swings or ladies with night sweats will be emergencies, but most are not. And we usually have a reasonable inkling who could wait or be signposted elsewhere. Perhaps the non-essential aspects of our work need to have fees attached.
It would be nice to believe that the health service had the answer to all of life’s ills. It would be great to think we could help every sad, lonely or troubled person. But we can’t, and the longer we pretend we can, the longer we will see patients lying in agony waiting for ambulances or sitting at home on hold to their GP, scared witless that they won’t get through.
I want my patients to be able to access help when they need it. It is time to stop medicalising normal life and start being realistic about what the service can offer. More of the same is not an option, as increasing numbers of GPs walk away. But do any of our leaders have the courage to fix this?
Dr Musgrave is a GP in Devon and quality improvement fellow for the South West
READERS' COMMENTS [42]
Please note, only GPs are permitted to add comments to articles
I agree Katie. There are a lot of factors driving this. The litigation culture. The victim culture. A gateway to not working and benefits. The fragmentation of families. Lack of work /life balance. Doctors cannot be all things to all people at all times, but the GMC and politicians don’t see it like this. Doctors are a resource like money. If you spend time doing one thing you can’t spend it on another. Ivan Illich wrote a book, The Medicalisation of Life, years ago. I read it in first year in 1977. It was probably the most insightful book in the entire course. Free at the point of delivery is a problem, but solving this won’t be easy.
I vote for you, spot on. Yes, a fever means you will die, a cough means cancer and a bit of bloating means you’ll explode into smithereens. The institutes have orchestrated all this mediocrity, anxiety and emptiness. Fake autobots. The human is no longer a human. And most humans don’t think they will die, but live in cotton wool and roses all their fairy tale life – with one hand attached to a GP, whilst stimulated on sertraline, alcohol, social conditioning and white powders. Privilege and naivity will self-combust all countries. Ignorance isn’t bliss, it is painful unawareness. Explaining the trivial is like explaining why you breath, everyday. Drink water, sleep well, try and smile and don’t be such an ego is like rubbing ones face on a grater in 2022. The treatment is no treatment, wake up and face the facts, not your delusions and imagination. Modern progressive nothingness. Pat on the back. Good doers, being buddies and social workers. The mirror is a painful place, sticky plasters are a sick distraction. It won’t end, this pays bills and medicalisation churns a multi-trillion dollar industry.
Completely agree and well expressed, Dr Musgrave
It’s not that we have medicalised normal life. It’s that life is no longer normal. Our society is fundamentally broken. The housing system, our economy, the constant war on the poor, the post industrial labour system that makes labour cheap in the pursuit of growth forcing people out of work and those in work relying on wages they can’t eat, pay rent or stay warm on. No, we as doctors can only manage the systems of our toxic country. We need radical change.
Excellent article, well done. It is quite clear that for the NHS to progress it needs to define its purpose – and its priorities.
The alternative -? Go woke – go broke.
Dear All,
How refreshing to see sensible opinion being expressed by a Quality Improvement person. All our local “improvers” don’t understand the concept let alone have anything sensible to say.
Devon, i’m jealous.
Regards
Paul C
Totally agree. This is actually the root cause of most of the problems in primary care. Can’t get to see your GP? This is why.
Can’t argue with any of article or replies but it encapsulates why I will be gone from GP F2F at end of year.
Will do sessions at Hospice (have a pragmatic sensible relevant acceptable solution to appraisal) where it’s real medicine & feel may actually be doing a benefit.
Congratulations NHSE 27 years GP experience binned
Chocolate kettles are very useful. They can be consumed to keep the dementors at bay (Harry Potter would know about that).
The rest is just right. We need a truthful, honest, respectful government that will tell people what they can realistically expect, and invest in improving life and fairness generally, not expect GPs to do it all.
A bit of investment in genuine general public health, and maybe preventing all those commercial interests and awareness adverts designed to sell consumables would also be a good idea.
“It’s time to stop pretending the health service can answer all of life’s ills” – I never thought that through training and it is a shame some only realise that whilst working. Better late than never I suppose.
“the constant war on the poor” – Does the “poor” include the lazy, the self-afflicted (drug/alcohol misuse – on the subject of overmedicalisation…), the illegal migrants?
What do the “poor” get? Minimum wage, welfare, healthcare, housing, education, massive redistribution of resources, mainstream media backing…
What do the “rich”/hardworking get? High progressive taxation, censorship, pariah stigmatisation.
It’s not the “post-industrial labour system”, Simon, it’s Tony Blair’s open-borders that’s done it. How much did our population increase again via migration in the last yr? And what is the British indigenous replacement birth rate?
And for all your moaning, you’re free to contribute more of your hard-earned wages to help, but you’re unlikely to convince me to.
“stay warm on” – again that’s not “post-industrial labour system”, that’s the net-green agenda for you. How much of your energy bill is mandatory green subsidies again?
Net zero agenda, I should say
Like I said, you can no longer differentiate the public from a patient. It is all one grey homogeneous thing. How bland. And never ending.
Great article.
