The limits of primary care
The limits of primary care

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The limits of primary care

1: Introducing Jim and Marianne

The lifestyles of long-term drug abusers are frequently sensationalised
The lifestyles of long-term drug abusers are frequently sensationalised

Jim and Marianne’s story is based on a real couple, but heavily fictionalised to protect their identity. Their story is a way of tracking the intricacies of the health and care system through the eyes of people for whom it is supposed to work.

Jim and Marianne, our case study for this course, are ‘long-term heroin addicts’. The lifestyles of long-term drug abusers are frequently sensationalised in the media, as in the photograph, and the following extract fromTrainspotting, a novel about Scottish heroin users that was turned into a hugely successful film:

He droaps a cotton ball in tae the spoon n blaws oan it, before sucking up aboot 5 mls through the needle, intae the barrel ay the syringe. He's goat a f*****n’ huge blue vein tapped up which seems tae be almost comin through Ali's arm. He pierces the flesh and injects a wee bit slowly, before suckin blood back intae the chamber. Her lips are quivering as she gazes pleadingly at him for a second or two. Sick Boy's face looks ugly, leering and reptilian, before he slams the cocktail towards her brain.

She pulls back her heid, shuts her eyes and opens her mooth givin’ oot an orgasmic groan.

(Welsh, 1993, pp. 8–9)

However, I introduce Jim and Marianne not through a description of such gruesome practices, but through hearing about the people behind the heroin addict label.

Jim and Marianne

Jim and Marianne are a couple. When I met them for the first time they were in their early thirties. They had been together for about ten years. Although they had been having unprotected sex during these years they had no children and Marianne had never become pregnant. They met when they were both in a drug rehabilitation centre on the outskirts of a northern industrial town. They became the ‘star pupils’ of the centre.

They both tried to outdo each other in getting clean from drugs and in striving to become model citizens. They took up all sorts of sporting activities, participated in the groups and in the running of the centre. Eventually, the time to re-enter the community came and they were helped to move into their own flat. Jim was offered a job at the rehabilitation centre itself and Marianne, helped by her family, tried to establish a little business for herself buying and selling things from car boot sales and cheaper antique shops.

Jim described his childhood as ‘difficult’. He never knew his father, and he said his mother was unable to cope with him because of her own problems with alcohol. He had spent many of his childhood years in a variety of foster homes and children's homes.

Marianne's parents owned three newsagent shops and were comparatively prosperous. But, according to Marianne, the relationships within her family were not straightforward. Her father had a series of extra-marital affairs, but when his own health deteriorated he came back to be with his wife, Marianne's mother. Their relationship seemed to stabilise but Marianne said they had never been very communicative or demonstrative with each other, or with her, and usually tried to solve problems by spending money on them.

In Jim's words to Marianne:

I don't know what's better, my family who f****d me up when I was young, or yours who's always muckin’ us about now. They really do my head in. I know they don't like me, and blame me for things. They offer us things, but always with strings attached. I think they want you to leave me, and go back to them.

The quality of Jim and Marianne's lives deteriorated after a few years out of the rehabilitation centre. Neither of them could sustain the progress they had made. They found that making friends in the community who were not their old junkie’ friends was very difficult and they became quite socially isolated. Marianne described her family as supportive in some ways, but the emotional costs of getting help from them seemed to be considerable.

Jim felt patronised and Marianne felt unable to really confide in either of her parents and was wary of her brothers and their circles of friends. Together Jim and Marianne slipped back into increasing drug use. Jim lost his job immediately at the rehabilitation centre, which insisted on a drug-free environment, and Marianne found it harder than ever to make a living. Both confessed that they were involved in petty crime at this stage. Their general health started to decline.

Marianne found that the sites she was using for injection became persistently infected and she spent several spells in hospital with swollen legs and nasty ulcers. Jim had had a valve problem in his heart since birth. His lungs had been damaged by this and by the repeated chest infections he developed. Both of them had hepatitis C infection, which probably contributed to them feeling low in energy and being susceptible to persistent infections.

Activity 1: The people behind the label

The account in the case study box is about the people behind the drug addict label.

  1. Did it change your view of them?

  2. What advantages do you consider such additional knowledge might have for a health practitioner meeting Jim and Marianne for the first time?

  3. Can you foresee any problems for a practitioner supplied with this additional information?



  1. People who read the course varied in their response. Two said emphatically that they did change their views. Another, accustomed to working with people who are often the subject of negative stereotyping, said: ‘I would always seek to find the person behind the label’.

  2. Maybe a practitioner would have more sympathy with Jim and Marianne than if she had simply been presented with bald medical information – intravenous drug user, faulty heart valve, damaged lungs, infertility, subject to persistent low-level infection.

    She might be less inclined to make moral judgements such as ‘they don't deserve help’ or ‘they brought it on themselves’.

    The additional information might also suggest a broader range of helpful interventions than straightforward medical treatment: family therapy, even fertility treatment for Marianne, whose childlessness was a cause of regret.

  3. A practitioner might feel overwhelmed by the plethora of problems. It would be much easier, perhaps, to prescribe some antibiotics, give some advice on diet or suggest a detoxification centre.

    She might feel that even if she wanted to do more for them, resources were such that she should confine herself to her immediate remit, treatment for the problem as presented.

A doctor working in the biomedical framework may act differently from one who took a more holistic approach to patients’ problems. The next section takes this discussion further by looking at the moral dilemmas a real practitioner faces when coming into contact with people who clearly need help, but who may be classed as ‘difficult’.


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