English Pastoral and rural primary care

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

James Rebanks lives and farms not far from where I live and have worked as a semi-rural GP. Reading his book, English Pastoral, was a moving exercise as he grapples with the emotional experience of the death of traditional farming methods and with the explosion of factory farming.

He writes about his sense of retrieving some of what was lost in order to make life and farming more meaningful and differently productive. Getting the voice of the traditional farmer heard was an uphill battle, until the Soil Association found that the soil in the old farm rotating its crops was completely healthy and needed no more fertiliser than the manure already provided by the animals.

Significantly, what also produced success was close and compassionate observation of livestock, getting cattle out to grass, making hay less often, and using less medication. An apprenticeship to someone who deeply loved the work was the foundation of learning.

My childhood GP, Alwin Latham in Earl’s Court, London, was known to be a good diagnostician. I can remember her ‘popping in’ to check on me when I had a near brush with meningitis after a playground nose injury. She would simply look at me and take in how I was before checking vital signs, smiling, and moving on. She kept the headachy febrile me at home on antibiotics.

“… we have disempowered patients … become blind to symptoms and illnesses that aren’t in the ‘paid-to-do box’.”

Her practice was in the basement of her home. She set up a house for unmarried mothers. She developed facilities for drug addicts and better living arrangements for older people. She died in 2000 and many of her community ventures are still working. She taught general practice at medical school and taught the consultants to see the person behind the diagnosis. She changed people’s lives. I wanted to be a doctor like her, though perhaps cycling around London on home visits with a black bag in a basket wasn’t to be my forte.

General practice as it is now would not have attracted me. The whole-person medicine I was trained to appreciate and embrace at medical school at University College Hospital in the 1970s is now hard to find and sustain. Writing a list of the numerous subtle losses to prompt discussion at a Royal College of General Practitioners Cumbria faculty meeting raised questions. Who has been in charge of the processes of change in the last 20 years? Who has recognised the unintended consequences of changes? Is it too late to save family medicine 70 years on? What ingredients must be restored now that we have a full-blown factory farm model of primary care medicine?

We are told that demand has increased, GPs are leaving in droves, and retiring early. What is not thought about is how we have increased that demand ourselves, how we have disempowered patients in the process, how we have become blind to symptoms and illnesses that aren’t in the ‘paid-to-do box’.

It is time to sit back and reflect with our patients and colleagues about what we want to happen next in each of our diverse communities. Cecil Helman talks about the need to be a chameleon to understand where the patient is coming from. Maybe we also need to be a chameleon to understand the context of our communities rather than adopting the grey, ‘one-size-fits-all’ colour of bureaucracy.1

What was enjoyable?

I loved the surprises of each surgery. Every symptom and person mattered (there was payment by capitation fee rather than diagnosis). I loved home visiting and seeing the family relaxed in their environments talking more honestly. I loved the ‘cradle to grave’ approach of seeing people through life events with their social and medical aspects. We managed to create care continuity when it was needed, even for dying people. We knew the consultants at the hospital and they put on interesting seminars. Sometimes they did joint domiciliary visits, which were always informative. General physicians had an overview of medicine and supported primary care. It was going well.

Then something happened

Specialisation happened and the focus changed: in hospitals and in primary care. General physicians disappeared, except in geriatrics. Technology disrupted relationships in consultations and in making bookings for second opinions. ‘Choose and book’ was deemed to be more efficient, though it took a lot of admin and patient time. GPs became distanced from their hospital colleagues. Patients missed the reassuring effect of their doctor knowing the consultant about to offer them a scary procedure: a different sort of care continuity.

In 2004, with Quality and Outcomes Framework payments, GPs and practice nurses specialised in diabetes, asthma and chronic obstructive pulmonary disease, cardiovascular disease (CVD), dementia, and mental health. Neurology became a forgotten speciality as it wasn’t paid for except for epilepsy reviews. Acquired brain injury is as common as CVD, yet is much more complex to live with.2,3

“What ingredients must be restored now that we have a full-blown factory farm model of primary care medicine?”

Patients with a new diagnosis of cancer got sucked into the cathedral of the hospital system. It became hard to reflect with them about what they were experiencing, what they really wanted, and to advocate for them if treatment was being over- or underdone. Palliative care developed and was taken over by GP leads to whom the extended community team related. They weren’t necessarily used as consultants within the practice.

