Offline: General practice—changing the laws of nature

Abstract

Julian Tudor Hart (1927–2018): “The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.” He wrote his famous Lancet paper on the inverse care law from the Glyncorrwg Health Centre in Port Talbot, Wales, in 1971. His death last year was the motivation for an inspirational gathering of 200 people in Glasgow last week to discuss the exceptional potential of general practice. Led by Graham Watt, Emeritus Professor of General Practice and Primary Care (University of Glasgow), the meeting aimed to distil lessons from Tudor Hart's work and examine how those experiences have informed one of the most ambitious and transformational health programmes ever implemented in the UK—the Deep End Project. (Deep End began in Scotland and is now a UK-wide primary care initiative to advance the health of people living in especially deprived communities.) Tudor Hart's philosophy might be summarised in three principles. First, medicine without a theory of justice is no medicine at all. Second, the health of individuals cannot be separated from the health of societies and the values underpinning those societies. Third, research matters, not only because it delivers reliable knowledge but also because it can be a powerful political instrument for social action. The forces threatening these principles today are formidable. Governments, despite their words, seem less committed, some even actively hostile, to the notion of a publicly funded health system free at the point of use. The political dangers facing health and health care extend well beyond the reach of governments—transnational corporations, international private finance, and a more intensive era of capitalism that promotes the alleged magical powers of the market. And our own profession has been (and remains) complicit. When one examines the work of the most powerful health institutions shaping health policy in the UK—the Academy of Medical Royal Colleges, Public Health England, Wellcome Trust, Medical Research Council, National Institute for Health Research, and medical schools—one question looms: where have they been? In campaigning against health inequity and health injustice in society, nowhere. Preferring, perhaps, to retain a seat at the tables of political power rather than contribute to what Graham Watt has called a “resistance movement”, these institutions have failed to defend the society they claim to be concerned about. General practice can, at least partly, fill the void. But one should be careful too. Careful not to pit general practitioners who emphasise the value of continuing personal stories against colleagues who work tirelessly to deliver the highest quality medical care. Careful not to pit primary care against specialist care. (The Lancet's Liver Commission proves that hospital specialists are just as committed to tackling deprivation, poverty, inequity, social exclusion, and stigma.) And careful when saying “we are on a ship that is sinking” or that the UK's National Health Service (NHS) is “on the brink of collapse”. There are those who want NHS professionals to admit failure. If we say the NHS is sinking and about to collapse, we give those who wish to dismantle the NHS the authority to do so. We should be more strategic. There are great opportunities. In Graham Watt's words—in his exceptional book, The Exceptional Potential of General Practice (2019)—general practitioners are rebuilding society as a cooperative endeavour. Evidence presented in Glasgow showed that the inverse care law is not a law. A law is a phenomenon that always occurs if certain conditions are present. Inverse care is not such a phenomenon. General practice can change the laws of nature. As Graham writes, “general practitioners are at the crossroads of societal change”. Research provides the platform for political action. Why haven't we used research findings to reject the vicious, racist myths about migrants, their health, and their contributions to society? Why haven't we taken on the commercial determinants of health? Why haven't we held politicians more accountable for the promises they have failed to deliver? Graham writes that there is “something elemental about general practice”. What he and his extraordinary Deep End colleagues have created is a unique programme of clinical, social, and political action. It is reproducible. Doctors should flock to Glasgow, Dublin, and Yorkshire to understand their remarkable achievements.