Initially, I felt embarrassed that I couldn’t think of a single paper that has changed my life. Did this mean that I was getting arrogant and unreceptive with age, or did it reflect the progressive ‘camembertisation’ of my temporal lobe, or both? But then I decided that lives are changed by new ideas and beliefs, and these are almost always dependent on contact with other people. The style of scientific publication is too impersonal. But if I can’t remember being bowled over by a published paper, I can think of a number of lectures, which have left me in awe of not just the intelligence and achievement of the lecturers, but also their showmanship. Showmanship need not be a term of denigration: it is the essential human factor needed for the promulgation of new ideas. There is little showmanship in a published paper: the personality of the author is suppressed by scientific convention (and if it ever escapes, it is usually only to show its more venal, self-promoting side).
Showmanship comes over also in books, and I want to describe two – both recently published – in which the writer’s message has already had a profound effect on my thoughts and self-belief. Both are masterpieces of their craft and utterly convincing. Both are concerned with the plight of the NHS, and the awful destructive spiral currently engulfing both clinical practice and medical professionalism. The first is NHS plc: The Privatisation of Our Health Care by Allyson Pollock, a professor of health policy and health services research. The second is a collection of essays, Hippocratic Oaths: Medicine and its Discontents, by Ray Tallis, a professor of geriatric medicine.
NHS plc is staccato in its tensely passionate, but clinical, listing of every cynical step taken by successive governments (and principally the present one), in order to prepare the ground for privatisation of the administration of both primary and secondary care. In some instances, the perpetrators have benefited personally from the changes, which they, as public servants, have instigated. But leaving any question of corruption aside, the outcome of the present process is inevitable. Much of the public health (and disease) care budget is already squandered on daft ideas and crass mismanagement, but an increasing proportion of what remains is now being diverted into private pockets. The consequence is that comprehensive NHS care will very soon be unsustainable, and two-tier or multi-tier disease management will be inevitable: a system that is insurance based, with payment for item of service, supplemented by private practice – and devil take the hindmost. The morality and processes of government are such that those in power learn nothing from earlier disasters, such as the privatisation of the railways. The NHS has been a priceless asset but is one that is now being greedily dismantled by those who know not what they do.
The language and style of Hippocratic Oaths is more wide-ranging in its analysis of the state of medical professionalism, but the message is the same. The immensely gifted author is also a dedicated coal-face worker (if that metaphor has not been outdated by the privately held and publicly funded convictions of Margaret Thatcher). He gives a very personal (but impersonalised) account of the bloody awfulness of a consultant’s life in British hospitals: insatiable clinical need, resources that are both inadequate and being progressively squeezed, mounting bureaucracy and inefficiency – open-ended accountability for services over which she/he has little control. All of this is endured in a climate of criticism and complaint, which has been openly encouraged by government. The consultant is sustained only by the ethics of her/his profession. But these very ethics are being eroded: it is now illegal to work long hours in order to compensate for the deficiencies in other parts of the service. The consultant is only allowed to be dedicated for 48 hours each week (although accountable for 168). The picture will be all too familiar to many who read this article.
As I have watched events unfold over the last 15 years, I had begun to fear that I was going mad, and that my perception was distorted. The effect of these two books has been to reassure me that it is not my perception that has been at fault, but my self-confidence. When things fall (or are kicked) apart, ‘The best lack all conviction, while the worst are full of passionate intensity’. But while I am obviously pleased to find that I have not (yet) gone mad, I also realise that it would be far better for the rest of the country if I had. If I am not hallucinating, then the things I am witnessing are real: I am no more psychotic than the little boy who saw through the emperor’s new clothes.
But what next? These books have both rekindled my self-belief, and fanned my despair. They have also left me asking what we are all going to do about it. I can’t help feeling that doctors have been abject in allowing their profession to be raped by the Janjawid of New Labour. My generation has enjoyed the glory of the NHS as it evolved from the idealism-cum-necessity that followed the Second World War. But now the welfare state must succumb to the more despicable elements of human nature, as, perhaps, the world-weary gods on Mount Olympus would have said was inevitable. The gods might say that we should be grateful that the NHS has lasted as long as it has. But is there just a chance that it could last a little bit longer? Is there just a chance that doctors could preserve their professionalism? I don’t know. I suspect not, but then again… There may be quite a number who are thinking, ‘If you push me too far, I just might…’
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9 Nov 2023