Can GP practices become hubs for transition?
Article by Jane Myat, GP
With Rob Hopkins, Transition Network and Michael Dixon, College of Medicine
Published in JHH 17.3 – Beyond COVID
The experience of working for more than 20 years as a primary care physician in an inner city practice in north London has led me to the conclusion that in our secular society we have a duty to advocate for our communities.We may be the only licensed listeners for many. In bearing witness to our patients’ stories, to their suffering and sharing their uncertainties, their hopes, their fears, we become embodied in our communities, feeling what they feel. Recognising the honour and the privilege of this position, inspired by our oath and rooted in the belief of the power of deep thinking, social courage, moral imagination and joy, I have been on a journey seeking to heal the whole person. I know many ordinary, extraordinary people and believe that if we use the power of our collective knowledge with a compassionate intent to develop practical healing spaces, we have the potential to transform life for ourselves, our patients and the communities within which we live and work.
Love the questions themselves, as if they were locked rooms or books written in a very foreign language. Don’t search for the answers, which could not be given to you now, because you would not be able to live them. And the point is to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer.
Rainer Maria Rilke, 2012
Penny’s story (1)
‘I think I’ve accepted that the time has come to ask you for a prescription for antidepressants’, she said. ‘I never thought I’d be here; I’ve always managed but I’m in the depths of despair.’ My heart went out to Penny, a private, thoughtful and generous woman who has been my patient for many years but who consults rarely. Penny is in her early 80s now and was reeling in the aftermath of the death of her beloved daughter after caring for her overseas before she died from complications of cancer. Uprooted, unattached and disorientated, life no longer had meaning or any sense of purpose. ‘I knew one day the time would come, maybe this is it, the end of the line?’, she mused, more to herself.
You may wonder how this story panned out. If you work in primary care as I do you may know the likely path – perhaps a negotiation around a prescription, a referral to the local psychology service, ongoing attentive follow- up, perhaps a resignation on all sides that this is how life will be. We have been there many times. But what if there is another way? What if we have what we need to do things differently, more imaginatively?
Before I share what happened next for Penny, let me tell you some other stories.
Three ‘what if’ stories
First, how environmentalist Rob Hopkins co-founded Transition Town Totnes and the Transition Network. He is the author of From what is to what if: unleashing the power of the imagination to create the future we want (2019). Rob asked himself a ‘what if ’ question when he founded Transition, a movement characterised by people self-organising to develop local projects which strengthen community resilience and reduce carbon emissions.
It describes itself as a movement of real people coming together to reimagine and rebuild our world using ‘head, heart and hands’. It began with two groups, in Kinsale in Ireland and Totnes in Devon, in 2006, growing to more than 1,300 initiatives across more than 50 countries. Initially focusing on concerns relating to climate change and peak oil, its remit has broadened to include groups working on food, energy, community relationships, engaging with the natural world, localising the economy, skill development and sharing. Writing in the Journal of Public Health, Rob suggests that Transition could help reduce the pressure on the NHS through reframing change, preventing disease, improving staff wellbeing and increasing local economic resilience (Smith et al, 2016; Hopkins, 2014).
Our second story is about Dr Michael Dixon, a GP in Cullompton, Devon. His numerous roles include National Clinical Lead for Social Prescribing, Medical Advisor to HRH the Prince of Wales and Chair of the College of Medicine. I heard about Michael as one of the growing number of GPs, who like Bromley-by-Bow’s Sir Sam Everington, had also asked himself a ‘what if ’ question. As a result, the green spaces around his practice are now used therapeutically and creatively for the benefit of patients and staff.
Michael recalls: ‘No one had previously been in the medical profession in my family. I was keen to do a job that made a difference though my initial interest was more in the mind than the body. My interest in complementary medicine developed after 10 years as a country doctor as I began to realise that there were so many gaps in what we could do for patients using only conventional medicine – for example patients with chronic tiredness, frequent infections, irritable bowel, premenstrual syndrome, depression, stress, back pain, neck pain and so many other conditions. It was frustrating to have such a limited range of options for treating conditions that I would see in surgery every day. It made my medicine more effective and colourful and restored my sense of self-worth as a doctor.’
