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Br J Gen Pract. 2008 July 1; 58(552): 511.
PMCID: PMC2441519

Public Squalor, Private Squalor

I arrived at the surgery one day last month, during the BMA's ‘Support Your Surgery’ campaign, to find the door encased by a massive roll-down metal screen. This is supported by a crudely constructed buttress in which neither the brick work nor the mortar matches the existing building. Shoddily built by the old area health authority in the 1970s, our health centre has never had any pretensions to architectural distinction. Now, on the initiative of the primary care trust, our latest landlords, the centre welcomes patients to enter through what looks like the gate of a lock-up garage or a military bunker.

Wishing NHS general practice ‘a very happy 60th birthday’, the BMA's campaign invites patients to sign a petition calling on the prime minister ‘to support our existing NHS surgeries’. It protests against the takeover of surgeries by ‘commercial companies who are accountable primarily to shareholders rather than patients’. But nobody consulted our patients about the new barricade. Needless to say, neither were the staff consulted (although we had been complaining for around 10 years about the state of decay of the old wooden doors).

In the traditions of austerity and poor workmanship associated with the public utilities and nationalised industries, our rotten old surgery doors transmitted a message of contempt for patients. The high security features of the new gates add a new element of hostility. We are, after all, in inner-city Hackney, where, by implication, patients should be expected to put up with low standards of public amenities, which now need to be fortified against the presumed threat of local criminality. (We have had one minor burglary in our surgery in 20 years).

According to the BMA's petition ‘toolkit’, we should strive to ‘ensure that patients and the general public are aware of the high-quality services that their local GP surgery provides’. We like to think that we provide high quality services, but we cannot escape responsibility for the fact that, on the 60th anniversary of the NHS, we are still struggling to do so in shabby and overcrowded conditions. If the gates are menacing, the toilets are disgusting.

The facilities in our purpose-built health centre may be grim, but they are superior to those in smaller nearby surgeries in adapted residential premises where, in the early decades of the NHS, running water was often considered a luxury.

A recent visit to a local surgery that has been handed over to a commercial company suggests that privatisation will do little to improve standards or staff–patient relationships in general practice. The first person I met, at the door of prefabricated cabins protected by an extensive wire fence, was a burly bouncer, considered necessary by the new management to protect doctors and nurses from the anticipated wrath of the patients. For the first six decades of the NHS, staff in primary care somehow managed without implicitly threatening patients with violence.

The BMA, which bitterly opposed the introduction of the NHS 60 years ago and continued to fulminate against ‘nationalised’ health care into the 1960s, has now discovered a deep commitment to publicly provided health care.1 But even when they are armed with the BMA's ‘toolkit’, GPs are unlikely to succeed in rallying patients to support ‘our existing surgeries’. Why should patients support surgeries in which they are treated, at best, like poor supplicants expected to display appropriate deference and low expectations, or at worst, like truculent consumers at risk of antisocial behaviour?

Like the public–private partnerships in the hospital sector, the government's promotion of privatisation in primary care seems to be driven by a combination of dogma and a commitment to subsidise ailing capitalist enterprise. As a result, it seems that, once the creditors and investors and managers have taken their cut, patients in Labour's new NHS will be faced with a novel choice in GP surgeries: public squalor — or private squalor.


1. Nicholas Timmins. The five giants: a biography of the welfare state. London: Fontana; 1996.

Articles from The British Journal of General Practice are provided here courtesy of Royal College of General Practitioners