Where are the medical voices raised in protest?
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7569.660 (Published 21 September 2006) Cite this as: BMJ 2006;333:660All rapid responses
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Comparing notes with medics at international conferences has been
deeply depressing for many years. Despite all the new cash it continues to
be so. Knowing what treatment is available in other countries, and then not
letting the British Public know what treatment they should have, and
thereby forcing the government to do the right thing, makes us as doctors
responsible for the poor state of the NHS. Opinion polls always demonstrate
that doctors are trusted ahead of politicians and journalists and the
public could therefore be appealed to directly. Unfortunately the medical
profession is too hierarchial and the leadership is too often far from
the business of looking after patients as well as being too vulnerable to
persuasion of many varieties.
Competing interests:
None declared
Competing interests: No competing interests
‘Where are the medical voices raised in protest?’ asks Greener, in
his article about the onslaught of NHS reforms. Protest to whom? Hospital
managers are desperate, ministers are not interested. Medical voices are
easily characterised by the media as self-interested. More importantly,
public awareness of the true direction of the reforms has been limited.
However, when departments or hospitals close, and tax-funded services
transfer to for-profit organisations, then protest at last is likely to
be heard, from doctors -and patients. It is premature to conclude that the
profession has acquiesced to the blitz that is descending on Bevan’s NHS.
Competing interests:
None declared
Competing interests: No competing interests
Where Are The Medical Voices Raised in Protest: Fit For The Future?
Dr Greener asks whether the medical profession approves of the
government's reforms and wonders whether the long history of medical
resistance to health policy is gone for good. As he points out, proposed
changes in the provision of healthcare throughout the country are
providing the source of much debate. Principal among these is the
proposed role of the district general hospital within the secondary
healthcare system with the onus appearing to be a downgrading or closure
of many such hospitals. This implies that either there is capacity within
local hospital networks to absorb the current work or that primary care is
both willing and able to provide extended services to prevent the need for
much of secondary care. This is said to be both effective and achievable
and in line with ‘modern changes in healthcare’. We are consultants
involved in acute medicine in West Sussex a part of the Kent, Surrey and
Sussex Strategic Health Authority which has attracted considerable
interest of late regarding the possible restructuring of services. Not
least among these are dramatic proposals in the reduction of workload from
primary care, which we are assured are supported by colleagues in primary
care. In order to assess the genuine views of our primary care colleagues
a simple survey was conducted to gauge the degree to which our colleagues
felt that proposed changes could actually be instigated.
130 questionnaires were sent to all general practitioners registered
in the Arun, Adur and Worthing district addressing both emergency and
elective medical care. 86 replies were returned (66%) of which 2 were not
completed and one practice of 6 partners felt that they could not comment.
This left a sample size of 78 general practitioners (60%). Based on
proposals which had been made by the previous primary care trust (now of
course restructured…) the following were asked.
1) Did our colleagues feel that a 20% reduction in emergency workload
at the acute hospital (as proposed) was achievable without compromising
clinical care in emergency general medicine, clinical haematology,
cardiology, medical oncology, neurology, rheumatology and geriatric
medicine?. Less than 10% felt that a 20% reduction was achievable and
approaching 75% felt that no reductions at all were possible. The results
are shown in figure 1 together with percentage reductions thought
feasible.
Figure 1:Percentage of GP respondents who felt that each percentage
reduction in emergency workload was possible
2) We asked if a 30% reduction (as proposed) in outpatient workload
was achievable in the specialities mentioned plus gastroenterology,
dermatology, respiratory medicine and nephrology. Again 85% of the GP
sample thought the proposals unrealistic within the current system.
Interestingly, only 15% of GP’s felt that a 30% reduction in dermatology
outpatient referrals were possible despite this being an oft targeted area
nationally (Figure 2).
Figure 2: Percentage of GP respondents who felt that each percentage
reduction in outpatient workload was possible
3) We asked if the proposed 8% reduction in ICU admissions was
believed to be possible: not a single GP responding felt that this was
achievable.
4) Finally we asked whether the suggested 57% reduction in A&E
admissions was believed to be possible. Only one GP of the sample of 78
thought this feasible.
This was a simple study to gauge the feelings of our local primary
care practitioners towards the proposed changes which appear to being
instituted as a matter of faith without any evidence base. Clearly there
is little confidence in the proposals among the GPs who will have to
manage the referrals under the proposals. No doubt significant investment
may make some of these targets achievable but at what cost? Not only
would this require financial outlay but would also be to the detriment of
locally provided secondary care. If the proposals were instituted a
minority of patients would perhaps be better served with regard to ‘care’
being closer to home. The majority however would face longer journeys to
larger secondary care centres and in emergency situations this could prove
unsafe.
