Doctors in these times of general suspicion have generally been among the most trusted of professionals, despite occasional revelations of serious wrongdoing by individual members of the profession. Even the evil activities of Dr Shipman hardly dented the regard in which doctors were held, and no one seriously feared to encounter his like when consulting his or her doctor. Everyone implicitly understood that he was one of a kind, and that in any large number of people there were bound to be some who fell far short of the expected high standards.
But trust can easily evaporate and is hard to re-establish once gone. The behaviour of the junior doctors, reminiscent of the unionised car-workers in the 1960s and 70s who did so much to destroy the British car industry by pursuing ruinous pay claims, has severely damaged their prestige in the eyes of the public. They are no longer special; they are no different from any other group that thinks it can hold the public and the government to ransom. For them, the suffering they intend to inflict on patients (for how else is their strike supposed to have an effect?) is no different from the inconvenience inflicted on the public by a strike of train drivers.
However, they are also behaving in a way that is a natural response in the way in which they have been treated. The rot started with Mrs Thatcher and has only accelerated since.
Mrs Thatcher, perhaps unwittingly, began the trend to de-professionalisation. Perceiving, quite rightly, that there was gross inefficiency in the public service, not least in the health service, she exalted the supposed science of management, shifting the balance of power decisively from professionals to bureaucrats. Management was a kind of transcendental, abstract logic applicable to any organisation, irrespective of what its purposes were. If you could manage a supermarket or a car factory, you could manage a hospital.
Unfortunately, management is composed of beings of flesh and blood, not of calculating machines with no interests of their own to pursue. Managers in the public service who were supposed to be increasingly business-like came to think of themselves as actual businessmen, though with no genuine balance sheet that reflected the actual performance of what they managed, and no capital of their own. The result was organised, if also legalised, looting, and the creation of a large and inherently expansionary apparatchik and nomenklatura class. The purpose of administration was henceforth not to administer, but to create even more administration. Procedure was the idol before which everyone had to bow down: let the heavens fall, so long as procedure is followed.
In all this, doctors were deprived of any real say, and did very little to counteract or even protest against the tendency, despite being in an apparently strong position to do so. Once, for example, I received a telephone call from a manager to say that I had not filled my activity returns, to which I replied that not only had I not done so, but that I was never going to do so and my in the matter decision was final. I never heard any more of it: and as far as I am aware, the hospital did not collapse, and no patient suffered as a result of my missing activity returns. Neither was I fired: the object of the form was let doctors know who was boss.
A senior doctor in the prison in which I worked taught me a very valuable lesson about bureaucracy. One day I found him in his office suspending over his waste-paper basket a form between his forefinger and his thumb as if it were a noxious or repulsive insect. The form was from the Home Office, as it then was, inquiring about the prison’s needle exchange scheme. The prison didn’t have one, because the doctor didn’t agree with the whole idea.
“If I so much as put a mark on that form and send it back,” he said, “I’ll never hear the end of it. But if I throw it in the wastepaper backet, all that will happen is that I will receive another one in six months’ time, which I shall also throw away.”
And he was right. Another form duly arrived six months later.
Doctors became almost unimportant in the running of a hospital. This was brought home to me graphically by a large public poster showing the management of the hospital in which my mother died. There was a kind of pyramid composed of six layers, with photos of the people at the various layers of management, more of them as you descended the layers. From looking at the first four of these, you would not have had the faintest idea what kind of institution or organisation the managers were managing, or what the organisation was for: it could have been anything from a nuclear power station to a casino. There were directors of strategic planning and directors of commercial operations; there were assistants to directors of strategic planning and directors of commercial operations.
It was only at the fifth layer that one caught a faint glimpse of what the hospital was for: for here, included among other personages of middling importance, was the medical director – though with no photograph of him. Whether he refused to provide one, whether he was ashamed to provide one, or whether he was to be put in his place by forcibly remaining unrecognisable, I do not know; but the absence was striking.
No doubt there is no art to find the mind’s construction in the face, but when I looked at the pictures of the people in the first four layers of the management structure, all smiling broadly and even happily, I could not help but see a large element of triumph in their expression: and they were justified in their sense of triumph. Here were the new masters.
Meanwhile, my mother, who stayed six weeks in the hospital before she died, saw her consultant, nominally in charge of her treatment, only twice. He didn’t know who she was or anything about her; nor did she see any other doctor above the level of houseman more than twice in all that time.
In short, continuity of care had been managed and organised out of existence. There was no sense of teamwork, not surprisingly because there were no discernible teams – as were once de rigueur in hospitals. Patients had become like parcels in a game of pass the parcel; the doctors were now shift workers, and when the music stopped, that is to say when their shift was over, they handed the parcel on as quickly as possible, even in mid-examination. Thanks to the European Working Time Directive, which management enforced with delectation because it increased their power over doctors, managers prowled the wards to ensure that no doctor exceeded his or her permitted working hours.
Continuity of care is obviously efficient (because doctors’ knowledge of patients is implicit as well as explicit), as well as humane and comforting to patients, but it is inimical to bureaucratic control. Absence of such continuity saps medical work of much of its interest and satisfaction, for brief encounters with people merely to carry out a protocol decreed by someone else is not very fulfilling for people who have undergone an arduous education and training, only to find themselves treated as if they were on a production line.
Targets have introduced another source of misery for doctors, as well as a source of intellectual and moral corruption. Such targets can almost always be met by a combination of creative manipulation both of reality and statistics, together with distortion of priorities. When the government decreed, for example, that no patient should have to wait more than four hours for admission to a hospital bed once the decision had been made to admit him, and that the performance of hospitals would be judged by how far this target was met, various methods were devised by different hospitals for the achievement of the target. Some refused to allow patients out of the ambulance in which they arrived at the hospital, others relabelled trolleys in corridors as hospital beds. But the bureaucratically-imposed imperative to admit patients within four hours, irrespective of other needs, led to distortion of efforts rather like the misallocation of funds in a centralised economy. In one case known to me, a doctor was repeatedly called to casualty to attend to a patient who was about to “breach” the four-hour rule while he was resuscitating a patient on the ward.
What is true in hospitals is fast becoming true in general practice: for example, the patient now is lucky who gets to see the same doctor on two successive occasions.
Governments have ground extremely small in their efforts to turn doctors into workers like any others. For example, the imposition of the NHS logo throughout the country reduced local pride in particular institutions, no place being allowed a particular identity; local pride and loyalty are an obstacle to centralised control.
Having undergone an arduous training, doctors are treated like minor functionaries. It is difficult for s sense of vocation to survive such a dispiriting contradiction.