Guardians of the primary care wall

Andrew Papanikitas is the Deputy Editor of the BJGP. He is on X: @gentlemedic

In Neil Gaiman’s 1999 fantasy novel, Stardust, the hero’s journey begins in a little English village called Wall. The village takes its name from an ancient stone wall, beyond which lies the magical and perilous realm of Faerie. The wall has one opening, which is guarded night and day by two men who carry cudgels.1 Such a mystical dividing line appears when we are concerned with health and illness. Gaiman’s novel does not set up the realm of Faerie as a benefit to be protected from overuse by the masses. It is both miraculous and dangerous. Similarly, GPs have been called ‘gatekeepers’ to health care, because of our role in determining eligibility for medical treatment and social support (chiefly in the form of being excused from work without falling into destitution). And yet we have long known that GPs do more than this. Our wall is not a line but an indistinct zone between health and illness that is hard to navigate, especially for those who disrespect its mysteries.2,3

Three of the articles this month refer explicitly to ‘sick note culture’. GPs are in the firing line of efforts to reduce sickness certification. The implication is that GPs have been too generous in admitting people to the domain of illness and allowing them to take paid time off work.4 Ben Hoban argues that to be fit for work, a person must be capable of more than simply carrying out in isolation the tasks required by their role: they must be able to do so repeatedly, to a consistent standard, and in a way that represents a reasonable balance of benefits and burdens to them.5 To consider ill health without taking into account our wider cultural context is a non-starter. Nada Khan reflects that a properly funded occupational health service could help ease people back into work, but that this has yet to happen.4

Placing a wall between ‘everyday worries’ and mental illness

The current Prime Minister wants us to be ‘more honest about the risk of over- medicalising the everyday challenges and worries of life’. Elke Hausmann reflects on the distinction between distress caused by life events and distress caused by mental illness.6 This may determine who might benefit from a medication but ought not be used to withhold support from those without a medical diagnosis. She reminds us that distress is distress regardless of whether it appears in a psychiatric manual. Many aspects of 21st century society arguably contribute to both kinds of distress. Richard Armitage reviews The Anxious Generation by Jonathan Haidt, noting a surge in the prevalence of mental illness in those aged 16–24 years.7 For Haidt, this is not an outbreak of ‘failure’ among young people and family doctors, but the harmful effects of changes in society coupled with the insidious effects of smartphone technologies made manifest. Hannah Milton zeros in on the neuroscience of trauma and Adverse Childhood Experiences (ACEs) and how this can lead to adults who struggle with everyday interactions and who are more prone to physical and mental ill health.8

What makes us consider certain testimony untrustworthy, or less important? Trisha Greenhalgh reviews Unheard by Rageshri Dhairyawan and reflects on the phenomenon of medical silencing — when clinicians ignore or dismiss what patients say is happening.9 It stems from our assumption (often unconscious and unexamined) that the patient’s subjective and lived- experience knowledge is untrustworthy. Polnay and Burley focus on our disbelief of patients with medically unexplained or factitious illness. Rather than taking an approach to a patient that they are either telling the truth or lying, they suggest it can be helpful to consider a middle way: the patient may be faithfully describing a problem, but doing so in a coded or implied way. They may expect that telling their story in a straightforward manner does not work.10

Beyond the pale

But it is not just patients who are unheard. Saul Miller discusses ‘Capital advantage’, which he summarises as the idea that those who are closest to the source of financial wealth have the strongest voices in the political arena. He suggests that the often terrible treatment of ordinary healthcare workers trying to convince the authorities that something is wrong stems from our persistent deference to wealth and status.11 This too often results in gross injustice and avoidable tragedy. Will we ever learn?

This issue we also cross the wall to explore the humanities, get insights from a breadth of research, and draw inspiration from evolving traditions in a different continent. John Launer reviews The Shooting Party, the classic novel by Anton Chekhov, and is drawn into the games that the author and his fictional alter ego play with the reader.12 Alex Burrell shares some gems from the yonder of healthcare research, including research on the hidden work of GPs, which can be mistaken for administration and under-costed in terms of time and resources, but nonetheless has to be full of care because it affects people’s lives.13 In a travelogue from India, Shilpa Verma tells us how a community in the state of Bihar celebrates nature and the birth of girls with the gift of a fruit tree from the ‘oxygen man’.14

In UK politics, the ‘red wall’ is an expression referring to the regions in the Midlands and North of England that traditionally voted for more socialist political parties. In the 2019 election, many of these constituencies were won by the Conservative party. While the ‘red wall’ may have turned blue (Conservative)15 and shows every sign of turning red again imminently, politicians should be mindful of the primary care wall (who knows what colour it is!). The space between health and illness (that primary care inhabits) is critical to the future health of the UK. Any new government ignores this at the peril of us all.

1. Gaiman N. Stardust. London: Headline, 1999.
2. Mathers N, Hodgkin P. The gatekeeper and the wizard: a fairy tale. BMJ 1989; 298(6667): 172–174.
3. Heath I. The mystery of general practice. 1995. (accessed 14 Jun 2024).
4. Khan N. What drives the ‘sick note culture’ in the UK? Br J Gen Pract 2024; DOI:
5. Hoban B. Sick notes and culture. Br J Gen Pract 2024; DOI:
6. Hausmann E. Normal worries or mental illness? Br J Gen Pract 2024; DOI:
7. Armitage R. Books: The Anxious Generation: How the Great Rewiring of Childhood is Causing an Epidemic of Mental Illness. Br J Gen Pract 2024; DOI:
8. Milton H. ‘Unlucky’ patients. Br J Gen Pract 2024; DOI:
9. Greenhalgh T. Books: Unheard: The Medical Practice of Silencing. Br J Gen Pract 2024; DOI:
10. Polnay A, Burley A. Telling tales: storytelling and disbelief in clinical encounters. Br J Gen Pract 2024; DOI:
11. Miller S. Capital advantage. Br J Gen Pract 2024; DOI:
12. Launer J. Books: The Shooting Party. Br J Gen Pract 2024; DOI:
13. Burrell A. Yonder: Hidden work, inhaler use, step counts, and appendicitis and colorectal cancer. Br J Gen Pract 2024; DOI:
14. Verma S. A greener tomorrow: saplings and girlhood flourishing hand in hand. Br J Gen Pract 2024; DOI:
15. Wainwright D. General election 2019: how Labour’s ‘red wall’ turned blue. BBC News 2019; 13 Dec: (accessed 14 Jun 2024).

Featured photo by Cici Hung on Unsplash

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