An ecological prescription for primary care?

Venetia Young is a retired GP, family therapist, and safeguarding lead with a continuing involvement in creating a thriving community.

One day you are passing a five-bar gate leading up the fellside. You see sheep behaving in an agitated way. Some stock-still, some running away, lambs bleating noisily, a ram pawing the ground. If they panic, they could fall in the ghyll and drown in the stream.

What has caused this distress? The sheep need to be calm, many are pregnant. Do you try to calm them yourself, call the farmer? Do you offer a sedative of meadow grass? You open the gate to see better.

…Lurking in a stand of trees is a wolf.

The wolves in the forest that frighten human beings are now at last being accurately named: poverty, homelessness, hunger, unemployment, domestic abuse, adverse childhood experiences. Humans like sheep have a basic need to feel safe. They can’t function well until that need is met. Their fears need to be named including the causes. Fear is not an illness needing sedating. It is a call to action. Sedation may make animals less able to defend themselves.

Lambing

Lambing is hard work for several months, labouring ewes often needing hourly checking and intensive care for 24 hours. Lambing gets interfered with by bad weather and fear. Lambs are the future wealth of the shepherd.¹

Felitti et al² produced landmark studies showing that adverse childhood experiences (ACEs) were clearly associated with morbidity in later life of physical illness: diabetes, obesity, cardiovascular disease, cancer. There was also an increased likelihood of mental health issues and drug and alcohol problems. The likelihood rises exponentially with the number of different ACEs. The first 3 years of human life are especially critical as the brain is developing in such a way that it can cope with the demands of the life the baby has been born into.

Supposing we seriously saw the well-being of infants, children and young people being our wealth, what would this mean for the task of primary care? What would it mean for our communities?

In the last decade Surestart centres were closed across our Cumbrian community; health visitors and midwives decreased in number. It is hard to understand what was happening here, perhaps an institutional form of misogyny, that excused itself by thinking child-rearing was a natural process and so didn’t need help? This is a profound denial of the experienced reality of maternal mortality and perinatal infant death.

Gavin Young³ studied the safety of the GP led maternity unit in Penrith, Cumbria. The surprise finding was that it was safer to be a low risk mother and deliver 25 miles from an obstetrician, than to journey to the consultant unit in Carlisle. The ideology at the time was that ‘bigger was better’ and many small GP units were closed. In Cumbria we talk of sheep being ‘hefted’ to the land. We humans are ‘hefted’ to our homes and neighbourhoods. Maybe such hefting makes a delivery safer when it is closer to home.

A single family hub is now being opened to applause in North Cumbria for a population of 300,000. How will this hub meet the needs of distressed rural families? Safeguarding children and families has been expanded but where is the local preventative work to make safeguarding less necessary? Where is the sense of consistent organisational attachment and bonding?

Fears for patients

Since Covid there are considerable fears for patients: Will I get an appointment? Will I be believed? Might I die waiting for an ambulance? Will I get treated with kindness and respect? Patients’ behaviour may change in the consulting room: they may be hostile or overly compliant; they may have waited too long; they may not be able to think straight; they may have heard bad stories from friends, family or in the press. Much of this fear is left unsaid.

It is as though there is a pack of wolves lurking and scaring the sheep. The reliable sheep dog and his shepherd has gone from view.

Fears for clinicians

There are now magnified fears for clinicians: missing diagnoses, prescribing errors, complaints, getting burnt out. Trainees are raised on the fear of, ‘not following the evidence’. They are told to expect complaints and to prepare for probable GMC hearings.

The art of medicine vanishes with all this fear. Medicine becomes like painting by numbers: no painting across the line without fear of a comeback. A new colour may be disapproved of as there is, ‘no evidence,’ for its use. As curiosity and imagination are stifled, creation of new evidence becomes less likely to happen, When new evidence does emerge, then it may be blitzed by an organisational equivalent of herbicide, especially if it threatens anyone’s interests. If painting over symptoms is the aim, then the vital question of. ‘What has happened to you?’ doesn’t get asked. There are growing social blind spots in the medical picture. Older experienced GPs are leaving the profession and their younger colleagues are left without their art, wisdom and confidence.

