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This collection of stories from two practising GPs describes the
reality of working within a failing and highly bureaucratic system,
where there is a balancing act: regulation versus relationships;
autonomy versus standard practice; algorithm versus individual
attention. We aren’t suggesting a return to a ‘better’ time.
We don’t object to being bureaucrats, embedded within and
accountable to the systems we are in. But we do want to consider
how and with what the gap left by the old-fashioned GP has been
filled. We use stories based on our experience to describe the
effect of different facets of bureaucracy on our ability to
maintain a nuanced, individualised approach to each patient and
encounter; and to question the prominence and effect of protocol.
We are interested in the way professional relationships are
influenced by protocol: between and within organisations; and most
importantly with patients/clients/service users.. We are accustomed
nowadays to automated telephone lines, chatbots, website FAQs- the
frustration of being unable to connect with another human being who
will listen to our particular question and give us something other
than a generic answer. The same issues that are facing society at
large have changed the way in which we work as GPs and the care we
give. Introduction – an analysis of the different aspects
of bureaucracy and regulation which influence decision making in
general practice. Poppets and Parcels – healthcare systems
are not designed to meet the needs of everyone. This chapter is
about a fundamental but undocumented component of general practice
- the ‘holding work’ required for patients whose problems
can’t be solved in the usual ways, the ones for whom there
isn’t a simple answer. Waiting to Connect – In this
chapter, the stories are about flow – the flow of patients
through a turbulent, over-stretched system in which access and
response are often controlled by algorithm. Taking
Liberties -this chapter examines the role of GPs as agents of
social control in the restriction of civil liberties - in the
context of the mental health act and of safeguarding. Guidelines,
Tramlines, Mindlines -how guidelines are developed and the
difficulties of applying them in the messy world of general
practice. The Elephant in the Room -the stories in this
chapter are about biography and biology; about medical
categorisation and its effects and shortcomings. The Bureaucracy of
Death - In the realm of death, protocol -which has become the
bedrock of clinical practice- is less useful, because the right
decisions and the right timing are so individual and nuanced. These
stories are about death and bureaucracy. Conclusion and Afterword A
Labour of Love -a few stories to end, of healthcare enacted
with love
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