Review

Conflicting interests in practice

Practitioners and Practices
Julian Pratt
Radcliffe Medical Press, 1995, £16.50

Pratt provides an excellent and concise description of the two, sometimes incompatible, demands placed on GPs in the modern NHS.

On the one hand, there are the values traditionally held by practitioners in their everyday work, values such as the importance of one-to-one relationships and responsibility for individuals’ concerns. According to these values, the GP acts to use available resources to improve the well-being of individual patients, is accountable to the patient and his or her family and seeks to provide personal, continuous care. Because the GP holds these values, the patient can trust the doctor to be interested primarily in his or her well-being above other considerations.

But on the other hand, are the values of practice, as encouraged by the 1991 NHS reforms. Practice values are more centred on improving the health of all registered patients, at least as far as they can be met within available resources. In this approach, the core value is for efficiency in the use of limited resources, so that the greatest good can be achieved for all patients. The doctor is accountable to fellow workers and society generally, who can trust the doctor to attend to the social context of care.

Pratt explores the ethical tensions between the principles of autonomy (the obligation to further the self-determined interests of an individual) and equity (the obligation to ensure the just distribution of resources). This tension has always existed in providing care, but the NHS reforms have tipped the balance in favour of practice rather than practitioner values.

I found this an excellent little book (90 pages of text plus references) in helping me to understand the impact of the reforms on general practice. As someone not involved in providing clinical care in this way, it has provided me with a better understanding of the dilemmas involved. The book is well organised and would certainly be most useful for trainees, and perhaps also for GPs working in the NHS, since it clarifies many of the issues involved.