This collection of stories from two practising GPs describes the reality of working within a failing and highly bureaucratic system, where there is a balancing act: regulation versus relationships; autonomy versus standard practice; algorithm versus individual attention.

We aren’t suggesting a return to a ‘better’ time. We don’t object to being bureaucrats, embedded within and accountable to the systems we are in. But we do want to consider how and with what the gap left by the old-fashioned GP has been filled. We use stories based on our experience to describe the effect of different facets of bureaucracy on our ability to maintain a nuanced, individualised approach to each patient and encounter; and to question the prominence and effect of protocol. We are interested in the way professional relationships are influenced by protocol: between and within organisations; and most importantly with patients/clients/service users..

We are accustomed nowadays to automated telephone lines, chatbots, website FAQs- the frustration of being unable to connect with another human being who will listen to our particular question and give us something other than a generic answer. The same issues that are facing society at large have changed the way in which we work as GPs and the care we give.

Introduction – an analysis of the different aspects of bureaucracy and regulation which influence decision making in general practice.

1. Poppets and Parcels – healthcare systems are not designed to meet the needs of everyone. This chapter is about a fundamental but undocumented component of general practice - the ‘holding work’ required for patients whose problems can’t be solved in the usual ways, the ones for whom there isn’t a simple answer.
2. Waiting to Connect – In this chapter, the stories are about flow – the flow of patients through a turbulent, over-stretched system in which access and response are often controlled by algorithm.
3. Taking Liberties -this chapter examines the role of GPs as agents of social control in the restriction of civil liberties - in the context of the mental health act and of safeguarding.
4. Guidelines, Tramlines, Mindlines -how guidelines are developed and the difficulties of applying them in the messy world of general practice.
5. The Elephant in the Room -the stories in this chapter are about biography and biology; about medical categorisation and its effects and shortcomings.
6. The Bureaucracy of Death - In the realm of death, protocol -which has become the bedrock of clinical practice- is less useful, because the right decisions and the right timing are so individual and nuanced. These stories are about death and bureaucracy.

Conclusion and Afterword

A Labour of Love -a few stories to end, of healthcare enacted with love