Time and the consultation in British general practice

In this long read, Martin Moore shares thoughts from his research into how British GPs have historically configured time in relation to “the consultation”.

 

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Towards the end of her pregnancy in the summer of last year, my partner suffered a severe bout of iron-deficiency anaemia. Her antenatal care had been rather disjointed through the impact of the pandemic, and it turned out that she had gone several weeks without treatment. Anxious and exhausted, she called the local GP surgery and awaited a telephone consultation with an available doctor. Given the issues we had experienced co-ordinating care in the preceding weeks and months, we did not wait with great expectations.

Figure 1 – Me, thinking of this GIF-based  joke

The call came, typically, in the middle of one of her work meetings that day. The doctor asked how she was feeling, reviewed her record and talked us through the treatment options.

Once the prescribing was done, however, the doctor kept the call – or rather, the consultation – open. They asked how things had been, whether we had any worries about the upcoming labour. They were happy to chat and listen, acting in clear violation of the “one appointment, one problem” posters that had covered the walls of the physical waiting rooms we were now locked out of.

 

Figure 2 – If only the poster was clearer about how patients should bring their problems to the GP

This unexpected offer of time and attention – of care in a period when previous promises of care had been thrown into disarray – was unexpectedly moving, valued as much as the iron tablets that followed.[i]

 

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At least in its early months, the pandemic had complex effects on general practice consultations.

However, one particularly notable shift was a sharp fall in the number of appointments being made.

Whether resulting from anxieties around infection, from practice policies, or perhaps from political appeals for the public to wait with problems – to refrain from engaging services where possible in order to “save our NHS” – a year-on-year comparison between May 2019 (24.6 million appointments) and May 2020 (16.6 million appointments) revealed a 30% decrease.

GPs experienced – and displayed – mixed feelings to this development.

On the one hand, there were fears that patients would suffer consequences. For instance, that early signs of cancer would be missed, reducing or missing the temporal window in which investigation and treatment would be most effective. These certainly appear to have been borne out in terms of referral figures.

On the other, some revelled in the time that had seemingly been created by reduced demand, and even suggested that the “dross” work that they usually performed had decreased.

Figure 3 – Comment to “Pulse” (Magazine for GPs)

Such complaints about trivial and minor illness – about not doing “real medicine” – are at least as old as the NHS itself.

Whether complaining about increased responsibilities for sick notes, “neurotics”, patients attending for conditions requiring no treatment (or treatment they could, and previously would, have performed themselves), or patients simply coming out of newly-formed “habit”, GPs had long pointed the finger at unnecessary demands as a cause of stressful time-compression. Worse, it supposedly took time and attention away from those who truly needed it.

Figure 4 – Manchester Guardian, 1949

 

They even labelled this type of attendance an “abuse” of the service, calling for ways to discipline patients for their behaviour.

Figure 5 – The Guardian, c. 1956

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Figure 6 – The Times, c. 1964

 

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Such complaints, were not, however, universal.

Particularly from the later 1950s and 1960s onwards, a minority of GPs rejected complaints around trivia. They noted that patients just “dropping in”, even with issues which might appear minor, provided useful opportunities for curtailing problems before they became serious.

Figure 7 – British Medical Journal, c. 1965

Others suggested that chronic attendance – especially for minor ailments – was actually a sign of unresolved conflict and trauma in a patient’s life. These were precisely the patients who needed time and attention, both to ease their suffering and to eventually end their regular attendance at the surgery.

This was particularly the case for those doctors associated with the work of the psychoanalysts Michael and Enid Balint. Together with colleagues at the Tavistock Clinic in London, the Balints ran regular “research seminars” through which local GPs could discuss cases and the psychosocial features of general practice.

Out of this work came a conviction that the most potent drug a GP could prescribe was the doctor, but only if prescribed in the right way and in the right amounts.

Starting from the belief that many seemingly physical illnesses and symptoms were in fact psychosomatic – rooted in how present-day social, emotional and mental conflict triggered past traumas and developmental problems – the Balintian model of the consultation reframed the temporal aspects of the doctor-patient encounter.

Firstly, the consultation connected past, present and future in new ways.[ii] Patients’ recurrent attendances were pathologized as psychological repetitions that required exploring both present relationships and early childhood.

In his foundational 1957 report on the GP seminars, The Doctor, His Patient and the Illness, Michael Balint even hypothesised the existence of a “basic fault” within every individual, emerging out of the ‘considerable discrepancy between the needs of the individual in his early formative years (or possibly months) and the care and nursing available at the relevant times’. This fault, he suggested, potentially structured ‘all the pathological states of later years’ (pp. 255-6).

Figure 8 – What’s internationally renowned and red all over?

