Ben Hoban is a GP in Exeter.
When someone asks me what I do, I generally say that I’m a doctor, which invites the usual follow-up questions: What sort? Where? For how long? It would be at least as accurate if I were to say instead that I sit at a desk, take part in meetings, and generate various kinds of paperwork, or indeed that I try to look after people who come to me for help, although that might seem evasive. Identity, activity, and motivation are all different ways of framing an answer to the question from a personal perspective, just as structure, process, and outcome might be equivalent ways of doing it from an organisational one. So: the NHS is an entity which manages estates, equipment, staff, and data; it provides public services through various contracts and pathways; and it exists to improve the health and wellbeing of the people who use it. So far, so clear. There is something else going on too, though, which despite its woolliness often feels more real. I may be a doctor, for example, but my ability to help patients often depends more on my competence as a human being than as a professional. The things I do for someone may or may not benefit them, but always and despite my best intentions, they also have the capacity to harm, whether through side effects, false reassurance, or needless worry. Health and wellbeing are certainly worthwhile goals, although the means we use to pursue them are essentially negative, relying almost exclusively on the elimination of diseases, and casting the net ever wider to capture those who might be at risk of them. In promoting health, we have encouraged more and more people to see themselves as sick. If we consider what it is that we do as doctors, there is therefore a truth which is clearly defined and straightforward. There is also another which is more subtle, entangled with the first but distinct from it, like a vine climbing up a trellis.1
…my ability to help patients often depends more on my competence as a human being than as a professional.
The idea that medical practice should balance the potential risks, benefits, and burdens of any intervention is not new, although this generally comes down to practicalities rather than principles. We can calculate both the Number Needed to Treat and the Number Needed to Harm for a given therapy, but there is no easy way of gauging its impact on someone’s perception of themselves, for example, or on society more generally. We have occupied ourselves with developing the means to extend life as far as we can on the assumption that this is a neutral goal and that questions of meaning and purpose are a matter for individuals. We have built many trellises without first considering that how we go about this has a profound effect on the vine. By default, we have defined a good life as one that is simply as long and comfortable as possible, and good health as a state which in the long run can only truly be achieved through proactive medical intervention. Our implicit purpose is therefore not that people should be free to pursue their own goals without being held back unduly by disease, or that they should be well enough to get by without regular healthcare input, but that the ratio of planned to unplanned medical activity should be as high as possible.
We have built many trellises without first considering that how we go about this has a profound effect on the vine.
Something similar happens in the consultation. Given the choice, would you rather see someone who is friendly and sympathetic, or who gets the diagnosis and treatment right? It is of course a false dichotomy, partly because accurate diagnosis requires effective communication, which is itself built on good rapport.2 Still, it is easy to think of illness as a problem solved through an essentially rational process only incidentally supported by “soft skills” in the consultation. The imbalance between technical and personal modes of practice has long been recognised, although it is surely not deliberate; the technical just happens consistently to be favoured at the expense of the personal.3 The discovery that continuity of care improves measurable outcomes should in theory have resolved this on the basis that good medicine can be shown to work best when mediated by an ongoing relationship.4 Unfortunately the medical workforce has also become increasingly unbalanced, with far more doctors in secondary than primary care, and little has in fact changed.5 Indeed, the Modern General Practice model, in which triage is used to identify discrete problems which can be solved according to standard operating procedures by the most appropriate generic clinician, is becoming the norm.6 This is a predictable response to a crisis involving both inflated demand for medical care and a failure to train and retain enough GPs to provide it, and yet it risks confusing what seems expedient with what is desirable.
At every level, and in every aspect, of healthcare, we have prioritised what is concrete, defined, and measurable, not because those qualities matter in themselves, but because they make it easier to explain and justify what we are doing, whether to our paymasters, our regulators, our patients, or ourselves. There is no shortage of care pathways, policies or procedures; our trellises are solid and dependable. The point of having a trellis, though, is to enable the vine to thrive, and we appear to have lost sight of this. The lack of balance that we are forced to deal with every day is not itself the problem. It is instead symptomatic of a lack of purpose in a system that is inherently controlling and intolerant of ambiguity. Ultimately, we cannot make anyone healthy just by directing more and more healthcare at them and hoping for the best. In taking this approach, we have created an environment in which it becomes harder for people to live meaningful lives on their own terms, and in which they simply do not feel cared for. The trellis is crowding out the vine rather than supporting it.
The next time someone asks me what I do, I would like to say that I am a gardener. It might be more honest, though, to tell them that I manage trellises, and that if I do it well, I get to see something amazing growing around them.
References
- Colin Marshall and Tony Payne, The Trellis and the Vine: The Ministry Mindshift that Changes Everything, Matthias Media, 2nd edition, 2021
- Emily Alison and Laurence Alison, Rapport: The Four Ways to Read People, Vermilion, 2020
- Neal Maskrey, Rebalancing Medicine, PN Books, 2024
- Kate Sidaway-Lee, Denis Pereira Gray, Nada Khan, Lispeth Abraham, Philip Evans, GP continuity -the keystone of general practice, available at www.continuitycounts.com/the-evidence, accessed 22.8.26
- www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/workforce/medical-staffing-in-the-nhs, accessed 9.8.26
- www.england.nhs.uk/gp/national-general-practice-improvement-programme/modern-general-practice-model/, accessed 22.8.26
Featured Photo by Brittney Strange on Unsplash
