The sickness at the heart of modern healthcare
Two new books take the temperature of the NHS.
Hippocratic Oaths: Medicine and Its Discontents, Raymond Tallis, Atlantic, 2004.
NHS plc: The Privatisation of our Health Care, Allyson Pollock, Verso, 2004.
Raymond Tallis, philosopher and geriatrician, is a Renaissance man whose assessment of the ills of contemporary medicine covers a broad canvas. Indeed, if his book has a fault, it is that it tries to cover too much. Readers who are interested in his defence of scientific medicine against the ‘regressive temptation’ of alternative health, his critique of popular notions such as the ‘expert patient’, ‘consumer empowerment’ or the cult of ‘organised distrust’, or indeed his trenchant views on MMR, Alder Hey and ‘defensive medicine’ are advised to read this excellent book. I focus here on one chapter, entitled ‘Communication, time and waiting’.
Tallis’ method is to begin with an insight derived from his experience of clinical practice which leads into a discussion of some of the difficulties inherent in the doctor-patient relationship. This in turn leads to a critique of the irrational responses to these difficulties that are currently influential in medical practice, often to the detriment of both doctors and patients.
‘Poor communication’ is the most common complaint against doctors. Yet, as Tallis notes, despite a decade of formal teaching in communication skills and a sharp increase in the proportion of the supposedly more empathic female doctors, patient dissatisfaction seems to have increased.
This is not surprising, because the fundamental difficulty in this area arises from the ‘incommensurability of the personal experience of illness and the scientific understanding of it’. Teaching doctors standardised communication skills may equip them to play the part of salesman to the patient as customer, but they are of little use in dealing with the sick. Nor are formalised policies of ‘informed consent’ likely to help doctors and patients deal with the real problems of working out the ‘what’ and ‘how’ and ‘when’ of passing on information. As Tallis observes, ‘there are many people who are confident that they know the answers to these questions’. But ‘very few of them are doctors who meet patients, day in and day out’.
In practice, the greatest limit to communication is time, and ‘over the last few years, the gap between expected and available time is widening – and it will get wider’. As patient expectations have grown in tandem with the advance of medical technology, doctors have found more and more of their time taken up with management and training, and with monitoring and maintaining standards.
The resulting pressures on doctors have contributed to growing job dissatisfaction: whereas 20 years ago it was considered necessary to make retirement at 70 compulsory, now the trend is towards early retirement. Manpower shortages and recruitment problems are creating serious difficulties in many areas of medicine. New regulations and contracts affecting hospital doctors and GPs encourage shift-working, part-time working and the abandonment of evening and weekend commitments.
Yet, as Tallis notes, the shift away from continuity of care and individual responsibility for patients signals a ‘profound change in attitudes’. It seems that many doctors are more concerned about improving their ‘work/life balance’ than with defending professional autonomy. Together with alarming trends towards the dumbing down of medical education, these developments threaten to de-professionalise medical care to the detriment, not only of doctors, but of patients too.
In the climate of heightened anxieties about health that has been assiduously fostered by New Labour, any delay in medical consultation and treatment must be regarded as a grave violation of consumer rights. Any patient who is advised that the best course of action is to ‘wait and see’ is now encouraged to believe that they are ‘being fobbed off’, ‘not taken seriously’ or ‘patronised’. In fact, as Tallis wisely notes, waiting is ‘inherent in illness’: we wait to see if the fever abates or the pain resolves, we wait to see if simple measures work and we hope that, in time, things will improve. Mercifully, for doctors as well as for patients, things usually do.
For Tallis, ‘the knot of waiting, impotence and uncertainty at the heart of sickness contributes to many patients’ standing discontent with medicine’. The instant availability of diagnosis from NHS Direct and the quasi-statutory right of access to a GP within 48 hours may not benefit patients. It usually takes time for the distinction between the serious and the trivial to become apparent. A most powerful diagnostic tool – time itself – is being squandered through the subordination of medicine to political expediency.