As Dr Greener says, the government has found ways to interfere in
medical practice on a remarkable scale. Our results show that proposed
reductions in secondary care are deemed impossible without unprecedented
change detrimental to all.
We thank our colleagues in West Sussex for taking the time to answer
our questions.
Lui G Forni Consultant Intensivist & Physician
(lui.forni@wash.nhs.uk)
Mark Signy Consultant Cardiologist (mark.signy@wash.nhs.uk)
Richard M Venn Consultant Intensivist & Anaesthetist
(richard.venn@wash.nhs.uk)
Worthing General Hospital, Lyndhurst Road, Worthing, West Sussex BN11
2DH.
Competing interests: We work in the National Health service and wish
to preserve its integrity.
Competing interests:
None declared
Competing interests: No competing interests
One of the reasons why protests gradually die down is because of the
realization that it may be futile and harmful for your future prospects.
The medical hierarchy has as many powers of patronage as the political
hierarchy and are not loath to use them. They are also entrenched and often
deprive those who raise issues of quality from membership in interview
panels, discretionary points, and budgets to improve their departments.
Many would feel it is not worth the trouble to damage your prospects for
career enhancement by standing up for what is right and those who talk
about merit, quality and clinical autonomy are considered quixotic.
I feel
that there should be constant replenishments of the entrenched medical
hierarchy so that fresh ideas can blossom. Many have been in positions
longer than the prime minister and, as one chairman in the USA memorably
said, "You have the freedom of speech but I have the freedom to fire".
Competing interests:
Supporter of clinical autonomy and pure merit in the NHS
Competing interests: No competing interests
Lost voice of the medical profession
Greener asks the devastatingly obvious question as to why there is a
lack of real protest by the medical profession against what is being done
to the NHS by the present government. Thank God he asks it, because it
seems no-one has done so before, or at least effectively.
Of course there are paradoxes to his query, because in the same breath as
asking where the protest is, Greener also mentions "the opinions expressed
by the doctors I speak to every week". So what he really means is
'effective protest'.
British doctors everywhere, in every walk of medical life, realise that
such profound damage is being done to the NHS as we know it that there
will be little recognisable left within 5 years and indeed it will
probably have imploded like a dying star.But they are not speaking out.
Why?
For a start they remain cowed by the way the Bristol, Ledward, Alder
Hey and Shipman affairs, all to do with renegade individuals no more
numerous than one might find in any group of over 100,000 individuals (be
it politicians, journalists or even ministers of religion) have been very
effectively stage managed to create the image of a tarnished profession.
This was a true gift from God for a government intent on weakening the
only potential opposition to their plans.
Secondly, doctors are embarrassed by the massive pay-rises accorded
them by recent contract negotiations. Consultants, especially, never
wanted their new contract. All they wanted was recognition that they
worked a lot more for the NHS than the government said they did.
Government did not recognise this and said "We'll put you on a contract
which counts your hours". In fact it might be said that this was the first
manifestation of its obsession with numbers and targets rather than
quality. The consultants responded by calling their bluff and saying "OK,
if you dont believe us, then lets have a contract and you can put your
money where your mouth is". Surprise, surprise, the government has now, to
its horror, realised that the consultants were right, as every single job
plan has been agreed with managers. They have scored a massive financial
own-goal and are squirming to find a way out. If the government wanted to
salvage even one tiny lesson from this contract debacle, it would be that
the only group who REALLY know what is going on at the coal-face of the
NHS are the doctors.
But this doesn't really explain why doctors are not shouting from the
roof-tops about the sack of the NHS. There is a bigger picture. Despite
their fondness for money and a comfortable life, doctors are pretty
socialistic creatures. They have a Robin Hood like philosophy which
usually put their patients interests ahead of everything else because its
the right thing to do. Even ahead of their families. Or at least that WAS
the principle. When I entered medicine in the 1970's, the institution came
first in one's life, ahead of all personal things. One worked until the
job was done and snatched family life in the remaining hours. One had the
ethos of wanting to do the best for that institution, whether it was the
family practice or the hospital department. And therefore the best for the
patient.
