Why the culture of medicine has to changeBMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39349.488484.43 (Published 11 October 2007) Cite this as: BMJ 2007;335:775
- Richard Hayward, consultant neurosurgeon
Why haven't doctors embraced health service reform? The thought came to me during a recent medicolegal conference with counsel. The year under discussion was 1996, and the issue was a possible delay in referral for a specialist appointment. The general practitioner's letter to the local hospital had been annotated for an appointment “soon” by the consultant (correctly, it was agreed) and “soon” in 1996 meant three months. But before those three months were up the child had collapsed with an intracerebral catastrophe and has been left severely damaged as a result. And my thought was, why did the medical profession remain generally silent for so long about waiting times which for “clinically non-urgent” surgery once stretched to well over a year? It wasn't as if doctors weren't aware of the problem, and I don't buy into the idea that it was all a cynical ploy to boost private practice. When reducing waiting times became a government priority the medical response was less than enthusiastic: the most common excuse was that it involved overriding clinical priorities by managerial (non-medical) diktat—a justifiable complaint, but even so . . .
Tony Blair said in a conference speech not long after the 1997 landslide that the culture of medicine would have to change. What do we mean by the culture of medicine? The word I kept coming up with was independence. Consider this. What do we doctors like doing? What particular deployment of our abilities makes us feel most good about ourselves?
I'll answer from a surgical perspective, although what I say applies to clinical medicine as a whole. We like to be presented with a patient or a problem for whom or which we can deploy our skills in a way that will gratify ourselves and hopefully the patient as well. It's very much an individual to individual business, even when we're working in teams—indeed, the doctor-patient relationship is actually defined in the singular.
I used to sit on the selection committee for a London teaching hospital and the most common response to the inevitable ice breaker, “Why do you want to be a doctor?” was “I've always liked science at school and I want to work with people.” Early on, the practice of medicine is based on a culture of science oriented attention to people as individuals.
Such an attitude takes priority over concern for the community as a whole—which is not to say that doctors aren't interested in the NHS, but it's too diffuse a focus to warm their blood. This is why recruitment to specialties such as preventive medicine and public health is so difficult, despite the fact that treating the community as a whole (for example, through improved sanitation, nutrition, and immunisation) has historically provided greater health benefits than the individual to individual treatments that most clinicians practice.
Now doctors have been asked (to put it politely) by a monopoly employer to surrender a measure of their independent individual to individual culture for a community-wide or societal approach to disease, disability, and deformity. The cultural shift that is needed is seen as so threatening that even substantial pay increases have not been enough. The medical profession's response has been interpreted by government as at best conservative, and at worst self-interested protectionism, and this has led to the profession being effectively sidelined during the process of health service reform. Even the royal colleges, who profess the improvement and protection of standards of health care as their primary function, have failed to provide a bulwark against state encroachment on clinical practice. Perhaps this is not surprising—they are headed by senior and independent practitioners, terrified that their institutions will be left completely out of the policy making loop. So we have two contradictory forces at work. Health care has become an instrument of social policy for all developed societies, including ours, and independence is always in some degree of conflict with the state.
But the government has not completed its agenda—indeed, assuming a target of the best health care the nation can afford, it never can—so more pressure is inevitable. And what better way to alter the culture of medicine than to undermine the doctor-patient relationship by doing away with continuity of care? With the start already made by GPs relinquishing out of hours care, and the depredations of shift working and the European Working Time Directive on hospital practice, a cynic might claim that the government has only to sit back and wait.
But the MTAS fiasco (for which all parties must share responsibility) stands as a dire warning to government and medical profession alike of trying to reform health care without cooperation between the two. Expect the current rocky ride to continue until and unless the government and the community of independent medical practitioners find common ground—something that will require a shift of culture on both sides if the NHS is really to benefit.
The MTAS fiasco stands as a dire warning to government and medical profession alike of trying to reform health care without cooperation between the two