Sec. Sci. & Med., Vol. 11, pp. 485 to 490. Pergamon
SOCIAL
Press 1977. Printed in Great Britain.
CARE AND THE ROLE OF THE GENERAL PRACTITIONER* GERRY
V.
SnlllsoN
Institute of Psychiatry, 101 Denmark Hill, London S.E.5, England Abstract-United Kingdom general practice is taken as a case study of the way in which new areas of concern come to be seen as within the sphere of competence of doctors. In defining the themes of generalpractice, prominent U.K. practitioners have pointed to a social orientation which distinguishes general practice from other areas of medicine. This loosely defined social orientation appears to include several themes. On the one hand there is an awareness of social relationships, social factors in disease and illness behaviour, and of the social causes of disease, and on the other, a feeling for a responsibility for caring for the social consequences of diseases, for social welfare problems, and for socio- or psychotherapeutic care. An involvement in social care raises certain questions about the role of the general practitioner which have not been explored by those doctors who have discussed this social orientation. At one level there are practical problems of the conflict between the provision of medical and social care and the relationship with other care workers, but at a more basic level there is a fundamental question concerning our socio-political approach to social problems.
Such is the power of language that from a statement about a social care role we might assume that it is a “good thing” that general practitioners have such a role, or that if they do not, they should have-all that remains is the problem of how to improve it or implement it. I think that the discussion should start several stages back, and we should ask what we mean by social care and then ask whether this is possible or desirable within the’ framework of general practice. Central to such a discussion is what we mean by “general practice” and from where we draw our examples. General practice is one way of providing primary medical care. Its characteristics are that practitioners are trained to the same initial level of competence as other doctors but practice as generalists. rather than as specialists, i.e. they attend to the whole range of conditions and diseases; work is conducted at the individual (patient) level in a personal (one-toone) manner and the practitioner works alone or in a small group outside of the hospital setting; there is usually some temporal continuity of care and responsibility beyond specific disease episodes [l-4]. Further refinement of the definition of general practice will reflect national differences in the ,provision of medical care. General practice is only one of many ways in which primary medical care is provided; reasons for its development will be found in an historical analysis of European medicine. In this paper I will use United Kingdom general practice as an example of the provision of primary care in urban industrial countries. The role of the primary care practitioner needs to be considered in the light of the current medical tasks and, as these tasks are very different between the Third World and the West, general practice may not be an appropriate
* Background paper prepared for the section on “Social Care Roles of General Practitioners” at the 5th International Conference on Social Science and Medicine, Nairobi, 8-12
August
1977.
485
model for primary care in non-industrial countries. However, I have chosen the U.K. firstly because of my familiarity with it and secondly because in recent years prominent U.K. doctors have claimed a social element-which includes social care-as important to general practice. I do not think they have clearly defined what they mean by this nor thought through the implications of this view. Without further clarification there are a few limits to the activities which general practitioners might see fit to engage in. CONCERN
ABOUT
THE GENERAL
PRACTITIONER’S
ROLE
If general practice was clearly limited to general medical care, and if general medicine was capable of easy definition, then there would be little debate about the practitioner’s role. This is not the case. In the U.K. since the establishment of the National Health Service in 1948, and perhaps before, general practitioners have continued to debate their role. Thk pessimistic have said that the separation of general practice from the hospital service left general practitioners with the medical and quasi-medical tasks which others were not prepared to do. Further, U.K. practitioners have been given some difficult social control tasks, such as the provision of sickness certificates for exemption from employment. It has been claimed that the unattractiveness of general practice puts it in danger of becoming the “dustbin of meditine”-recruiting those doctors who do not make it into better parts of medicine. On the other hand, the optimistic have emphasised the essence of general practice as family, personal and community medicine, giving the practitioner opportunity for patient contact unrivalled in other branches of medical practice [l, 41. This view, to be discussed more fully below, has prevailed among prominent general practitioners. The debate is also found in other affluent countries, and is evidenced by the relative unpopularity of general practice. For the poor in the U.S. an adequate
486
GERRYV. STIMSON
primary health care service remains “an illusory dream”, and in the U.S. and Canada there has been a decline in general practice in favour of specialist medicine [S, 61. In the U.S.S.R. there is a high turnover of those general physicians (terupeuti) who are supposed to be personal physicians with a continuing responsibility for patients, and articles in medical journals complain that they have become simply “trained dispatchers” [7, S]. In Israel doctors are attracted to specialist medicine and there is a shortage of general practitioners [9]. In France, specialist medicine is becoming increasingly popular at the expense of general medicine [lo]. If we look at the problem from a sociological perspective we might conclude that the debate flows from a concern about the status of the general practitioner, and, the feeling that general practice has lower status than other branches of medicine. The “concerned” want to raise the status of general practice (and not to lower the status of specialist practice-which is an unlikely alternative solution). In Western medicine those branches of medicine with high status have a monopoly over some area of knowledge, some medical task, or method of approach-they have a specialty. The problem for general practice is that it is general medicine, and the paradox is to make this occupation into a specialty when its main claim is its lack of specialisation [ll]. Concern about general practice in the U.K. led to the “new movement” or “renaissance” of general practice, a movement which started in the U.K. in the 1950s [12,13]. This movement has promoted general practice by undergraduate and postgraduate medical education and by concern for the quality of care. A College of General Practitioners was founded in 1952 and granted a Royal Charter in 1972. The College publishes a journal of general practice, monographs and books, and has research units. There are now vocational training schemes for practitioners, postgraduate medical centres for continuing education, and more recently departments of general practice with professorial chairs have been established in medical schools. An indication of the success of the movement is that the Royal College of General Practitioners membership examination is now needed for senior academic posts in general practice [13]. A great deal has been achieved in setting the framework for improving general practice, and for making it more attractive to newly qualified doctors, but it would be optimistic to say that the role uncertainty has been resolved, indeed to the credit of the new movement the questioning continues. It is useful to look at how the role of the general practitioner has been described in these discussions. DEFINING THE THEMES OF GENERAL PRACTICE
I am taking my evidence from those doctors who see it as their task to write and talk about general practice, mainly a number of people who have been prominent in the Royal College of General Practitioners. We do not know how representative College members are of the total population of general practitioners. About 8000 of the 23,000 general practitioners in the U.K. belong to the College and only a handful of these have been active and vocal in discussing the
