After a quiet few days, there have been some yelps squeaks and barks from UK medical bloggers about the British Medical Association’s SRM (Sham Representative Meeting) called earlier this week to decide the Association’s position on the government’s proposed NHS reforms. Dr Grumble meanwhile has adopted an “I’ve been telling you for years, will you believe me now” tone under a reckless headline on the ways of parliament. Or perhaps it isn’t so reckless after all – for who knows how many tens of thousands will die unnecessarily if the Tory health reforms become reality.
The trouble with all these yelps squeaks and barks (and Dr No has been at it too) is that they are faux-outrage at what is in fact inevitable. It is the inevitable result of what many of us call democracy, but which is in fact nothing of the sort, being instead something which Dr No called Sham Dem eighteen months ago; and the thing about Sham Dem is that it is anything but democracy, by any accepted definition of the term. It is, to give it a more descriptive but less snappy name, serial, or perhaps more accurately, interval, oligarchy. If that sounds a bit technical, Dr No apologises, but hopes to make all plain.
There is a custom in health service research of dividing investigation into three separate but related areas: structure, process and outcome. To put some flesh on these bones, structure might be how many hospital beds, nurses and doctors you have; process how many operations you do, and outcome is how many operations are successful. As a rule, the further along the structure-process-outcome line you are, the more useful is your research. It is – usually – of more interest, and use, to know that one in three of your patients died in hospital after surgery than you had twenty doctors, fifty nurses and five hundred beds.
Now, sometimes the order of importance is reversed. The trouble with the yelping, squeaking and barking, and indeed Dr Grumble’s analysis of parliamentary process, is that they (and Dr No) are all complaining about process, and so, by implication, outcome, when in fact the real villain is structure: the structure of our so-called democracy. The reason this matters is because if we want to do anything about the dreadful process and dire outcome, we need to focus on the real cause of trouble: the structure.
The modern populist view of democratic government is that it is that form of government where every now and then the people are given a chance to vote on who should govern them. So far as it goes, this much is true; but in reality it tells as much about what really happens in a so-called democracy as does observing that traffic lights stop and start traffic flow tells us about what the traffic really does on our roads. Sometimes the lights change, but the grid-locked traffic fails to move. At others, a hot-head crashes a red light. And the fact that a driver filters left or turns right on the green – or indeed the amber – tells us absolutely nothing about where they go after disappearing from our sight. We may, or may not, see them back at the same light. For all we know, some may even have crashed into a duck-house, or – Heaven forbid! – be stranded in a moat.
In much the same way, at election time, governments get a green light (a majority) or an amber (minority, or a coalition), but once past the lights the road is their own for the taking. They can speed up, slow down, overtake obstructions recklessly, take unexpected turnings, crash, burn, U-turn – whatever – and the lights are powerless to control them. And the trouble is, in our political system, the structure, including crucially the traffic lights –the elections – are very thin on the ground, and the road between them unmarked and unmapped. There is precious little structure or form: once past the green or amber light, the man at the wheel can drive where he wants, at whatever speed he fancies – until such time as the next traffic light, or election. Sure there are police – the opposition – but they are armed with water pistols. Even if it is a coalition, those who have jumped on the band-wagon for the ride sit tight, because they fear if they rock the wagon they will be thrown off, into the ditch, flies buzzin’ around their eyes…
And it is precisely this lack of form and structure between the distant controls of elections that allows a government to act not in the interests of the people, but in its own ways and fancies. It drives not for the people, or for the nation as a whole, but for its own ends, and its own purposes.
Over two thousand years ago, the nature of government was scrutinised by Aristotle, and little has changed since. His analysis was simple and elegant. Governments were, he said either good (ruled in the interests of all the people) or bad (ruled only in their own interests); and a further distinction could be made between rule by an individual, a minority or a majority. And so a two by three table, classifying the types of governments can be laid out, and the types of government given names:
|
Good or Bad? |
Rule by one |
Rule by minority |
Rule by majority |
|
Good (nation’s interest) |
Kingship |
Aristocracy |
Polity |
|
Bad (own interest) |
Dictatorship |
Oligarchy |
Democracy |
It is interesting to note here that even a true democracy (where a majority rule in their own interest) is considered a bad form of government . Churchill of course was on to such things in his many quips about democracy. The nominal majority might rule, but what if the minority be substantial, might even be right, or at the very least have rights, and yet be trampled upon?
