Intended for healthcare professionals

Observations Life and death

The growing gap

BMJ 2007; 334 doi: (Published 29 March 2007) Cite this as: BMJ 2007;334:670
  1. Iona Heath, general practitioner
  1. London
  1. iona.heath{at}

    The collusive relationship between the state and the market is at odds with the promotion of free choice for patients

    A teacher once told me that it was the experience of enduring the dying days of communism in Poland that enabled him to recognise the obsession with regulation and control within the New Labour state education system. Perhaps similar experiences explain the insights of another Polish exile, Zygmunt Bauman, the emeritus professor of sociology at Leeds, who has described “a growing gap, indeed a contradiction, between values promoted in public discussion and those whose cause is served by political practice.” It is not difficult to recognise this description within New Labour's version of the National Health Service.

    Public discussion is directed towards the worthy aspiration of improving services for patients. Patients' views are given a central place within official rhetoric. Glossy NHS publications are now routinely illustrated by pictures of contented and attractive patients being cared for in optimal surroundings. Professionals are instructed to provide both “choice” and “patient centred care.”

    Yet, on the far side of the gap, we have the accelerating privatisation of healthcare provision, for which there is no electoral mandate, and a medical profession that is being simultaneously coerced and demoralised for political ends. A weakened medical profession may be more politically compliant and less able to resist the distortion of the health service for commercial ends, but it cannot serve patients well.

    Consider the chaos surrounding the new systems for recruiting young doctors into specialist training. Here are all the characteristics of Bauman's “rationalist bureaucracy,” which seeks to subjugate individual thought and action to the application of universal rules. The use of computer technology means that doctors are selected for interview on the basis of application forms that allow almost no scope for individual expression. Each applicant is required to illustrate certain expected virtues, such as leadership and teamwork, through vignettes of less than 150 words. These are then assessed in isolation from the relevant CVs in a process that has rapidly degenerated into a lottery. Young doctors are prevented from choosing the locality within which they wish to work, let alone which hospital, and as a result they face enormous stresses on their personal relationships. Once again doctors are treated as cogs in a machine and none of their personal aspirations or needs are accommodated. Yet these are people who, in their professional work, are supposed to put their patients' needs and aspirations above all else.

    The whole process contributes to the political objective of enforcing conformity and marginalising dissent. This in turn damages patient care both directly and indirectly. Conformity stifles both innovation and creativity, as neither curiosity nor imagination is explicitly valued. Patterns of care become ossified within official guidance. Young doctors, educated within the NHS and committed to it, are forced abroad to complete their training and to find work. This in turn will have an effect on recruitment into medical school. How is medicine to continue to attract high calibre applicants if this sort of career path awaits them?

    Only if doctors have the freedom to explore and explain options can patients be free to make their own decisions. Doctors who actively elicit the patient's own values and priorities and support an informed decision based on awareness of both the possible harms and the potential benefits of a proposed treatment will reduce levels of pharmaceutical consumption. But, of course, this operates against the interests of the medical-industrial complex. If doctors are encouraged to offer standardised care, as they are under the quality and outcomes framework, pharmaceutical consumption rises and patient choices become constrained.

    Here again we find the growing gap. Public discussion promotes self determination and free choice for patients, but political practice dictates that only those choices that concur with the interests of the politically and economically powerful are actively supported. For example, patients are enabled to choose a referral to a private provider or to see a GP while visiting a supermarket but not to attend a local hospital earmarked for closure or to register with a singlehanded practice. Most people want good healthcare services from their local NHS hospital and are not interested in shopping around, yet the rhetoric around choice is all about doing just that. There are clear limits to officially sanctioned choice, and the word itself becomes corrupted.

    Contemporary Western societies are dominated by the twin powers of the state and the market, in an increasingly collusive relationship. Organisations that operate independently of these two make up a third sector, which is described as civil society, and professional groups are crucial components of this third sector. The traditional professions, which include teaching and medicine, are in daily contact with ordinary citizens and see at first hand how society goes wrong. This contact brings with it a responsibility for interceding with the powerful on behalf of the relatively powerless. When the independence and morale of these professions is eroded, as happens within totalitarian regimes and increasingly within contemporary, market driven societies—and as is happening right now to the profession of medicine—important elements of civil power and societal justice are suppressed.

    Sick people need good doctors. Society needs the most able young people to want to study medicine and then to be able to use their knowledge and skills, independently of political and economic power, for the benefit of all. Has this suddenly become an impossible aspiration? It is time to close the gap.

    Patients are enabled to choose a referral to a private provider or to see a GP while visiting a supermarket but not to attend a local hospital earmarked for closure or to register with a singlehanded practice


    • I am grateful to Charlotte Williamson, former chairperson of the Patients Liaison Group of the Royal College of General Practitioners, for making clear to me the extent to which patients' autonomy is dependent on clinicians' autonomy.

    View Abstract