A Primary Care Christmas Carol: Stave 4

By Dr Pete Aird, written for Resilient GP

Stave Four – in which the future appears far from bright.

Alone again, Scrooge, out of force of habit, checked his phone for notifications. No red circle had appeared in the corner of the Facebook icon to indicate that someone, somewhere cared about what was on his mind. This was not unexpected as it had been a long time since anyone had ‘liked’ him – still longer since he’d been loved. It was a surprise to him, therefore, when the phone vibrated alerting him to the arrival of a text message.

‘This is to remind you that your appointment with the Ghost of General Practice Yet To Come is scheduled for now. Please access your Babylon Wealth account and prepare to speak to somebody with no soul’

Scrooge noticed a new app had appeared on his phone’s home screen. It glowed menacingly, demanding to be tapped. Scrooge couldn’t help thinking that ‘Babylon’ was a curious name for a company to chose to call itself, recalling, as he did from his days in Sunday School, how Babylon represented all that was evil, ‘the mother of earth’s abominations’ and a ‘dwelling place for demons’. Perhaps, he concluded, it was strangely fitting after all.

Against his better judgement, Scrooge opened the application and was greeted by a disclaimer making it clear that any advice given was only valid for minor, self limiting medical conditions and any harm that resulted from Babylon clinicians failing to appreciate a more serious underlying problem was not their responsibility. Those experiencing more complex health concerns were directed to approach less forward thinking health providers. Scrooge was requested to indicate his acceptance of these conditions and, having complied, the screen gave out a burst of light and there then appeared what looked for all the world to be a businessman dressed in an executive suit.

‘Welcome to Babylon Wealth,’ the man announced. ‘where your health needs are our business opportunity’. He smiled a self-satisfied smile, which Scrooge did not find reassuring.

‘Are you the Spirit of General Practice Yet To Come?’ Scrooge enquired.

The spirit’s smile wavered a little. ‘Is that what The Ghost of Christmas Present called me? She is so yesterday. I’ve been rebranded and, from now on, I am to be known simply as ‘The Future’. Exciting isn’t it? Now, how can I profit from you?’

‘I believe you’re supposed to show me my future’

‘Yes of course, but I don’t have time to talk to you about that in any depth. So, in the interests of efficiency, I’d like to request that you utilise this corporate video feed. If you’ve any further questions you’ll be required to make a further appointment. You will receive an invoice for the services I have provided today and your account will be automatically debited the requisite amount. Thank you for using Babylon Wealth. Have a nice day.’

Lost for words, Scrooge tapped the link that had appeared on his phone and continued to gaze at the screen at what seemed to be, if such a thing was possible, a broadcast from the future. It began with an aerial view of a huge featureless building over which an audio commentary played. “Welcome to the world’s first fast health outlet. – Where health is cheap and time is short”. A notice board at the entrance of the building came into focus revealing that ‘The National Wellbeing Centre’ was open 24 hours a day, 365 days of the year. Two enormous panels straddled the entrance bearing images of the Secretary of State for Health and the President of the National Pharmaceutical Board. They were pictured smiling benignly down upon the multitude who were milling around a large reception area.

As the camera roamed around, the audio commentary explained how no appointment was necessary but that, on arrival, patients were required to utilise electronic panels positioned in the foyer to answer a series of questions by way of ‘Yes’ or ‘No’ answers only. As a result of the responses that were given, each individual would then be assigned to a wellbeing advisor. If, and only if, it was deemed necessary that face to face contact should ensue, they would then wait outside one of the 666 consulting rooms housed within the complex until their allocated interaction was scheduled. Patients were advised that only objective quantifiable, symptoms could be dealt with and that treatment options would be determined solely on the basis of the medico-economic considerations pertinent to each individual case. Reassurances were offered that a number of payment options were available.

Around the foyer, electronic panels displayed information for consumers alongside a number of company disclaimers:

“Due to many drugs now being of limited availability, if medication is advised, the sourcing of that medication is entirely the responsibility of the customer.”

“Please be assured that we respect your anonymity and consider it of paramount importance to maintain the highest levels of confidentiality. In order to guarantee this, no wellbeing advisor will consult with the same client on more than one occasion and no personal communication is permitted between clinicians. A mask can be worn over the face if desired.”

“The National Wellbeing Centre cannot accept responsibility”

“Strict quality control measures are in place to guarantee the optimal outcome of each clinical interaction. Each consultation is electronically monitored and any deviation from company protocols will result in disciplinary action being taken against the clinician concerned.”

The announcements seemed endless, each, it appeared to Scrooge, alienating the individual in need still further from the connection they craved with somebody who just might care enough to show a little concern. Patients were managed without any warmth or compassion – processed by a system that existed solely for the benefit the state that had created it.

