Public health initiatives are forcing doctors to take on a wider social role as arbiters about the ways people live their lives, writes Dr Michael Fitzpatrick
Whether it is commissioning social care services, preventing obesity or deterring teenage pregnancy, GPs are increasingly expected to take on the roles and responsibilities of social workers. Social workers may doubt whether doctors have the skills to take on these tasks. Doctors may ask whether this expanded role is likely to benefit their patients.
The drive to extend the role of the GP proceeds in parallel with the inflation of health. In the past, doctors worked in a society that made a clear distinction between health and illness. For society, improving standards of health were regarded as the benefits of wider social progress for the individual, health was the precondition for the achievement of wider social or spiritual goals. Illness was a transient phase requiring the treatment of disease and the restoration of the capacity to participate actively in society.
The biomedical model of medical practice assumed a doctor skilled in diagnosis and treatment according to the principles of scientific medicine and a patient who was a self-determining individual whose personal conduct was their own responsibility.
The new concept of doctor reflects a fundamental shift in society. Health has become both the ultimate goal of individual existence (“a state of complete physical, mental and social wellbeing” according to the World Health Organisation) and an unattainable ideal – as all those who go to the gym can testify. The paradoxical effects of the widespread dissemination of the gospel of health promotion and the enhanced awareness of disease are that everybody now feels ill. This is why it is not surprising that the numbers on invalidity and other sickness benefits have soared over the past decade.
Contrary to the rhetoric of empowerment, the doctor as social worker and health promoter assumes a passive and dependent patient. Health promotion initiatives target those hapless individuals such as the obese and smokers who appear incapable of adopting healthy lifestyles in terms of diet, exercise and other socially-approved behaviours.
At least one-third of the population are deemed powerless in the face of chemical dependencies and fast food advertising and judged incapable of defining their own interests. Hence they require support to make healthy choices through healthy living centres and Sure Start programmes and similar initiatives.
The public esteem enjoyed by professionals in primary health care gives them a powerful appeal to politicians and state bureaucrats seeking to find new agents to implement their projects of social and moral engineering. But, if GPs take on a wider role in relation to child protection and domestic violence, family support and parenting, they will be drawn into a more intrusive and authoritarian approach to their patients.
Whether such initiatives will benefit patients is doubtful, they will certainly prove damaging to doctor-patient relationships. Doctors and nurses will soon find that their popularity and prestige are rapidly dissipated if they assume the mantle of social work. It is ironic that, after seeking to take over the management of social as well as medical problems, many GPs complain of high levels of stress (and a growing inclination among their patients to assault them).
Michael Fitzpatrick is a GP in the London Borough of Hackney
If you have a comment for Dr Fitzpatrick, e-mail Graham Hopkins
World Health Organisation
This article appeared in the 17 May issue under the headline “Doctors should stick to what they know best: healing the ill”