In a later chapter, Tallis examines the ‘permanent revolution’ that has gripped the NHS over the past decade. The drive to wrest control from the medical profession has dictated a hectic pace of structural change and institutional reform. Like Tallis, I can think of numerous doctor-led innovations in health care in recent decades, but none that derives from managerial initiatives. Disillusionment with the austere public sector collectivism of the NHS has prompted the drive to import alternative models, from Europe, the USA, or, most popularly, from the private sector. The result is the chaotic combination of policies that now drives Tony Blair’s modernised NHS.
For Allyson Pollock, professor of health policy at University College London, ‘the NHS is being dismantled and privatised’, creating a ‘disaster’ that is ‘overwhelming in its complexity and its magnitude’. She hopes that ‘one day people will demand the restoration of a national health service’ but fears that, by then, ‘the institutional memory will have been lost’.
In NHS plc she provides a devastating critique of the consequences of the current vogue for introducing commercial principles – and commercial enterprises – into our hospitals and surgeries. Whatever the defects of the old NHS, the new NHS is more costly and less efficient. Pollock is both horrified and mystified that New Labour has proved ‘able to convince so many people that it was still committed to comprehensive, universal and equal-access health care, when its policies were clearly running in the opposite direction’.
Pollock prefers Old Labour to New Labour: for her the replacement of Frank Dobson with Alan Milburn in 1999 symbolised the transition from the collectivist NHS to the modernised and privatised health care system that is now taking shape. But in her understandable antipathy towards the Blairite cynics and their smug corporate allies, Pollock tends to sentimentalise the old NHS, failing to grasp how its complacency and low standards in many areas paved the way for managers and entrepreneurs promising a more efficient and responsive service.
Pollock chooses to exemplify her argument with the case of children’s hospital services in Hackney, where I work as a GP. She tells the tale of the closure in 1998 of Queen Elizabeth Hospital, which she describes as ‘a model of how a hospital in a severely deprived inner city should be run…accessible, open and caring, and with exceptional expertise and a superb service’.
In fact, this is a considerable exaggeration: some departments were sensitive to local needs, but it is also true that some of the consultants were aloof and indifferent, more concerned with their academic links to Barts and Great Ormond Street than with the social problems of Hackney. This is one reason why local opposition to the closure – from doctors as well as patients – was not quite as vigorous as Pollock implies. It is also worth noting that the service for children in Hackney that has subsequently been developed at the Homerton Hospital is, in general, far superior to that previously provided at QEH (even though the occasional child needing intensive care has to be transferred elsewhere).
As it happens, Homerton is one of the first wave of ‘foundation’ hospitals. Pollock’s tendency to identify the old NHS as good and the new NHS as bad ignores both the failings of the old order and some of the benefits of the new. It also implies a strategy that simply seeks to return to the mythical golden age of the postwar NHS.
Pollock only turns to the question of ‘what is to be done’ on page 225 of a 226-page book. After a couple of anodyne paragraphs about planning, transaction costs and waste, in her final sentence she suddenly issues a dramatic call to the barricades: ‘What is required now is not reform but revolution – a quiet, collective and reflective revolution of the sort that brought the NHS into being in the first place.’
In fact it was war, not revolution, that brought the NHS into being. At the moment, when there seems little prospect of either in Britain, Pollock’s rhetoric merely expresses the despair of the old left about how to deal with the monster it has spawned. Some quiet, collective, reflection on how the failures of state socialism paved the way for Margaret Thatcher and Tony Blair might usefully complement her acute analysis of the current state of the NHS.
Hippocratic Oaths: Medicine and Its Discontents, by Raymond Tallis, is published by Atlantic Books (buy this book from Amazon (UK)). NHS plc: The Privatisation of our Health Care, by Allyson Pollock, is published by Verso Books (buy this book from Amazon (UK) or Amazon (USA)).
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