First published in the NASGP Newsletter on 6th June 2022
If you publish a book about a GP in the Forest of Dean and title it A Fortunate Woman, you are inviting comparison with its predecessor, A Fortunate Man, about a previous GP practicing in the Forest of Dean.
When I first read A Fortunate Man I didn’t believe it. Or I didn’t want to believe it. Such commitment! Such idealism! How could I ever aspire to be such a doctor?
Looking back, half a century later, was it believable? A Fortunate Man came out in 1967, during the decade when British GPs’ morale was so low that three-quarters of them gave the BMA post-dated letters of resignation from the NHS. The outcome was the 1966 Family Doctor Charter which ushered in ‘a golden age’ of general practice. But John Sassell, the Fortunate Man, in the Forest of Dean, had already been practising in his golden age for many years.
It turned out that A Fortunate Man was not entirely believable. Not every patient loved him. Few of them read the book and some of those who did felt it patronised them. He suffered episodes of severe depression. His wife – only mentioned once in the book – was the foundation on whom the idyll depended. When she died the scaffolding collapsed and there was no-one to take away his gun. Shortly after her death he shot himself.
A Fortunate Woman follows the life of another GP – ‘the doctor’. She is never named but must be recognisable to everyone in her community. She practises in Sassell’s old practice and lives within sight of his house. Both she and the author, Polly Morland, who also lives in the Forest of Dean, were inspired by A Fortunate Man and inevitably there are echoes. But the full-colour cover signals that the Forest has changed. The black-and-white photographs in the text retain its atmosphere, but now they are sharp. Technology is better in the practice, too.
A Fortunate Man now seems a museum piece; A Fortunate Woman is a bridge to our world in 2022. The Forest of Dean is not immune to social change. Families move away, incomers don’t integrate. Tourists come to experience the secret fairy forest. Expectations change.
The safety net of the community has frayed. But the close links between doctor and patient remain strong.
Patients present with traditional problems: heart attacks, antepartum haemorrhages, dementia. And twenty-first century problems like gender dysphoria. And tragedies. Suicide. No GP ever forgets a patient’s suicide. ‘The doctor’ usually knows those close to someone who has taken their own life, and she knows their community. But now it may be a GP many miles away who is charged with picking up the pieces, without that local knowledge.
All suicides linger but that of your GP is hard to absorb. How much of Sassell’s legacy was threatened by his suicide?
Sassell was a cottage industry. His successor has professional partners and a practice team, changes made possible by the 1966 Family Doctors Charter. Her workload, like every GP’s, includes the preventive activities pioneered by Dr Julian Tudor Hart, the GP of a mining village in the Welsh Valleys. In A Fortunate Man’s day, people with chronic disease bore their affliction stoically; now GPs have a central role in enabling them to live better lives. Supporting patients takes time and sensitivity, but in a community like the Forest of Dean you don’t need to call it social prescribing. That’s what they’ve always done.
Making your way through the forest to a home visit sounds idyllic, but is it so very different from inner-city practice? Trudging along slushy pavements searching for the right council tower block and wondering if the lifts are
working and safe is less romantic, but the process is the same. The comparison is between a landscape painting by, say, John Constable, and a gritty work by the pitman painter, Norman Cornish.
The only GP I ever met from Forest of Dean didn’t come over as a rural mystic, and I wonder how much of the pastoral aura which still hangs over the first chapters might be nostalgia rather than an accurate portrayal of the current situation.
‘The doctor’ is aware of the danger of exhausting her capacity to practise as she would wish. She, too, has a rock. Her husband gave up his career to support hers, caring for their two sons as they grew up, keeping house and rescuing her when her transport – car, bike, feet – let her down. Her strategies for protecting her mental and physical health are the same as ours – family time, exercise, walks, music, reading. She seems still to maintain her ideals.
But, by the last quarter of the book, the pandemic has darkened the picture. The pressures of Covid-19 and vaccination clinics make it harder to foster personal relationships. It all sounds less magical, a lot more everyday. Like so many GPs, she compares practice during the pandemic to working in a call centre. Everyone’s morale and health is affected. Her family are anxious about her catching Covid-19.
However fortunate she is, the doctor faces the challenge of maintaining what she knows is important: continuity of care, time to listen to the stories which tell her what a patient’s real problem is, learning when candour or touch are needed and when to wait for a better moment. Learning that however panicky a situation, you will manage it better if you slow down. Living with uncertainty. The importance of curiosity, the vital quality for anyone who seeks to understand and improve.
There is sound evidence that patients do better when they and their GP know and trust each other. But such relationships are more difficult in a mobile society and when GPs are in short supply. General practice, like a sick patient, is teetering on the edge of a precipice. Continuity of care is rewarding for GPs, beneficial for patients, and, indeed, for the health of the NHS. Maybe the motion passed at this year’s LMC conference will push policy makers to give it more than lip service.
Locums may seem the antithesis of continuity, but in this situation, it is they who keep the wheels on the bus, and they know how to bridge the continuity of care gap.
A Fortunate Woman is vividly told, and it rings true. The book updates rural practice to the difficult present while reminding us of the inherent values that make general practice worthwhile wherever you practise. Nostalgia is a poor reflection of the reality of the past and a worse guide for the future. Yet, the professional life of a GP, though rarely romantic, can still be amply rewarding.
A Fortunate Woman by Polly Morland, with photography by Richard Baker, is out now in hardback, ebook and audiobook.