content of the new general practice. I should make it clear that I am discussing the views of this vocal group concerning what general practice is or should be like. A clue to how general practice is viewed is found in the RCGP mott+Cum Scientia Caritas-which loosely translates as “knowledge with caring”. The two themes which are emphasised are the science of medicine coupled with a social orientation [14]. The general practitioner is a “personal, family and community doctor”, whose “field of work will be the illnesses and social problems that might be expected to occur in a population of about 2500 persons” [14] and whose “diagnoses will be composed in physical, psychological and social terms” [l]. We are told that he is a manipulator of the patient’s personal, social and medical environments whether in the family, at work or elsewhere-in other words he engages in physical, psychological and “social treatment” [ 11. In this definition of general practice the general practitioner is expected to view illness in its wider community context [ 141. The solution to the problem of making general medicine a specialty when it has no special medical knowledge or task is to emphasise a unique social orientation. It is not only what is practised which is important but how it is practised and where it is practised-the style and context is as important as the content. Discussion of this social orientation pervades the literature. The Futur‘e General Prnctitioner [l] was written by six general practitioners and whilst not intended as such, has been taken as reflecting the policy of the RCGP [16]. It is mostly about the social and organizational aspects of practice and has little medical content. One general practitioner reader has commented that “it is difficult to believe sometimes that the book is about medicine at all” [17]. Surveys of practitioners reinforce this impression that the opportunity for patient and family contact are important in definitions of the role [14, 181. The attributes of the general practitioner are said to include those “human qualities” which the practitioner can find described in accounts of the founding fathers of general practice; as portrayed in commemorative lectures these gentlemen had the clinical rigour and insight we attribute to most medical workers, but what marks them out from other doctors is their caring relationship and informed concern for their patients [13,15]. Thus the contemporary statement of the role posits a significant social element alongside the medical. The aspects of work stressed in the renaissance of general practice are the indeterminate, those that defy precise formulation and which are learnt by experience on the job rather than the technical or codified medical knowledge and skills which are shared with the rest of medicine [19]. In the past personal relationships and the “whole man” approach could be described as “compassion” and “intuition”. But the problem for those who wish to improve the status of general practice is that these unique indeterminate features eventually have to be taught-the social orientation has to be turned into subjects for the curriculum. Consequently, General Practice Departments in medical schools now teach courses on “the social aspects of
Social care and the role of the general practitioner medicine” or “medicine in the community” [20] and they draw on disciplines which are broadly concerned with human behaviour--such as psychology, psychotherapy, social science, and social work. A prominent general practitioner is able to claim that the academic status of general practice will be raised if it has its own area of research in a field unique to general practice, and for him this field is “human behaviour” [21].
THE NATURE
OF THE SOCIAL
GENERAL
ELEMENT
IN
PRACTICE
The problem with such a sweeping view of the social element in general practice is that it can be taken to mean different things. It is variously taken to mean that the general practitioner should have an understanding of the social situation of patients, a social work role, a social therapy role, a responsibility for the effects of social problems-r simply that he is a nice compassionate man with a good bedside manner. In the U.K. the content of primary health care is essentially unplanned, and individual doctors are to a large extent able to set and define their area of work. If they want to do psychotherapy and social work in addition to providing medical care there is nothing to stop them doing so. The nearest thing to a job specification is found in the terms of service of their contract with the local Family Practitioner Committee: primarily the general practitioner’s job is to “render to his patients all necessary and appropriate personal medical services” [22]. How doctors interpret this is up to them. It seems to me that we have to sort out what doctors mean when they refer to this social element in their work, and from the writings of general practitioners we can isolate several themes which seem to be included under this heading: (1) The importance of social relationships in general practice-the area of the doctor-patient relationship. The social element here ranges from a feeling that doctors should be compassionate and have a “caring concern” for their patients, to an awareness of the complexities of communication between doctors and patients. Those who emphasise the mystique and magic of medicine argue that the doctor’s manner affects the amount of faith the patient has in the doctor’s actions, and thus the success of the treatment. The “rationalists” argue that attention to communication and social skills is important so that patients’ expectations will be better, understood and treatment made more effective. (2) Awareness of social factors in disease and in illness behaviour. Firstly there is the awareness of the influence of occupational and life-style factors on the course of a disease, and secondly the awareness that social factors influence patient behaviour such as the willingness to consult and the willingness to use treatment. The idea here is that treatment is made more effective if the doctor is aware of and takes into consideration the social context of the patient. It is argued that hospital doctors often ignore the social setting because the patient is captive, but that because the general practitioner sees patients in the com-
481
munity the context of their lives and the social consequences of medical decisions cannot be ignored. (3) Awareness of the social causes of diseasethat occupation and living conditions can affect the certain diseases-obvious of suffering chances examples here are occupational disease and the link between life style and heart disease. The view is that “the general practitioner cannot be neutral towards the factors in our lives that influence health and disease” [l]. (4) Awareness that many illness conditions have serious social sequelae and that the doctor is therefore responsible for caring for the social consequences of diseases or of ensuring that they are cared for. The idea is that it is insufficient for the doctor to provide medical care if he knows that the person’s life will be impaired by the illness-therefore he has to ensure that social as well as medical care is provided. Certainly the disease pattern in industrial countries encourages this view. The major health problems are no longer the infections and the high mortality of children under five years (which are the major problems in the Third World) but chronic health problems such as the degenerative diseases (cancers and heart diseases accounting for half of all deaths) mental illness, mental and physical handicaps, and care of the elderly [23]. (5) Awareness that many problems brought to the doctor are not diseases but social welfare problems. The idea is that the doctor comes across these problems because his work takes him into people’s lives and because, in the U.K. at least, he is one of the more accessible professionals. Because he comes across the problems some suggest that he has a clear duty to provide social care or see that it is provided. For instance, a Royal College of General Practitioners’ publication draws attention to the responsibility of the doctor to care for “social and quasi-medical problems” and lists the “social pathology” which a British general practitioner might face in a typical 2500 person practice: 350 people over age 65; 150 receiving welfare benefits; 60 one parent families with children under 15; 70 with severe physical handicaps; 50 male homosexuals; 30 alcoholics; 25 deaf and 7 registered blind; 10 severely mentally handicapped; 5-10 problem families; 5-7 juvenile delinquents; 3 suicide attempts each year and one successful suicide in four years; one road traffic fatality in four years. In some communities, e.g. those in declining industrial areas in the U.K., poverty and handicap may be considerably greater [24]. (6) Awareness that the doctor has a responsibility to care for individuals with emotional problems-that the doctor has a socio- or psycho-therapeutic role. The idea here is that a significant part of the doctor’s work load is with illness which has a significant psychogenic component, or which is predominantly psychological in origin. In the U.K. evidence for this is found in prescription data: one in five prescriptions dispensed under the National Health Service is for a psychotropic drug-tranquillisers, antidepressants, sedatives and hypnotics. Further evidence is found in the interest of many general practitioners in psychotherapeutic counselling-this has been an important theme within the renaissance of general practice in the U.K. [25,26].
