Words are all we have
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7166 (Published 09 November 2011) Cite this as: BMJ 2011;343:d7166All rapid responses
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Iona Heath appears to have forgotten that those she purports to represent, namely GPs daily balance private gain with public interest in the running of their practices. I have considerable knowledge of practices and have never known one run entirely for either private gain or public interest. Why should Gps not be able to achieve that balance in commissioning as they do in running practices.
Competing interests: No competing interests
Iona Heath quotes Colin Talbot, professor of public policy and management at Manchester Business School, who argues that all organisations are to some degree “public” and that they are all also to some degree “private.”
The NHS in Wales may be more ‘public’ than ‘private’ (i.e. operating in line with the public interest rather than private gain) compared to the direction the English NHS is going, but the lexicon of private gain still exist this side of Offa’s Dyke.
Modern management attempts to improve productivity and cost-saving through fear and aloofness are all too common. The days of managers on walkabout supporting and praising staff seems to be a thing of the past, with many now passing down dictats and threats via email.
Caring words such as imagination, trust, commitment, concern, conscience, and tenderness have indeed been replaced by a chilling vocabulary of management babble.
It doesn’t need to be like this. Some of the most successful private companies in the world (for example Google, Microsoft, Starbucks, Four Season Hotels) nurture their internal clients (staff) knowing that in doing so the external clients (customers) end up receiving a first class service.
A public interest organization like the NHS would do well to learn from these examples.
Competing interests: No competing interests
The abuse of language for the purpose of marketing neoliberal policies, notably the deliberate dismantling of the NHS, is indeed nauseating. But newspeak is hardly dangerous. Being a top-down artefact, it is easily spotted for what it is. It is rendered incapable of doing its designated job: facilitating the acceptance of the unacceptable. Indeed, like Iona Heath, I cannot imagine a single doctor in this country believing that the destruction of the NHS could be even remotely compatible with a genuine notion of ‘big society’.[1]
Having said that, I know many doctors who seem to believe that the increasingly anti-patient medicine they are forced to give is fully compatible with their increasingly patient-centred ethic. As a matter of fact, that’s exactly what I—a bioethicist—am effectively supposed to teach my students, future doctors. But is that really possible? Can an anti-patient medicine have a genuinely pro-patient ethic?
The conception that prevails among my colleagues suggests it can. It works in the silent assumption that medical ethics and medicine have no meaningful constitutive-functional ties. It presupposes that medical ethics is nothing but a moral benchmark for a morally imperfect medicine. If there is anything wrong with our health care system, then this must be only because it is not ethical enough.
There is also another possibility, which rests on the contradicting observation that most anti-patient practices tend to abide by the ethic rather piously. It maintains that medical ethics is a system of rules that emerges from particular social power relations and is therefore bound to reinforce them. But then, what should we make of an ethic that regulates relations whose beneficiaries and victims are the bankers and the patients, respectively? What would it make us, ethical doctors? And us, bioethicists?
I am not sure which of the perspectives is right. But considering what is at stake, I dare say that there is no question about medical ethics or about medicine that is as important and as urgent as this one. A top-down cynical rhetoric is certainly repellent. But a bottom-up ideological construct—a simulated patient-centred ethic—would also be dangerous.
1 Heath I. Words are all we have. BMJ 2011;343:bmj.d7166.
Competing interests: No competing interests
Re: Words are all we have
Iona Heath alerts us to the degradation or subvertion of the meaning of care, quality and profession, and the slow disappearance of attentiveness, wonder, courage, trust commitment, concern, conscience, touch and tenderness.
The space for these 'softer' but vitally important values is being swallowed up and crushed between the Scylla and Charybdis of QOF and Revalidation, which force general practitioners to spend every spare moment and ounce of energy ticking boxes, doing audits, reviewing our colleagues' referrals, arranging multi-source feedback, of doubtful value, and so-on. While some of these activities may be of value, the sheer quantity is overwhelming and demoralising, especially when the essential work we do, listening to our patients, showing empathy, helping them negotiate the complex hospital interface, and providing continuity of care, seems to be completely unrecognised and unrewarded.
Part of the cause may lie in the disastrous trap of only measuring, and valuing, things that can be measured easily,and as Dr. Iain McGilchrist argues in his seminal work, The Master and his Emissary, the dominance of left brain over right brain function in our modern world.
While those of us lucky enough to have trained in the 70's and 80's still struggle on and try to provide a genuinely patient-centered service, I fear that the current generation of GPs, brought up in this new mechanistic environment, may find it harder to provide primary care that really serves patients' needs and best interests, rather than those
of governments and 'experts' .
In the age of ' evidence based medicine', where are the research studies that show that these changes, imposed on all GP's (how I wish we had ever signed up for the new GP's contract in 2004!) are really better at responding to patients' needs, than where we were in the 1990s?
Competing interests: No competing interests