The third ‘what if’ story, is my own, of a woman of mixed heritage, from everywhere and nowhere, a ‘mongrel’ as my father affectionately said. Since I first found my place in 1997 when I started working as a GP in Kentish Town, north London, I have witnessed a lot of change: progress through clinical advances and better technology certainly. But in stark contrast we find ourselves living in increasingly disconnected times, unmoored from a sense of place or belonging and exposed to bewildering arrays of consumerist choices that sometimes feel like no choice at all. It seems we have lost a sense of who we are or what we should do; many people feel lonelier and more afraid.
Like Michael, I see this expressed every day: in mental health problems, in the many chronic diseases born of
our ‘modern’ lifestyles, addictions, persistent physical symptoms and chronic fatigue. Sadly as a profession we may over-diagnose, and respond by supplying an expanding array of medications, unrealistic ‘magical’ cures or attempting to anaesthetise distress (Heath, 2013). Much is missing in the space humans now inhabit, whiplashed between extremes of passivity and constant unquestioning actions and reactions. No wonder we find solace where we can, getting lost in electronic worlds, overfed and undernourished, in bloated consumption whether of goods, gaming, gambling or chemical substances of one kind or another. If these ‘remedies’ are so good, why do so many people feel unhappy?
Can social prescribing be truly restorative?
Perhaps help is at hand? Social prescribing is in vogue and huge hopes are being laid at the doors of the ‘growing army of social-prescribers’ tasked to help us on the frontline in primary care (Pulse, 2020). But in primary care we are fatigued and sceptical, for we are used to empty promises. In reality though, is this sort of language helpful? Are we really in a battle, a fight with problems that needs fixing? Or might the notion of social prescribing act as an invitation to reflect, use our collective imagination and respond in other ways?
Change comes about at the margins. People in the centre are not going to be the big change makers. You’ve got to put yourself at the margins and be willing to risk in order to make change. But more importantly, you have got to approach differences with this notion that there is good in the other. That’s it. And if we can’t figure out how to do that – if there isn’t the crack in the middle where there’s some people on both sides who absolutely refuse to see the other as evil, this is going to continue.
Frances Kissling, 2011
If it is to be used less like a traditional prescription, we have to be clear about the process of social prescribing and not focus only on its content. As an enthusiastic cook I see social prescribing’s content as the ingredients and the process as the recipe. And this recipe is just our starting point, for it’s when we cook together that we develop our skills. So, when sipping from the cup of life, how do we want it to taste? What sort of an ingredient am I, are you: do we even know? And what part might we play in telling the story of cooking? All good recipes have been tried and tested, perhaps rooted in family and cultural history, but at the same time personalised so they become our own. As an enthusiastic social prescription-maker, I have had to ask myself how to develop our own unique recipes for social prescribing.
Perhaps we have to start by imagining what it would be like to be fully human and what we have lost along the way now that our social fabric is so threadbare. If we are to gather the yarn and start weaving together again we will need a safe base: places for integration and where we can reconnect to ourselves. Places for re-embodying our minds, and understanding our thoughts and feelings so we can reconnect to each other, to our histories, to the world from which we have come. A place for embracing the wide mystery of our universe, so that we can hold life and its uncertainty with awe and wonder and not just fear.
Pieces-sewn-by-our-practice-community-towards-our-‘Hope-in-our-Hands-wall-hanging…now-displayed-in-the-waiting-room-©-Simon-Lewis.jpg
This is not to say the journey will be easy. It will need courage, moral imagination (see Sacks, 2020; Novogratz, 2020) hospitality, humility, creativity and an openness to generous listening and adventurous civility in conversation (see https://onbeing.org/civil-conversations-project/ better-conversations-guide). We need to hold our destination lightly, be open to possibilities, to change our minds at times, to develop the resilience and flexibility to negotiate the twists and turns that life inevitably holds. We need to broaden our perspective, to look at what we are discarding and disregarding, moving from the linear to the circular. Nature can be our great teacher in this, the cycles of life, death and rebirth, the complexity of ecosystems, the fractals and patterns all around. The Transition strapline is: ‘If we wait for governments, it’ll be too little, too late; if we act as individuals, it’ll be too little, but if we act as communities, it might be just enough, just in time.’