488
GERRY V. ”>TIMSON
SOCIAL AWARENESS
AND
GENERAL
PRACTICE
I have suggested six themes which can be distinguished in the current trend for U.K. general practitioners to point to a significant social element in their work. The first three concern a social awareness on the part of the doctor. There is, I think, little dispute about the importance of an awareness of social relationships and an awareness of social factors in disease and illness behauiour-both seem necessary for efficient diagnosis, prognosis and treatment, from patients’ and the doctors’ points of view. Such awareness does not challenge the basic medical care role. It is here that social science can make a clear contribution to medical practice. The implications of an awareness of the social causes qf disease are more difficult for general practice for they do not neatly fit the general practice approach of individual care for diseased persons. The ideal approach is prevention, but in the West general practitioners have not developed a preventive medical role, except in a minor way with individual health education. We find repeated in the general practice literature that the doctor must diagnose and treat in physical, psychological and social terms, but just how, in practice, is he to engage in “social therapy”? Cl]. Some causes may be open to manipulation (advise the person to stop smoking, change diet) others less so (pollution, occupational disease). How does the doctor change social conditions? Here is a clear limitation in encouraging a social orientation-it points to the problems but does not show how to solve them. Identifying the social causes of disease could encourage doctors to engage in political and social action to improve the health of the community: such action on the part of doctors is rare in the West. It is difficult to see how the knowledge of social causes can be translated into action when the general practitioner’s basic work object is the individual, and his work unit is the one-to-one consultation. At the least, the awareness of social causes of disease may affect the doctor’s view of the patient; the view might be one of compassion if the patient is seen as victim of social conditions: on the other hand it may resign the doctor to feel that “nothing can be done”. SOCIAL CARE AND GkNERAL PRACTICE
The remaining three themes can be seen as falling within social care in that they concern material emotional welfare problems-these are a responsibility for caring for the social consequences of diseases, for caring for social welfare problems, and for providing socio-therapeutic care. I think that certain important questions have to be considered before we assume that it is possible for general practitioners to be involved in social care. The first question concerns a possible conflict between social and medical care. We have in fact little indication of the effectiveness of general practice in improving health. It may be that it has always had more of a palliative effect, rather than being a positive force in improving health, but if we assume that general practice continues to be concerned with the cure and palliation of sick individuals, we are faced with
the problem of getting the medical care where it is needed, and of ensuring that practitioners have adequate technical competence. This major task of the general practitioner-providing medical care-has not yet been adequately provided in most industrial countries. I have already referred to the shortage of general practitioners in many countries. In the U.K. there are marked regional and social class disparities in the provision of general practice and the quality of care [27-301. In the Third World it seeems naive to talk about social care when medical care is not available for much of the population. In developed countries the evidence abounds of the low quality of care, particularly for the financially poor. In the U.K. examination of prescription data reveals potentially dangerous therapy, and there is evidence of lack of knowledge of pharmacology and therapeutics-in particular of adverse drug reactions and interactions-by general practitioners [31]. Recent discussion among general practitioners indicates an awareness of the need to improve and audit the quality of care [32,33], but given the questions about the provision of and quality of medical care, it would seem that an involvement in social care could be to the detriment of providing what is expected from genera1 practitioners-technically competent medical care. Secondly there is the question of the general practitioner uis-&vis other care workers. The doctor is not the only professional who is available for social care. In this century the number of professionals has increased, and this expansion has been highest among the personal, as opposed to the impersonal, service professions. In England and Wales the number of such workers (clergy, physitians and dentists, nurses, teachers, social workers) per thousand of the population has risen from 27 in 1901 to 43 in 1961, despite the absolute and relative decline of the clergy [Sl]. There are now more potential helpers than ever before. If it is thought that someone should provide social care, should doctors be the ones to take this on or is this better done by other workers? One solution to the problem of numerous types of care workers and to the problem of a conflict between medical and social care is to propose a primary health care team comprised of doctors, social workers, health visitors and practice nurses [4]. In this model the general practitioner refers people with social care problems to the social worker. Thus the doctor is freed to concentrate on medical care, whilst ensuring that social care is also provided. The.questions are now ones of referral to and liaison with these other workers. Problems have been encountered where this model has been adopted and the difficulties seem explicable by the concept of professional dominance [34]. Some doctors see themselves as the obvious leaders of the primary health care team. Practitioners tend to define social work as ancilliary to medicine, rather than operating on an equal basis with medicine [35, 361. The questions of the conflict between social and medical care and of liaison between doctors and other care workers assume that care should be provided by some kind of professional worker. However, against the 20th century trend of professionalising
. Social care and the role of the general practitioner
been counter movements indicating the “revolt of the client” and which make “deprofessionalisation an alternate hypothesis for the future” [37,38]. Counter movements may affect clients’ relationships with professionals, may reduce professionals’ monopoly of knowledge, or through self-help provide alternative solutions to problems [39-42]. This brings us to the question of the political and philosophical view which guides our approach to social problems: do we want social care and do we want it to be provided by professionals? care have
SOCIAL
CARE AND THE POLITICS
OF CARING
The questions of social care therefore go much deeper than simply the practical questions of seeing that it is done. To suggest a social care role leads to an examination of a more basic question conceming our socio-political approach to social problems. It cannot be assumed that in the West there is consensus about how we approach social problems. There has been a longstanding conflict between those who see the care role as concentrating on the “financial, economic and social realities of human problems” [43] and those who prefer the “counselling ideology” [44] which stresses the need to help clients gain insight into their problems using the therapeutic aspects of the professional/client encounter. Both these approaches aim to help individuals by casework of one sort or another (yet controlled trials of casework give little indication of its success [45]). The personalised view of social problems, as typified by the counselling approach, has led to quite bizzare results. For example, the problem of low income could be “translated into the problem of the housewife who could not cope with household management, which in turn might be reduced to a ‘personality disorder’ which manifested itself in the inability to resist a few packets of cigarettes, a problem which itself could be traced back to ‘weak superego controls”’ [46]. Similar criticisms can be levelled at the use of psychodynamic techniques in general practice. It can be argued that as a framework for understanding patient behaviour the psychodynamic approach often inaccurately psychologises behaviour when there are plausible alternative explanations; and that it inappropriately places the locus and solution of the problem in the person, rather than in social, economic and political conditions. This is a problem of the way in which social problems are perceived by those who would do something about them. There are those who argue that many social problems are becoming inappropriately medicalised, and that there should be limits to the areas in which medical people can operate and in which a medical model is appropriate. For instance, Illich [47] has written about the dependence created by the medicalisation of many aspects of our lives, and others have written about the way in which many common life events and situations are depicted as putting people in a position where a psychotropic drug is seen as appropriate [48,49]. Medical metaphors now abound for describing aspects of our society [SO]. The question which has to be examined is the usefulness of a medical or individualised approach to social problems.