As Scrooge continued to watch, the announcements kept flashing across the screens, hypnotising those whose eyes were drawn lifelessly to their incessant messages. Dehumanised, everyone became the same – And that same was nothing more than a reservoir of data.

“Please be aware that displays of emotion are not encouraged in consultations and tissues are therefore not provided in the consultation rooms.”

“Customers will not be permitted to leave the centre until the requisite post interaction forms are completed. Not only does the filling of these forms provide the essential feedback necessary to identify suboptimal clinician performance, the personal data requested allows us to identify those agencies from whom we will profit most by our facilitating their communication with you.”

“Everybody here at the National Welfare Centre wishes you, and your purchases, a very merry Consumertide.”

And then, finally, before the cycle of messages started once more, one last announcement:

“Turmeric is available from the kiosk in the foyer”

The camera returned to a view of the outside of the building and Scrooge caught a glimpse of a small panel attached to the wall next to the main entrance. He paused the video and expanded the image to take a closer look. He could just make out the words that were inscribed on the ill maintained copper plate.

‘This facility was erected on the derelict site of what was once known as a GP medical centre. Drs J. Marley and E. Scrooge worked here for many years providing a form of medical provision which today is only of historical interest. The medical centre operated with the quaint intent to provide medical care that was responsive to patient needs. Dr Marley’s untimely death left Dr Scrooge struggling as he found it impossible to replace his former partner. He continued for a time supported by a series of doctors in training, but, after a personal tragedy struck the medical centre, it was no longer considered fit to remain a training practice. Dr Scrooge continued alone for a brief time, but the pressure of working in such an inefficient manner soon proved too much and he himself succumbed to a stress related illness. Happily, his demise proved the catalyst for the development of the progressive wellbeing centre that we benefit from today.’

Scrooge could not believe what he had witnessed. It struck him that there had at no point been any mention of there being any doctors present in the running of the well-being centre. It was almost as if there was now nobody providing a professional opinion, nobody making a judgement, nobody applying a bit of wisdom and that clinical algorithms were being used to make each and every decision. Were there, he wondered, any doctors still in existence at all? Perhaps, in the future, nobody wanted to be one. The questions kept coming. Was this really the future of the health service that once, years previously, he had been so proud to be a part? What about Cratchit? What did the ‘personal tragedy’ refer to? And what of his own future? Could any of this be changed?

Scrooge tapped frantically on his phone seeking a further appointment with the Ghost of General Practice Yet To Come. Fortunately, for all the faults of Babylon Wealth, having made the appropriate additional payment, an appointment was easy to come by, and soon, the business-like figure of the spectre, who had been so brusque with him earlier, appeared on the screen once more.

‘Good Spirit’ Scrooge implored, ‘Assure me that I may yet change these shadows you have shown me by an altered life’

The spirit laughed. ‘It’ll take more than one doctor changing to alter the future of the health service. That’s the trouble with you people. Too often you think it’s all down to you’. The spirit made a poor attempt at a Clint Eastwood impersonation, ‘A doctor’s got to know his limitations.’

‘And besides, what’s your problem? What we’re doing merely reflects the ideology of the nation – that everything comes down to money. We measure and record data because data sells. What we understand at Babylon Wealth is that people are commodities. For example, we record an elevated cholesterol solely because we know there is somebody out there who is selling a product to reduce lipid levels and is willing to pay for the information we collect. We don’t care about people, only the wealth that they generate for us.’

‘But it’s not all about money’, Scrooge insisted.

‘Isn’t it?’ countered the spirit. ‘It seems to me that everyone has a price Dr Scrooge. Are you really the exception?’

‘Well maybe I do have a price, but if I have, it’s at least partly because, in recent years, with so much of the joy having been sucked out of the job, the only way that I’ve been in any way rewarded for my efforts is financially. There’s no appreciation from those who call the tune, no recognition of how difficult the job has become and nothing but constant demands that I must do better. Take appraisal – if a requirement to show year on year improvement doesn’t amount to saying that we’re not good enough as we are, I don’t know what is. Something has to change’.

‘Well good luck to you with that, Scrooge. I concede that, as a profession, challenging the status quo rather than capitulating to the spirit of the age whilst all the while laudably endeavouring to deliver its impossible demands would be a step in the right direction. But I can’t see it ever happening – you’re all too busy just trying to keep your head above water to organise a concerted campaign for change.’

‘But let me try, spirit. Let us try. I have learned my lesson well this night. Perhaps things need not turn out the way you have shown me”.

And with that, Scrooge deleted the Babylon Wealth app from his phone, never to be installed again. He got back into bed. He’d seen and heard quite enough.