Equally, the GP’s own routines were cast as having contributed to recurrent physical symptoms and consultations with the patient – typical practices of clinical examinations reinforced the sense that patients should only bring physical complaints to the doctor, whilst uncritical reassurance that “nothing was wrong” failed to address ‘the patient’s most burning demand for a name for his illness’ (p. 25). Instead, ‘the patient’s increasing anxiety and despair’ could result ‘in more and more fervently clamouring demands for help’ (p. 26)

Secondly, during the 1950s, proponents of this psychoanalytically-informed practice promoted the wider adoption of both hour-long interviews to explore the potential psychosocial causes of illness, and regular follow-up consultations to undertake psychotherapeutic treatment.

Balint warned GPs, however, not to rush such interactions, but instead to travel at the patient’s own pace.

‘It is equally dangerous to hurry a patient, not to allow him sufficient time to work out his own solution of the problem and to overcome his resistances to it, especially those caused by shame, embarrassment, and above all, by guilt feelings. All this needs tact, patience and time’ (p. 275-6).

Finally, within this framework of care, consultations with the patient were neither considered as one-off events nor considered as a chain within a single ‘episode’ of illness.

Rather, they formed important parts of an ongoing and continuous relationship between practitioner and patient. Through repeated encounters, the GP and patient would not only get to know one another but develop a mutual trust and respect.

It was this mutual investment, moreover, that provided GPs with a particular opportunity to undertake psychotherapy. It allowed the GP to undertake both ‘considered risks’, and to be patient and watchful.

‘Even if the openly psychotherapeutic relationship is broken off’, Balint suggested, ‘the patient may, and indeed does, come back to his doctor with a cold, or indigestion, or a whitlow, or a bruised finger, or to have his child inoculated, and so on ad infinitum’ (p. 158).

 

Indeed, he went on:

‘If for some reason or other the progress of treatment has become blocked, and further probing is either unsuccessful or inadvisable for the time being, a well-calculated amount of medicine will bring the patient back at a time when the atmosphere may be more favourable. Again, if the practitioner is uncertain whether the time has come to stop, arranging for the patient to come back for a new prescription, or a check-up enables him to keep an eye on developments and to “start” again if events demand or suggest it’ (p. 170).

The temporal orders constructed, the offer of time made, and the type of attention afforded to patients within the psychosocial general practice consultation thus entailed a considerable reworking of more clinically-oriented practice.

 

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As Shaul Bar-Haim has noted, this psychosocial orientation to general practice, emerged at a time when the morale and status of general practice was at a nadir, and some GPs saw within it an opportunity for remaking their identity and positionality within British medicine.

It greatly influenced many of the doctors who assumed leading roles in academic general practice, and particularly the Royal College of General Practitioners, into the 1960s and 1970s. The lasting legacy of the Balints, moreover, can be seen in the continuation of the Balint Society to the present day.

However, the effect on everyday practice appears to have been neither immediate nor widespread.

Academic general practice was only slowly constituted over the early post-war decades, and vocational training not made a compulsory part of qualifying for general practice until the 1980s.

Moreover, elite institutions of general practice could be hostile and exclusionary spaces. As Julian Simpson’s work suggests, many South Asian practitioners – on whom the NHS had come to rely heavily, particularly in unfavoured industrial and urban settings – experienced racism and discriminatory attitudes in elite organisations, freezing out large swathes of the GP workforce into the 1980s.

At the same time, although GPs’ feelings of time-compression reflected shifting working conditions, their autonomous choices about temporal patterns of work, and changing cultural expectations around medical practice, they also emerged from doctors’ engagement with patients’ chronic and unresolvable demand for GPs’ attention.

Of course, individual consultations could be extended relative to the problems being discussed. Likewise, research into GPs’ working days (weeks and years) consistently found variation in the average duration of consultations. Whereas some practitioners in the 1950s reported average consultation times of 5 minutes, others recorded figures of 8 and a half minutes.[iii] Similar variations were recorded in subsequent decades.[iv]

Largely, these were the products of GP’s own ingrained habits. However, there were some structural limits to such variations.

Though studies found that only very small or extremely large patient lists exerted pronounced effects on the average duration of consultations, or on the number of consultations that GPs conducted per week, this same work also suggested that larger list sizes were not consonant with high annual consultation rates. They thus amounted to less time given per patient over the year.[v]

In other words, at some point, the time offered to one patient either needed to be compensated for by shortening consultations with another, or by seeing some patients (or even the same patient) fewer times over the year.

To refer back to the discussion of “trivia” or “dross”, then, GPs’ complaints here undoubtedly reflected culturally-bound determinations of who “deserved” attention. Nonetheless, they also reflected the structures within which general practice has had to work.

