How free is my patient? Health inequalities and the GP consultation

Will Mackintosh is a GP in Carmarthenshire with an Interest in Medical Education and Leadership. He is on Twitter @will_mackintosh

Our conceptual framework for consulting should include an understanding of constraints on freedom as a method of understanding inequalities in health

The focus and debate around the role of British general practice in addressing health inequalities is not new and has rightly been reinvigorated by the covid-19 pandemic.¹ There is much understandable frustration that shortly after the thirtieth anniversary of the inverse care law that there is still so much to do in addressing these underlying inequalities.

There are excellent examples of GPs in deprived communities making a difference to those populations by following the lead of Julian and Mary Tudor Hart and adopting principles of public health and indeed by advocating political change.² Notable example are the deep end practices in Scotland.

There have been associated calls within the RCGP for GPs to receive additional public health training to assist them in this work. We can learn from both Tudor Hart and more recently Marmot, that one of the key features of inequality is that it is often hidden from view. Our current lens through which to view this problem is through the identification of deprived regions or communities.³

While much is made of the benefits of holistic practice, at least to date, there has been no specific attempt to make inequalities central to the consulting practice of all GPs, including those in more affluent or rural communities. Given that we understand the key determinants of health relate to those inequalities, is it arguably the remit of all practicing GPs to learn about how they affect individuals, not just those at the ‘deep end’. While those in deprived areas rightly claim they should be the focus of additional resources for primary care it is time, in my view, to make identifying inequalities a skill for all GPs to learn, practice and teach.

With this in mind it is worth remembering that the consultation remains the basic unit of general practice. It is what patients ask for and it is what we spend most of our time doing with an estimated 307 million appointments taking place a year in England alone in 2018.⁴

Consultations happen in all communities and have a track record in uncovering the causes and consequences of ill health.⁵ It appears therefore that additional conceptual thinking around inequalities could be helpful to all GPs, and that our consultation theory should be adapted to include them.

Consulting, science and free will

Science matters to doctors. The link between good science and good medicine is so strong that the boundary is not even visible to most practicing doctors. The evidence-based medicine (EBM) paradigm is the main driver of modern medical practice, grounded in epidemiology and an outlook for discovery which relies on statistical significance.⁶ It is within general practice, with its focus on individual patient assessment in a community setting and, where presenting problems are poorly differentiated, that this link comes under most strain.

It is no surprise, therefore, that the skills we learn from the likes of Roger Neighbour and perhaps more recently Martin Burnett (in his book ‘A tale of two houses’) sit alongside the NICE guidelines in the conceptual toolbox of GPs.⁷

Consultation models are perhaps the best example of a basis for useful knowledge which extends to the boundaries of what science can tell us. Yet it remains true that most UK GPs (along with most doctors) value a model of practice that relies heavily on what might be boiled down to the ‘natural laws’ of science.

Whether through an understanding of the chemical equations that underpin our physiology to the mechanism of action of drugs it is these immovable notions that hold sway in our minds. In practical terms this is solidified in GP training where, up until its suspension due to the pandemic, the clinical skills assessment (CSA) set cases, each with their own associated basis in EBM.

What is also anecdotally characteristic of medical practice (and indeed the rest of human kind) is the enormous value we place on the notion of free will. Not only do we believe that we are firmly in control of medical decision making but we also believe in the power of patients to contribute to (where possible lead on) key decisions about what happens to them.

So at least, superficially, it appears the basic conception of laws of nature as we understand them leave little room for the patient (or the doctor for that matter) to make a free choice. This dichotomy might play out in GP consultations where on the one hand we recommend treatments based on natural laws of science and in turn are advising our patients to change their behaviors.

Many patients, and in my experience, those who have the most difficult lives, already inform us of this problem and will respond to our attempts to explore their ‘Ideas, Concerns and Expectations’ by reflecting the questions back. ‘You’re the doctor, you tell me!” Or when medical advice is countered with “Yes, but”, from patients whose lives cannot accommodate practical advice. When this happens in consultations, it should not be regarded as a failure of a valid attempt at patient centeredness but, as we shall see, as a possible marker of inequality in its own right.

How free is my patient?

Perhaps we can begin by appreciating that some room for freedom matters firstly (at least on a superficial level) to our general attitude within consultations. If we are to accept that deterministic scientific laws are true, we must appreciate that the unhealthy behaviors and circumstances of our most deprived patients are somewhat less under their control than we believe them to be. Perhaps in a deterministic universe they are not responsible at all. This in itself may lead to more productive engagement with those who might have find themselves routinely marginalised when they try to access healthcare.⁸

On first reading this is helpful, but perhaps, on reflection becomes jarring for lots of doctors who (like most human beings) hold a profound attachment to their own free will and rightly believe that patients have it too. The basic task therefore becomes identifying constraints on people’s lives, not simply passively documenting their preferences. We need to begin to ask ourselves, as a fundamental principle of consultations: How free is my patient?

