Governing Medicine: Theory and PracticeBMJ 2004; 329 doi: http://dx.doi.org/10.1136/bmj.329.7478.1351 (Published 02 December 2004) Cite this as: BMJ 2004;329:1351
I've a fantastic idea for a reality TV show. But it's one with a twist: the future of the NHS will be decided on the outcome. The show takes place in a hospital, and the contestants will be doctors and managers. The audience will be the patients, who vote on how to run the hospital. But they won't be told that the options are unworkable. The contestants know, given the equipment and information supplied to them, that the options are impossible. But they're out of the show (it's in their contracts) if they say anything to try to influence the voting. There'll be plenty of crisis and angst. The contrast will be provided by the nurses: they'll exude calm while the protagonists argue. But peace won't break out; it's not good for ratings.
The game rules are that the doctors must do what they are trained to do: treat the sick to the best of their ability. But they also must prove it to the satisfaction of the managers, who aren't trained to know. Meanwhile the managers have to get the doctors to see certain patients when and how we tell them. And we'll change that from episode to episode ostensibly on the basis of audience voting. We all know that making doctors do anything against their will is like herding cats. So the managers can't make it work either. Brilliant, isn't it?
Governing Medicine shows the extent to which the NHS has become a cynical political game. Gray and Harrison have brought together an impressive list of observers of the health service who have produced a highly readable social commentary on clinical governance. I found the introduction and the first section to be riveting. The thesis is that clinical governance is really a means of controlling doctors, while the publicly acceptable rationale is to drive up standards. The authors of the first six chapters provide ample evidence and cogent reasons for the likely failure of that rationale. The second section reveals practical faults in the bedrock of clinical governance: the use of randomised controlled trials to predict best practice, guidelines that don't allow for human nature, information systems that are judged in different ways by policy makers and practitioners, and circumscribed user involvement.
However, I was disappointed by the third and final section. The authors seem to have learnt nothing from the analyses of the earlier sections and revert to the rhetoric of clinical governance and NHS politics. The premise seems to be that if only everyone would behave as they're supposed to then clinical governance would work, and doctors, nurses, managers, and patients would between them create the ideal health service. Unfortunately the anthropological critique in the first two sections shows that people don't always follow the script.