489
There has recently been a revolt by social workers against this personal&d view of social problems. Social work has begun to rediscover political problems such as housing, rents, low wages, racism and educational inequalities. The activities of radical social workers have recently tended toward community action, work with claimant unions, squatting and other social action. Where does this leave the doctor? The doctor has the same problem here as with trying to deal with the social causes of disease. Under the current structure of medical care the doctor’s work is organiscd around helping individuals, not around social or political action. T’he consequence is more likely to be that the social problems are individualised to fit the current paradigms of care, rather than the paradigms of care being changed to fit the problems. It is very easy to suggest the idea of social care and social therapy as part of the role of the general practitioner. Those general practitioners who have attempted to extend the theoretical boundaries of their work by claiming an involvement in social care do not appear to have worked through the practical and socio-political implications of this claim. In a time when many are seeking to limit the activities of medical and other professional workers, adding a new feature to the role of the general practitioner cannot be discussed without considering the more fundamental question of the way we wish to tackle our social and medical problems.
Acknowledgements-Many thanks to David Hall, Margaret Reid, Barbara Webb and Norma Raynes who commented on an earlier version of this paper.
REFERENCES
1. Royal College of General Practitioners. The Future General Practitioner. London, 1972. 2. McKeown T. Medicine in Modern Society. Allen & Unwin, London, 1965. 3. Stevens R. Medical Practice in Modern England. New Haven, 1966. 4. Present state and future needs of general practice. J.R.C.G.P. Report from General Practice No. i6, 1973. 5. Wolfe S. Primary health care for the Door in the United States and Canada. Int. J. Hlth Sekes 2, 217, 1972. 6. Wolfe S. and Badgley R. F. The Family Doctor. Mac-
millan, Toronto, 1973. 7. Ryan T. M. Primary medical care in the Soviet Union. Int. J. Hlth Services 2, 243, 1972. 8. Hyde G. The Soviet Health Service. Lawrence & Wish-
art, London, 1974. 9. Medalie J. H. The present and future of primary medical care in Israel. Int. J. Hlth Services 2, 285, 1972. 10. Wright A. F. Primary medical care .in France. J.R.C.G.P. 25, 158, 664. 1975. 11. JetTreys M. The doctor’s dilemma-a sociological viewpoint. In A Sociology of Medical Practice (Edited by Cox C. and Mead A.). Collier-Macmillan, London, 1975. 12. Hunt J. The renaissance of general practice. J.R.C.G:P. 8 22 (Suppl. 4), 1972. 13. Irvine D. 1984: the quiet revolution?. J.R.C.G.P. 25, 155, 399, 1975.
490
GERRYV. STIMSON
14. Mechanic D. Practice orientations among general practitioners in England and Wales. In A Sociology qf Medical Practice (Edited by Cox C. and Mead A.). Collier-Macmillan, London, 1975. 15. Knox J. D. E. Willian Pickles Lecture-“Peter Piper’s Peck”. J.R.C.G.P. 26, 476, 1976. 16. Norell J. S. J.R.C.G.P. 25, 155, 439, 1975. 17. Meyrick R. L. What nobody is sure about. J.R.C.G.P. 24, 144, 505, 1974. 18. Cartwright A. Doctors and their Patients. Routledge & Kegan Paul, London, 1969. 19. Jamous M. and Peloille B. Professions or self-perpetuating systems? Changes in the French university-hospital system. In Professions and Professionalisation (Edited by Jackson J. A.). Cambridge University Press, 1970. 20. Reid M. The specialisation of generalists-General Practitioners in university departments. Paper presented at the conference on Medical Ideologies, Bath, England, 1974. 21. Hodgkin G. K. H. 16th James McKenzie Lecture. R.C.G.P. Ann. Rep., 1970.
22. National Health Service, General Medical and Pharmaceutical Regulations. H.M.S.O. 1972. 23. Powles J. On the limitations of modem medicine. Sci. Med. & Man 1, 1973. 24. Hart J. T. The health of coal-mining communities. J.R.C.G.P.
21, 517, 1971.
25. Balint M. The Doctor, his Patient and the Illness. Pitman Medical, London, 1964. 26. Balint E. Six Minutesfor the Patient. Tavistock, London, 1974. 27. Townsend P. Inequality and the Health Service. Lancet, 1179, 1974. 28. Hart J. T. The inverse care law. Lancet i, 405, 1971. 29. Butler J. R., Bevan J. M. and Taylor R. C. Family Doctors and Public Policy. London,. 1973. 30. Consumer’s Association. Which? London, 232, August 1975. 31. Parish P. A., Stimson G. V., Mapes R. E. A. and Cleary J. Prescribing in general practice. J.R.C.G.P. 26 (Suppl. l), 1976. 32. Rose J. C. Recertification and peer review in the United States. J.R.C.G.P. 24, 595, 1974.
33. Buck C., Fry J. and Irvine D. H. A framework for good primary medical care-the measurement and achievement of quality. J.R.C.G.P. 24, 599, 1974. 34. Freidson E. Professional Dominance: the Social Structure of Medical Care. Aldine, Chicago, 1970. 35. Ratoff L., Rose A. and Smith C. Social workers and general practitioners-some problems of working together. J.R.C.G.P. 24, 750, 1975. 36. Goldberg E. M. and Neil1 J. E. Social Work in General Practice. Allen & Unwin, London, 1972. 31. Haug M. R. and Sussman M. B. Professional autonomy and the revolt of the client. Social Problems 17, 153, 1969.
38. Haug M. R. Deprofessionalisation: an alternate hypothesis for the future. Social. Rev. (Monogr. 20), 195, 1973. 39. Caplan G. and Killilea M. (Eds.). Support Systems and Mutual Help: Multidisciplinary Explorations. Grune & Stratton, New York, 1976. 40. Katz A. H. and Bender E. I. (Eds.). The Strength in Us: Self-Help Groups in the Modern World. Franklin Watts, New York, 1976. 41. Newell K. N. (Ed.). Health by the People. W.H.O., Geneva, 1975. 42. Robinson D. and Henry S. Self-Help and Health. Martin Robertson, London, 1977. 43. Hawthorn G. Review. New Society 973, 1970. 44. Halmos P. The Faith of the Counsellors. Constable, London, 1965. 45. Fischer J. Is casework effective? A review. Social Work 18 (No. I), 1973. and 46. Pearson G. Sociology and social work-knowing doing. Med. Social. Newsletter 2 (No. 4). 1975. 47. Illich I. Medical Nemesis: the Expropriation of Health. Caldar & Boyars, London, 1975. 48. Lennard H., Epstein L. J., Bernstein A. and Ransom D. C. Mystijcation and Drug Misuse. Jossey-Bass, San Francisco, 1971. 49. Stimson G. V. The message of psychotropic drug ads. J. Communication 25, 153, 1975.
50. Zola I. K. In the name of health and illness: on some socio-political consequences of medical influence. Sot. Sci. & Med. 9, 83, 1975. 51. Halmos P. The Personal Service Society. Constable,
London. 1969.
