The Veiled Heart of General Practice.

John Rawls, the American political philosopher, is best known for his deceptively simple thought experiment the ‘original position’ or, as it is sometimes known, the ‘veil of ignorance’. How would we structure society if we had no knowledge of the position we would have in that society? The starting point is that we have no idea where we would be born and we don’t know how wealthy we would be, our ethnicity, our gender, or anything else. It’s a useful exercise and it can be applied at health policy and practice level: how would we design a healthcare system if we didn’t know at what point, and with what illnesses, and in what social circumstances we would tumble into it with? Now, the ‘original position’ is a thought experiment, not a blueprint, however Daniel Chandler, in his book Free and Equal: What Would a Fair Society Look Like?, has argued that Rawls’ framework ‘is an essential starting point for developing a truly transformative politics’.1 Another aspect of Rawls’ work suggests that if we are to offer anybody a privileged position in society then we should expect that we should only tolerate such an inequality in certain circumstances. This is the ‘difference principle’ and allows for inequalities — but only if they are of benefit to the least favoured in society. It is easy to see a theoretical pathway for doctors to be afforded higher salaries and status — they can help provide care for the most vulnerable. At the moment, it feels like general practice is being stripped back and we have to hope that we will be granted the opportunity to rebuild and restrengthen. A set of principles upon which we could lean will be useful and we could do worse than to have Rawls’ philosophies in mind. We need to ally that approach to the discipline’s values we hold dear to our heart. What is at the heart of general practice? The consultation might come out near the top. Continuity will feature on many lists and community will be a well- used noun in many descriptions. Almost everyone would agree that we should do more to consider the patient perspective here as well, and I understand that the BJGP has as much responsibility in this regard as anyone. Two letters this month offer some patient perspective: Patricia Wilkie, the President of the National Association for Patient Participation, reasonably highlights that a ‘romantic vision’ of general practice doesn’t always square with the current reality; and testimony from one person who has self- harmed over many years neatly encapsulates many of the strengths and weaknesses in our current systems.2,3 Let’s ask again: what’s at the heart of general practice? Continuity, consultations, and community: yes, all of the above. However, I suspect many patients might feel, darkly, that GP’s place themselves and their self-interest first. That may not be fair, but it might be something we should keep in mind. | This month we have an editorial on the ongoing challenge of managing cardiometabolic health in people with severe mental illness. It’s not new but it smoulders away. And on the topic of burning concerns we publish a joint editorial on the climate emergency. If either of those topics raise your blood pressure or give you palpitations then turn to the research on hypertension (and accompanying editorial) and atrial fibrillation. We also have an analysis article exploring how to best support autistic adults in primary care, coverage of the Research Paper of the Year awards, and clinical guidance on managing adenomyosis. Don’t miss the letters for an account of one patient’s experience of long-term self-harm. | Footnotes See online Supplementary Data for references. - © British Journal of General Practice 2023