These doctors often felt burdened by the care they gave. Midwives were moved out of practices and GPs were left with the initial pregnancy referral and the 6-week postnatal check. Nurses looked after contraception and sexual health. Health visitors and school nurses were moved to public health and were promptly reduced in numbers. District nurses were employed by different organisations making decisions to cut numbers without consultation with primary care.

Community psychiatric nurses were taken back into community mental health teams (CMHTs). The way CMHTs took over the physical health checks of patients with severe mental illness undermined the management of physical illness for this group in the practice. Primary care mental health services were solely developed around cognitive behavioural therapy. Practices stopped employing their own eclectic practice counsellors and GPs felt deskilled in their counselling skills. An excellent certified training course was developed for drug and alcohol issues. The role of alcohol in a significant number of hospital admissions was neglected.4,5 A modified training course should have been delivered to all GPs. Physiotherapy became self-referral. GP appraisal was developed to help GPs reflect but it quickly became a tool of regulation and unhelpfully knotted in with revalidation by the General Medical Council. Johann Hari describes vividly the unintended losses associated with changes in Stolen Focus.6

The big picture adds more change

Aside from these multiple local organisational changes were major political changes to the medical landscape. Andrew Lansley’s one in 2012 was allegedly devised on the back of an envelope. In our area there were at least six changes of structure from 1999. With each restructuring, knowledge, memory, and experience was lost. The financial costs of this were never made explicit.

Politicians thought they could helpfully tinker with what they didn’t understand. Worse still, they didn’t know what they didn’t know. They failed to deliver drug and alcohol strategies, failed to understand how the diet of the nation created diabetes, heart disease, and obesity, and so increased the workload of primary care. Conflicts of interests abounded, with politicians holding hands with the food and alcohol industries, and some clinicians in the pay of drug companies to develop markets for new drugs. Even the Patients Association is funded by drug companies!

“It is time to take charge of what we do in our new primary care networks to make them more like what we had before it all went sour.”

The specialism of generalism in primary care medicine still isn’t recognised despite its advocates like John Horder in the early 1950s. This has allowed denigration to run rampant in the press. Politicians played a part in the war on expertise. Were they envious of professions and knowledge? Were they fearful of what they couldn’t control?

More organisation and oversight was deemed to be the answer: National Institute for Health and Care Excellence guidelines and evidence-based medicine, care pathways, the Care Quality Commission, command and control structures, algorithms, thresholds, and referral criteria. At times the barrage of information and new rules felt like a war zone, with a GP holding a shield to protect the patients from the artillery to get them to safety and treatment. Woe betide if, as a vulnerable patient, you needed a ‘circle of care’ rather than a stepped care pathway that you couldn’t quite manage to step onto.

Dr. Google and social media increased expectations of success with health and happiness in the medical hurdle race. Increasing poverty, loneliness, and family breakdown don’t help wellbeing. Are pills used to treat or numb these social causes of distress? Safeguarding adults, children, and families from a huge list of potential harmful situations has been added as part of the psycho-biosocial approach but not included in the GP contract — so social safety seems like an optional extra. Domestic abuse is as common as coronary heart disease.7

Professionals also need to feel safe physically and free from needless litigation and complaint. Work satisfaction and prevention of burnout depends to a great extent on relationships with colleagues and patients. The evidence-based maximum worked each day should be 8 hours.8,9 Longer than this and mistakes are made that can cause harm and take a long time to resolve. Lorry drivers have tachographs and pilots restricted flying time to prevent accidents and mistakes.

What is the job we are tasked to do?

My intention in doing medicine was to diagnose people’s illnesses correctly, help them feel better, and live happier lives. John Paulley (general physician in Ipswich) asked me as a medical student if I ‘was a healer?’ I said I didn’t know but I wanted to be. He said that if I wasn’t a healer I might as well quit, as my patients wouldn’t do well.10

Pereira Gray and others ponder the physician healer.11 The moral injury sustained by not being able to be any sort of healer is behind much burnout. The word ‘vocational’ was taken from GP training scheme titles by Health Education England. Was just the word lost or was the concept lost?

It is time to take charge of what we do in our new primary care networks to make them more like what we had before it all went sour. We can redevelop primary care, much as James Rebanks has redeveloped farming ideas.12 We need to give thought to ‘crop rotation’ in posts so that professionals get a healthy variety rather than a mentally constipating diet of telephone triage.

