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 who looked after the poorly People. The Wizards in their Castles and the Gatekeepers in their Houses cost the King more and more gold but the poorly People were still queuing in the Castle Courtyards to see a Wizard. And now it was even sometimes difficult for a poorly person to see a Gatekeeper. The King’s Minister, and it was too soon to say whether he was a Wise Minister, had convened a Great Assembly to hear what the People thought were the reasons for the National Poorliness Services’ difficulties, and what could be done about them.
The Wizards in their Castles and the Gatekeepers in their Houses cost the King more and more gold but the poorly People were still queuing in the Castle Courtyards… now it was even sometimes difficult for a poorly person to see a Gatekeeper.
One of the very best things that had happened in the Kingdom since the very wise Welsh Minister created the National Poorliness Service was that no one now thought it surprising that Very Important Gatekeepers and Very Important Wizards were now both men and women. Indeed many of the People thought that they had been waiting far too long before Wise Women had become Very Important. Anyway, according to Ancient Laws, the Kingdom’s Chief Wizard spoke first.
She told the Assembly that “Many years ago the Gatekeepers and the Wizards mostly looked after People with sudden poorliness, often due to nasty germs. But over many years, very very clever Wizards had made powerful potions; almost everybody had had these potions to prevent poorliness from germs. With clean water and better food, this meant poorliness from germs was now much less common. This is a very good thing. And gradually many People have forgotten about those times when many People, especially children, died from nasty germs.
But now that germs are less of a problem, more People are living to a greater age, usually with several long term poorlinesses. Living longer is mostly a very good thing, but the work of the Wizards and the Gatekeepers has changed. Many People in the Wizards’ big castles do not need Wizards and their powerful spells and potions despite them being a bit poorly in several ways for a long time. These good People need warmth and care and good food and light and fresh air and kind People called Human Angels, along with all sorts of Elves and Fairies and Jesters and Minstrels looking after them for their long-term poorlinesses. Usually a kind Gatekeeper can keep an eye on them, and mostly they are best served by taking only a few essential potions from the Apothecaries. Sometimes great expertise is needed by the Gatekeepers or Apothecaries to make decisions to not use magic spells and potions for some People; potions are more likely to do harm in these People simply because they have had more birthdays.
Yet despite many People needing care and warmth and Human Angels and Elves and Fairies, there are too few places for them to get such kindnesses.” The Chief Wizard took no pleasure in pointing out that many Kings and Ministers had had the opportunity to look after these frail, older People with several long term poorlinesses, and that none of them had taken that opportunity.
The Minister’s Political Adviser spoke. “We have spoken about these things many times, Minister. I think we all know that the biggest difference we could make for the People would be to create what we might call a proper National Kindness Service to properly look after these frail, mostly older People with several poorlinesses. This would mean that some of the People currently being looked after by the Wizards in the Castle could be looked after largely by Human Angels and Apothecaries and other Elves and Fairies and Jesters and Minstrels, either in the People’s own homes or in Kindness Homes. This is what most of the older People with several long term poorlinesses want and deserve. And if we did this well the Human Angels working in the Kindness Homes would get better training and a career structure, and there is a chance that there will be fewer people shouting in the courtyards of the Wizards’ castles that they have been waiting too long for spells and potions.
“You know the difficulties, Minister. The People want this to happen but then we cannot find a way to pay for the National Kindness Service that all the People think is A Good Thing. But there is no way round it. The need becomes greater every year, and many Kingdoms face the same problem”.
“I know” sighed the Minister-Who-Might-Be-Wise. “I have asked a Wise Wizard to look at this and produce a Big Report in three years. I have even wondered if I should try and persuade the King that there should be a referendum on setting up a National Kindness Service. But then we all know what happened the last time there was a referendum, don’t we?”
“Yes, we do” said the Political Adviser quickly, and very firmly.