In asking this question we have a platform to explore almost every factor that may underpin inequality. We might have a measurable starting point to explore the experience of a young person who is not free to express their true gender. What about the terminally ill person who wishes to die, free from excessive medical intervention, perhaps at odds with the views of their doctor? What about the migrant who finds themselves constrained by the bounds of an unfamiliar language and culture?

What is more, an enhanced understanding of freedom gives us an opportunity to reflect on the freedom of those individuals who disengage when asked their opinion about their care. It is also worth noting that patients facing such problems may find their challenges compounded by ‘future discounting’ where the constraints of their lives leave them with little chance but to take short term choices rather than plan ahead.

We may, as practicing GPs, already appreciate that in the best consultations this work already occurs. However, this incredibly valuable approach is not measured, not systemically taught and passed off as part of the ‘art’ of general practice because it cannot find a natural home in the EBM paradigm.

The wider adoption of social prescribing (an intervention notable for its lack of empirical evidence) in primary care organisations perhaps proves this point. What we might take forward, however, is a more nuanced approach to our definitions of what is medical and what is ‘non medical’. While our colleagues in secondary care adopt an ever more focused approach to specialist practice, underpinned by the EBM paradigm, we must remain clear that the role of general practice is not to better define the boundary between the medical and non-medical but to proudly occupy this grey zone as we have always done. This involves a finely tuned understanding of when our patients need assistance or advocacy to remain well rather than understand only how they get ill.

As we have learned from the consultation models of the past, the best approaches to improving consultations do not add more tasks but provide more depth. Getting to the root cause of issues is not only better for patient outcomes but usually saves precious time in consultations and can be applied across all settings.

Wider considerations, political problems

There are wider and more complex versions of freedom which at times seem to depend on your own definition of the word. One is to remind doctors of their own constraints and freedom. Just a couple of factors to consider are the effects of working in a health system which holds up the powerful threat of litigation together with the sometimes-overwhelming moral commitment to a system delivered free at the point of care.

What we can perhaps appreciate better, is a framework that reinvigorates that moral commitment and pushes the work of Tudor-Hart and others forwards. This appreciates that freedom from illness is not just founded on economics but an understanding that good healthcare is about production and not consumption.⁹

We can also be aware that a discussion around freedom in this vein becomes particularly problematic for some. Tudor-Hart was notable for championing a particular left leaning political outlook amongst doctors, (which was firmly aligned with a public health approach) and for some this simply does not appeal. Similarly, notions of freedom might fall foul of neoliberal political viewpoints, which advocate very strongly for personal rights which in turn can have a damaging effect on public health, such as the right to own a gun.

Luckily modern thinkers can reassure us that ideas of freedom are useful because they are mutable and complex. Maggie Nelson in her recent book ‘On Freedom’, reminds us of the importance of the philosopher Ludwig Wittgenstein’s assertion that the meaning of a word relies on its use.¹⁰ In this sense we can turn our attention away from a clear definition towards better use of the concepts of freedom and constraint as applied to the lives of our patients. This approach, helpfully, does not rely on a specific political commitment but rather a commitment to a more robust form of patient centeredness.

Conclusion

Health inequalities can no longer be ignored by doctors. There is no excuse for just accepting that some patients will get sick without us appreciating why.

General Practice has made great strides in the last few decades in understanding why a public health outlook may be a key part of our role as clinicians. What remains central to our specialty, however, is the GP consultation. We need to better appreciate the scientific origins that inform our interactions with patients and think creatively about connecting better with the issues that drive poor outcomes.

Our frameworks for consulting need to be updated to reflect this fact and a new focus on understanding freedom and constraint paves the way for more productive consultations with those most in need.

 

References

1. Poverty, Health Inequalities and the role of General Practice Lunan C, Liiv A Item 15 RCGP UK Council 18/92020
2. The Exceptional Potential of General Practice: Making a Difference in Primary care Graham C M Watt CRC Press 2019
3. Build back Fairer: The Covid-19 Marmot Review accessed via: https://www.health.org.uk/publications/build-back-fairer-the-covid-19-marmot-review
4. Appointments in General Practice, October 2018 NHS Digital Accessed via : https://digital.nhs.uk/data-and- information/publications/statistical/appointments-in-general-practice/oct-2018
5. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. doi:10.1111/j.1468-0009.2005.00409.x
6. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology: A basic science for clinical medicine. Boston, Mass: Little, Brown and Company; 1991.
7. The GP Consultation Reimagined: A Tale of Two Houses. Martin Brunet Scion Publishing Ltd, 2020, ISBN 9781911510598
8. O’Carroll A, Wainwright D Doctor–patient interactions that exclude patients experiencing homelessness from health services: an ethnographic exploration
   BJGP Open 2021; 5 (3): BJGPO.2021.0031. DOI: 10.3399/BJGPO.2021.0031
9. A New Kind Of Doctor The General Practitioner’s Part in The Health of The Community. Julian Tudor Hart The Merlin Press LTd. 1988 ISBN 978-0-85036-300-5
10. On Freedom. Maggie Nelson. Penguin Random House, 2021. ISBN 9781787332690

 

Featured image by Zulmaury Saavedra on Unsplash