The NHS: last act of a Greek tragedy?

BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7260.572/b (Published 02 September 2000) Cite this as: BMJ 2000;321:572

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Government that puts money into redressing inequalities is worthy of support

  1. Ruth Brown, general practice principal
  1. Lisson Grove Health Centre, London NW8 8EG
  2. Hampton Wick, Kingston upon Thames KT1 4AS
  3. Bury St Edmunds, Suffolk IP33 2BN

    EDITOR—How sickeningly predictable is the editor's response to more funding for the NHS.1 Having spent decades demanding more money; the journal then rubbishes the government that finally comes up with it; predicting that the much loved British institution is going to sink.

    Primary care groups were formed only last year, and fundholding unravelled at the same time. Since then, in my primary care group, we have put in place “gold standard” care for diabetes, which will reduce morbidity and mortality, and reviewed funding at practice level to ensure it is led by workload and needs. Furthermore, we are set to launch a primary care group wide programme for the management of ischaemic heart disease and asthma, which should be up and running by Christmas. This was done with no expectation of the kind of funding announced recently and was about a desire to achieve high standards for its own sake.

    I would remind the editorial board of the BMJ that the only reason that there has been criticism of this government about mortality from heart disease and cancer is because clinical outcomes have been prioritised—for decades, it was only money which mattered.

    I also remind you of the fiasco of the Tomlinson report of 1994, which pushed down bed numbers in London relentlessly despite protest from general practitioners, hospital juniors, and patients, and in the face of a 300% rise in the use of the emergency bed service. Well paid researchers and managers, who did not bear the clinical responsibility for 95% bed occupancy, insisted on this policy until the current government was persuaded by the evidence to abandon it; it has since published accurate estimates of bed numbers which have been most unfairly used against it.

    If the current leadership of the medical profession wants something to really whine about, the displacing of the current administration and the installation of the Conservative Party's leader, William Hague, and his party colleagues will give it to them in abundance; but I will not be among those assisting Mr Hague to achieve his ambition.

    For those of us working in the inner city a government that finally recognises the link between health and social deprivation (see the lecture given by the Health Secretary, Alan Milburn, to the London School of Economics on 8 March 2000) and puts money into redressing these inequalities is worthy of support. The remaining years of my practice will be a challenge to make that which is good better—a prospect that I had hardly dared to contemplate.


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    Creativity is not valued in public sector

    1. Chris Manning, co-chair, PriMHE (Primary care Mental Health Education) (chris.manning{at}primhe.org)
    1. Lisson Grove Health Centre, London NW8 8EG
    2. Hampton Wick, Kingston upon Thames KT1 4AS
    3. Bury St Edmunds, Suffolk IP33 2BN

      EDITOR—With reference to the editor's comments on the government's increased funding for the NHS,1 raising the morale of the NHS workforce is now imperative. The direct affirmation of this by the King's Fund is a breath of fresh air in an environment where, despite the prime minister's recent statement about a feature of Britishness being creativity, the exact opposite is the experience of many in the public sector.

      Many caring “canaries” are breathing their last in an atmosphere of top down, reactive, and downstream attitudes. In the past few months I have read about two doctors who committed suicide and two young teachers who left suicide notes mentioning impending Ofsted inspections.

      Instead of revaluation and plaudit, we have revalidation and audit. Instead of advocacy and support, we have governance and punishment. We need all these surely, evenly applied, if we are to achieve a balance?

      Of course, we all want to live in a healthier culture where care is more evenly apportioned and better delivered, but the evidence is mounting that this will be increasingly realisable through the motivation of individuals, teams, and collaborations in a culture of respect and not by the constant politicisation of the NHS, short-term populist agendas, and high tech medical interventions.

      It is not as if most people, including healthcare professionals, wish to be mediocre. It is rather that most have high hopes and aspirations initially, to then have them frequently frustrated and dashed by training and working in an uncaring system. The fact that the doctor described as exemplifying “patient centred behaviour” and “patients' unvoiced agendas” is known to me and has just left the NHS for precisely these reasons is a glaring demonstration of the truth of this.

      The fact that the NHS Executive still, after many years of lobbying by many concerned individuals and organisations, has produced barely an inch of movement in a positive direction on the morale and health issue of the NHS workforce and the introduction of an independent occupational health service, is indicative of the truth of what the King's Fund is saying.

      We know enough about human needs and aspirations to be moving this forward. With less unhappiness, people would be more fulfilled, more productive, and less inefficient.

      Many of us are highly committed to this issue, and the endorsement of the need for a new approach is warmly and genuinely welcomed.


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      NHS should be abolished

      1. F S Goldby, retired consultant physician. (Stephen{at}goldb.freeserve.co.uk)
      1. Lisson Grove Health Centre, London NW8 8EG
      2. Hampton Wick, Kingston upon Thames KT1 4AS
      3. Bury St Edmunds, Suffolk IP33 2BN

        EDITOR—The NHS is not the subject of a Greek tragedy, only an anachronism.1 It served the purposes of a nation exhausted by war in 1948. It is ill suited to the needs of one of the richest free market economies in the world. All discussion of the NHS is so bedevilled by Orwellian doublethink that it needs to be stated loud and clear: the NHS is long past its sell by date and should be abolished.

        I put forward some propositions for discussion.

        • The NHS is not good value for money. It is cheap because it provides a low level of service

        • The NHS is not the “envy of the world.” British people are, rather, travelling elsewhere to get their treatment

        • The general practice service rations care and limits access to specialist opinion, and hence is loved by the government as it saves money

        • General practitioners are forced to be “Jacks of all trades,” which is impossible in modern medicine

        • It is insulting to a learned profession and its clients to expect a professional medical opinion to be given in a pressured 10 minute interview

        • A general practitioner cannot be expected to be a paediatrician, obstetrician and gynaecologist, general physician, and surgeon rolled into one

        • General practitioners working in groups should specialise, so that someone with a sick child sees a doctor who sees sick children every day. Much of the work presenting at practices can be done by nurses while doctors get on with being doctors

        • The concept of family medicine should be abandoned. When I see a doctor I want my complaint put right, I do not want a discussion with a social worker. A good doctor takes a family history

        • Central manpower planning has failed. It is a device to ration the supply of doctors, which should be opened up to market pressures, so that, for example, there are more than enough orthopaedic surgeons to satisfy the demand for joint replacements, cardiologists and cardiac surgeons for heart disease, and so on. Plenty of doctors are keen to train for these specialties. The NHS will not, and cannot, pay for them

        • There is nothing morally wrong with having a basic tax funded service to ensure that life saving care is available to all while other treatments are provided by an insurance based system. People can then get what they want without interminable and distressing waiting. Why are men going to France for their prostate operations?

        • The medical profession does not want to lose the NHS because it provides secure employment for life—and a copper bottomed pension to round it of—but I fear that it no longer serves the needs of our patients as it should.


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