Wolves come in sheep’s clothing.

When the NHS was born in 1948 just after the second world war, cheer and hope were needed. It came in the NHS as a ‘pill for every ill’. There was a deeply embodied wish for no more suffering, no more pain. This need for cheer has recurred with Covid, climate change, and the nuclear war threat.

Wolves in sheep’s clothing have come in the form of drug companies, hungry for the market and the huge profits they see.⁴ A belief was encouraged that if you had an illness you were somehow ‘deserving’. If you had social problems you were somehow ‘undeserving’. People scrambled for illnesses to get the patient status and be ‘deserving’. A dependency culture was born and a split between social care and medicine.

Kroenke and Mangelsdorff⁵ wrote about the large percentages of people seen in medical outpatients whose symptoms weren’t explained by disease. Medical training focussed entirely on the organic illnesses. The task of the doctor became to treat ‘real illness’. The role of the patient was child-like to accept the wisdom dispensed, to worship in the medical cathedral to the delusion of a pain-free life. Knapp et al⁶ found that unexplained symptoms cost 2-3 times as much as explained organic ones. Health anxiety generated meant that patients became determined to find a cause for their symptoms and pursued test after normal test down to the last genome or high resolution MRI scan. They often didn’t feel any better for these biological answers.

Reviving primary care

‘Watchful waiting’ was the way we worked with many clinical issues. Supposing we now simply watch, ‘the primary care patient,’ and observe for a while, what might we see? Resourcefulness can be born out of fear,. The small green shoots of recovery and innovation can be noticed. Isabella Tree’s book ‘Wilding’⁷ describes how a lack of attention can cause flourishing. Patience and courage are needed as the ecosystem restores itself in remarkable, unimagined ways.

The lack of contact with primary care during COVID means that many people have self-managed quite serious illness with pulse oximeters. They have used friends and family members to discuss and compare symptoms. They have researched medication and may know more than their clinicians. Some are setting up patient support groups.

Referrals to mental health services however have risen dramatically, as people are struggling to cope alone with their personal wolves. What is surprising is the fact that antidepressants are suggested by secondary care to ‘tide them over’ until they are seen for therapy. GPs are expected to sign the prescriptions and have no time to safety-net and talk through side effects such as the emotional numbing, akathisia, suicidal thoughts and sexual dysfunction (which may persist after discontinuation).. Are we creating a monster?⁴

Flocks of patients

An answer maybe is to get patients in flocks of peers so that they can support each other: to lower blood pressure, HbA1c and cholesterol, to take inhalers more reliably, to learn how to calm themselves and find a purpose in being on this planet in these challenging secular times. The current model of individual targets and technology can mean that patients feel bullied into taking increasing medication rather than addressing root causes of illness.

Patients find that the mention of the stress they are undergoing is ignored, as if it’s not part of the clinician’s job description. Stress has been devolved into well-being services, which have almost become another siloed industry. Simple stress relieving factors aren’t added into the primary care prescription.

Much is being talked about the menopause in the press. In our practice the first time we looked at our frequent attenders data, we noted it was predominantly menopausal women. A menopause evening for 60 women put them at the heart of their families: they were stressed caring for an older generation and for their children now having children. To add to this they were often working and managing the variety of symptoms of the menopause. They hadn’t realised that they were so much the lynchpin of their families and needed to take themselves seriously. Clinicians need to do the same. Maybe these women need stress management techniques and self-help groups.

Physiology of fear

The physiology of fear is simple. Fear produces adrenaline and steroids to enable a flight, fight or freeze response. All are normal responses. If the action needed to respond to the threat isn’t completed, then the person is left in an aroused state. The adrenaline causes this arousal and hyperventilation. Hyperventilation causes a decrease of CO2. This causes nerves and muscles to be tense, jittery and ready for action. This includes every body organ: the frontal lobe arteries constrict and cause tunnel thinking, angina may occur, asthma may worsen, blood pressure rises.