SOCIAL
Press 1977. Printed in Great Britain.
CARE AND THE ROLE OF THE GENERAL PRACTITIONER* GERRY
V.
SnlllsoN
Institute of Psychiatry, 101 Denmark Hill, London S.E.5, England Abstract-United Kingdom general practice is taken as a case study of the way in which new areas of concern come to be seen as within the sphere of competence of doctors. In defining the themes of generalpractice, prominent U.K. practitioners have pointed to a social orientation which distinguishes general practice from other areas of medicine. This loosely defined social orientation appears to include several themes. On the one hand there is an awareness of social relationships, social factors in disease and illness behaviour, and of the social causes of disease, and on the other, a feeling for a responsibility for caring for the social consequences of diseases, for social welfare problems, and for socio- or psychotherapeutic care. An involvement in social care raises certain questions about the role of the general practitioner which have not been explored by those doctors who have discussed this social orientation. At one level there are practical problems of the conflict between the provision of medical and social care and the relationship with other care workers, but at a more basic level there is a fundamental question concerning our socio-political approach to social problems.
Such is the power of language that from a statement about a social care role we might assume that it is a “good thing” that general practitioners have such a role, or that if they do not, they should have-all that remains is the problem of how to improve it or implement it. I think that the discussion should start several stages back, and we should ask what we mean by social care and then ask whether this is possible or desirable within the’ framework of general practice. Central to such a discussion is what we mean by “general practice” and from where we draw our examples. General practice is one way of providing primary medical care. Its characteristics are that practitioners are trained to the same initial level of competence as other doctors but practice as generalists. rather than as specialists, i.e. they attend to the whole range of conditions and diseases; work is conducted at the individual (patient) level in a personal (one-toone) manner and the practitioner works alone or in a small group outside of the hospital setting; there is usually some temporal continuity of care and responsibility beyond specific disease episodes [l-4]. Further refinement of the definition of general practice will reflect national differences in the ,provision of medical care. General practice is only one of many ways in which primary medical care is provided; reasons for its development will be found in an historical analysis of European medicine. In this paper I will use United Kingdom general practice as an example of the provision of primary care in urban industrial countries. The role of the primary care practitioner needs to be considered in the light of the current medical tasks and, as these tasks are very different between the Third World and the West, general practice may not be an appropriate
* Background paper prepared for the section on “Social Care Roles of General Practitioners” at the 5th International Conference on Social Science and Medicine, Nairobi, 8-12
August
1977.
485
model for primary care in non-industrial countries. However, I have chosen the U.K. firstly because of my familiarity with it and secondly because in recent years prominent U.K. doctors have claimed a social element-which includes social care-as important to general practice. I do not think they have clearly defined what they mean by this nor thought through the implications of this view. Without further clarification there are a few limits to the activities which general practitioners might see fit to engage in. CONCERN
ABOUT
THE GENERAL
PRACTITIONER’S
ROLE
If general practice was clearly limited to general medical care, and if general medicine was capable of easy definition, then there would be little debate about the practitioner’s role. This is not the case. In the U.K. since the establishment of the National Health Service in 1948, and perhaps before, general practitioners have continued to debate their role. Thk pessimistic have said that the separation of general practice from the hospital service left general practitioners with the medical and quasi-medical tasks which others were not prepared to do. Further, U.K. practitioners have been given some difficult social control tasks, such as the provision of sickness certificates for exemption from employment. It has been claimed that the unattractiveness of general practice puts it in danger of becoming the “dustbin of meditine”-recruiting those doctors who do not make it into better parts of medicine. On the other hand, the optimistic have emphasised the essence of general practice as family, personal and community medicine, giving the practitioner opportunity for patient contact unrivalled in other branches of medical practice [l, 41. This view, to be discussed more fully below, has prevailed among prominent general practitioners. The debate is also found in other affluent countries, and is evidenced by the relative unpopularity of general practice. For the poor in the U.S. an adequate
486
GERRYV. STIMSON
primary health care service remains “an illusory dream”, and in the U.S. and Canada there has been a decline in general practice in favour of specialist medicine [S, 61. In the U.S.S.R. there is a high turnover of those general physicians (terupeuti) who are supposed to be personal physicians with a continuing responsibility for patients, and articles in medical journals complain that they have become simply “trained dispatchers” [7, S]. In Israel doctors are attracted to specialist medicine and there is a shortage of general practitioners [9]. In France, specialist medicine is becoming increasingly popular at the expense of general medicine [lo]. If we look at the problem from a sociological perspective we might conclude that the debate flows from a concern about the status of the general practitioner, and, the feeling that general practice has lower status than other branches of medicine. The “concerned” want to raise the status of general practice (and not to lower the status of specialist practice-which is an unlikely alternative solution). In Western medicine those branches of medicine with high status have a monopoly over some area of knowledge, some medical task, or method of approach-they have a specialty. The problem for general practice is that it is general medicine, and the paradox is to make this occupation into a specialty when its main claim is its lack of specialisation [ll]. Concern about general practice in the U.K. led to the “new movement” or “renaissance” of general practice, a movement which started in the U.K. in the 1950s [12,13]. This movement has promoted general practice by undergraduate and postgraduate medical education and by concern for the quality of care. A College of General Practitioners was founded in 1952 and granted a Royal Charter in 1972. The College publishes a journal of general practice, monographs and books, and has research units. There are now vocational training schemes for practitioners, postgraduate medical centres for continuing education, and more recently departments of general practice with professorial chairs have been established in medical schools. An indication of the success of the movement is that the Royal College of General Practitioners membership examination is now needed for senior academic posts in general practice [13]. A great deal has been achieved in setting the framework for improving general practice, and for making it more attractive to newly qualified doctors, but it would be optimistic to say that the role uncertainty has been resolved, indeed to the credit of the new movement the questioning continues. It is useful to look at how the role of the general practitioner has been described in these discussions. DEFINING THE THEMES OF GENERAL PRACTICE
I am taking my evidence from those doctors who see it as their task to write and talk about general practice, mainly a number of people who have been prominent in the Royal College of General Practitioners. We do not know how representative College members are of the total population of general practitioners. About 8000 of the 23,000 general practitioners in the U.K. belong to the College and only a handful of these have been active and vocal in discussing the