Indeed, even doctors influenced by Balint admitted that compromises to pragmatism were required; they developed new “flash” techniques for psychotherapeutic work over the 1960s, publishing their research in a text tellingly titled Six Minutes for the Patient (1971).

Figure 9 – Has there been a more 70s book cover?

These structural constraints were, to be sure, mutable to some extent.

Appointments systems enabled the GP to regulate the number of patients consulting per surgery session. Likewise, professional bodies lobbied government around payments and list size limits to make smaller list sizes practical propositions.

And indeed, drives to offer greater time to patients were not unidirectional. The Royal College adopted an ideal of the 10-minute appointment in the 1980s, and this still provides the standard time allotted to patients today.

Figure 10 – Journal of the Royal College of General Practitioners, c. 1989

 

However, should my reaction (and that of my partner) to our GP’s unexpected offer of time indicate anything, it is how trained we have become to expect this 10 minutes to be focused – and even pressured – ending with the (metaphorical or literal) tearing of the prescription pad, rather than being open ended.

 

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It is likely that “our” GP’s generosity with their time reflected how their own consultation style found expression amid the shifts in working patterns experienced at that point in the pandemic.

Reports on video and telephone consultations from that period, for instance, demonstrated that they were, on average, shorter than in-person equivalents.

Moreover, our capacity to access tele- and digital medicine reflected our own racial, class and linguistic privileges: historical and contemporary research has shown that moves to new platforms have reinforced inequalities of access.

Our experience suggests, in this sense, that though the long-term effects of the pandemic on general practice are still in the balance, we must continue to be mindful of how formal changes in policy will not play out equally. Who receives time and attention will continue to be shaped by historical structures of privilege and discrimination, by long-formed expectations of what time is reasonable, and by practitioners’ own orientations to care in the consultation.

Martin D. Moore

 

Notes

[i] Thankfully, everything went as well as could be expected with the rest of the pregnancy and labour. We are now the parents of an adorable, disturbingly loud, 5-month old.

[ii] As Rhodri Hayward has shown, psychological and psychoanalytic concepts, perspectives and practices were not entirely new to British general practice: R. Hayward, The Transformation of the Psyche in British Primary Care, 1870-1970, (London: Bloomsbury Academic, 2014) However, they were not particularly widespread by the mid-century, and Balint problematised GPs’ routines and patients’ recurrent appearances in novel ways.

[iii] Cf: John Fry, ‘A year of general practice: a study in morbidity’, British Medical Journal, 2:4778 (2 August, 1952), 249-52; Alistair Mair and George Mair, ‘Facts of importance to the organization of a National Health Service from a five-year study of a general practice’, British Medical Journal, (Supplement, 20 June 1959), 281-4.

[iv] T. S. Eimerl and R. J. C. Pearson, ‘Working-time in general practice. How general practitioners use their time’, British Medical Journal, 2:5529 (24 December, 1966), 1549-54; Norma V. Raynes and Victoria Cairns, ‘Factors contributing to the length of general practice consultations’, Journal of the Royal College of General Practitioners, 30:217 (August, 1980), 496-8.

[v] D. Wilkin and D. H. H. Metcalfe, ‘List size and patient contact in general medical practice’, British Medical Journal, 289:6457 (1 December 1984), 1501-5.

Lisa Baraitser, ‘Enduring Time – On Violence and Care’, Alt_Cph_2020, 16 September 2020

Our PI Lisa is speaking on ‘Enduring Time – On Violence and Care’ as part of Alt_Cph_2020 on Wednesday, 16 September 2020 at from 5 – 6.30pm (UK time).  This event is a Zoom webinar and is free to attend.

Lisa’s talk will be part of the Patterns of Resistance programme of events and you can sign up for the webinar here or visit the Alt-Cph_2020 site here.

In its early stages, the ongoing global pandemic laid bare the hidden structures of care and dependency that we often close our eyes to. COVID-19 also alerted us to our collective vulnerability and dependency – and the violence that so often goes hand in hand with care.

In her 2017 book ‘Enduring Time’ psychoanalyst and cultural theorist Lisa Baraitser diagnoses our present as a moment of suspended time. Between a traumatic past and a foreclosed future, we find ourselves in stuck time, a time closely connected to the time of care. In this talk Lisa Baraitser will be in dialogue with the curator Miriam Wistreich to use our current moment as a thinking space to consider the relationships between vulnerability, violence, resistance and care.