We need to move from a focus on ‘I’ to ‘we’ The African proverb reminds us: ‘If you want to go fast, go alone, if you want to go further, go together.’
My recipe for an NHS practice in transition
Nearly five years ago, we started a small project with big dreams. We called it The Listening Space. Inspired by the pioneers, Michael Dixon and Sam Everington, and with reference to the guiding principles of the Transition Network, we collaborated with patients, members of our local community and Transition Kentish Town. We crowd-funded, worked our own gift-economy, exchanging skills and time for food, good company and celebration. We repurposed found objects and as we worked together to transform a large disused space in the courtyard of our urban general practice into a therapeutic garden, we found we had developed skills of many kinds, woven connections and made new relationships. We valued the journey, though we didn’t always know which way things would go, which can be anxiety provoking and threatening to those who like to have more concrete plans. We decided to celebrate all the small gains along the way and not to be harsh about the things that have been less successful, seeing them instead as our good teachers. We are now so proud of our place of refuge and shelter, a place where we can free up our imaginations, a space where we can listen to what nature has to teach us. And in opening up these possibilities, we have gained the confidence to generate new ideas, new branches from our roots. I am excited about the further possibilities opening up for our community in our latest collaboration with Jane Riddiford of Global Generation, expanding our reach by taking ‘story walks’ between the green spaces of north London.
From burning out to burning in
When we started out, I felt like Penny – lost in a land without hope, burned out having been overburdened with mindless, misdirected work trapped within a system that increasingly cared for numbers rather than valuing care, in a climate of endless reorganisation, under relentless pressure from top-down initiatives.
I have found hope again by tending to the soil and working from the grassroots. I found myself ‘burning in’ to a more stable but energised place where my work regained coherence, meaning and purpose. The hours may be similar but the emphasis has shifted from the mechanistic pursuit of efficiency and outcomes, to a focus on real compassionate patient care. My joy has been restored. In the greatest book ever written about general practice, A Fortunate Man (1967), John Berger describes his friend John Sassall, a country doctor in the 1960s as ‘… a fortunate man because his work occupies and fulfils him; his work and his life are not separate’.
Our project has grown, literally and figuratively. It expanded from our early gardening groups, into organised and impromptu gatherings and waiting room ‘crafternoons’, then came a poetry pharmacy and story- walking. At the outbreak of the pandemic, galvanised by our knowledge of how to work as a good team, we were able to quickly set up a pop-up social kitchen, to feed staff and patients in need. The role of the clinician has been to facilitate participation, to invite civility in conversation across diversity, to provide support and navigate difficulties when there is distress, or if inevitable tensions arise in group situations. Our social prescriber Jo, who facilitates and supports the various groups that have developed, acts as a true link-worker, a warm and welcoming connector between all of us in the practice. In this way our work can remain expansive. We focus on working with our relationships and less transactionally, always aiming for more equal partnership with our patients, other community organisations, individuals and businesses. Through this participatory approach and by ensuring our activities are fun, inclusive and positive at their heart, we are growing the community we imagined, rather than building an army. As each participant finds their place we are learning to work supportively and to grow our resilience and ability to rise to the challenges we will all face.
A tree can be only as strong as the forest that surrounds it.
Peter Wohlleben, 2016
Penny’s story (2)
So, what of Penny? As I listened to her tale unfold and her self-diagnosis of depression, I gently suggested that perhaps in her situation, sadness was understandable. And sadness requires mainly gentle observant company and community. We talked of what once had nourished her, her love of nature, of gardening and of her teaching. With our expanded outdoor ‘consulting room’ we were able to offer an alternative prescription. That evening, Penny and I met, wandered among the flowers, the herbs and the productive beds of The Listening Space. We spoke of other gardens, the power of nature to ground and to heal; and imagined together a different future path.
Penny joined us the following day for a distanced, intergenerational gathering and walk between The Listening Space in Kentish Town and The Story Garden in King’s Cross. I spoke to her in a follow-up appointment two weeks on from our more despairing conversation.
