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Where are the medical voices raised in protest?

BMJ 2006; 333 doi: (Published 21 September 2006) Cite this as: BMJ 2006;333:660

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Lost voice of the medical profession

Greener asks the devastatingly obvious question as to why there is a
lack of real protest by the medical profession against what is being done
to the NHS by the present government. Thank God he asks it, because it
seems no-one has done so before, or at least effectively.
Of course there are paradoxes to his query, because in the same breath as
asking where the protest is, Greener also mentions "the opinions expressed
by the doctors I speak to every week". So what he really means is
'effective protest'.
British doctors everywhere, in every walk of medical life, realise that
such profound damage is being done to the NHS as we know it that there
will be little recognisable left within 5 years and indeed it will
probably have imploded like a dying star.But they are not speaking out.

For a start they remain cowed by the way the Bristol, Ledward, Alder
Hey and Shipman affairs, all to do with renegade individuals no more
numerous than one might find in any group of over 100,000 individuals (be
it politicians, journalists or even ministers of religion) have been very
effectively stage managed to create the image of a tarnished profession.
This was a true gift from God for a government intent on weakening the
only potential opposition to their plans.

Secondly, doctors are embarrassed by the massive pay-rises accorded
them by recent contract negotiations. Consultants, especially, never
wanted their new contract. All they wanted was recognition that they
worked a lot more for the NHS than the government said they did.
Government did not recognise this and said "We'll put you on a contract
which counts your hours". In fact it might be said that this was the first
manifestation of its obsession with numbers and targets rather than
quality. The consultants responded by calling their bluff and saying "OK,
if you dont believe us, then lets have a contract and you can put your
money where your mouth is". Surprise, surprise, the government has now, to
its horror, realised that the consultants were right, as every single job
plan has been agreed with managers. They have scored a massive financial
own-goal and are squirming to find a way out. If the government wanted to
salvage even one tiny lesson from this contract debacle, it would be that
the only group who REALLY know what is going on at the coal-face of the
NHS are the doctors.

But this doesn't really explain why doctors are not shouting from the
roof-tops about the sack of the NHS. There is a bigger picture. Despite
their fondness for money and a comfortable life, doctors are pretty
socialistic creatures. They have a Robin Hood like philosophy which
usually put their patients interests ahead of everything else because its
the right thing to do. Even ahead of their families. Or at least that WAS
the principle. When I entered medicine in the 1970's, the institution came
first in one's life, ahead of all personal things. One worked until the
job was done and snatched family life in the remaining hours. One had the
ethos of wanting to do the best for that institution, whether it was the
family practice or the hospital department. And therefore the best for the

But around the 1980's there came a veritable explosion in medical
technical advances.....heart and kidney transplants, CT and MRI scanners,
new cancer drugs, microsurgery, new cardiac drugs and so on. Whilst 'doing
the best' for one's patient remained the ideal and indeed was allowed
during the following 15 'golden' years, suddenly the treatments prescribed
by doctors became a real threat to the economics, indeed the survival, of
many Western governments or health insurers.These governments realised
that they had to curb doctors' spending, but they couldn't do it openly
because they knew that doctors always wanted what was best for their
patients and therefore to curb them would be an open expression of
reduction in medical quality.

This is when they started to investigate other more oblique, and
opaque ways of cutting expenditure on medical treatment. In Britain the
process started under the Tories when their hard man, Kenneth Clark,
introduced the White Paper reforms of the early 1990s where under the
guise of putting doctors in control of spending (something they were never
intrerested in and always devolved to managers) he introduced departmental
budgets in hospitals and Fund-holding in general practice. This was a
Governmental masterstroke along the lines of 'divide your enemy and rule
them' because doctors within the same hospital suddenly vied with each
other for budgets and for the work which brought in the money, and GP
practices suddenly found themselves powerful enough to bully hospitals
over income. This was the start of the break-up of professional coherence
in the UK. At the same time, for reasons more difficult to understand,
Britain as a medical leading nation was losing its world position. London
as a medical mecca for patients seeking the very best treatment went onto
a very steep slope of decline from which it has only now reached the
zenith point where not only have we lost all this business, but every
single one of our own Premiership footballers who needs his knees operated
on now goes abroad. Simultaneously we lost almost every single visiting
doctor from the old Commonwealth who came here to learn his/her trade in
medicine. Now WE go abroad for OUR experience as trainees.

Therafter, during the 1990's and the past 6 years of the 21st century
the screw has turned ever more painfullly with one political reform of the
NHS after another. Virtually every one of these has attacked the ability
of doctors to carry out the best treatments unfettered by policital
considerations. Recently 'targets' have blatantly addressed quantity over
quality, patients are moved openly or clandestinely to the private sector
(which secretly most specialists despise), referrals are now made to
hospitals rather than individual doctors ( which effectively nullifies the
natural demand of patients to flock to the best) and once again the
community finances all hospiatl activity with crippling pressures on the
GPs who refer (or rather are encouraged not to), and on the hospitals who
receive (or rather should).

So why, one may ask, is all this silencing doctors to the measures
they see government taking which are producing such irreversible damage to
our NHS? Because all this has happened so fast, within effectively a
single generation of the profession,that the victims are shell-shocked.
They have had their breath taken away, their ambitions to do 'the best'
badly dented. They understand that whilst its easy to put the savings
represented by firing half the secretaries and outsourcing their typing to
India on the balance sheet, it will never be easy to express the results
of a badly done hernia operation in the same way. They have been forced to
swallow their instincts and almost to connive with the Govt at budget
medicine for all. But can they sleep easily with this? Yes, because they
are so well paid now, and its so important not to rock the institutional
boat to gain one's new in-house merit award, that life is easier if one
just plays the ghastly game and leaves the hospital on the dot of 5pm (as
per one's new contract) and goes back to the family one had previously
neglected and who are willing blindly to forgive past absences and rejoice
that 'Daddy will be able to take us to Scouts, or Daddy will be here for
the football game on Saturday morning'.

Basically, the activities of this Government, far more than any
other, have successfully shot the medical profession's previous pride and
resistance to pieces. It is no longer interested in fighting. Why should
it be. The Government has allowed more of the rich to get richer,
encouraged the purchase of honours, intimidated those who don't do its
beck and call, and rewarded mediocrity. It is simply not fashionable to be
a professional in modern new-labour Britain.

And there's a final issue....leadership. Just as the entire Western
world seems unable to find statesmen as leaders, so at a national level
its just not in vogue to 'lead' from the front. Whilst the British Medical
Association presumes to be the leader for all UK medics, yet so little is
it in tune with the thinking of its members that only 3 years ago the
contracts which it had so painfully negotiated for consultants and GPs
were rejected. And where, on the basis that most doctors will admit that
the NHS is on the edge of irreversible destruction, has been its clarion
voice? Amongst the Academic institutions, the Royal College of Surgeons
came very close indeed to getting into bed with the Government in return
for relatively trivial sums for a new surgical unit, until it recently
gained one of the few Royal College presidents prepared to speak out. And
so when there are no leaders, there is no common voice.

And so I fear that Greener's informers are correct ...... the will
for resistance is gone, and the power is gone. All in the space of less
than 2 decades.

Competing interests:
None declared

Competing interests: No competing interests

02 November 2006
peter j mahaffey
consultant surgeon
bedford hospital