But around the 1980's there came a veritable explosion in medical
technical advances.....heart and kidney transplants, CT and MRI scanners,
new cancer drugs, microsurgery, new cardiac drugs and so on. Whilst 'doing
the best' for one's patient remained the ideal and indeed was allowed
during the following 15 'golden' years, suddenly the treatments prescribed
by doctors became a real threat to the economics, indeed the survival, of
many Western governments or health insurers.These governments realised
that they had to curb doctors' spending, but they couldn't do it openly
because they knew that doctors always wanted what was best for their
patients and therefore to curb them would be an open expression of
reduction in medical quality.
This is when they started to investigate other more oblique, and
opaque ways of cutting expenditure on medical treatment. In Britain the
process started under the Tories when their hard man, Kenneth Clark,
introduced the White Paper reforms of the early 1990s where under the
guise of putting doctors in control of spending (something they were never
intrerested in and always devolved to managers) he introduced departmental
budgets in hospitals and Fund-holding in general practice. This was a
Governmental masterstroke along the lines of 'divide your enemy and rule
them' because doctors within the same hospital suddenly vied with each
other for budgets and for the work which brought in the money, and GP
practices suddenly found themselves powerful enough to bully hospitals
over income. This was the start of the break-up of professional coherence
in the UK. At the same time, for reasons more difficult to understand,
Britain as a medical leading nation was losing its world position. London
as a medical mecca for patients seeking the very best treatment went onto
a very steep slope of decline from which it has only now reached the
zenith point where not only have we lost all this business, but every
single one of our own Premiership footballers who needs his knees operated
on now goes abroad. Simultaneously we lost almost every single visiting
doctor from the old Commonwealth who came here to learn his/her trade in
medicine. Now WE go abroad for OUR experience as trainees.
Therafter, during the 1990's and the past 6 years of the 21st century
the screw has turned ever more painfullly with one political reform of the
NHS after another. Virtually every one of these has attacked the ability
of doctors to carry out the best treatments unfettered by policital
considerations. Recently 'targets' have blatantly addressed quantity over
quality, patients are moved openly or clandestinely to the private sector
(which secretly most specialists despise), referrals are now made to
hospitals rather than individual doctors ( which effectively nullifies the
natural demand of patients to flock to the best) and once again the
community finances all hospiatl activity with crippling pressures on the
GPs who refer (or rather are encouraged not to), and on the hospitals who
receive (or rather should).
So why, one may ask, is all this silencing doctors to the measures
they see government taking which are producing such irreversible damage to
our NHS? Because all this has happened so fast, within effectively a
single generation of the profession,that the victims are shell-shocked.
They have had their breath taken away, their ambitions to do 'the best'
badly dented. They understand that whilst its easy to put the savings
represented by firing half the secretaries and outsourcing their typing to
India on the balance sheet, it will never be easy to express the results
of a badly done hernia operation in the same way. They have been forced to
swallow their instincts and almost to connive with the Govt at budget
medicine for all. But can they sleep easily with this? Yes, because they
are so well paid now, and its so important not to rock the institutional
boat to gain one's new in-house merit award, that life is easier if one
just plays the ghastly game and leaves the hospital on the dot of 5pm (as
per one's new contract) and goes back to the family one had previously
neglected and who are willing blindly to forgive past absences and rejoice
that 'Daddy will be able to take us to Scouts, or Daddy will be here for
the football game on Saturday morning'.
Basically, the activities of this Government, far more than any
other, have successfully shot the medical profession's previous pride and
resistance to pieces. It is no longer interested in fighting. Why should
it be. The Government has allowed more of the rich to get richer,
encouraged the purchase of honours, intimidated those who don't do its
beck and call, and rewarded mediocrity. It is simply not fashionable to be
a professional in modern new-labour Britain.
And there's a final issue....leadership. Just as the entire Western
world seems unable to find statesmen as leaders, so at a national level
its just not in vogue to 'lead' from the front. Whilst the British Medical
Association presumes to be the leader for all UK medics, yet so little is
it in tune with the thinking of its members that only 3 years ago the
contracts which it had so painfully negotiated for consultants and GPs
were rejected. And where, on the basis that most doctors will admit that
the NHS is on the edge of irreversible destruction, has been its clarion
voice? Amongst the Academic institutions, the Royal College of Surgeons
came very close indeed to getting into bed with the Government in return
for relatively trivial sums for a new surgical unit, until it recently
gained one of the few Royal College presidents prepared to speak out. And
so when there are no leaders, there is no common voice.
And so I fear that Greener's informers are correct ...... the will
for resistance is gone, and the power is gone. All in the space of less
than 2 decades.
Competing interests:
None declared
Competing interests: No competing interests