COVID-19: Making History

Martin Moore writes:

It is something of a foundational belief in the Sociology of Scientific Knowledge (and related fields) that knowledges are always shaped by the context within which they are constructed. Scientific knowledges are thus never independent of the social relations, economic structures, political pressures, ideological and tacit practices from which they emerged, and they are themselves cultural artefacts.[1]

Historians work with similar understandings about historical knowledge. Though articles or monographs do not routinely include historicisations of their own origins (though, note feminist histories like that by Catherine Hall and Carolyn Steedman), historians will usually recognise the circumstances of their text’s production in their acknowledgements.[2] Here they raise to the level of consciousness funding sources, intellectual interlocutors, social relationships and even some biographical detail to help make sense of where a particular work has developed.

The first page of acknowledgements by a certain author, who we shall call “M. Moore” to preserve their anonymity. That might be too obvious, let’s call them “Martin M.”

This is not to say that historians work unreflexively in relation to their origins, nor that they never publicly look to contextualise their own knowledge. Rather, they have tended to reflect most heavily on the relationship between past and present in historiographical and methodological texts.[3]

Recently the Waiting Times team has been thinking about how the current pandemic has been reshaping relationships to time (and care), which we will be sharing in a forthcoming dossier on COVID-19. It was in this context that I was reminded about E. H. Carr’s famous suggestion that history was an ‘unending dialogue between the present and the past’.[4] As historical and social subjects, in other words, historians are just as much a product of their particular time and place as those they write about, and our interpretations of the past will be inescapably influenced by our biographical, social and cultural relations.

Broadly speaking, historians have tended consider the relationship between the present of scholarship and the history produced in terms of large-scale social, economic and political formations and trends. How has a historian’s position in the social field shaped their view of the past? How might experiences of particular events or existence within specific cultural and political milieu shape the questions that are asked within research?

Regardless of how long the current measures of containment, delay and mitigation last, the impact of COVID-19 on psychosocial, economic and political life will likely be profound, and thus so will its effects on historical scholarship. Although it might be folly to think about precisely what these effects will be whilst we are still in the midst of the crisis – of a moment that might be an historical rupture and beginning of a new normal, or prove to be something far less monumental – it is nonetheless possible to consider how historical scholarship is already being reshaped. To explore how COVID-19 is already making history.

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Perhaps the most overt ways in which the pandemic is influencing scholarship is in terms of disruption to intellectual networks and project temporalities.

It might be tempting to point to the cancellation of conferences and reworking of seminars as a major consequence of COVID-19, and to consider how difficult it is to recreate opportunities for conversations and collaborations that tend to emerge from interaction outside of the formal conference room.

However, as disability activists and scholars with caring and familial responsibilities have pointed out, these issues are long-standing. It should be a matter of shame that it has taken a global pandemic to force able-bodied academics to think seriously about alternative ways of working, when this has been so long denied to colleagues unable to be physically present at large, and often distant, events.

Instead, a problem more directly caused by the pandemic is how COVID-19 has radically disrupted postgraduate and PhD research, and will potentially reduce the time available to undertake ongoing projects. At the time of writing, some funding bodies have so far shown a willingness to ensure no cost extensions in proportion to the disruption experienced, but considerable anxiety and uncertainty still exists, and the internal research leave and fixed contract arrangements of individual universities are being addressed idiosyncratically. The absence of a sector-wide response – of guaranteed secure employment at (or above) present levels of pay for casualised staff – has begun to generate political action under the banner of a Corona Contract. However, even if agreed, the personal circumstances of researchers change over time, and their capacity to undertake the same work may well be altered in the future. The knowledge produced will thus likely be substantively different as a result.

Similar analyses can be applied at the level of teaching. As was made clear at the Modern British Studies conference last August, history modules are already being shaped by the short fixed-term, zero-hour contracts spreading throughout academia. This has often reduced preparation time and opportunities for scholars to create their own offerings, leading to modules being inherited and reworked where possible by temporary staff. Individual universities have used COVID-19 as legitimation for laying off staff or refusing to continue contracts of fixed-term employees, and together with social distancing the landscape of teaching looks very different as a result.

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Of course, the pandemic is also shaping the knowledge it is possible to produce at the level of sources and methods.

Closures of archives and libraries has ensured a majority of resources remain inaccessible, and de facto quarantine is altering the way we can undertake oral historical work. (Given that the direction of an encounter is often shaped by the embodied interaction of interviewer and interviewee constructing the interview together in the same room, it is likely that even online interviewing will produce different testimonies.)

Some textual and visual materials are available online, partly due to digitisation and partly due to the increasing use of the internet as historical object and source.

However, a reliance on digital and virtual sources has its own implications for how we relate to, use, and think about historical materials.

