Richard Smith: In the goldfish bowl with GPs

Richard SmithTwo weeks ago I spent 90 minutes in a goldfish bowl with about 30 GPs. The goldfish bowl is a process to encourage reflection, and it certainly caused me to reflect.

The goldfish bowl features in the leadership course of the Royal General College of Practitioners. Somebody with some pretensions to having been a leader is asked into a central ring of five or six GPs. The remaining GPs sit in an outside ring. The GPs in the centre have read up on the “leader” and ask questions that aim to explore his or her experiences, thoughts, values, and anything else that might be useful. After some conversation, those in the central ring shut up and those on the outer ring make observations and suggest further topics for discussion. Those in the central ring then begin again, and the conversation may move between the rings. It’s leadership’s equivalent of dissecting a frog.

I’d done it once before and found it fun. No preparation is necessary. You talk about yourself, and if like me you never know exactly what you are going to say until you’ve said it, you learn about yourself. You also meet “bright young things” (well youngish) and discover what they think of you. The experience is, I imagine, a little like having your portrait painted or appearing in somebody’s novel.

Just as last time, the main question the GPs had for me was “How come a nice guy like you ends up working for a wicked, private company?” Nobody was that blunt, but that was the central question.

Generally GPs did think of me as OK because when I edited the BMJ it became friendlier to general practice, and when I was very first at the BMJ it was my job to develop a section for GPs. I was also viewed as left wing with a strong social conscience. So how could I leave the BMJ and join UnitedHealth, a private company that was caricatured in its early days of working with the NHS as “the shark in the goldfish bowl” (a very apt image in the circumstances).

People inevitably develop their own theories to explain my Mephistopholean conversion. I’d sold out for the money. I’d been a fake all those years at the BMJ. I’d had some kind of values or mental breakdown. Or perhaps I’d been seduced by smooth talking, Machiavellian types.

I explained how my change was prompted primarily by deciding I’d been at the BMJ long enough (25 years) and that it was time to let younger people come through and do new and interesting things (a decision amply vindicated in my mind by the wonderful developments in the BMJ.) “Most people,” I warned solemnly, “go on too long in their jobs.”

Then I explained how I believe that the public sector plus the private sector is more powerful than either alone, reminding the GPs that most of them are in the private sector. I think that private companies have a lot to offer the NHS, not least in supporting commissioning and introducing new ways of doing things. “New entrants” are very important in encouraging innovation, not least in the “old players”— look at the effect of low cost airlines. (And yes I know health is different, but it isn’t that different.)

Certainly, I said, I like very much what I’m doing now, working with people in 11 centres in low and middle income countries to counter chronic disease. Even here the GPs were suspicious, thinking that I was forcing American ways on people in poor countries. I explained that the people in the low and middle income countries propose and run the programmes. We simply fund and work with them.

I doubt that I convinced many, and the narrative of my life, perhaps reflected someday in an obituary, will be that I was a reasonable person who went off the rails. Perhaps the obituarist will speculate on why. As I learnt from a very experienced Fleet Street editor, once a narrative is established—for example, that Alexander Fleming alone discovered penicillin when a spore floated through his window, that doctors are good and drug companies bad, that the public sector has high values and the private sector low values—it’s impossible to run against it no matter whether it’s right or wrong.

Competing interest: RS works for UnitedHealth Group running a philanthropic programme in low and middle income countries. UnitedHealth UK offers commissioning support services to the NHS, but RS has no responsibility for the UK company.