Neal Maskrey is a former GP and visiting professor of evidence-informed decision making, Keele University
Jamie Hayes is an executive and team coach, honorary professor of medicines optimisation, Cardiff Metropolitan University
Helen Maskrey is a retired public health pharmacist
John Seddon is an occupational psychologist, specialist in organisational change, and visiting professor at Buckingham University Business School.
Once upon a time in a green and pleasant land there lived Gatekeepers and Wizards. The Wizards lived above their towns in big white Castles. And in their Castles, they had magic crystal balls which told them why people were poorly. Then the Wizards would use one of their powerful magic spells and potions to make the poorly people better. The spells and potions did not always work, but the People knew that the Wizards had studied wizarding for many years and always tried their very best to help them.
After all, the Wizard and the Gatekeeper had both gone to the same school for wizards, although they had learnt different sorts of magical powers after leaving it.
The Gatekeepers lived in houses next to the entrance of the Castles. Their job was to use their own crystal balls to decide what was making someone poorly, and to use their own spells and potions. If they needed to, they could open their gate and send very poorly People to see the Wizard for the most powerful of spells. After all, the Wizard and the Gatekeeper had both gone to the same school for wizards, although they had learnt different sorts of magical powers after leaving it.
For many years the King and his Ministers and all the people were very proud of the National Poorliness Service and the very Wise Welsh Minister who had created it. The Wizards and the Gatekeepers and the Apothecaries and the Human Angels and everybody who worked for the Poorliness Service were proud to be doing good work. They knew they had a secure job, and whilst they were not paid lots of gold they had sufficient to feel valued, and when they themselves became too old or too ill themselves to work they had a pension which meant they could look after themselves without worrying too much.
All that now seemed a long time ago. Many times in the past poorly People had had to wait to see a Wizard. Indeed it seemed to many Wizards and Gatekeepers that every single year had been the hardest year yet for the National Poorliness Service. In each crisis the King and his Ministers would somehow find some more gold, which was of course raised from the People who paid their taxes to the King or borrowed from other Kingdoms. Somehow the Wizards and the Gatekeepers would manage to gradually help most of the poorly People who were waiting. Until the next crisis arose.
But this time things seemed different. Not only were there many poorly People waiting to see the Wizards, but they were now waiting to see the Gatekeepers as well. A few years ago a new plague had been visited upon the green and pleasant land. Many of the People were very poorly and many died, despite the heroic efforts of all of the Wizards and the Gatekeepers and the Elves and the Fairies and the Human Angels and all the Apothecaries in the towns and villages. Some of the Wizards and Gatekeepers and the Human Angels even died from the plague themselves, and many more were laid low with long term, post-plague poorliness.
The People were very sad and had to spend many long months in their houses on their own to stop the plague spreading. But they were saved by the new magic potions made by very very clever Wizards and Goblin-Apothecaries – potions that were like those that had stopped much of the acute poorliness from nasty germs many years previously. The People and the Town Criers clapped loudly in appreciation of the Wizards and Gatekeepers and the Human Angels, and for a short time everyone hoped the Kingdom, once it recovered from the effects of the plague, would become a better place.
And then the Town Criers discovered that the previous King and his Ministers had been having many parties with their friends in the Palace, when all the People had been staying away from each other to stop the plague spreading – even not being able to go to the funerals of their friends and family who had died from the plague. The People and the Town Criers were very angry indeed, and they shouted loudly for a very long time that they wanted a new King and new Ministers. And after many long months, that is what the People had achieved, and many of them still vowed that they would do their best never to have the old King and his Ministers and their like looking after the Kingdom again – or at least not until they had sat on the naughty step for a long time, had said “Sorry” properly, and looked as if they meant it.
The new King now looked across his Kingdom and made a Great Proclamation. He said “The National Poorliness Service is broken but it is not beaten. The National Poorliness Service is one of the great creations of Civilisation. The ancient separation of Gatekeepers and Wizards is essential for the care of the People, and proven by many learned scrolls , but we need it to work better. We shall ask everybody – Wizards, Gatekeepers, Apothecaries, and all the Human Angels of all kinds, and especially the People – how we can make the system the best it can be. We shall listen to them all, and when we have listened, we shall create great a Great New Plan.”
But still the People were queuing outside the Gatekeepers’ houses and in the Courtyards of the Castles.
And if there wasn’t enough gold then either the quality of care the Gatekeepers and Wizards provided was less than perfect, or the queues to see the Gatekeepers and Wizards got longer, or both things happened.
The King appointed a new Minister. Nobody could tell if he was a Wise Minister, and there had been very few Wise Ministers for a very long time. He knew that for many years, different Kings and different Ministers had been wrangling with the problem of the Gatekeepers and the Wizards. Nothing seemed to work well, at least not for long. Many Kingdoms only had a limited amount of gold to pay the Gatekeepers, Wizards, Apothecaries and everybody else that looked after the People. And if there wasn’t enough gold then either the quality of care the Gatekeepers and Wizards provided was less than perfect, or the queues to see the Gatekeepers and Wizards got longer, or both things happened.
The Wise Minister talked with many People and read many scrolls. Most People and many of the scrolls claimed to be able to make the Wizards and Gatekeepers work better for the People, but the Wise Minister was not convinced. “This is a complex problem” he said. “Complex problems do not have simple solutions. Many People tell me about the one thing that they think will make the National Poorliness Service good again. These simple solutions are always wrong; we have tried many of them before and they have been found wanting”.
Eventually the Minister said there would be a Great Assembly of Wizards, Gatekeepers, Human
Angels, Apothecaries, Goblins and the wisest of the People. The Great Assembly would consider all the evidence written in the learned scrolls, and the Wise Minister wanted to hear from many People and consider many ideas. He needed a plan so cunning that you could put a tail on it and call it a weasel.
The People waited and waited for the new King and his Minister to make things better. They were not happy. And nor were the Wizards and Gatekeepers.
To be continued…
Acknowledgement.
The authors wish to thank Nigel Mathers, Paul Hodgkin, and Andrew and Barbara Herd for introducing the world to the parables of Wizards and Gatekeepers, See: Mathers N, Hodgkin P. The Gatekeeper and the Wizard: a fairy tale. BMJ. 1989; 298. DOI: https://doi.org/10.1136/bmj.298.6667.172
Deputy editor’s note – see also: Machin A R, GPs are far more than gatekeepers,
Featured Photo by Artem Maltsev on Unsplash