Be all that as it may, the reality of United Kingdom elections has for several decades been that the winners have been voted in by a minority of the people; so what we call our democracy cannot in fact be a democracy. It is instead pretend – sham – democracy; rule by a minority masquerading as rule by a majority; and in between elections, because of the lack of structure, of accountability, of traffic lights, the government can do pretty much what it wants to do. It can ride rough shod over opposition, crash through red lights, all in the pursuit of its own interests. And a rule by a minority, in the interests of that minority is not a democracy, but an oligarchy. And because it happens serially, one government after another, we may call it a serial oligarchy.
What happens at government level also happens at the professional level. The ‘democratic’ BMA, with its elected representatives, is in just the same way not a true democracy, but a serial oligarchy. It rules not in the interests of all members, but in the interests of its elected representatives who – between elections, some might add even at elections – do not represent rank and file doctors one jot; and furthermore, lacking the accountability of elections, are free to drive their own route through the sands of history.
And so it is that Dr No concludes that it is inherent in the structural nature of our governments, and our professional representation, that we find a form, a structure, so loose that it allows, perhaps even makes inevitable, a divergence between the best interests of the people, and the intentions of government, and professional of representation for much, if not all, of the time between elections.
How, we might ask, do we do anything about this sorry state of affairs in general, and the Health and Social Care Bill in particular? Why – it’s simple! We stop whingeing and moaning about process, and go for the structure. A well placed road block will do the trick just as well as a set of traffic lights…
The Lib-Dems have it within their power to set up such a road block, and bring the coalition to a crashing halt – and so another election; and were that to happen, we might all be weary – and wiser – of Tory intentions. But the Lib-Dems, despite fine words last weekend, appear to have to have lost the will to fight.
The medical profession has the power to do it, by rejecting the Bill ‘in its entirety’. And yet our elected representatives, our serial oligarchs, have failed to represent the will of the profession, and have embarked on a Faustian Pact with the Government.
We, the rank and file of public and profession, have before us many dark days of arduous toil if we are to save our NHS, which we hold so dear. But, as Churchill might have said:
‘I have, myself, full confidence that if all do their duty, if nothing is neglected, and if the best arrangements are made, as they are being made, we shall prove ourselves once again able to defend our NHS, to ride out the storm of war, and to outlive the menace of tyranny, if necessary for years, if necessary alone. At any rate, that is what we are going to try to do. That is our resolve. That is the will of all of us, and of the nation.’
‘The British public and the medical profession, linked together in their cause and in their need, will defend to the death their NHS, aiding each other like good comrades to the utmost of their strength. Even though large tracts of the health service and many old and famous hospitals have fallen or may fall into the grip of the privatisation and all the odious apparatus of Tory rule, we shall not flag or fail. We shall go on to the end, we shall fight in the corridors, we shall fight on the wards and in the clinics, we shall fight with growing confidence and growing strength in the media, we shall defend our NHS, whatever the cost may be…until, in God’s good time, the New NHS, with all its power and might, steps forth to the rescue and the liberation of the old.’
Feeling rebellious Dr No? You’re not suggesting a revolution, are you?
Because, with revolutions there is always a vacuum going hand in hand with a vicious power fight, you never know how things will turn out to be or who will get to form the new oligarchy. At the moment, one hopes that those who have already revolted elsewhere in the world may not be getting sharks and extremist demons muscarading as angels to begin with instead, and then those self serving but moderate dictators may will be very sadly missed when it is too late. Sometimes, if it can’t fix, and not many can, a revolution makes everything too late.
Terrifying stuff!
… and, this is a nice post 🙂
I can’t remember who it was that said that British government was a dictatorship tempered by assassination. I think the next blow is going to be up to the Scots, Dr No. The Holyrood elections are coming up in a few weeks and how well (or badly) the Lib Dems do in that will be an indication to them of how they should proceed. I think they’re going to be wiped out – not so much on the health front but because they allied themselves with the Tories. And the other red letter day will be the vote on AV (the same day as Holyrood. After that is through, I think the cracks will start to appear in the Lib/Con pact. Hopefully we will not miss and hit the wall on this, as Messrs Hamish Meldrum and Nick Clegg have done.