The Chief Wizard was keen not to have the Minister thinking that the problems with the National Poorliness Service were just about older People with several poorlinesses. “It is true that a National Kindness Service would be a very good thing for many reasons. But there are two more factors which actually play a much bigger part in our current problems. We need to talk about these in great depth later in the Great Assembly, but I should like to introduce them now:
Firstly, Wizards and Gatekeepers can do much more now for poorly people than in the past. More powerful spells and shiny new crystal balls keep being developed by very clever Goblin-Apothecaries and Engineer-Wizards. These mean the National Poorliness Service needs more and more gold from the King because new things are always more expensive. But also they mean more and more work for the Gatekeepers and Wizards and everybody else who works for the Poorliness Service. It is true that expanding the sort of poorlinesses that can now be mended is a good thing, but it also means a constant need for more Wizards especially, and everybody gets busier and busier. Add this onto more and more of the People who have several long term poorlinesses, and care gets ever more complex and requires more time. Wizards and Gatekeepers and the People and even Ministers have acquired a taste for shiny new crystal balls and new spells and potions, but more and more gold is needed, and in addition everyone struggles to look properly into whether this gold and especially the time spent is truly wise and good.”
The Chief Wizard took a big breath before she continued, for she knew this next bit was going to be even more difficult. “So the second big thing I want to talk about now is Prevention, and I mean prevention in all its forms. Prevention can be about promoting healthy diets in schools and ensuring clean water.”
And when making this point she glanced across to the Minister. But the Minister was looking at the floor because everyone knew that many Kings and Ministers had made People very unhappy about the number of times there was raw sewage in the People’s rivers and on the People’s beaches.
She kept going. “Prevention can also be about preventing the onset of poorliness. Vaccinating against many poorlinesses is now routine, as is detecting high blood pressure to prevent heart and stroke poorliness. Then the third type of prevention is finding poorliness early, sometimes even before people feel the slightest poorliness. We can now use shiny crystal balls to detect some cancers early, and we monitor many long-term poorlinesses frequently to halt or slow poorliness. And then finally we use spells and potions to reduce the impact of an existing poorliness.
All this is prevention, and it can be a very good thing. Yet although the principle of “prevention is better than cure” is intuitively appealing, the capacity of the Poorliness Service is finite. The time taken to perform the volume of prevention tasks a Gatekeeper now should undertake, according to the scrolls, is greater than twenty four hours every day. Prevention has literally become impossible for the Gatekeepers and the Human Angels who do much of this work in the Gatekeepers’ Houses. And few of them realise when measuring the progress of chronic poorliness using crystal balls, that the combined effects of day to day biological variation and the imprecision of the crystal balls means tests can be normal when they look as if they might be abnormal; more frequent tests are performed, more worry is created, and less time is available to see people with new poorliness.
The Chief Wizard took a big breath before she continued, for she knew this next bit was going to be even more difficult. “So the second big thing I want to talk about now is Prevention, and I mean prevention in all its forms.
Much of this prevention work by the good people working in the National Poorliness Service has little or no evidence to support it, and yet it feels – even to me when I know that this change in work towards prevention has created many problems – it feels very hard to say that some of this is not worthwhile. But we must think again. Some prevention work is low value and doing so much of it means that now there is little capacity for Gatekeepers to see People with new Poorliness. And being unable to see a Gatekeeper for new poorliness, we all know is one of the really big problems for the National Poorliness Service.”
There was a low hum of disquiet In the room. The Minister said “My brain hurts, and whilst I think we all need to talk and think some more about prevention, I hear what you say. But now we need to take a break, and have a bun and a cup of tea”.
A grey-haired, weary Gatekeeper listening to the Assembly said to anyone who was listening “I wonder if this is a Wise Minister or not?”. “Well, he likes tea and buns and that’s a start” said one of her colleagues.
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:
The gatekeepers and the wizards revisited (part 1): Seventy eight years of fairy tales: https://bjgplife.com/the-gatekeepers-and-the-wizards-revisited-part-1-seventy-eight-years-of-fairy-tales/
Machin A R, GPs are far more than gatekeepers,
Featured Photo by Artem Maltsev on Unsplash