For instance, texts that are available digitally and made keyword searchable can grow in epistemological importance. Equally, engagement with uncatalogued materials becomes impossible, and the assessment of a source’s materiality – its physical substance, potential sensory responses, clues to its production – are also precluded or made more difficult. In this sense the pandemic risks compounding historians’ existing reliance on the narrow range of sources that have managed to survive, and which have often been produced by social elites and from positions of (often violent) power. We will require further innovation in approaches and methodologies to avoid reproducing historical violence in the present.

At the same time, public and political discourses of healthcare, disease and contagion – as well as experiences of illness and practices of social distancing and self-isolation – are also altering how we might read and interpret our sources.

At a very basic level, I am currently revisiting my own work on waiting rooms. Under present conditions, materials relating to concern of infection are beginning to stand out more. References to feeling disturbed or diminished by waiting with patients with ‘hacking coughs’, for example, take on greater resonance, as do recollections of the way such anxieties shaped practices of attending surgery and sharing the time of waiting.

Take, for instance, one letter to the Manchester Guardian in 1951 about trying to collect a sickness certificate:

‘Ministries and medicine’, Manchester Guardian, 17 January 1951, p. 4

The day before I returned to work I thought I would ask my doctor about a certificate. I was, I hoped, still a little wan. His crowded waiting-room quickly drove me back into the street, so great was the barrage of coughing and sneezing. Half an hour after the official “hours” ended the crowd had thinned to a mere thirteen, so I ventured to wait. In another half an hour I was before the doctor.

Previously, I may have read this in terms of anxieties of waiting for – and consulting – the doctor when appearing healthy, in relation to the performativity of sickness. Equally, the source raises questions about the length of acceptable waiting, the responsibilities that doctors had to attend their patients after surgery hours, and the role of the medical profession in sick note certification. Even though I would have registered the disquiet with the waiting room as a source of infection, the fear of contagion would not have hit home in the same way.

Similar alterations in my interpretation have manifested in relation to GP’s frustrations with patients bringing in “dirt” to their waiting rooms. I have previously read such complaints in highly symbolic terms, in line with my interest in how discourses of dirt and cleanliness have been historically racialised and classed. Now, however, I am paying greater attention to dirt’s materiality. Though GPs’ irritations cannot be conceptually divorced from “dirt’s” cultural values, my own anxieties around the ongoing pandemic has made me appreciate the medical concern with hygiene embedded in GP’s choices of easy-to-clean materials for redecorating waiting in a period of regular infectious disease outbreaks.

Finally, even should the present proscriptions around “staying home” be eased, and libraries and archives swiftly reopen, the emotional experience of being in and using such spaces will also have been altered.

I already feel much more “exposed” simply going to a small supermarket, so I can only imagine that the experience of using public transport, sharing the space and time of research with others, and interacting with well-handled resources will be radically different for some time. To presume that such affective responses will not alter how I interact with historical sources (the time I can bear to be with them, how much more I rely on digitised versions) or the sorts of questions I will ask of them would be disingenuous.

Of course, even as I write many people literally cannot afford to avoid public transport or working away from home

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There are, of course, much more complicated ways to think historically about epidemics, time and care in relation to scholars’ experiences of the present moment, and undoubtedly our teaching on history of disease and medicine modules will also be shaped by our students’ personal perspectives on their lockdown and social distancing.

Moreover, that I – and scholars like me – are only beginning to consider such questions seriously can itself be historicised.

This very reflection is the product of my having grown up in a period and place in which my privilege as a heterosexual, white (once working-, now solidly middle class) male living in Britain has afforded me protection – not simply from the epidemics that have tended to exist geographically and socially “elsewhere” (from HIV/AIDs to Ebola) but also from the structural violence that has consistently distributed disease disproportionately among the poorest and those most discriminated against in Britain (and globally). Even now, my positionality is proving protective, as underlined by reports that BAME communities are suffering disproportionate mortality from COVID-19.

Given the racial, class and gender disparities among the historical profession, I suspect that my experiences may be widely shared.

Nonetheless, whether explicitly discussed in acknowledgements, expressed within the subjects, questions and contours of research, reflected in how we organise and practice intellectual network formation, or manifest in the conditions within which teaching is delivered, the effects of COVID-19 on the present and future of historical scholarship will likely be widespread and significant. As such, though academic departments are by no means the only source of historical knowledge and narrative, it is fair to say that the present pandemic is also rewriting the past.

 

Notes

[1] For classics in the field and useful reviews: S. Shapin and S. Schaffer, Leviathan and the Air Pump: Hobbes, Boyle and the Experimental Life, (Princeton: Princeton University Press, 1985); S. Woolgar and B. Latour, Laboratory Life: The Construction of Scientific Facts, (Princeton: Princeton University Press, 1986); K. Knorr Cetina, Epistemic Cultures: How the Sciences Make Knowledge, (Cambridge, Mass: Harvard University Press, 1999); L. Daston and P. Galison, Objectivity, (New York: Zone Books, 2010).