By happy coincidence a link to an article “GPs to send women to period course via social prescribing” appeared below your article, just to reinforce your point.
Patients are now tins of beans (cut-price of course)on a production line and we are the factory workers.A grey amorphouse entitiled mess.
Really good article- thanks Katie. The forces ranged and safe and effective ‘self care’ are varied and many unfortunately.
I agree with many of your frustrations, the public turn straight to GPs for everything and expect us to wave a magic wand.
However including menopausal symptoms and suggesting that hot flushes are medical minutiae when they signal a very dramatic change in a woman’s health reverses the advances being made in this area.
The menopause impacts every woman, every aspect of her life, those who she works with and those who share her life.
10% of working women leave their jobs because of menopausal symptoms. That’s 10% of 13 million women!
I agree. About 2/3 of my surgeries are ‘patient wants this referral or that medication’. What is sad is that the patient doctor consultation appears to have been eroded to more of a ‘I want this from you’ rather than ‘ I have this issue and am asking for your opinion’. I have found respect for GPs seems to have dropped very low since the pandemic and this is driven by the media and also government. I have also noted the younger patient population appear to be getting more entitled and seem to see general practice as just another service they contact to order what they want such as amazon or deliveroo. They are conditioned to get anything they want at the push of a button immediately and cannot seem to manage any minor symptoms by means of watchful waiting any more. I agree social structures and family units have eroded and general practice is seen as the surrogate parent to take away all their problems the vast majority with no medical basis. Self care is now filling in an econsult. The only way out of this is changing what the expectation of general practice is. Start attaching a cost for each consultation and reduce the routes into general practice.
Thank your Dr Musgrave for having the courage to write what most of us think but don’t dare say. This mindset has turned Primary Care from clinically driven places to mental central.
Fantastic article.
Sadly it’s incredibly difficult to stuff the genie back into the bottle.
Curiously, though, there’s a slither of hope via over-saturation.
For example, for decades the parents of moody teenagers were encouraged to “see their GP” for onwards referral.
When CAMHS etc inevitably became massively oversubscribed, their response was to reject >90% of GP referrals.
Whilst in the short term this has cast us as hapless piggy-in-the-middle, shrugging our shoulders and offering homespun BS platitudes rather than non-existent referral, I’ve noticed that many parents simply give up trying the medical route and deal with the issue themselves.
Perhaps the “whilst I sympathise I’m afraid there’s really nothing I can do to help” line is our salvation, but sadly the media-driven frenzy to demand your GP to fix all life’s problems will be with us for decades, and it’s a fight many of of us don’t have the stomach for.
…. And London GP’s have a pot of 250K to prescribe fruit and vegetables!!!
Why is there no consensus on what it is appropriate for us to do ?
Basically, what GPs want to say – and have always wanted to say which is why they leave the UK – is that they couldn’t care less about half the cr*p churned up in this sick perverse system, and really find it sh*t boring making up explanations for nonsense that doesn’t exist, but have to do it in a patient centered way to nanny one’s lazy imagination and fake intelligence disreality.
👏👏👏Great article, sums what we’re all experiencing perfectly.
Perhaps a small charge to see GPs might help people think a little before booking an appointment?
Totally agree with you Katie, however it’s not up to us to sort/prop up an obviously broken system. This country needs a grown up discussion about lots of services and expectations. Why does it surprise
people that countries that pay more get a better service for example Unfortunately, this dose of reality is kicked down the road by politicians and media who prefer to endear themselves to the entitled masses rather than confront reality. As a tax payer I don’t believe in the bottomless pit of healthcare that some consider a right rather than a privilege. However, whilst the legal vultures, abetted by the usual culprits, stating anything but excellence is culpable then the dangerous end game plays out. It isn’t surprising that some decline to keep playing!
Don’t think any of us can see a way out of this one but flogging the workforce certainly isn’t going to work despite what the Mail might wish!
As always. Few options for solutions.
The NHS will continue to get worse.
Any doctor with any sense will find a career for themselves outside the NHS.
If you think staying in the NHS and simply waiting for someone else to make it better is the answer then more fool you.
Too right! I am finding myself becoming increasingly school marmy in my approach.
Good article Katie
I agree with Thomas Kelly. Massive cultural change over recent years, especially since the pandemic. No or negative respect for medical professionals and younger folk want instant relief/gratification.
This is the best article i have read for years – Dr Katie says what i am thinking — and it is glorious – it is a epiphany / i am changing the way deal with other professionals because of this. esp nhse and also all the do gooders out there – well done Katie!!
Doctors Medicalise ordinary human suffering, not patients. GPs manage two boundaries: between primary and secondary care, and between illness and disease. An illness is a patients subjective experience of suffering/ their symptoms. A disease is a clinical condition. As Iona Heath pithily put it, “an illness is what you have when you go to the doctor, a disease is what you have when you leave”. The best book I’ve read on the differences between illnesses and disease in mental health is Head First by Anthony Santhouse https://www.theguardian.com/books/2021/jul/14/head-first-by-alastair-santhouse-review-a-medical-memoir-with-elegance-and-integrity
GPs should have the option of transferring to being a Consultant Community Physician. Then whoever runs Primary Care can decide if they really want a consultant to be seeing trivia.
very good article, spotted
but what are those reasons that unnecessarily to be seen by GPs, ?
