Intended for healthcare professionals

General Practice

The wizard and the gatekeeper: of castles and contracts

BMJ 1995; 310 doi: (Published 22 April 1995) Cite this as: BMJ 1995;310:1042
  1. Barbara Herd, consultant physiciana,
  2. Andrew Herd, general practitionerb,
  3. Nigel Mathers, senior lecturerc
  1. a North Tees NHS Trust, Stockton, Cleveland TS19 8PE
  2. b Health Centre, Spennymoor, County Durham DL16 6ED
  3. c Department of General Practice, Medical School, Sheffield S10 2RX
  • Accepted 24 March 1995

The wizards and the gatekeepers were unhappy. There were many reasons for their unhappiness. They worked hard but felt that too much was being demanded of them. The poorly people's charter was resulting in unrealistic expectations, and changes in the apprenticeship for wizards were putting great strain on their mentors. The wizards enjoyed their work less and less, and it was getting difficult to find new gatekeepers. On the other hand, the way the system worked meant that there had to be plenty of goblins and the number of scrolls that had to be filled in was rising sharply. The wizards and gatekeepers tried to point out ways to improve things that would ensure that poorly people were better treated, but there was no easy solution. With the ominous sign that the recruitment of wizards and gatekeepers was becoming more difficult, an answer was needed—and soon.

The wizards and the gatekeepers were very unhappy.1 2 Once upon a time they had enjoyed their work of looking after the poorly people of the kingdom and had felt appreciated. They had always worked hard and done their best, and even when their magic potions hadn't worked (which sometimes happened) the poorly people and their families knew that they had done their best and were grateful.

Things had changed. Although there were lots more wizards and gatekeepers, with better spells and magic potions, all was not well in the kingdom. The king was worried that he was not very popular and needed more support from his people. “Sire,” whispered his chancellor, “you need a big idea if you want to stay king.”

The king thought very hard about this. “Surely the charters3 were a big idea?” he asked.

“Why not make them bigger and better?” suggested the chancellor. “The goblins can produce lots more charter proclamations telling everyone how much better things are getting.”

“Gosh, what a splendid idea,” said the king, and he summoned all his ministers to tell them the good news.

Keeping up with the charters

The wizards and gatekeepers read the new charters; they tried to keep up with them, but pretty soon they were besieged by the people. “We want to see a wizard now,” the people cried to the gatekeeper. “You must make us better more quickly,” they demanded of the wizard. All the wizards and gatekeepers got more and more tired as they worked harder and harder. They complained to the goblins, but the goblins said that it was difficult enough managing the contracts—seeing all the poorly people was the wizards' problem. The goblins maintained that the wizards could work much harder if they really had to. The wizards did work harder, because they worried about the fate of the poorly people if they didn't. With more and more poorly people being seen, the wizards had to work later and later each day, and they got tired and sometimes they weren't very cheerful.

It wasn't long before the people started to complain. The wizards had to spend time listening to the complaining people and so had less time to cast spells. The wizards also began to feel cross after seeing grumpy people because they had been trying so hard that it seemed unfair of the people to grumble about the wait instead of saying thank you for being cured. The gatekeepers got increasingly annoyed as the goblins gave them more and more to do, and there were ever more complaints about the service provided. Even worse, the more poorly people a wizard and gatekeeper saw, the more difficult it was to remember each one and give him or her the individual attention deserved. After all, both the wizards and gatekeepers only did the job because they liked making poorly people better. It was not even as if they were paid as much as the wizards and gatekeepers in other lands; and they didn't spend as much either.

There were still lots of poorly people who couldn't be cured, and some of the magic potions were a bit unpredictable, with no one knowing how they actually worked. Some of the new ones were very expensive. The wizards started asking if the king and his chancellor wanted these new spells and, if so, how they were to be paid for. “More efficiency!” howled the minister; “No more money,” chanted the chancellor; “The wizards and the gatekeepers must compete for poorly people,” roared the king. How this was to be done wasn't made clear. There was no more gold to pay for the elves and fairies, who were vital to care for the very poorly people, and the number of goblins needed to run things properly was getting out of control. “Send the poorly people back to the gatekeepers as soon as possible,” came the command from on high to the wizards. “Keep them at home; don't send the poorly people to the wizards,” the gatekeepers were told. Everyone began to feel unsafe—the poorly people because they weren't in the wizards' castles for very long; the wizards because they had to send them out of the castles too soon; and the gatekeepers because they felt guilty about sending people into the castle for fear of the wizards being unable to cope.

The people's complaints grew louder. Whenever something went wrong or a magic potion didn't work it was always somebody's fault and the inquisitors were called in. Pretty soon ever more tests were being done “just in case,” and of course the more tests that were done, the more false positive results were found.4 The wizards and the gatekeepers began to feel that the poorly people were the problem, rather than their illnesses. The whole system of looking after poorly people began to grind to a halt, but the goblins had to keep producing statistics that showed that it was getting better and better.

Campaigning for reduced hours

Then there was the problem of the apprentice wizards. They had always worked hard and had not been paid much. They had been very helpful to the wizards as well as learning a lot from them, but they decided that it wasn't fair to be up half the night looking after the poorly people because they had to work the next day (and the day after that). They campaigned for reduced hours. This was all very well, but the king wouldn't pay for any more apprentice wizards; so they had to work harder. Well, they soon got fed up and began grumbling too.

