Better ways to get better: the radical GP changing lives
Accessed from the world wide web at 09:00 hrs 26.06.22.
Working as a GP in 2022 brings Dr Laura Marshall-Andrews deep joy and pride, but it also scares the living hell out of her. She greets me in the waiting room of her Brighton practice, a tall building on a shopping parade close to the beach, and we climb up to a consulting room, where through an open window come sounds of drunk men and seagulls. Though I’m sitting in the patient’s chair, today it’s the doctor who will tell me what’s wrong.
It is a particularly difficult time to be a GP. The British Medical Journal reports that police see an average of three violent incidents at surgeries every day. Not long ago, at an appointment, a patient tried to strangle Marshall-Andrews. Last year, Sajid Javid joined a Daily Mail campaign demanding that GPs restore pre-Covid working practices, promising to “name and shame” practices that offer too many video appointments. Increasing numbers of doctors are quitting, citing stress. In 2019, Boris Johnson promised to increase the number of GPs in England, but in fact it has fallen. The doctors remaining are struggling, which means Marshall-Andrews’s book, What Seems to be the Problem?, a memoir about her pioneering approach to frontline medical care, feels especially vital, and oddly hopeful.
“What scares me,” says Marshall-Andrews, “is that at the moment the system feels out of control. What’s happened is a fragmentation of care.” As areas of the NHS have been segmented off, different organisations are running different services, “and so it’s created this culture of everyone saying, ‘This doesn’t fit my box.’ The management of referrals used to be run by clinicians, who would understand if you said, ‘I’m not quite sure what’s the matter with this patient, but I’ve got a bad feeling.’” But clinicians were replaced with administrators, which has resulted, she explains, in patients regularly being rejected or bounced from service to service, becoming increasingly frustrated, and often, increasingly ill. “You get these islands of care. But there are quite a lot of patients who seem to sort of bob around in the sea, between these islands of care. So they keep… floating back.”
These floating patients were one of the things that started to shift her ideas about medicine and care. It was the early 2000s when Marshall-Andrews (then in her 30s, with three small children) started to notice more and more people responding unexpectedly to treatments, undermining “the gods of mass trial data and clinical evidence” that she’d worshipped at medical school in Southampton. “People, I realised, are not textbooks. They are far more complicated than that, and far more interesting.” After a worrying blood test at the surgery, a patient called Julie received the prognosis that she had only months to live. She returned with a very clear idea of how she wanted to die. Declining medication in favour of acupuncture and homeopathy, Julie changed the way Marshall-Andrews looked at her role as a doctor. “We sort of went on a journey together. And it changed me. It was difficult to negotiate through a system that was very restrictive, but trying to bend it really made me realise that we could do things better.” She helped Julie with palliative support on a final holiday to Wales and, visiting her in the hospice in her last days, started to feel a pull towards a different way of practising medicine.
And so, here we are. The first thing Marshall-Andrews did when taking over these premises, a surgery based between four homeless hostels that house many patients suffering from addictions, was remove the safety screens around the reception desk. It was a statement of intent. Today, the waiting room at the Brighton Health and Wellbeing Centre is pasted with self-portraits in pastels, work from the patients’ art group. This is where the singing group practises, too. The photography group regularly takes a bus out to Seven Sisters cliff and the Downs to talk and walk and take photos of nature. There are dance classes and creative writing. “There was a big study,” Marshall-Andrews tells me, as we walk through the surgery, “that showed every £1 spent on arts in health saves the NHS £11.” It’s not just art – there’s a growing body of evidence that “social prescribing” (ranging from support for people with housing issues to tackling loneliness through local walking groups) reduces pressure on the NHS.
An evidence summary published by the University of Westminster suggests that where someone has support through social prescribing, their GP consultations reduce by an average of 28% and A&E attendances by 24%. Last year in Brighton, people engaging in three or more group sessions at Marshall-Andrews’s practice saw a 41% reduction in their need for GP appointments. Down the road the gardening group are working on a patch of land behind another doctors’ surgery, and takes foraging workshops, and there’s coursework with horses. This is not your average GP surgery. Upstairs, right at the top of the building, are therapy rooms for acupuncture and massage. When I put my head round the door a therapist is setting up for a reflexology session where the patient shakes – “neurogenic tremoring” – to release trauma. Everything smells of tea and flowers.
This was what Marshall-Andrews dreamed of when she decided, soon after Julie’s death, to set up her own “integrated” practice, with space for therapists as well as doctors, offering meditation alongside medication and (through a charity she set up) access to complementary therapies for anybody who wanted them. “We’re trying to enable people to have the tools to improve their lives, which will make them healthier. And there’s so much evidence now that the way you live, not just in terms of your diet and your exercise, but loneliness and social connection, changes your physiology. Psychoneuroimmunology [looking at the interactions between the central nervous system and the immune system] is coming to the forefront, particularly since Covid.” The final chapters of her book document life as a doctor in lockdown, wrestling with PPE in the wind, arguing for ventilators and seeing the crumbling mental health of patients who her team has worked hard for years to stabilise.
One of those patients was Eric, who had freed himself of opiate addiction using acupuncture for his chronic pain, and regular visits to a table tennis club. But alone in lockdown he slipped, got into crystal meth, arriving at the surgery in a violent “state of total emergency”. Seeing a psychiatrist at that point (and with his recent drug use) was unlikely. Marshall-Andrews, in the calmest voice she could find, suggested he talk to their homeopath.