content of the new general practice. I should make it clear that I am discussing the views of this vocal group concerning what general practice is or should be like. A clue to how general practice is viewed is found in the RCGP mott+Cum Scientia Caritas-which loosely translates as “knowledge with caring”. The two themes which are emphasised are the science of medicine coupled with a social orientation [14]. The general practitioner is a “personal, family and community doctor”, whose “field of work will be the illnesses and social problems that might be expected to occur in a population of about 2500 persons” [14] and whose “diagnoses will be composed in physical, psychological and social terms” [l]. We are told that he is a manipulator of the patient’s personal, social and medical environments whether in the family, at work or elsewhere-in other words he engages in physical, psychological and “social treatment” [ 11. In this definition of general practice the general practitioner is expected to view illness in its wider community context [ 141. The solution to the problem of making general medicine a specialty when it has no special medical knowledge or task is to emphasise a unique social orientation. It is not only what is practised which is important but how it is practised and where it is practised-the style and context is as important as the content. Discussion of this social orientation pervades the literature. The Futur‘e General Prnctitioner [l] was written by six general practitioners and whilst not intended as such, has been taken as reflecting the policy of the RCGP [16]. It is mostly about the social and organizational aspects of practice and has little medical content. One general practitioner reader has commented that “it is difficult to believe sometimes that the book is about medicine at all” [17]. Surveys of practitioners reinforce this impression that the opportunity for patient and family contact are important in definitions of the role [14, 181. The attributes of the general practitioner are said to include those “human qualities” which the practitioner can find described in accounts of the founding fathers of general practice; as portrayed in commemorative lectures these gentlemen had the clinical rigour and insight we attribute to most medical workers, but what marks them out from other doctors is their caring relationship and informed concern for their patients [13,15]. Thus the contemporary statement of the role posits a significant social element alongside the medical. The aspects of work stressed in the renaissance of general practice are the indeterminate, those that defy precise formulation and which are learnt by experience on the job rather than the technical or codified medical knowledge and skills which are shared with the rest of medicine [19]. In the past personal relationships and the “whole man” approach could be described as “compassion” and “intuition”. But the problem for those who wish to improve the status of general practice is that these unique indeterminate features eventually have to be taught-the social orientation has to be turned into subjects for the curriculum. Consequently, General Practice Departments in medical schools now teach courses on “the social aspects of
Social care and the role of the general practitioner medicine” or “medicine in the community” [20] and they draw on disciplines which are broadly concerned with human behaviour--such as psychology, psychotherapy, social science, and social work. A prominent general practitioner is able to claim that the academic status of general practice will be raised if it has its own area of research in a field unique to general practice, and for him this field is “human behaviour” [21].
THE NATURE
OF THE SOCIAL
GENERAL
ELEMENT
IN
PRACTICE
The problem with such a sweeping view of the social element in general practice is that it can be taken to mean different things. It is variously taken to mean that the general practitioner should have an understanding of the social situation of patients, a social work role, a social therapy role, a responsibility for the effects of social problems-r simply that he is a nice compassionate man with a good bedside manner. In the U.K. the content of primary health care is essentially unplanned, and individual doctors are to a large extent able to set and define their area of work. If they want to do psychotherapy and social work in addition to providing medical care there is nothing to stop them doing so. The nearest thing to a job specification is found in the terms of service of their contract with the local Family Practitioner Committee: primarily the general practitioner’s job is to “render to his patients all necessary and appropriate personal medical services” [22]. How doctors interpret this is up to them. It seems to me that we have to sort out what doctors mean when they refer to this social element in their work, and from the writings of general practitioners we can isolate several themes which seem to be included under this heading: (1) The importance of social relationships in general practice-the area of the doctor-patient relationship. The social element here ranges from a feeling that doctors should be compassionate and have a “caring concern” for their patients, to an awareness of the complexities of communication between doctors and patients. Those who emphasise the mystique and magic of medicine argue that the doctor’s manner affects the amount of faith the patient has in the doctor’s actions, and thus the success of the treatment. The “rationalists” argue that attention to communication and social skills is important so that patients’ expectations will be better, understood and treatment made more effective. (2) Awareness of social factors in disease and in illness behaviour. Firstly there is the awareness of the influence of occupational and life-style factors on the course of a disease, and secondly the awareness that social factors influence patient behaviour such as the willingness to consult and the willingness to use treatment. The idea here is that treatment is made more effective if the doctor is aware of and takes into consideration the social context of the patient. It is argued that hospital doctors often ignore the social setting because the patient is captive, but that because the general practitioner sees patients in the com-
481
munity the context of their lives and the social consequences of medical decisions cannot be ignored. (3) Awareness of the social causes of diseasethat occupation and living conditions can affect the certain diseases-obvious of suffering chances examples here are occupational disease and the link between life style and heart disease. The view is that “the general practitioner cannot be neutral towards the factors in our lives that influence health and disease” [l]. (4) Awareness that many illness conditions have serious social sequelae and that the doctor is therefore responsible for caring for the social consequences of diseases or of ensuring that they are cared for. The idea is that it is insufficient for the doctor to provide medical care if he knows that the person’s life will be impaired by the illness-therefore he has to ensure that social as well as medical care is provided. Certainly the disease pattern in industrial countries encourages this view. The major health problems are no longer the infections and the high mortality of children under five years (which are the major problems in the Third World) but chronic health problems such as the degenerative diseases (cancers and heart diseases accounting for half of all deaths) mental illness, mental and physical handicaps, and care of the elderly [23]. (5) Awareness that many problems brought to the doctor are not diseases but social welfare problems. The idea is that the doctor comes across these problems because his work takes him into people’s lives and because, in the U.K. at least, he is one of the more accessible professionals. Because he comes across the problems some suggest that he has a clear duty to provide social care or see that it is provided. For instance, a Royal College of General Practitioners’ publication draws attention to the responsibility of the doctor to care for “social and quasi-medical problems” and lists the “social pathology” which a British general practitioner might face in a typical 2500 person practice: 350 people over age 65; 150 receiving welfare benefits; 60 one parent families with children under 15; 70 with severe physical handicaps; 50 male homosexuals; 30 alcoholics; 25 deaf and 7 registered blind; 10 severely mentally handicapped; 5-10 problem families; 5-7 juvenile delinquents; 3 suicide attempts each year and one successful suicide in four years; one road traffic fatality in four years. In some communities, e.g. those in declining industrial areas in the U.K., poverty and handicap may be considerably greater [24]. (6) Awareness that the doctor has a responsibility to care for individuals with emotional problems-that the doctor has a socio- or psycho-therapeutic role. The idea here is that a significant part of the doctor’s work load is with illness which has a significant psychogenic component, or which is predominantly psychological in origin. In the U.K. evidence for this is found in prescription data: one in five prescriptions dispensed under the National Health Service is for a psychotropic drug-tranquillisers, antidepressants, sedatives and hypnotics. Further evidence is found in the interest of many general practitioners in psychotherapeutic counselling-this has been an important theme within the renaissance of general practice in the U.K. [25,26].
