Intended for healthcare professionals

Observations Life and Death

Words are all we have

BMJ 2011; 343 doi: (Published 09 November 2011) Cite this as: BMJ 2011;343:d7166
  1. Iona Heath, president, Royal College of General Practitioners
  1. iona.heath22{at}

The changing language of healthcare reflects the seismic shift from the logic of public interest to that of private gain, says Iona Heath, writing in a personal capacity

In his 1998 novel The Time of Light the Norwegian writer Gunnar Kopperud noted that “a railway station mirrors the soul of the place where it’s located.” Perhaps in the same way a health service reflects the soul of the society it serves. If so, this could be bad news for the health service of a society in which the gap between rich and poor grows ever wider and where there seems to be a steadily eroding commitment to an inclusive social contract.

In his Whitehall Watch blog, Colin Talbot, professor of public policy and management at Manchester Business School, argues that all organisations are to some degree “public” and that they are all also to some degree “private.” It follows, he says, that “there is always some ‘grey’ in statements about ‘public’ and ‘private’ organisations” ( Talbot takes UK universities as paradigmatic examples of this twilight zone, but his arguments must also apply to health services, such as that in England, where concerns about drives towards further privatisation are consistently countered by claims that the health service is already to a considerable extent private.

Despite the lack of a clear demarcation, Professor Talbot goes on to make clear the vast and yawning chasm between what he describes as the logic of public interest and the logic of private gain. “Most employing organisations are dominated by one or the other logic. The values, aims, processes, and purposes of organisations—almost everything about them—are shaped by either the logic of public interest or private gain.” However, much as the government would like to claim that the two logics are compatible, they are fundamentally different, and it is all but impossible for an organisation to follow both simultaneously. The NHS in England is currently in crisis, with changes being imposed that are vehemently opposed by many of the healthcare workforce and the informed public. Part of this crisis would seem to be the seismic shift from the logic of public interest, which has underpinned the NHS since its inception, to the different logic of private gain.

Each of these two distinct logics actively structures thinking and is expressed in a deliberate choice of words. In his 1978 book on Heidegger, George Steiner wrote: “Words and language are not wrappings in which things are packed for the commerce of those who write or speak. It is in words and language that things first come into being and are.” Words are fundamentally important and can tell us much that we might otherwise not notice or prefer to ignore. In the context of today’s NHS there are many words whose meanings seem to have become progressively degraded or subverted: care, quality, profession, and education, to mention but a few. In his Nobel lecture in December 1980 the great Polish poet Czesław Miłosz warned that “whoever wields power is also able to control language and not only with the prohibitions of censorship, but also by changing the meanings of words. A peculiar phenomenon makes its appearance: the language of a captive community acquires certain durable habits; whole zones of reality cease to exist simply because they have no name.” When poets warn us about the abuse of words it is perhaps wise to pay attention.

At the same time, another set of words seems to be slowly disappearing, words such as attentiveness, imagination, wonder, courage, difficulty, trust, commitment, touch, concern, conscience, and tenderness. And I ask myself whether these express something of the waning logic of public interest. On the other hand, formerly unfamiliar words are beginning to permeate the health service and are heard in various combinations at almost every meeting: regulation, inspection, failure, enforcement, contract, competition, safety, risk, protocol, and competency. It seems likely that these words reflect significant aspects of the logic of private gain.

Those who work day in and day out trying, in many different ways, to help patients are brought into intimate contact with the effects of worsening inequality; they are fully aware, despite all the egregious rhetoric of the “big society,” that the price of private gain is worsening health for those who consistently lose, and it is perhaps this that makes the language so repellent. The logic clearly implies that gain at the expense of others is legitimate and indeed encouraged. And this is underlined in the continuation of massive pay awards for those at the top of the managerial pyramid, while the poor bear the brunt of the cuts that are supposedly essential because there is not enough money to go round. Those who gain are rewarded with longer and healthier lives; those who lose confront a waning of hope, coherence, and meaning and will tend to die significantly earlier.

A society that is increasingly dominated by the logic of private gain perhaps deserves the health service reforms on offer in England. Here, as the philosopher Martha Nussbaum writes in The Fragility of Goodness, “words will become not bonds of trust, but instruments of ends; communication is replaced by persuasive rhetoric, and speech becomes a matter of taking advantage of the other party’s susceptibility.” Hope lies in the logic of public interest that persists in the three devolved nations, where inclusion and fairness seem to remain public virtues and to inform the conduct of the health services. But is the language of healthcare any less constrained, and what do we think of the railway stations?


Cite this as: BMJ 2011;343:d7166


  • IH, though president of the Royal College of General Practitioners, writes in the BMJ in a personal capacity.