One solution is to simply breathe slowly with the diaphragm, a longer breath out than in. This stimulates the vagus nerve and the person is calmed. The expiratory carbon dioxide level rises. A breathing rate of 5.5 a minute is considered optimal. 15 minutes of slow breathing improves cognitive performance and lowers the perception of pain.⁸

The physiology of fear is chemical as well as being mediated by the autonomic nervous system, the amygdala and the limbic system.

A prescription for primary care

The slow breathing GP with improved cognition will perhaps read John Seddon.⁹ They will understand the need to examine ‘failure demand’ in the complex arms-distance systems set up to cope with COVID. They will get patient data to inform thinking. They will redefine what the purpose of their work is. Fear in the practice will begin to subside, for staff and for patients. The wolves named and tamed.

As a family doctor they will pay especial attention to the most stressed life-cycle stages of young families and menopausal women. They will move away from targets and the bullying fearful consultations they engender.

They will see the need to be visible in their community and be cured of their current institutional agoraphobia. Shepherds and farmers prefer to be seen medically at agricultural fairs. Maybe GPs will be visible in schools, for staff in hospitals, village halls and WIs, and create a sort of community social medical school. Calming will be at the centre for chronic disease management. They will understand the benefits of patients being seen in groups. They will develop groups for young families to teach about the sick child. They will employ their own health visitor. They will train doctors with a different sense of smell to sniff out and deal with the fears people have in the contexts they live in. They will make sure that all their sheepdogs have a clinical sense of the whole person. The GP in a Fortunate Woman11 sends out bereavement cards marking the end of the life-cycle, a compassionate and simple gesture. They will become the ‘thinking doctors’ understanding their ecosystems, that Iona Heath asks for in her re-wilding paper.¹⁰

Such doctors will use their shepherd’s crooks with kindness to pick patients out of the ghyll they have tumbled into. Maybe they will also use them to hold professionals to account!

They will understand the social history of what has worked in primary care: the Peckham experiment, the Marylebone experiment, the Vanguard Model.^12,13,9 Maybe politicians will learn the rewards of treating doctors as professionals rather than as functionaries or widgets and maybe much paranoia on all sides will disappear.

We can then all sigh with relief and breathing slowly notice the sheep safely grazing.

Deputy editor’s note: See also Venetia Young reflecting on rural primary care through ‘An English Pastoral’ here: https://bjgplife.com/english-pastoral-and-rural-primary-care/

References

1. Rebanks J. The Shepherd’s Life: A Tale of the Lake District  Penguin 2015
2. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998
3. Young GL. Are isolated units run by GPs dangerous? BMJ 1987:294;744-746
4. Whitaker R The Anatomy of an Epidemic: Magic bullets, psychiatric drugs and the astonishing rise of mental illness in America Crown Publishing 2010
5. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy and outcome Am J Med mar; 86(3):262-6 1989
6. Knapp M, McDaid D, Parsonage M. Mental health promotion and mental illness prevention: the economic case Department of Health 2011
7. Tree I. Wilding: The return of nature to a British farm, Pan Macmillan 2018
8. Mckeown P. The Breathing Cure: exercises to develop new breathing habits for a healthier, happier and longer life OxyAt Books 2021
9. Seddon J. The Whitehall Effect: How Whitehall Became the Enemy of Great Public Services – and What We Can Do About it Triarchy Press 2014
10. Heath I. Rewilding general practice. Br J Gen Pract. 2021 Nov 25;71(713):532-533.
11. Morland P. A Fortunate Woman: A Country Doctor’s Story Picador 2022
12. https://en.wikipedia.org/wiki/The_Peckham_Experiment [accessed 24/5/23]
13. Pietroni P, Pietroni C. Innovation in Community Care and Primary Care: the Marylebone Experiment Churchill Livingstone 1996

Featured photo by George Hiles on Unsplash.