[2] The most self-conscious example I have seen is the preface to a history on international development and the social sciences, which begins: ‘this book as much as the institutions which are its subject, comes out of a particular history, a certain intellectual climate, and specific funding possibilities’: R. M. Packard and F. Cooper (eds), International Development and the Social Sciences: Essays on the History and Politics of Knowledge, (Berkeley: University of California Press, 1997), p. vii. For examples of texts firmly grounded in the historian’s own positionality: C. Hall, White, Male and Middle Class: Explorations in Feminism and History, Cambridge: Polity Press, 2007 [1992]); C. Steedman, Landscape for a Good Woman: A Story of Two Lives, (London: Virago, 1986).

[3] For instance: A. Green and K. Troup, The Houses of History: A Critical Reader in History and Theory, Second Edition (Manchester: Manchester University Press, 2016); L. Jordanova, History in Practice, Third Edition, (London: Bloomsbury Academic, 2019).

[4] E. H. Carr, What is History?, Second Edition (London: Penguin, 1990 [1961]), p. 30.

 

Messages in Bottles: Showcases at Honiton hospice

As part of our ongoing partnership with Hospiscare, Messages in Bottles, we held three showcases of work produced by service-users of the Honiton day hospice.

These three events presented written stories, pictures, songs and short films made in our storytelling and story sharing collaborative workshops.  We had participants – service-users, staff and researchers – as well as family, friends, carers and other members of the Hospiscare team come along for an afternoon of reading, thinking, talking and sharing at the King’s House day hospice in Honiton.

We also had plenty of tea, cake, laughter and the occasional tear.

Our next planned event is a tour of local libraries.  We’ll be taking interactive displays of the stories to Honiton, Seaton, Sidmouth, Axminster and Exeter.  We had planned to start this tour in April 2020, but we had to postpone for obvious reasons.  Hopefully, libraries will re-open after the summer and we will be able to take take our show on the road then.

Until then, you can listen to some of the stories here.

Lunchtime seminars with Occupational Therapy at the RD&E

In collaboration with Dr Arthur Rose (Bristol), Michael organised a series of lunchtime seminars for Occupational Therapy and Physiotherapy practitioners at the Royal Devon and Exeter hospital.

The workshops grew out of discussions with an OT nurse who attended a Waiting Times workshop at the Wellcome Centre for Cultures and Environments of Health.  In addition to fostering links and dialogue between the research team and healthcare professionals, the seminars aim to provide humanities research-based ideas and inspiration for developing clinical practice, using the Waiting Times research as a major source of insight.

In November 2019, Michael shared stories, video and audio from the Messages in Bottles project he and Kelechi have worked on in partnership with Hospiscare.

In February 2020, Michael ran a workshop on how semiotic techniques can be applied to understand and improve upon communication, information exchange and partnership between patients and healthcare professionals in the clinical encounter.

Dr Rose, Michael and the OT team at RD&E will be planning future lunchtime seminars for the year 2020/21.

Accessing the GP and the Time of Care in British General Practice, Martin Moore

‘My own doctor is a charming man when one can eventually win an appointment to see him’: accessing the GP and the time of care in British general practice

Martin Moore writes:

At a meeting of English local medical committees during November last year, GPs passed a motion to end home visits as a contractual obligation for NHS practitioners, advocating for a  special acute service to be established to undertake such work.

Although, according to recent NHS data, on average only 1% of total primary care appointments were for home visits, the motion provoked a considerable backlash among patient groups, senior healthcare professionals, the press and Government ministers.

Critics broadly focused on the capacity for severely ill and immobile patients to access the GP, whereas supporters argued that GPs ‘no longer have the capacity to offer’ visits. At its heart, in other words, were questions about for whom and for what GPs should reasonably make time.

As my recent work on appointments systems is revealing, GPs’ time and patients’ rights of access to care have formed a central object in public debate since the foundation of the NHS. By contrast to the current proposals, however, the emergence of full-time appointments systems for surgery sessions in general practice generated far less initial resistance, despite affecting a far greater proportion of the practice population.

‘Much of the overwork of which doctors complain  is due to lack of proper business methods’

The first decades of the NHS witnessed a considerable change in how people waited for a GP consultation.

In the early 1950s, only 2% of British general practices employed full time appointments systems for their surgery sessions.[1] In the vast majority of practices, those patients wishing to see the doctor could simply arrive at the premises during surgery hours and wait to be seen in turn. Even practices with appointments systems quietly reserved part of the surgery session for patients arriving without an appointment.

