Julian Tudor Hart, Why are doctors unhappy?

WHY ARE DOCTORS UNHAPPY, AND WHAT CAN BE DONE ABOUT IT?

BMJ 2001

GPs are squeezed between patients� expectations for instant remedies without risk or error, and government pressures to speed the conveyor and tighten quality control. Extending the strategy initiated by the Conservatives in 1990, New Labour’s Alan Milburn is developing an industrialised, consumer-led NHS. Meanwhile bureaucracy marches on: as a proportion of spending on healthcare, administrative costs have doubled from about 6% before the 1990 “reform” to about 12% now. This is still behind USA at about 25%, but the modernisers are on course to reach that target.

The driving force behind this strategy is perception of the NHS as an industry producing clinical interventions as discrete commodities, episodically consumed by patients. In the programme espoused by New Labour, innovation will come from State-assisted corporate investors, for whom public service will be subordinated to pursuit of profit. Motives for this electorally unpopular(1) strategy were explained by Richard Smith in 1996(2) and Allyson Pollock in 1999(3). New Labour�s devotion to creeping privatisation of the NHS starts from its conversion to classical economics, the World Trade Organisation, the World Bank, and its commitments to the General Agreement on Tarrifs, Trade and Services to open all public service to global competition and investment. None of these has any mandate from the Party membership or the electorate.

To prepare for this, all NHS activities are so far as possible being parcelled into commodity units, suited to profitable provision by traders in public service. But how far is possible, without impeding effective and efficient care? Conservative governments tried and failed to create market competition between hospitals and between GPs. New Labour tries and will fail to get private investors to build new hospitals and develop new primary care where there is greatest need for improved care, not where these investments would be most profitable. As with other privatised national services, investors will make the profits (mainly by reducing the number, pay and security of staff), while the NHS and its patients keep the risks.

Things would be easier if New Labour could proceed directly to North American solutions. If the NHS didn�t have to provide the most difficult services for the most difficult people, but just let them pile up in hospital Emergency Rooms, we could concentrate on high quality care for easy people, and heroic salvage for the rest. But in the UK, according to opinion polls, a substantial majority even of conservative voters continues to believe in a socialised NHS, based on neighbourhoods and devils they know, not on shopping around between competing providers(4). Doctors either don�t know this, or let themselves be persuaded by the free medical tabloids to forget it. The professional optimism of the 1970s has gone. Sons and daughters of professors of medicine no longer grieve their parents by �throwing their lives away� in general practice, and GPs now curse their patients as they did in the early 1960s. Why? Because they see them as insatiable consumers, not potential partners in production of health gain. Successive governments have imposed a new consensus that clinical production must follow an industrial model, enforced by tight management. This violates the continuity, solidarity, and locality that made for satisfying work in the past, and promotes mistrust. Like patients, a large majority of doctors remain loyal to the original principles of the NHS, but also like patients, their hopes diminish that these principles will be upheld by any political party in office. On this hopelessness industrialisers and commercialisers depend(5).

Richard Smith rightly describes as bogus the assumed contract between doctors as providers and patients as consumers. Instead he proposes an honest contract between doctors and patients as equally valuable and essential co-producers. This needs to be spelled out as a material foundation for post-industrial production of socially useful value, beyond, outside, and eventually alternative either to commodity trading for profit, or to the old authoritarian pattern of State paternalism(6). Clinical medicine is effective, and more so than ever before(7). Its efficient delivery depends on continuity, social solidarity, and locality, all of which impede and confuse trade in care as a commodity, but meet profound human needs. This is something health professionals could understand very much better than career politicians, if only we were prepared to take a few infant steps toward critical social and economic literacy. Over the past 50 years, first the Lancet, then the BMJ, have developed into an increasingly effective dissident press, able to see that the New Emperors have no clothes, and daring to say so. To restore professional morale, we need a much clearer, bolder, and more independent perspective, recognising that we can gain the initiative whenever we dare to accept it. In the early 20th century doctors got themselves a special relationship with rulers. In 1990 they lost it. This loss made possible a more dignified and rational alternative, a working alliance with patients, both able to see that in a society whose decks are awash with wealth, we can easily afford an NHS to be proud of. We already have the beginnings of this alliance in the ordinary processes of continuing anticipatory clinical medicine: all we need is to recognise our friends.

1. Jowell R, Curtice J, Park A, Brook L, Thomson K, Bryson C (eds). British Social Attitudes: the 14th Report: the end of Conservative values? Aldershot: Ashgate Publishing/SCPR, 1997.
2. Smith R. Global competition in health care. British Medical Journal 1996;313:764-5.
3. Price D, Pollock AM, Shaoul J. How the World Trade Organisation is shaping domestic policies in health care. Lancet 1999;354:1889-92.
4. Guardian supplements 20/21.3.01.
5. Bosanquet N, Pollard S. Ready for Treatment: popular expectations and the future of health care. London: Social Market Foundation, 1997, pp.98-103.
6. Hart JT. Two paths for medical practice. Lancet 1992;340:772-5.
7. Bunker J. Commentary: The role of medical care in contributing to health improvements within societies. International Journal of Epidemiology in press 2001.