CUTHBERT FLANGE

By Ken Hambly
Contact the author via Chris Johnstone by e-mail at christopher.johnstone@ntlworld.com

I don't know where Cuthbert Flange came from. He popped into my imagination when Ian McKee phoned me one day in 1981 to ask me to write a column for a Scottish doctor's magazine he was proposing to publish. I had just finished writing a column for the medical newspaper "Pulse" on the media entitled appropriately: "As others see us" and I was looking for something else to do, so Ian's phone call was timely. The column, Cuthbert Flange and his sidekick and faithful Trainee Malcolm were born, along with the now greatly missed "Scottish Medicine."

The intention was to entertain, but to entertain with an edge. General practice was going through major changes and many of us were feeling the pinch, so inevitably Cuthbert's jaundiced view of medicine and the medical establishment coincided with mine. I found myself in the privileged position of being able to comment on the absurdities of general practice with a voice which was not my own, and to do so with enough humour to make it acceptable. Prime targets were the training establishment, the govern-ment, patients, academia and the RCGP.

Novelists will tell you that the characters they create take on a life of their own and in doing so dictate the course of the narrative. Cuthbert and Malcolm did just that, so that soon the double act of Cuthbert and his resigned trainee (in the days before GP Registrars) seemed to write the column themselves. All I had to do was to pick a suitably absurd subject from the many I encountered in the medical press or in the mayhem which formed the daily round of my own practice. Cuthbert and Malcolm would handle it in their own inimitable style. It was a double act, Dr. Flange's misguided benign authority set against Malcolm's misguided naïve enthusiasm.

I have just resurrected the Diary of Cuthbert Flange and re-read it. I found it surprising in that it represents a way of life now completely changed. It is about a general practice that doesn't exist any more, and for many of the doctors practising today it isn't even a distant memory - they have no knowledge of that style of practice, its values and its traditions. Now I'm starting to talk like Cuthbert, but it would be sad if the tradition of family practice simply disappeared without comment. It has already gone, and I suspect no one has really noticed.

It is possible to be nostalgic about the days when doctors were respected by patients and administrators, and were largely autonomous. GPs weren't Gods, that was the previous generation, but they still had the trust of their patients and that trust created the responsibility to go the extra mile and do the extra house call at three in the morning. It was hard work, but often it was rewarding and there was a sense of satisfaction. So what did Cuthbert moan about so fervently?

There was plenty to complain about. The articles cover a wide range of perceived problems and grievances. General practice was no bed of roses, even with the benefit of a rose-tinted retrospectoscope. He pokes fun at patients, but most of Cuthbert Flange's anger is directed at imposed changes in general practice, GP training and the Health Service. He railed against many aspects of training, audit, unproductive courses, health education clinics, targets, computers and self-professed experts. He believed that the NHS was going from worse to worse at a speed comparable to that of the Titanic, also the envy of the world in its day. He also detested the increasing abuse of the out-of-hours service provided by the practice, and the lack of respect, or perhaps the lack of appreciation shown by patients who probably didn't know any better, and by the government and administrators who should have known better.

The changes that so upset Cuthbert were nothing compared to those suffered by GPs subsequently, which have led the profession to where it is today. Audit, computers, chronic disease management clinics and practice nurses have greatly helped general practice, but the things that have gone are harder to quantify. But it wasn't the imposition of daft regulations that finished old-style family practice, it was the increase in the expectations of patients, the need for 24 hour access which increased out-of-hours work to unmanageable proportions.

So reading the Flange diaries certainly brings on a bout of nostalgia for the older members of the profession, but it should also be informative and educational for the newer members. What goes around comes around, as some would say. Cuthbert didn't stay around long enough to understand what was really happening. He was killed off in the prime of his indignation and replaced by his ungrateful creator with a certain Dr. Angry.

The Diary of Cuthbert Flange lives again on the computer and can be accessed by anyone possessing a credit card. In my well-earned retirement I have created a web site intended to sell books, and Cuthbert's diary is there to be purchased for a modest fee. It is ideal for GPs to read off the screen between patients in those endless gaps in the surgery when there is absolutely nothing else to do. Or am I thinking of a previous age, a time with leisure during the day, when surgeries could be half-empty on those long summer evenings when patients were occupied with other pursuits. Perhaps Cuthbert was right after all, and an age on innocence has been lost forever.

For me Cuthbert provided a release of the anger I often felt about the changes in medical practice. The feeling of being taken for granted was dreadful for a generation that was used to deference, and being manipulated by a scheming government was a further thorn in the flesh. At a meeting when I volunteered a response from the floor I heard a colleague behind say when asked who I was, "It's just that Cuthbert Flange guy." My doppelganger was better known than I was. Past Trainees read it with avid interest, desperately trying to identify the patients and individuals from the fiction on the page. But, like all good things, it had its time and died an honourable death.

With Volume 18 No.3 in the year 2000, "Scottish Medicine" came to the natural end of its valuable, productive life with the millennium number. To mark the demise of an institution, I wrote an article in which I saw the Millennium Dome as a huge call centre covering the entire country, with computer based telephonists using algorithms to diagnose all illnesses. And he saw a small group of doctors standing together on a cold windy afternoon in the driving rain and, with all the dignity they could muster, laying general practice to rest. At least he got something right.

(PS My registrar has read the diary and said it was the best thing he had read all year- Ed.)

To obtain the Diary of Cuthbert Flange for £3.20 see: www.web-lit.com

Other online articles by Ken Hambly can be found at:
hoolet edition 45 - Green Oranges on Lion Mountain
hoolet edition 45 - Cuthbert Flange Revisited
hoolet web extra - Letter to the Editor

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.