‘I can’t believe how different life looks. I didn’t think at this point in my life, there could be anything else. But I know where I am now and what I want to do with whatever time remains for me.’ Penny is now volunteering with us, a valued, worldly-wise elder in our community already sharing English conversational skills with those from other lands who are also growing roots in our re-generating and re-membering community.
What if GP surgeries became catalysts for Transition?
So how do we weave a stronger social fabric; how do we learn to mend, remake, grow it and sew it? I was fortunate enough to be in conversation with Rob and Michael as part of Rob’s podcast series ‘From What If to What Next’ (Hopkins, 2020), where we were given generous space to reimagine healthcare for the future and had carte blanche to suggest policies as ministers of the imagination. Perhaps you will listen and join us?
The system will collapse, if we refuse to buy what they are selling – their ideas, their version of history, their wars, their weapons, their notions of inevitability. Remember this, we be many, and they be few.They need us more than we need them. Another world is not only possible, she is on her way. On a quiet day, I can hear her breathing.
Arundhati Roy, 2003
Penny is not my patient’s real name although she gave me full permission to share her story with you. She told me at our last meeting that she had spoken to her friends about what had happened to her and reported their collective wish to have care and treatment in practices like ours. Yet I do not believe we are all that unusual, though we have travelled into a less unfamiliar place. Having explored the territory we are here to tell you about the wonderful view and invite you along. So I write this piece in ‘Penny’s’ honour and on behalf of all the future patients we may be better able to serve if only we free up our imaginations, let our compassionate, authentic human selves back into our work, knowing we too will find nourishment in the process.
If we in general practice were to act as hubs and safe spaces for transition, what would our world be like?
We all, adults and children, have an obligation to daydream. We have an obligation to imagine. It is easy to pretend that nobody can change anything, that we are in a world in which society Is huge and the individual is less than nothing: an atom in a wall, a grain of rice in a rice field. But the truth is, individuals change their world over and over, individuals make the future and they do it by imagining things can be different.
Neil Gaiman, 2013
References:
- Berger J (1967) A fortunate man: the story of a country doctor. Allen Lane.
- Gaiman N (2013) Why our future depends on libraries, reading and daydreaming. Lecture for the Reading Agency, delivered on Monday October 14 at The Barbican Centre, London. Available at: www.theguardian.com/books/2013/oct/15/neil-gaiman-future-libraries- reading-daydreaming (accessed 6 October 2020).
- Heath I (2013) Overdiagnosis: When good intentions meet vested interests. BMJ, 347:f6361.
- Hopkins R (2020) The ministry of imagination: Episode 4 with Dr Jane Myat and Dr Michael Dixon. [podcast]. Available at: https://sound- cloud.com/transition-culture/from-what-if-to-what-next-episode-four- what-if-doctors-surgeries-became-catalysts-for-transition (accessed 4 October 2020).
- Hopkins R (2019) From what is to what if: unleashing the power of imagination to create the future we want. London: Chelsea Green Publishing.
- Hopkins R (2014) A healthy society is just as much about community as healthcare. The Guardian, 26 June.
- Kissling F (2011) On being podcast: What is good in the position of the other. First broadcast January 20.
- Novogratz J (2020) Manifesto for a moral revolution: practices to build a better world. New York, NY: Henry Holt & Co.
- Pulse (2020) NHS England bids PCNs to hire ‘army’ of social prescribers. [Online]. Available at: www.pulsetoday.co.uk/news/ workforce/nhs-england-bids-pcns-to-hire-army-of-social-prescribers (accessed 6 October 2020).
- Rilke RM (2012) Letters to a young poet. Penguin. Roy A (2003) War talk. South End Press.
- Sacks J (2020) Morality: restoring the common good in divided times. London: Hodder and Stoughton.
- Smith J, Hopkins R, Pencheon D (2016) Could the transition movement help solve the NHS’s problems. Journal of Public Health, 39 (4) 841–845.
- Wohlleben P (2016) The hidden life of trees: what they feel, how they communicate. Discoveries from a secret world. New York NY: Harper Collins.