Whenever she mentions homeopathy, I stutter a little, so we stop, and I ask, what are the ethics of a GP recommending something that the chief executive of the NHS expressed “serious concerns” about, claiming the practice is “fundamentally flawed”? Marshall-Andrews sighs politely. “I’ve seen loads of patients do better with homeopathy than they have with my medicine. It makes no sense, the way I was trained. And I can’t explain it other than it being a placebo effect.” The cultural meaning of a treatment impacts its results – patients get better, not because of the “remedy” necessarily, but because of a placebo effect and a compassionate clinician. “A lot of it is in your intention – the way the person delivers it is really important. That’s what alternative practitioners do way better than us. They create a caring environment, they listen.” The homeopathist here used to be a psychiatrist, “and a lot of the people who she sees are patients with personality disorders, or people who had a very refractory illness, where we’ve tried treating them and they’re not getting any better. I sometimes tell a patient, ‘Try that, it might help.’” She smiles carefully.
As the lockdowns continued, it was their homeopath who Eric thanked for getting him off meth. “She gives me tablets,” he told Marshall-Andrews, “but I think it’s talking to her that really helps.” Good care, she believes, requires a team working together, “integrating different systems”, treating Eric “as a whole person” rather than a series of boxes to tick. “The cultural shift that we need to see is that health is made in communities,” she says. “And if you look after your community and keep them happy and healthy and creative, then you’re not going to need loads of expensive hospital treatments.” People know about the importance of exercise and a healthy diet, “but they can’t do it. Because a lot of the time, they don’t have the capacity to because it costs money, or they’re working really hard, or they just don’t value themselves. They may have had trauma in their past – in fact, we’ve looked at difficult-to-control diabetics and most of them have quite high ACE scores.” That stands for Adverse Childhood Events, a tally of different types of abuse and neglect. “Psychology, lifestyle, connection and these kind of groups should really be embedded in the first stage of their treatment.” So why is Marshall-Andrews’s approach so rare? “It’s easy prescribing to someone, and it doesn’t take very long. And when you’ve got 90 patients to see in a day, it’s hard to have that conversation.” Yet she persists.
We walk out into the warm afternoon and find a bench in a community garden. She’s wearing blue scrubs and bright nails, and the people we pass nod to her with a respectful reverence. I want to talk about wellness, a concept (and industry) Marshall-Andrews’s work aligns with closely, but one which often requires interrogation. “Yes,” she nods. “It can be really good and incredibly helpful. But what can be difficult and confusing for patients is when there’s a gap between that and doctors with western medicine, so, an acupuncturist who says, ‘You mustn’t take that medication,’ or ‘Vaccines are bad,’ or doctors who go, ‘Anything else is a waste of time.’ But if you’re working together, it can be great.”
Yes, in a neutral and apolitical world her approach might already have rolled out across the UK, but we live in this world, tilted and divided, with attitudes and treatments often seemingly welded together. She thinks for a second. “The brilliant thing about a lot of alternative practices is they’re not looking for a diagnosis. They’re looking to treat the whole person. We doctors can get really stuck on diagnoses, particularly mental health diagnoses that change all the time, and there’s very little consensus on them anyway. But actually, often it doesn’t really make any difference. Sometimes when you’ve got someone who is distressed, you can help them without coming down on a diagnosis. I think we’ve got a lot to learn from alternative practitioners.” She gives the impression this is an argument she’s had to make many times.
In trying to fashion a new way to care, Marshall-Andrews has inevitably fought many battles, including with a Clinical Commissioning Group (who brought a case against her for, among other things, her approach to prescribing unlicensed medication) and on behalf of patients, many of whom appear in her book, sucking fentanyl lollipops, chattering through cancer, living with pain, dying in love. What’s the most controversial aspect of her work today? “We’ve had a lot of negative scrutiny from authorities recently – NHS England, the CCG and the GMC [General Medical Council], it seems because someone in the regulating bodies has a problem with our work [prescribing hormones] with transgender people. We’ve had two NHS England investigations, both of which have ended up with them saying, ‘This is a great practice.’ Which is good, but it’s just very stressful going through it. It’s the societal context that we live in, I guess.” She shrugs impatiently. With every story she tells, of humanness, of providing care to patients marginalised by circumstance and luck, it seems wilder and wilder that her methods are seen as contentious.
Would she recommend a job as a GP? “It’s brilliant, and it’s an honour,” she says. “And it’s difficult. But then, nothing that’s worthwhile is ever easy.” As we walk back to the centre and she considers her next patients, I know it would be easier if she was able to simply tell herself, as GPs historically have, that “the doctor knows best”. But good medicine, she writes, is what works. “It’s the only way to bring about the changes we need. I believe that the practice itself has become a living manifesto for that change.” She’s proud of this, of pioneering a new way to care. “We’ve always tried to do what is right, rather than what is easy,” she smiles, grimly. “Even if sometimes, that gets complicated.” Do I know what the motto of the Royal College of General Practitioners is, she asks suddenly. “It’s Cum Scientia Caritas.” I wait. “Which means,” and she grins, “Science With Love.”