“The specialism of generalism in primary care medicine still isn’t recognised … “

We need thinkers and mentors like Margaret Heffernan to challenge our assumptions and our wilful blindness.8 We need organisational consultants like Frederic Laloux to show us other ways to work than command and control.13 We need journalists like Robert Whitaker to continue to investigate corruption in pharmaceutical research, and how to develop immediate transparency and safety.14

De-prescribing of medication and the understanding of medication’s hidden harms is long overdue. Prescribed medication and medication errors have a worryingly unquantified morbidity and mortality.15,16

Above all we need our patients to be able to trust us to care for them with the relationship skills we have in managing uncertainty and distress. Every symptom matters to our patients. Maybe as Victoria Sweet says in God’s Hotel, we can find the efficiencies in inefficiency and the inefficiencies in efficiency, and learn to look at our patients and communities with new eyes as they grow and learn.17 Public Health England, as the medical equivalent of the Soil Association, will tell us when the soil and context we have created for individuals and families to thrive in is just right. Poverty needs justice not the numbing effect of antidepressants.

In our medical homes we could shut the door to unhelpful politics and demand only intelligent respect to be allowed to cross the threshold. We don’t have to be victims of the system. Politicians could earn the right to comment by shadowing an experienced GP for at least a day, rather than behaving like Japanese knotweed, invasive and stifling other growth.

On the farm, James Rebanks pays attention to the field boundaries, fences, and walls to keep his livestock safe.12 He pays attention to the river and stream courses that need to meander to prevent flooding. He has undone the harmful work of the Victorian age, which wanted to straighten river courses out. Meandering is efficient. He pays attention to what Samuel Shem describes as ‘the spirit of the place’.18 Ronald Epstein describes the depth of relational care in Attending, just as James Rebanks’ grandfather noticed his animals health by simply gazing over the five bar gate.

The future

If we invited the shepherd farmer to look at our flocks of patients, how would he see them enabled to live as fulfilling a life as possible? He might describe how sheep in flocks do well together but also need to be seen as individuals to thrive. He might see the damage done in the second Elizabethan age of focusing on symptoms rather than what has happened.

GPs do not fit in the same flock as hospital doctors. GPs are like Herdwick sheep, tough, resourceful, resilient, and used to living out on the place beyond the field boundaries, where the hospital flock feel uncomfortable.

1. Helman C. Suburban Shaman: Tales from Medicine’s Frontline. London: Hammersmith Press, 2006.
2. Headway. Statistics. (accessed 14 Feb 2023).
3. British Heart Foundation. UK factsheet. 2022.—uk-factsheet.pdf (accessed 14 Feb 2023).
4. NHS Digital. Statistics on alcohol, England 2021. 2022. (accessed 13 Feb 2023).
5. Alcohol Change UK. Alcohol statistics. (accessed 13 Feb 2023).
6. Hari J. Stolen Focus: Why You Can’t Pay Attention. London: Bloomsbury, 2022.
7. WONCA Europe. Raquel Gomez Bravo — Visions for the future, vocational training and special aspects esp. family…. YouTube 2021; 14 Jan: (accessed 14 Feb 2023).
8. Heffernan M. Wilful Blindness: Why We Ignore the Obvious at our Peril. New York, NY: Bloomsbury, 2011.
9. British Medical Association. Safe working in general practice. 2023. (accessed 17 Feb 2023).
10. Paulley JW, Pelser HE. Psychological Managements for Psychosomatic Disorders. Heidelberg: Springer Berlin, 1989.
11. Dixon DM, Sweeney KG, Gray DJ. The physician healer: ancient magic or modern science. Br J Gen Pract 1999; 49(441): 309–312.
12. Rebanks J. English Pastoral: An Inheritance. London: Penguin, 2021.
13. Laloux F. Reinventing Organizations: A Guide to Creating Organizations Inspired by the Next Stage of Human Consciousness. Nelson Parker, 2014.
14. Whitaker R. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and The Astonishing Rise of Mental Illness in America. New York, NY: Broadway Paperbacks, 2011.
15. Elliott RA, Camacho E, Jankovic D, et al. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf 2021; 30(2): 96–105.
16. World Health Organization. Medication without harm. (accessed 14 Feb 2023).
17. Sweet V. God’s Hotel: a Doctor, a Hospital and a Pilgrimage to the Heart of Medicine. New York, NY: Riverhead Books, 2013
18. Shem S. The Spirit of the Place. New York, NY: Penguin, 2012.

Featured photo by George Hiles on Unsplash.

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Thank you! So much has changed that it’s hard to understand how we ended up where we are now, and helpful to break it down.

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