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4 February 2002

The doctor’s tale

NHS in crisis - The doctor's tale

By Theodore Dalrymple

The National Health Service is a special case of Britain’s growing national incompetence. It is not that the NHS lacks good or even talented people to work in it; nor is it that its staff are given to idleness. On the contrary: never has such a large staff worked so hard. Yet a visitor to almost any NHS facility would be struck at once by the prevailing atmosphere of crisis, incipient chaos and near desperation.

In the circumstances, it is remarkable that the British medical profession’s morale and esprit de corps should have held up as long as they have. It is true that working in conditions of shortage sometimes brings out the best in people, but usually this is true only when there is some hope that those conditions will cease. The contrast between the vast technical advance that medicine has made in the past half-century, and the successive financial and administrative impasses to which politicians have brought our system of healthcare, could scarcely be greater. Good medicine in this country has to be practised under bad conditions.

Successive surveys have established that an ever larger proportion of senior doctors want to retire early, while an ever larger proportion of junior doctors wish they had never qualified in the first place. This should be enough to alarm anyone who might have to consult a doctor at some point in the future: that is, the entire population.

Why should British doctors feel thus demoralised? Their disillusionment is not entirely a recent phenomenon: it has been growing over the past three or four decades, but it has now reached the steep part of an exponential curve.

There is more than one reason. In the first place, doctors feel themselves to be under attack in the media as never before. One can barely open a newspaper or listen to a news bulletin these days without being informed of a medical mishap, with the underlying implication that doctors are habitual careless bunglers, or worse. Though doctors as a professional group remain by far the most trusted by the public, the media feel unable to leave this unchallenged. Several times a year, I receive a request to write an article “breaking ranks with my colleagues” (as they put it, as if there were a vast Judaeo-Masonic-Bolshevik-plutocratic conspiracy afoot) and telling the British public from the inside about the division of doctors into two classes, the incompetent and the homicidal. My refusal, on the grounds of the falsity of this division, seems always to occasion genuine surprise.

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There have been real scandals concerning bad and vicious doctors: the names Rodney Ledward and Harold Shipman have not lent much lustre to the profession. However, the way in which the British public continue to hold the profession in high esteem shows that its understanding of such matters is actually more sophisticated and subtle than that of either journalists or politicians.

Until the recent spat over events at the Whittington Hospital in north London, successive governments have been content to undermine the the medical profession. There are two reasons for this. First, governments have been happy to use the profession as a lightning conductor for all those discontents over the provision of healthcare in this country which are, in fact, attributable to their own cowardice and lack of initiative. The undermining of the medical profession has been a short-term solution to a long-term problem, but short-term expedients can have long-term consequences.

Second, doctors are, potentially at least, a dangerous extra-parliamentary group, precisely because of the esteem in which they are still held by the public. It is true that they are not united and, on the whole, are not vastly interested in politics. None the less, as shown by the episode when Lord Winston spoke out in this magazine, politicians have much to fear from doctors. He spoke the unvarnished truth as he saw it, without imagining that he was making a party-political point, but the panic at the lying heart of the government was obvious for all to see. The question for the government was not “Is it true?”, but “Will the public believe him?”. In the circumstances, it would be only prudent to discredit the medical profession in general and in advance.

The whirligig of time brings its revenges, however. Now that the deficiencies of the health service can no longer plausibly be attributed to murderous or incompetent doctors, the government has suddenly discovered the concept of the unjustified and unreasonable complaint (having previously encouraged such complaint), against which the government must stand shoulder to shoulder with the long-suffering doctors. With friends like British politicians, who needs enemies?

There is another, even greater source of discontent in the medical profession, and that is the increasing managerialism of the health service. Never have so many decisions been made centrally and “cascaded down” (to use a term favoured, at least for the moment, by managers) to those who have to implement them. Arbitrary and centrally fixed targets are imposed upon a monopolistic system; and the result, all too predictably, is organised lying. Do you want to reduce the time a patient waits between being seen in a casualty department and being admitted to a bed on a ward? Simple: rename trolleys as beds, and call the corridors wards.

The whole purpose of these targets is not to bring about improvements in the health of anybody, but to intimidate. Who now remembers the fatuous and arbitrary targets laid down in Health of the Nation (including reductions in the national cholesterol level), and who cares whether they were met or not? The deadline for reaching the targets passed without so much as a murmur. But the white paper certainly achieved its end, if not its targets: to let everyone know who was boss, and to turn general practitioners into minor functionaries. That is why further, equally fatuous targets will be set, which will be reached by one of two means: statistical manipulation or the total neglect of more important matters.

We now live in a miasma of untruth as well as intimidation. There is talk about giving the guidelines laid down by the National Institute for Clinical Excellence some kind of legally binding power, which would not only circumscribe further the professional freedom of doctors, but also give them one more cause to look over their shoulder all the time. The revaluation of doctors and their obligation to produce annual Personal Development Plans (in which they are supposed to explain how they are going to make themselves better medical practitioners) have been accepted as rituals that must be performed, but which have no other meaning than to satisfy or propitiate our political masters. No one has ever bothered to demonstrate empirically, instead of by a priori reasoning, that the implementation of such bureaucratic tasks has ever improved the health of so much as a single patient, and no one seems to find it in the least bit necessary to do so. Untold thousands of hours of medical time that could otherwise be spent looking after patients are now to be spent in this fashion, and this is happening, it should be remembered, at a time when very large numbers of consultant posts are unfilled and Britain is scouring the world for medical staff to import.

Medicine in this country is becoming just another bureaucracy. It is certainly no longer recognisable as a liberal profession, and there could be nothing more corrosive of the morale of intelligent and educated people than the cynicism induced by the compulsory performance of meaningless bureaucratic tasks.

Britain, in its provision of healthcare, risks becoming like Zaire under Mobutu. There, the people had to scrabble around for whatever medical care they could find on the ground, while le Guide and les grands, as Mobutu and his acolytes were known, flew off to somewhere more comfortable whenever they had toothache.

Theodore Dalrymple is a doctor practising in Birmingham