From A. E. De La T. Mallett, ‘An appointment system in a group practice’, College of General Practitioners Research Newsletter, 3:8 (1955), 113-18

Finally, for those too ill to come to the surgery, visits were common; around a quarter of consultations on average occurred in patients’ homes.[2]

By the early 1970s this situation had dramatically altered. Around 80% of practices now employed full-time appointments systems.[3] Crucially, changes to NHS rules empowered doctors to defer treating patients who they felt were not in need of immediate attention. Patients were thus increasingly unable to access the doctor on demand without an appointment. A wait for the doctor might stretch to several days if one was unavailable immediately.

As with contemporary discussion around home visits, GPs’ concern with time pressure generated interest in appointments systems. Following the creation of the NHS, many GPs bemoaned having ‘much more work’ and feeling like they were ‘chasing [their] practice downhill all the time with no hope at present of ever catching up’.[4] As a result, many doctors sought organisational innovation to achieve ‘more economic use of … time and energy’.[5]

Notably, one particular attraction of new systems was that they might ‘reduce the demand for visits’, as reduced crowding and waiting times could make surgery attendance less taxing.[6] The time saved by reduced travelling could be put to use elsewhere.

Efficiency was not the sole factor motivating GPs to take up appointments systems, however. Traditional arrangements, for instance, could lead to late-running surgeries – any patient who arrived before doors closed had a right to be seen. As one satirical novel put it: ‘the patients came steadily to my cubby-hole, though every time I began to think about lunch and peeped outside there seemed to be as many waiting as ever’.[7]

Impression of a GP Waiting Room: Mass Observation, Meet Yourself at the Doctors (1949)

Constant work and anxiety about the waiting room’s ‘vast unknown population’[8] left GPs feeling exhausted and stressed. ‘A life of uncertainty as regards the working events of a day’, one GP noted, ‘is nervously exhausting at all times’. Only with an appointments system was ‘the element of being in a hurry… eliminated’ and ‘a much calmer atmosphere’ established.[9]

Appointments thus enabled GPs to reduce daily physical and psychological strains, and offered greater control of time in their working and social life. They could now make time for dinners and professional development opportunities. Such pursuits also led enterprising practitioners to engage in the first out-of-hours companies and develop rotas for the burden of night calls.[10]

‘They are not just “the next patient, please”’

Such substantive change did not go unnoticed. Traditional GPs in particular expressed concerns about how appointments created psychological barriers to attendance for patients with uncertain symptoms, preventing the opportunity for early diagnosis.

GPs also noted inequitable social consequences, pointing to poorer and elderly patients having difficulties making appointments. ‘The 3d for the telephone’, suggested one practitioner, was ‘an added expense to their budget’, whilst making timely journeys was made more challenging by reliance on public transport and greater geographical isolation.[11]

The Guardian, 12 December 1974, p. 8

Generally, however, patients seemed to accept new systems during the 1960s. Consumer bodies lobbied for them, and surveys revealed approval ratings as high as 98%. Primarily, patients appreciated reduced surgery waits (on average being halved) and liked being able to integrate appointments into their day, ‘shopping in what would previously have been waiting time in surgery’.[12]

Doctors also noted that patients appreciated having protected time with the GP. They even suggested that the work involved in securing a consultation meant had a ‘better understanding of the value of the time spent in consultation… emphasis[ing] the importance of the doctor’s advice’.[13]

It was when appointments proved hard to come by that dissatisfaction manifested. In response, some patients lamented losing the traditional guarantee of same-day consultation, describing the queue as ‘much more humane’ than the delay and ministrations of ‘a dragon of a receptionist’.[14] Indeed, receptionists attracted considerable public ire.

Figure 1 The Times, 22 February 1978, p. 6

By contrast, some critics noted the changing experience of waiting, bemoaning declining ‘comraderie’ in the waiting room.[15] Whereas once waiting patients were collectively left out of sync with the rest of the social and economic community – to paraphrase Harold Schweizer – under appointments they were out of sync with one another.

*

By the time appointments systems nationally began to struggle, reverting to older temporal orders was almost inconceivable. Individual practices did abandon appointments after bad experiences, but generally too much financial, organisational and psychological investment had already been made.

Today, receptionists are still maligned and the ‘same-day appointment’ has become an important metric for the NHS. Newspapers have even offered advice for getting an appointment for the day you want.

The drive for choice and immediacy in appointments has undoubtedly pressurised GPs to be time conscious, and – as in the 1960s – has contributed to the undesirability of home visiting.