Free NHS
lets thinks starting charging a fee in NHS and all those wondersome syndromes will stop
Exactly the reason I had had enough by 50 and left. Earn more from a small non-medical internet business that takes a few hours a day and pension goes up by index-linking. Damned waste of 23yrs f/t nine clinical session experience though. Good luck.
When Professors of General Practice are advocating that GPs begin prescribing fruit & veg it’s clear that the profession has only itself to blame for the current situation.
The GP is now expected to take the role previously occupied by the Vicar. This is NOT what we trained for.
I share your concerns about medicalisation but rising ambulance waiting times and poorer cancer outcomes are not due to GPs seeing teens with mood swings or babies with colic.
Our government says it is building 40 new hospitals (it isn’t) and wrote off £4 billion in fraud earlier this year
https://www.thetimes.co.uk/article/treasury-writes-off-4-3bn-in-covid-payments-lost-to-fraud-dfkxt5fr7
We are practising in a system that’s being run down.
There is a lot of truth in what you say but then we as GP now perhaps are disempowered to help. The ‘norm’ is that all young people with emotional distress need referral as opposed to the tiny serious minority . The idea of the GP having advice and wisdom on this subject without onward referral coupled with loss of other pastoral figures and the societal assumption that we should all have non misery all the time is creating a perfect storm. The media still promotes and the mental health industry still provides mass school counselling when there is a tragedy when the evidence is that this makes things worse (happy to be corrected if the evidence has changed)
Not sure though if loss of continuity with responsibility and family trust in their doctor may also have tiny part to play?
Great article great comments.
Well written and totally agree. Never seen so many comments! So just wanted to add another one..
Agree with most of the above – but interesting to note that the esteemed editor, Jaimie Kaffash, wrote an article on the 16th stating that we are all wrong! Stick to editing, methinks
Can’t believe nobody has mentioned adult ADHD
I’ve been a GP for over 22 years and I’m not sure the job had changed that much in this respect. We have always been responsible for the social aspects of health and illness – it’s part of the role.
What makes it more challenging is the current system failings and the demand/capacity mismatch.
It’s also an issue with systems and pathways and not placing the GP as first port of call for these referrals.
Young people need help more than ever now as their mental health has really deteriorated post pandemic lockdown. Bit they don’t necessarily need to access help through us and schools and self referrals should be adequate, but they are not.
And we must not lose sight of the fact that young people take their own lives – the most tragic outcome there could be.
Patient need better support and GPs need better support. We are all victims of the system
I agree with you Shaba. The main issues is demand/capacity and what we see in general practice doesn’t interfere with A&E waits, ambulance waits or hospital beds, OP treatment, OP rv etc.
The failings of acute medicine, ie when people urgently need medical input doesn’t interface onto General Practice much as most people know when they are ill enough to need hospital not us so for acute care we don’t impact the failings.
Re chronic OP care, the current crackdowns on referrals mean over presentation to GPs again doesn’t affect OP delays etc either much. If the referral isn’t clinically needed it has no chance of making it through.
The main issue for us is too much demand, not enough capacity and falling numbers of GPs.
We’ve always been there for 80% non-medical, 20%-yes you need medical input stuff.
Our role is to delineate on that. I’ve got no issue with that.
If we have enough capacity the 20% proper stuff won’t be blocked by 80% non-medical ahead in the cue. If the media and politicians would let us triage properly instead of dragging us into their political manoeuvring that would help.
The extra roles NHS England gives/enforces on us don’t help much. They just generate more work and demand.
No one has a bigger role in medicalising society than NHS England with its social prescribers and wellbeing advisers.
And no one addresses what would really help people’s health which is public health measures to tackle obesity; which would deal with type 2 diabetes, CVS and CVA, a big chunk of osteoarthritis/joint replacements, etc.
But that needs govt action on fast food, processed food, junk food advertising and taxation, subsidising healthy foods like fruit and veg and giving local councils funding to get decent active transport, sport and leisure, etc facilities.
None of which makes money or keeps the government donors and lobbyists happy; industrial farming to food industries; which are based on processed food and junk food.
So instead we are referring our patients in vast numbers for gastric sleeves, prescribing obesity injections and dealing with the multiple morbidities of obesity and related diseases.
No, the government is more interested in exploiting health data to boost up the pharmaceutical industry and help health tech, etc develop ever increasing ways of monitoring and treating our ill health.
The GP is the middle man. Data collector, keeper of the myth that pharmaceuticals and high tech solutions and data are the answers to problems we have long had the public health solutions to.
But there’s no one to lobby the government for those solutions. And no money to be made from them.
So lets keep chopping down the forest globally for meat and palm oil for mcdonalds and unilever, making our populations fatter and fatter and keep referring those patients for their gastric sleeve or obesity injections and keep the systems and the science, Big Pharma and health industry myths rolling.