THIRTY-NINE years ago tomorrow morning I arrived at the clinic in Balfron ready to start as a freshly-minted general practitioner in the very practice I had spotted as a medical student as my ideal working environment and, on Monday, I completed my last surgery and enjoyed an emotional farewell to both patients and colleagues.
I am, therefore, in reflective mode. Glad that over four decades the scale and scope of general practice has increased exponentially, glad for the opportunity to be part of that development, equivocal over moving into a new phase of my life, but also sad over losing patient contact and over some of the changes I have seen during that time. In 1974 general practice was a cottage industry. Since 1948 Balfron had been served by Dr Alfred Roy, MBE, who was to be my new GP partner; his wife was the receptionist, his home the surgery. His medical records were rudimentary, telephones a despised necessity and he was constantly on call, 24/7.
I am now leaving a practice with enlarged modern premises, computers, mobile telephones, an expanded team of doctors and nurses, out-of-hours cover and a workload that now encompasses much that was the remit of hospitals 40 years ago.
Part of my sadness arises from what I see as a progressive erosion of professionalism as the driving force behind general practice – micro-management and constant regulatory inspection replacing our self-driven ambitions to provide the very best service possible. In my case that ambition stemmed from youthful enthusiasm to be the very best – and Dr Roy was driven by his horrific experiences over four years as a doctor prisoner of war on the Burma Railway.
In my view there is a danger in prescribing solutions to an NHS under pressure that attempt to promise a cure without addressing the underlying problems.
Over the course of my 40-year career the NHS has changed from a service that was largely administered into one that has become the subject of managerialism and political short-term expediency in order to address the triple whammy it now faces. There will be a demographic explosion of elderly Scottish patients (of which I will eventually be one), the costs of new drugs have risen well over the level of general inflation and advancing anaesthesia and technology mean that more and more can be made available to that ageing population.
In Scotland we need to sit down as a community and decide what can be afforded from a reducing tax base and grapple with a necessary reconfiguration of services that may need to concentrate scarce resources in fewer centres of excellence.
That means less reliance on managers and regulators and more trust given to the clinicians that deliver patient care. It also needs a much more careful examination by the whole community of the social determinants of health inequalities.
So, as I canter into the gloaming of retirement I hope that the running of the NHS in Scotland can be better balanced between the professionals and the politicians, that management is developed to support good clinical care rather than to meet targets and that whilst regulation will always be necessary, it is configured to help us all learn from mistakes rather than to impart blame.
My excellent partners will carry on without me but as I wander around Balfron in my dotage my final hope is that whilst I will soon be forgotten, the principles of care I learnt from Dr Roy, and have attempted to follow over so many decades, are what will be remembered.
Dr Brian Keighley was a GP in Balfron for 39 years.
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