Though drawing lessons from the past is a dangerous activity, given the historical drift away from home visiting – and present pressures to access GPs on demand – it wouldn’t be a surprise to see home visiting hived off from GPs in the near future.

If it were, reintroducing home visiting to GPs after the act may well prove as difficult as removing the appointment. The other consequences of this change, though, are far more difficult to predict.

 

Notes

[1] S. Hadfield, ‘A field survey of general practice, 1951-2’, BMJ, 2:4838, (1953), p. 701.
[2] N. Bosanquet and C. Salisbury, ‘The practice’ in I. Loudon, J. Horder and C. Webster, General Practice under the National Health Service, 1948-1997, (Oxford: Oxford University Press, 1998), p. 47.
[3] ‘14 days to see your doctor’, The Lancet, 301:7809, (1973), 923.
[4] E. Anthony, ‘The GP at the Crossroads’, BMJ, 1:4661, (1950), p. 1078.
[5] J. Stevenson, ‘Appointment systems in general practice: do patients like them, and how do they affected work load?’, BMJ, 2:5512, (1966), p. 516.
[6] Central Health Services Council Standing Medical Advisory Committee, The Field Work of the Family Doctor, (London: HMSO, 1963), p. 15.
[7] R. Gordon, Doctor at Large, (London, Michael Joseph, 1955)
[8] ‘Why are we waiting?’, Platform, (Basingstoke Consumer Group, October 1964), p. 28.
[9] H. N. Levitt, ‘An appointment system in a single-handed general practice’, The Practitioner, 185 (1960), p. 213.
[10] Bosanquet and Salisbury, ‘The practice’, pp. 58-9.
[11] N. C. Horne, ‘An appointment system for use in general practice’, BMJ, (Supplement, 29 November 1952), p. 210.
[12] D. Dean, I. M. Dean, B. R. Wilkinson, and R. McMurdo, ‘Appointment systems in general practice’, BMJ, 1:5434, (1965), 592. Also: J. M. Bevan and G. J. Draper, Appointment Systems in General Practice, (Oxford: Oxford University Press on behalf of the Nuffield Provincial Hospitals Trust, 1968), pp. 113-15
[13] The Field Work of the Family Doctor, p. 27.
[14] K. Johnstone, ‘Trying your patients’, The Guardian, 1 February 1979, 13.
[15] J. Cunningham, ‘Doctors avoid ‘unnecessary’ calls’, The Guardian, 2 May 1973, 7.

You had better make a Jew of him’: The ninteenth-century medicalisation of circumcision and the talking cure

Please join Jordan Osserman (Birkbeck) for a seminar in Psychoanalysis and History at The Institute of Historical Research

When:

on Wednesday, 15 January 2020, 5:30PM – 7:30PM

Where:

Room 320, Arts Two, Queen Mary University of London, Mile End Road, London E1 4NS

FREE, but registration is required.

ihr.reception@sas.ac.uk
020 7862 8740

Waiting Times at NYPSI’s 1038th Scientific Programme Meeting:  Waiting for Psychoanalysis

This year we are honoured to be invited by New York Psychoanalytic Society &   Institute (NIPSI) to talk about “Waiting for Psychoanalysis”.
On Tuesday, 22 October, Lisa Baraitser, Jocelyn Catty, Raluca Soreanu, and Laura Salisbury,  (moderator) will talk on what it means to wait in and for healthcare to reflect on how psychoanalysis helps us to understand the difficulties and potentialities of waiting within contemporary lives that are increasingly experienced as frenetic, harried and time-starved, while also, paradoxically, impeded and stuck.
Psychoanalysis is a practice that takes and uses time self-consciously, working and thinking through rhythms that run counter to the values of immediacy, productivity and efficiency that orientate many of our experiences of contemporary life. By committing to the long timeline of psychoanalysis, the patient is brought into contact with something different: a demand for patience, for suffering and endurance in which processes of mourning, or the emergence and working through of traumatic memory, cannot be sped up but must be endured through time and ameliorated through a practice of endurance on the part of both patient and analyst.
This discussion will include academic researchers who also work clinically with patients in three different psychoanalytically-informed traditions to reflect on how psychoanalytic modes of care function through practices of waiting with – through the suspension of the everyday, the repetitions of the transference and processes of working through. They will discuss what this particular use of time might have to offer a social world in which, at one level, waiting seems increasingly devalued or intolerable, while at another the promises of a progressive future seem to be slipping from view – where all one can do it wait.

 

When: Tuesday, October 22, 2019, 8:00 – 10:00 pm

Where: New York Psychoanalytic Society & Institute, 247 East 82nd Street, NYC (btwn 2nd and 3rd Aves)

Register HEREvisit nypsi.org or call 212.879.6900 (New York, USA)