488
GERRY V. ”>TIMSON
SOCIAL AWARENESS
AND
GENERAL
PRACTICE
I have suggested six themes which can be distinguished in the current trend for U.K. general practitioners to point to a significant social element in their work. The first three concern a social awareness on the part of the doctor. There is, I think, little dispute about the importance of an awareness of social relationships and an awareness of social factors in disease and illness behauiour-both seem necessary for efficient diagnosis, prognosis and treatment, from patients’ and the doctors’ points of view. Such awareness does not challenge the basic medical care role. It is here that social science can make a clear contribution to medical practice. The implications of an awareness of the social causes qf disease are more difficult for general practice for they do not neatly fit the general practice approach of individual care for diseased persons. The ideal approach is prevention, but in the West general practitioners have not developed a preventive medical role, except in a minor way with individual health education. We find repeated in the general practice literature that the doctor must diagnose and treat in physical, psychological and social terms, but just how, in practice, is he to engage in “social therapy”? Cl]. Some causes may be open to manipulation (advise the person to stop smoking, change diet) others less so (pollution, occupational disease). How does the doctor change social conditions? Here is a clear limitation in encouraging a social orientation-it points to the problems but does not show how to solve them. Identifying the social causes of disease could encourage doctors to engage in political and social action to improve the health of the community: such action on the part of doctors is rare in the West. It is difficult to see how the knowledge of social causes can be translated into action when the general practitioner’s basic work object is the individual, and his work unit is the one-to-one consultation. At the least, the awareness of social causes of disease may affect the doctor’s view of the patient; the view might be one of compassion if the patient is seen as victim of social conditions: on the other hand it may resign the doctor to feel that “nothing can be done”. SOCIAL CARE AND GkNERAL PRACTICE
The remaining three themes can be seen as falling within social care in that they concern material emotional welfare problems-these are a responsibility for caring for the social consequences of diseases, for caring for social welfare problems, and for providing socio-therapeutic care. I think that certain important questions have to be considered before we assume that it is possible for general practitioners to be involved in social care. The first question concerns a possible conflict between social and medical care. We have in fact little indication of the effectiveness of general practice in improving health. It may be that it has always had more of a palliative effect, rather than being a positive force in improving health, but if we assume that general practice continues to be concerned with the cure and palliation of sick individuals, we are faced with
the problem of getting the medical care where it is needed, and of ensuring that practitioners have adequate technical competence. This major task of the general practitioner-providing medical care-has not yet been adequately provided in most industrial countries. I have already referred to the shortage of general practitioners in many countries. In the U.K. there are marked regional and social class disparities in the provision of general practice and the quality of care [27-301. In the Third World it seeems naive to talk about social care when medical care is not available for much of the population. In developed countries the evidence abounds of the low quality of care, particularly for the financially poor. In the U.K. examination of prescription data reveals potentially dangerous therapy, and there is evidence of lack of knowledge of pharmacology and therapeutics-in particular of adverse drug reactions and interactions-by general practitioners [31]. Recent discussion among general practitioners indicates an awareness of the need to improve and audit the quality of care [32,33], but given the questions about the provision of and quality of medical care, it would seem that an involvement in social care could be to the detriment of providing what is expected from genera1 practitioners-technically competent medical care. Secondly there is the question of the general practitioner uis-&vis other care workers. The doctor is not the only professional who is available for social care. In this century the number of professionals has increased, and this expansion has been highest among the personal, as opposed to the impersonal, service professions. In England and Wales the number of such workers (clergy, physitians and dentists, nurses, teachers, social workers) per thousand of the population has risen from 27 in 1901 to 43 in 1961, despite the absolute and relative decline of the clergy [Sl]. There are now more potential helpers than ever before. If it is thought that someone should provide social care, should doctors be the ones to take this on or is this better done by other workers? One solution to the problem of numerous types of care workers and to the problem of a conflict between medical and social care is to propose a primary health care team comprised of doctors, social workers, health visitors and practice nurses [4]. In this model the general practitioner refers people with social care problems to the social worker. Thus the doctor is freed to concentrate on medical care, whilst ensuring that social care is also provided. The.questions are now ones of referral to and liaison with these other workers. Problems have been encountered where this model has been adopted and the difficulties seem explicable by the concept of professional dominance [34]. Some doctors see themselves as the obvious leaders of the primary health care team. Practitioners tend to define social work as ancilliary to medicine, rather than operating on an equal basis with medicine [35, 361. The questions of the conflict between social and medical care and of liaison between doctors and other care workers assume that care should be provided by some kind of professional worker. However, against the 20th century trend of professionalising
. Social care and the role of the general practitioner
been counter movements indicating the “revolt of the client” and which make “deprofessionalisation an alternate hypothesis for the future” [37,38]. Counter movements may affect clients’ relationships with professionals, may reduce professionals’ monopoly of knowledge, or through self-help provide alternative solutions to problems [39-42]. This brings us to the question of the political and philosophical view which guides our approach to social problems: do we want social care and do we want it to be provided by professionals? care have
SOCIAL
CARE AND THE POLITICS
OF CARING
The questions of social care therefore go much deeper than simply the practical questions of seeing that it is done. To suggest a social care role leads to an examination of a more basic question conceming our socio-political approach to social problems. It cannot be assumed that in the West there is consensus about how we approach social problems. There has been a longstanding conflict between those who see the care role as concentrating on the “financial, economic and social realities of human problems” [43] and those who prefer the “counselling ideology” [44] which stresses the need to help clients gain insight into their problems using the therapeutic aspects of the professional/client encounter. Both these approaches aim to help individuals by casework of one sort or another (yet controlled trials of casework give little indication of its success [45]). The personalised view of social problems, as typified by the counselling approach, has led to quite bizzare results. For example, the problem of low income could be “translated into the problem of the housewife who could not cope with household management, which in turn might be reduced to a ‘personality disorder’ which manifested itself in the inability to resist a few packets of cigarettes, a problem which itself could be traced back to ‘weak superego controls”’ [46]. Similar criticisms can be levelled at the use of psychodynamic techniques in general practice. It can be argued that as a framework for understanding patient behaviour the psychodynamic approach often inaccurately psychologises behaviour when there are plausible alternative explanations; and that it inappropriately places the locus and solution of the problem in the person, rather than in social, economic and political conditions. This is a problem of the way in which social problems are perceived by those who would do something about them. There are those who argue that many social problems are becoming inappropriately medicalised, and that there should be limits to the areas in which medical people can operate and in which a medical model is appropriate. For instance, Illich [47] has written about the dependence created by the medicalisation of many aspects of our lives, and others have written about the way in which many common life events and situations are depicted as putting people in a position where a psychotropic drug is seen as appropriate [48,49]. Medical metaphors now abound for describing aspects of our society [SO]. The question which has to be examined is the usefulness of a medical or individualised approach to social problems.
