This is the arresting title of a piece by Glasgow General Practitioner, Margaret McCartney, in a recent edition of the British Medical Journal ( BMJ2016;353:i2822). It is one of her weekly “No holds barred” series and is characteristically forthright and insightful.
“Doctors used to have much autonomy, leading to innovation, excellent care, and high job satisfaction – but also to exhaustion and a few doctors taking advantage of minimal oversight. We now have a bureaucracy, intrusive checking of often irrelevant “performance” data, and an entire industry professing to regulate us. We no longer have a moral contract to practise medicine but instead have an angst ridden, nit picking one that assumes the worst and tries to find it.”
“ I won’t resentfully add up the extra hours I worked this weekend or before my official start time, as long as I’m doing a useful job that’s valuable to patients and I retain some control over my working life. If my work feels crammed with conflict, if I’m routinely pleading for referrals to be accepted, or when organisations change without consultation or consideration, then clock watching and declaiming that “it’s not my job” will become natural.”
“Treat workers as mere disposable cogs in the corporate wheel, and they won’t imagine or invest their future as part of it. So, no one will innovate, create or challenge. No one will feel ownership of a shared destiny. All of this will have to come from external management consultancies with variously laughable grasps of medicine.”
“If truth is the first casualty of war, the NHS is fighting for its moral life. Meeting the needs of everyone, free at the point of need; do this first, and then we can talk. We need an evidence based NHS, released from the stranglehold of party politics that causes so much waste and angst. But we also need to backtrack, to take advantage of professionalism and to allow staff to use it.”
Powerful stuff but is she right?
Was medical professionalism really a good thing? Many years ago when I worked for a regional health authority I had a particular responsibility for trying to ensure that our consultant employees fulfilled their contractual obligations in terms of productivity and quality. I assumed that human nature being what it is some consultants would work hard and deliver high quality care whereas others would operate at the other end of the spectrum. The problem was how to identify the latter. In practice this was very difficult as consultant colleagues rarely gave the game away and most managers clearly considered it not their business to spill the beans. During the 7 years that I fulfilled this monitoring role at no time did anyone approach me about a consultant’s poor performance. However, I soon came to realise that when a group of consultants came to see me to discuss the early retirement “on medical grounds” of a colleague it was often an admission that productivity and/or quality had deteriorated so much that urgent action was needed, albeit action which gave no direct hint of failure and which was easy to accomplish as who better than fellow doctors to testify to acceptable medical grounds?
So, as Dr McCartney nicely puts it, these were the “few doctors taking advantage of minimal oversight”. I did worry however that those put forward for retirement were probably the tip of an iceberg of unknown dimensions. So I am not certain that Dr McCartney’s few were really so few. And how reliable was the implicit guarantee provided by professionalism? Not very reliable in my experience.
Turning to the recent junior doctors’ strike, alluded to by implication in Dr McCartney’s piece, the idea of striking would never have occurred in my day. We were happy to work all hours for peanut pay in the sure and certain knowledge that what we were doing was valuable and that in due course we would have very well paid high status interesting jobs which would also allow a normal private/family life. Although the junior doctors made great play of their concern for patient safety we know from leaked emails that in truth the real reason for striking was pay. But why should today’s junior doctors be so different to those of my day? Evidence perhaps of the angst ridden, nit picking NHS culture that assumes the worst and tries to find it, as described by Dr McCartney.
I totally agree with Dr McCartney’s condemnation of the changes to the NHS done without proper consultation or consideration. Having started my medical career in 1965 I have lived through many reorganisations only one of which – the 1974 one, as slightly amended by the 1982 one – improved the Service. Putting community health services under the same management as hospital services made sense though it was a great pity that the transferred community services did not include adult social services. But transferring the non environmental elements of the public health function was a mistake that set back community medicine as the medical element of public health was then called by at least a decade. Introducing supermarket style general management into the NHS was also misguided – I speak as one of the few doctors who were foolish enough to take on general management roles in the wake of the Griffiths Report. The replacement of a directly managed regionally planned service by an internal market was similarly ill conceived. The latest Andrew Lansley changes seemed to be based on a personal whim, little understood and much regretted now even by the government that introduced them. What other national institution would be treated in such a cavalier fashion, I wonder?
As for new regulatory industry my own brief experience of this as a member of an inspection team leads me to believe that it serves only as a gravy train for the vast army of inspectors and that their conclusions are more or less meaningless.
So, if professionalism failed in the past, over bureaucratisation and regulation is failing now and the continuing level of political interference causes waste and destabilisation, what is the answer?
The last thing the NHS needs at the moment is another major reorganisation. A long period of system stability would, all other things being equal, be a good thing. But other things are not equal and nothing short of radical change will rescue healthcare in England from the sad state it has been driven into.
Paul Walker, June 2016.