Anonymouse – Dr No agrees revolutions are (by nature) unpredictable, and whatever fills the vacuum may be worse that that which went before. He is instead suggesting a (metaphorical) roadblock with a view to precipitating something between a radical rethink on the Tories’s part (ha ha very funny!) and/or an election before the Tories have had a chance to dump the NHS in the shredder. Given the Lib-Dems – Alarm Clogg Cleck, Vince-the-Crimp Cable and the rest of the Yellow Tendency – have been exposed behaving like Sunday School classmates caught with their Pantsdown, and McPoodle and been given his eggs back to play with, it seems to Dr No that the building of the needed roadblock must fall on the broader shoulders of the medical profession at large, and the even broader shoulders of the public. And here it seems that the big problem is one of widespread lack of awareness – Dr No wouldn’t go so far as to say ignorance, with its overtones of possible willfulness – about what is going on. That is where we, who have seen behind the Tory veil, have a duty at least to tell others what we have seen.
Julie – Dr No notes we were penning rallying calls-to-arms at much the same time! The Lib-Dems will certainly be vulnerable in Scotland (and Dr No suspects the English tuition fees fiasco will also ironically count strongly against them North of the Border as well as South), one hopes to the extent that it dawns upon them that their very survival as a party depends on a severance from the Tories, and so an end to the coalition.
Dr No is quite comfortable with an early national election. In fact he welcomes it. Now the Tories – who clearly lied at the last election – have shown their true colours, and the Lib-Dems have been exposed as turncoats, the great British public may well think all the harder about who they really want in power, and what policies they want their next government to pursue. Whether the next bunch of serial oligarchs will do better than the current lot remains to be seen, although it is difficult to see how they could shred the NHS any faster and more comprehensively than the current lot intend to.
“the building of the needed roadblock must fall on the broader shoulders of the medical profession at large, and the even broader shoulders of the public. And here it seems that the big problem is one of widespread lack of awareness – Dr No wouldn’t go so far as to say ignorance”
That’s what I was trying to touch upon in my latest post, governments and/or groups using the people’s ‘ignorance’ to push what can’t, and shouldn’t be pushed – and it doesn’t matter how well educated people are, because with politics, proper politicians will always be, not one step, but a few steps ahead of the public, including well educated professionals. For example, look how long it took the BMA to realise the full implications of the current reform. That’s despite them having, I presume, their own legal department in that big fancy and very imposing building, and despite all medical bloggers’ warning through debate, and the media, etc, etc. Hence, one assumes, rightly or wrongly, that perhaps they knew and ‘chose’ to ignore because of vested interests or whatever other reasons. But I refuse to believe they can be that dump. Hence, roadblocks falling on the shoulders of the professionals will never materialise unless there is ‘unity’ of thought plus a collective will to act. Medicine lacks both – and the public, as you said and I agree since I am one, are mostly ignorant.
“The medical profession has the power to do it, by rejecting the Bill ‘in its entirety’.”
Surely the issue here is that most doctors are Tory voters. Why would they vote against the Bill of the party that they are loyal to?
http://www.gponline.com/News/article/934786/Exclusive-Half-GPs-vote-Conservative/
The only issue doctors seem to get exercised about is their pay and pensions, so why would doctors vote against a Bill which stands to see them trebling their salaries to £300,000 a year?
http://www.guardian.co.uk/society/2011/mar/15/nhs-reforms-gps-double-income
It was in doctors’ hands to stop the Bill from going through but it’s not in doctors’ self-interests, so it’s pointless to hope that doctors will take any action over this Tory policy.
Anonymouse and Anonymickeymouse – This is why it is so grim. The public don’t realise what is happening. Only yesterday Dr No was talking to an intelligent Guardian reading teacher friend of his who declared she hadn’t the foggiest notion of what the reforms might mean in practice. Many doctors are pretty clueless too, and many that aren’t are already opening their mouths extra-wide, cuckoo in the nest-like, ready to receive their next shot of gold…
But unintentional apathy and avaricious greed doesn’t make the reforms a good thing…which is why Dr No writes what he does…
It is quite possible that major losses in the Scottish, Welsh and English elections and a loss of the AV referendum could cause a putsch in the Liberal Party. This would not nessecarily cause an election. The alternative would be a conservative minority government governing with the NI unionists, and quite possibly some Orange Book liberals.