489
There has recently been a revolt by social workers against this personal&d view of social problems. Social work has begun to rediscover political problems such as housing, rents, low wages, racism and educational inequalities. The activities of radical social workers have recently tended toward community action, work with claimant unions, squatting and other social action. Where does this leave the doctor? The doctor has the same problem here as with trying to deal with the social causes of disease. Under the current structure of medical care the doctor’s work is organiscd around helping individuals, not around social or political action. T’he consequence is more likely to be that the social problems are individualised to fit the current paradigms of care, rather than the paradigms of care being changed to fit the problems. It is very easy to suggest the idea of social care and social therapy as part of the role of the general practitioner. Those general practitioners who have attempted to extend the theoretical boundaries of their work by claiming an involvement in social care do not appear to have worked through the practical and socio-political implications of this claim. In a time when many are seeking to limit the activities of medical and other professional workers, adding a new feature to the role of the general practitioner cannot be discussed without considering the more fundamental question of the way we wish to tackle our social and medical problems.
Acknowledgements-Many thanks to David Hall, Margaret Reid, Barbara Webb and Norma Raynes who commented on an earlier version of this paper.
REFERENCES
1. Royal College of General Practitioners. The Future General Practitioner. London, 1972. 2. McKeown T. Medicine in Modern Society. Allen & Unwin, London, 1965. 3. Stevens R. Medical Practice in Modern England. New Haven, 1966. 4. Present state and future needs of general practice. J.R.C.G.P. Report from General Practice No. i6, 1973. 5. Wolfe S. Primary health care for the Door in the United States and Canada. Int. J. Hlth Sekes 2, 217, 1972. 6. Wolfe S. and Badgley R. F. The Family Doctor. Mac-
millan, Toronto, 1973. 7. Ryan T. M. Primary medical care in the Soviet Union. Int. J. Hlth Services 2, 243, 1972. 8. Hyde G. The Soviet Health Service. Lawrence & Wish-
art, London, 1974. 9. Medalie J. H. The present and future of primary medical care in Israel. Int. J. Hlth Services 2, 285, 1972. 10. Wright A. F. Primary medical care .in France. J.R.C.G.P. 25, 158, 664. 1975. 11. JetTreys M. The doctor’s dilemma-a sociological viewpoint. In A Sociology of Medical Practice (Edited by Cox C. and Mead A.). Collier-Macmillan, London, 1975. 12. Hunt J. The renaissance of general practice. J.R.C.G:P. 8 22 (Suppl. 4), 1972. 13. Irvine D. 1984: the quiet revolution?. J.R.C.G.P. 25, 155, 399, 1975.
490
GERRYV. STIMSON
14. Mechanic D. Practice orientations among general practitioners in England and Wales. In A Sociology qf Medical Practice (Edited by Cox C. and Mead A.). Collier-Macmillan, London, 1975. 15. Knox J. D. E. Willian Pickles Lecture-“Peter Piper’s Peck”. J.R.C.G.P. 26, 476, 1976. 16. Norell J. S. J.R.C.G.P. 25, 155, 439, 1975. 17. Meyrick R. L. What nobody is sure about. J.R.C.G.P. 24, 144, 505, 1974. 18. Cartwright A. Doctors and their Patients. Routledge & Kegan Paul, London, 1969. 19. Jamous M. and Peloille B. Professions or self-perpetuating systems? Changes in the French university-hospital system. In Professions and Professionalisation (Edited by Jackson J. A.). Cambridge University Press, 1970. 20. Reid M. The specialisation of generalists-General Practitioners in university departments. Paper presented at the conference on Medical Ideologies, Bath, England, 1974. 21. Hodgkin G. K. H. 16th James McKenzie Lecture. R.C.G.P. Ann. Rep., 1970.
22. National Health Service, General Medical and Pharmaceutical Regulations. H.M.S.O. 1972. 23. Powles J. On the limitations of modem medicine. Sci. Med. & Man 1, 1973. 24. Hart J. T. The health of coal-mining communities. J.R.C.G.P.
21, 517, 1971.
25. Balint M. The Doctor, his Patient and the Illness. Pitman Medical, London, 1964. 26. Balint E. Six Minutesfor the Patient. Tavistock, London, 1974. 27. Townsend P. Inequality and the Health Service. Lancet, 1179, 1974. 28. Hart J. T. The inverse care law. Lancet i, 405, 1971. 29. Butler J. R., Bevan J. M. and Taylor R. C. Family Doctors and Public Policy. London,. 1973. 30. Consumer’s Association. Which? London, 232, August 1975. 31. Parish P. A., Stimson G. V., Mapes R. E. A. and Cleary J. Prescribing in general practice. J.R.C.G.P. 26 (Suppl. l), 1976. 32. Rose J. C. Recertification and peer review in the United States. J.R.C.G.P. 24, 595, 1974.
33. Buck C., Fry J. and Irvine D. H. A framework for good primary medical care-the measurement and achievement of quality. J.R.C.G.P. 24, 599, 1974. 34. Freidson E. Professional Dominance: the Social Structure of Medical Care. Aldine, Chicago, 1970. 35. Ratoff L., Rose A. and Smith C. Social workers and general practitioners-some problems of working together. J.R.C.G.P. 24, 750, 1975. 36. Goldberg E. M. and Neil1 J. E. Social Work in General Practice. Allen & Unwin, London, 1972. 31. Haug M. R. and Sussman M. B. Professional autonomy and the revolt of the client. Social Problems 17, 153, 1969.
38. Haug M. R. Deprofessionalisation: an alternate hypothesis for the future. Social. Rev. (Monogr. 20), 195, 1973. 39. Caplan G. and Killilea M. (Eds.). Support Systems and Mutual Help: Multidisciplinary Explorations. Grune & Stratton, New York, 1976. 40. Katz A. H. and Bender E. I. (Eds.). The Strength in Us: Self-Help Groups in the Modern World. Franklin Watts, New York, 1976. 41. Newell K. N. (Ed.). Health by the People. W.H.O., Geneva, 1975. 42. Robinson D. and Henry S. Self-Help and Health. Martin Robertson, London, 1977. 43. Hawthorn G. Review. New Society 973, 1970. 44. Halmos P. The Faith of the Counsellors. Constable, London, 1965. 45. Fischer J. Is casework effective? A review. Social Work 18 (No. I), 1973. and 46. Pearson G. Sociology and social work-knowing doing. Med. Social. Newsletter 2 (No. 4). 1975. 47. Illich I. Medical Nemesis: the Expropriation of Health. Caldar & Boyars, London, 1975. 48. Lennard H., Epstein L. J., Bernstein A. and Ransom D. C. Mystijcation and Drug Misuse. Jossey-Bass, San Francisco, 1971. 49. Stimson G. V. The message of psychotropic drug ads. J. Communication 25, 153, 1975.
50. Zola I. K. In the name of health and illness: on some socio-political consequences of medical influence. Sot. Sci. & Med. 9, 83, 1975. 51. Halmos P. The Personal Service Society. Constable,
London. 1969.
