Waiting, staying and enduring in general practice

Davies, Stephanie Clare (2023) Waiting, staying and enduring in general practice. PhD thesis, Birkbeck, University of London.

Abstract

My thesis asks the question, ‘what forms of care can issue from time in general practice, in situations in which nothing appears to improve, or get better?’ With its attention increasingly turned towards intractable, complicated, long term and medically unexplained health conditions, NHS general practice is becoming more defined by situations that are demanding in terms of time and effort, but unproductive in terms of obvious clinical outcomes. Yet, there seem to be fewer ways now than ever for thinking about care outside of productionist modes. This is a problem because if we are only able to think about caring for health as an accretive, future making activity, then we risk cutting it off in response to those situations that seem the most demanding and the least promising. My research considers the claim that there are certain ‘practices’ of care in the NHS that only really begin at the point where progress in medicine drops off, giving rise to the potential for waiting (or not), staying (or not) and enduring (or not) for both practitioner and patient. I establish a method of testing this claim through a series of ethnographically derived ‘cases’ depicting seemingly unproductive episodes of care in general practice. They are crafted from material collected over the course of one year of observing physical and digital sites of general practice during the coronavirus pandemic in England. This includes interviews with healthcare workers in clinical and non-clinical roles, observations of routine GP appointments, observations of Balint group meetings and personal testimonies of general practitioners made publicly available online. I take an interdisciplinary, interpretive approach to handling this material, combining narrative and theoretical modes, not as a way of yielding a definitive explanation of what happens when the activity of care becomes detached from any definable notion of progress, but, as a way of unfolding the tensions and uncertainties of unproductive episodes and of keeping open the forms that care can take within them. In chapter one, I present close readings of pre-pandemic policy documents addressing the perennial problem of not having enough time in the NHS and offer different entry points to thinking about how this problem has shaped the relationship between time and care in contemporary general practice. In chapters two and three, I discuss the difficulties involved in observing something as elusive as non-progressive time. Then, I examine Michael Balint’s psychoanalytic method of ‘making cases’ in association with ‘difficult’ patients, so as to rework this as my own method of using the case as a mode of representation. In chapters four to seven, I test the claim that care can form in non-progressive ways in situations that show how practitioners have tried to offer care in response to inevitable decline, chronic illness, failing infrastructure and ongoing crises in the healthcare system. My findings based on this material, show general practice to be a site where the very possibility for care can rest on the willingness of patients and practitioners to refuse the categories of the epic and heroic in favour of finding other ways of ‘getting through’. My conclusion summarises what has emerged from these case studies on the question of how do we narrate the history of pandemic care, and argues for an approach to thinking about time in general practice that looks beyond progress, to the precarious world-making that comes afterwards.

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