This over-arching theme has three sub-themes. It refers to the ways in which our healthcare system works primarily with diagnoses and a curative approach, over a preventative approach, and that this is how loneliness is often managed in primary care. This theme also looks at the way in which GPs understand the idea of loneliness
85 as a social problem that exists within a medicalised role, and how this fits in with our wider cultural ideas of whose responsibility social problems are and how they should be addressed. There appears to be conflict between the medicalised way in which GPs construct loneliness and then the more individualistic, personal way they believe it should be treated, outside of the medical remit.
A curative system
GPs spoke about the physical and psychological effects of loneliness, which are only treated once apparent. GPs were open about their role in diagnosis and treatment of an existing problem, suggesting that their role is only live when there is something apparent to treat rather than preventing a problem from appearing in the first place:
“My role is to identify what the problem is, you know, treat the depression if that‟s a medical problem, and sort of signpost and to direct my patient to somebody who can help. So my role is sort of diagnosing and treatment of illness”
(GP10, female, urban, YOE: 27)
It appeared that GPs are working in curative, rather than preventive, system whereby the negative consequences of loneliness can be managed, but loneliness itself cannot:
“I don‟t know if we directly spend a lot of time managing people‟s loneliness, but we probably spend quite a bit of time managing the consequences of people‟s loneliness”
(GP13, female, rural, YOE: 10)
Treating only the effects of loneliness rather than also addressing the loneliness itself takes up GP time and resources, and crucially does not take away the underlying issue, meaning that these consequences may continue to arise in those patients.
Furthermore, it reflects a Westernised approach to healthcare, colluding with the idea
86 that tangible symptoms and diagnosis are required before treatment (e.g. use of DSM-V).
Medicalisation of a social problem
GPs discussed the issue of loneliness in a highly medicalised way, in the language that they used and the way they viewed loneliness as a medical problem which could be diagnosed and treated like any other physical medical problem. The medical use of language in this context is highlighted when GPs talk about how they tackle the issue in a very logical and medical way, and frame their actions using highly medical terminology:
“locally we‟ve got a system here we can refer patients now for assessment for social prescribing if we feel they are lonely, and that seems to work really well actually”
(GP15, male, urban, YOE: 29)
GPs also described being products of their training and naturally wanting to construct problems in a medical way, and as a result perhaps looking for medical reasons for patients‟ problems rather than considering social aspects that may be playing a role, such as loneliness:
“and yeah I think just, you know, our training is such that we go for the medical don‟t we, we‟ve got to go for the medical. And I‟m not saying this isn‟t important, all I‟m saying is it tends to, it‟s sort of secondary isn‟t it?”
(GP8, male, urban, YOE: 29)
One GP spoke about the limitations of medicine in general being synonymous with the limitations of their practice, suggesting that GPs and their work are encased within the limits of medicine:
87
“I think er gaining an understanding of the limitations of medicine and one‟s practice is pretty important early on otherwise you get completely defeated”
(GP5, male, urban, YOE: 5)
This poses a problem for any issue within general practice that is not medical, and may force medicalisation of more social issues. Furthermore, if a patient is only presenting with loneliness and it does not fit in with the medical
„template‟, it is portrayed as something unacceptable to be treating in general practice, and something that is still needed to be treated as a medical issue in order to make it more „acceptable‟:
“I think it only really became apparent to me when I was trying to work out quite why he was wanting to come and see me, so having his blood pressure measured every four weeks. And for a while I almost sort of felt like we made up sort of medical reasons why that was required […] I think a few of us have almost slightly guilty secrets about patients who come and see us every month and we kind of know it‟s not necessarily for a medical cause, and that I may not particularly share with my colleagues”
(GP5, male, urban, YOE: 5)
This theme shows the medical way in which GPs think about and manage loneliness, suggesting that they are constructing a medical problem from something which is inherently a social problem.
Whose responsibility is it?
There was some discussion regarding whose responsibility it is in managing and reducing loneliness in older people, whether it is down to the individual themselves or the wider society. There were some differences of opinion regarding whether
88 loneliness is something for which the responsibility should lie on the individual, versus it being something for which the GP is responsible for, much like any other medical problem. One GP suggested that lonely people who seek help from their GP may not necessarily take up what is offered to them, as those who are serious about reducing their loneliness will have already taken the necessary steps themselves: “the people that are going to be up for it will have done it themselves” (GP7, female, urban, YOE: 32). Another GP stated the importance of patients taking personal responsibility to help with their loneliness, again suggesting an individualistic viewpoint:
“I think that with a lot of things if you can get people to help themselves, and if it can be initiated by them… I would usually say “what do you think you could do?””
(GP2, female, urban, YOE: 1)
There was extensive discussion regarding the GP role with an issue like loneliness.
There appeared to be conflicts of opinion about whether or not it was a GP‟s job to work with and manage loneliness, however also confusion and uncertainty within individual GPs. Some GPs felt strongly that loneliness was a social problem and that it was not a GP‟s role to deal with social issues that presented in general practice, but rather that is should be managed on an individualistic basis:
“It‟s a bit like benefits or housing or, you know, those range of social issues that people have that may not actually be something that a qualified doctor is best able to deal with”
(GP3, male, rural, YOE: 24)
“families can be more interactive in getting their lonely family member..
like they can do our job in a way, they can find them clubs to go to or direct them in different ways so that kind of avoids having to come
89 through the GP really at all. And maybe offering them the reassurance instead of through us”
(GP11, female, rural, YOE: 3)
Some GPs talked about loneliness as something that was a result of an individual‟s way of being and brought on by themselves, implying that loneliness is more of a personal and individual issue rather than something that is social and a product of wider cultural ideologies:
“Some people are possibly lonely because they‟re not very nice, you know, they‟ve never made any friends „cause people don‟t want to talk to them and they‟re reaping the benefits of that”
(GP6, male, urban, YOE: 26)
However, others felt that it was indeed a GP‟s role to work with social problems, as they could offer skills such as listening and supporting in the long-term, rather than simply focusing on being curative:
“there is a lot of your job that is a lot of actually listening and almost kind of paying remiss or being somebody to hear about somebody‟s story – that‟s a pretty important part of the job”
(GP5, male, urban, YOE: 5)
“I think one of the strengths of general practice is, and it‟s important that it‟s not abused, but it‟s to support people as opposed to curing them”
(GP7, female, urban, YOE: 32)
The theme of „A Western Approach‟ considers Western, neoliberalist ideas of medicalisation of loneliness, and individual responsibility of problems. GPs showed some conflict about whether loneliness was an issue that should be managed within or outside of general practice. There was also discrepancy between the idea of medicalising loneliness, while simultaneously arguing that it is a social issue and
90 should be treated as such, outside of medical general practice. These conflicts, sometimes within the same GP may reflect a wider incongruency in general practice between how GPs are trained and how they subsequently have to work and manage their patients.