The king heard their grumbles and summoned his minister again. “How can we fix this one?” he asked. “Sire,” replied the minister, “let's shorten the apprenticeship but let them have more training (given by the wizards of course) and do less work with poorly people so that they have more time to study.” The wizards knew it was still very important that the apprentices looked after poorly people directly as no amount of sitting down with books could replace that. The wizards agreed with the idea of shortening the apprenticeship if they were allowed to employ more wizards, elves, and fairies to do all the work that the apprentice wizards had been doing. In fact, there were many fewer fairies5 as the inquisitors felt there had been too many of them, and after all, anyone could hold a hand or wipe a bottom—you didn't need a special person to do that.

Every week, more and more poorly people needed treating,6 and all the wizards were at their wits' end trying to fit everything into the day. If a wizard didn't find time to teach his or her apprentices then the Wizards' Convention would take them away. The wizards didn't want to lose their apprentices as most wizards enjoyed teaching, but sometimes it was difficult to see why they should bother.

In another proclamation the king told the wizards and the gatekeepers that keeping up to date was to be made compulsory.7 The king thought that this was a terrific wheeze that would really impress the people. The wizards and gatekeepers were annoyed at this proclamation. Ever since there had been a castle their conventions had repeatedly looked at ways to improve their spells and potions. The wizards had met regularly to look at the best ways of doing things and updated each other on the latest advances in, for example, crystal balls. They usually did this in their spare time because they liked being wizards and gatekeepers—they knew that some spells and potions were better than others and wanted even the least enthusiastic of their colleagues to be motivated and up to date. The new proclamation made it look as if they hadn't bothered to keep their castle in order.

Loss of energy and enthusiasm

The wizards and gatekeepers got increasingly fed up with being told what to do all the time. It became very difficult to get new gatekeepers,8 and many apprentice gatekeepers were deciding not to become gatekeepers after all. All the older wizards and gatekeepers, who would normally have worked past their normal retirement age, were leaving at the first possible excuse. This was a shame because some of the older ones knew a thing or two and could get the younger ones out of a jam with special spells. The older wizards said that they hadn't trained for the king's new system and they didn't like being at the beck and call of “buying goblins” and “consumerist poorly people.” Most wizards and gatekeepers had enjoyed their training as they had felt useful and appreciated, even if the work had been difficult and the hours long, but nothing had prepared them for this.

They began to stagger home late at night, dreading the next day. They did their best, but they no longer had time to sympathise as much with poorly people or to explain to their families what was happening, which was all part of the job, even if it wasn't part of the charter. In becoming more efficient, they seemed to be becoming less effective. The system had worked once, but now it was failing not only the poorly people but also the wizards, the gatekeepers, and all the elves and fairies who worked in it. Even the goblins sensed that something was wrong, but they didn't dare let it show in their statistics because their jobs depended on getting it right. The wizards started not to care about what happened to the people—they were too tired and picked on to care. They didn't have their old energy and enthusiasm. They worried about the trainee wizards, who were disillusioned before they started. It was hard to explain to a trainee wizard about the rewards there once were for helping a poorly person. Some wizards wished that they didn't care at all, as that would make it all a lot easier.

The big summit meeting

“Something must be done!” they all cried to the king, his ministers, and the inspectors. “Keep them talking and arguing,” whispered the king to his minister. “Divide and rule has always worked.” But the most important wizards and gatekeepers got together to hold a big summit meeting to decide what was really important in the care of poorly people now and for the future.9 Well, they talked through the night and all the next day. At last they decided that the quality of their relationship with the poorly people was the most important thing. If the poorly people's trust in them was broken by suspicion and hostility then the system wouldn't work. It was no good the king and ministers promising the poorly people everything without providing the necessary resources. As well as this, wizards and gatekeepers were competent not only to choose what and how to learn but also to work out how to learn it.10 If there were too many things to do and not enough time to do them then wizards couldn't cast their spells properly and the trust of the poorly people would be lost.

But the big summit didn't really change anything. The wizards and gatekeepers had so many different things to do for the goblins that looking after the poorly people was no longer the most important part of their jobs. Some wizards went into a decline because looking after the poorly people was why they had joined the profession.11 Every wizard dreamt that the poorly people's charter had been rewritten to make it clear to the poorly people how hard the wizards and gatekeepers were trying and that they weren't just grumpy people wanting to make pots of gold. Even the youngest elf hoped for the day when the king and his ministers realised that the pursuit of ever increasing efficiency damaged the trust that was necessary for poorly people to get better. Some of them dared to speculate that they needed a new king.

Something had been lost

After the summit, the king and his ministers listened carefully, but as usual they did nothing and hoped for the best. “Something will turn up,” muttered the king. The wizards gazed into their crystal balls to look for hints about how they could manage to do more and more with less and less, but none of them came up with any answers. The gatekeepers worried about whether they could continue to satisfy the poorly people's expectations and why so few new gatekeepers were coming forward. Some of the apprentices wondered why anyone wanted to become a wizard or a gatekeeper and went off and did other things.12 The only thing that all the wizards and gatekeepers could agree on was that something had been lost; but they didn't know what it was. They resolved to put all their resources together and to keep on looking until they found the answer.


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