If it did precipitate an early election it is far from certain that a conservative government would fall. Labour and LibDems have major financial issues, and the prospect of Prime Minister Milliband and Chancellor Balls is not a winning formula.
A better strategy is to emasculate the reforms so that they make very little change. I remember the furore about Foundation Trusts, but to get the policy through so many restrictions were placed on FTs that it is hard to see how they act any differently to any other Trust.
In all I expect the new consortia to be very similar to the old PCTs. There may be some increased competition, but I am happy that I can out compete my rivals.
Dr Phil,
I am scratching my head trying to think back over many, many years. I can’t for the life of me think of any situation at all when, as a doctor, I competed with anyone. I can’t think of any rivals that were there to compete with. I can’t think of any reason I would want to compete. I have co-operated with many colleagues and many have reciprocated by co-operating with me.
Is there something wrong with me?
Have I been practising medicine in a parallel universe?
Rivals and colleagues are often one and the same. Were you never going for the same job as another junior doctor in your department? Did you never get appointed as consultant/GP principal in open competition?
In a procedure orientated speciality like mine productivity and quality of work have fairly clear outcome measures. I have good working relationships with my colleagues at both Borchester General, little Harley street and adjacent providers, but I like to have better results than them. If my results are not better, then I think hard about the reasons why, and how I can improve, both on objective outcome measures and on subjective measures such as patient complaints, and patient satisfaction surveys.
If one of my colleagues produces better results consistently than I can manage then I refer those patients to them and concentrate on the things that I can do better.
No doubt there is an element of pride, and perhaps of greed (via private practice or CEA award), but there is a substantial element of putting the patient first, which may mean seeing someone else.
Some specialities are harder to measure in objective terms, but the issues are much the same.
Yes I did consider open competition for jobs as a possible rival scenario but dismissed it because I would not have taken other candidates into account when constructing a CV. I’m afraid “take me as I am or leave me” was my simple approach to job applications. Witches are all rather modest souls and we don’t like to sell ourselves at all… if fact we are inclined to do the opposite…. we are always rather surprised when we get offered a job, and we suppose some selection committees might even like the understated approach…..
Prodedures, diagnositic skills, outcomes, patient satisfaction etc. Treat patients to the best of your ability, treat them as you would want to be treated yourself, continually learn from each individual patient contact, continually learn from colleagues who are better than you and let them learn from you. I can’t see any rivalry there.
CEA and other awards. Witches don’t approve of them for doctors so it would be silly of us to bother filling in the appropriate documentaton just to refuse the money if we were awarded (although, I suppose we could donate the takings to The Big Society, so maybe we should have a rethink!) No, we don’t participate in such things that The Humankind holds so dear. So witches will always remain the poor relations of the medical profession. But we don’t mind. We still earn enough to buy the mince and we feel we have been true to our witchy selves.
“It was in doctors’ hands to stop the Bill from going through but it’s not in doctors’ self-interests, so it’s pointless to hope that doctors will take any action over this Tory policy.”
Good point, but let’s not generalise and say ‘doctors’ because it is not all doctors who will stand to benefit from Andrew’s policy.
It’s only partner GPs and not the now large numbers of salaried ones, and not the now poor in comparison, either financialy, authority or standing wise, majority of younger consultants. Or the way below proverty line juniors [thanks for the decades of neglect BMA], and those have been kicked from pillar to post since MTAS and now their training, if any at all, will definately become fragmented if reform as is gets fully implemented.. and no jobs for those few lucky enough they get fully trained too! When can the young ones hope for some justice and some future when the big fat cats are only thinking of themselves?!
Surely, all those are doctors too, and they would want to revolt against the reform and the BMA, or revolt against ‘the regeme’ because it sucks, either for them or for their patients because the message seems to be ‘cheap doctors for cheap patients’!
Rentokill – Too right – there are an awful lot of doctors out there who aren’t BMA establishment types – juniors, staff grades, salaried GPs – and they make up the rank and file that Dr No referred to in the original post, and are the ones whose voice needs to be heard.
I see also that the Witch Doctor has picked up on your ‘cheap doctors for cheap patients’ phrase – praise indeed!