Conveniently, the Health and Social Care Bill completed its final parliamentary stage on the eve of the budget, ensuring it was in hours knocked off the top of the news pile by Porgie’s Biddy Tax. But, mean as the Biddy Tax is, it is not the erosion and loss of the Pensioner’s Allowance that will hit Granny hard in the years to come, it is the erosion and loss of the NHS brought about by the Tories’ now soon to be unleashed health service reforms that will hit Granny – and indeed the rest of us when we need healthcare – hard. So the question arises: what are we going to do about it?
The Establishment, by which Dr No means the medical Royal Colleges, have, by and large, adopted a Vichy position: we do not like the reforms, but will collaborate in the interests of our patients. No doubt Marshal Pétain had similar thoughts about the French people – ‘it is necessary to stop the fighting’ – as he chose to sign up with the Nazis.
Others, meanwhile, may simply claim pragmatism, and advance the cause of the rule of law, the civil obligation to obedience. Indeed, few would disagree that pragmatic collaboration is a correct course to follow. But the question Dr No can’t help wondering is: is it the right course to follow. The question arises because, as Doctor Zorro reminded us recently, there have been many dark episodes in medical history when doctors may have done the correct thing by the rule of law, but by any other court have most definitely done the wrong thing.
It is a commonplace that the first duty of a doctor is to his or her patient. Indeed the GMC – that close friend of doctors – includes a similar notion as the first duty in its summary list of the duties of a doctor. In its quaint second person addressing-the-doctor way, Good Medical Practice says ‘you must make the care of your patient your first concern’.
Now, it seems to Dr No that this core guidance, which all good doctors would readily agree with, places the Royal Colleges in a spot. Most have conducted surveys and taken ballots, and in some shape or form issued statements to the effect that a majority of their college’s members believe the reforms will harm patient care. On these counts alone, given the GMC guidance to put patients first, the colleges’ and their members duties are clear: they should refuse to cooperate with reforms they believe will harm patient care. But – it seems – the spirit of Marshal Pétain is abroad.
GPs, who are required to get involved in commissioning, are likely to find themselves in an even hotter place. Most GPs lack even basic commissioning skills – monkeys commissioning bananas springs to mind. The monkeys might wish to remind themselves that the GMC is quite clear that doctors must work within the limits of their competence. Cavalier GPs who ride the commissioning cart while lacking in competence risk feeling the heat of the GMC breathing down their neck.
It seems to Dr No that there is a sound case for carefully reasoned civil disobedience. Such disobedience is neither wanton not maverick, but a reasonable response to unreasonable circumstances; a balanced resolution to the conflict between civic responsibility and professional calling. Consider this: if a third of GPs – about 10,000 – refuse to go along with the reforms, then the reforms will falter and stall. Even if only a third become objectors, there is safety in numbers. Suing 10,000 GPs for anti-competitive practice – say referring patients exclusively to NHS providers – simply is not going to happen. There is no need for Dr Finlay to be shy: Dr Spartacus will protect him.
Appeasement, and cooperation with the reforms in the interests of patients is certainly an option, as a similar appeasement in the interests of the French people was an option for Pétain. But those doctors contemplating the Vichy option might wish to reflect: not only history, but his own people, judged Pétain harshly. He was convicted of treason.
Dear Sam,
Greed is your word not mine. Dr No is no longer on the medical register, thejobbingdoctor is looking forward to his retirement, Dr Crippen retired a year or two back. I am not planning to retire for at least eight years.
The difference is that I have become adept at working within the system that they all feel is morally wrong. But which is the bigger moral wrong: to leave patients to fend for themselves, or to work with the system to benefit the patients?
My NHS Trust has financial difficulties and will make further redundancies. My NHS pension is under threat. CEAs are suspended, possibly abolished without consultation.
My response is to prepare for whatever is likely to happen and to work within whatever health system evolves in England to provide high quality care for my patients and high quality medical training to my junior doctors. I like my job and like my patients and will not let the bastards grind me down.
There will be a clear out of senior doctors over the next few years due to revalidation, redundancy, early retirement and emigration, but I will remain for duty. The future belongs to me.
Greed is one of the seven deadly sins. Another is Envy, the hostility to others who have posessions. We should avoid both of these sins if we want to live a fulfilled life. When someone is accused of being greedy, the accused should reflect on whether it is true and the accuser should consider whether they are being envious.
Best wishes
Boots
I do not have a problem with your position, Dr Phil – not everybody is an advocate of the old NHS.
It’s just really disappointing that there was not a proper debate about how our health system should change.
Covert privatisation was smuggled in under bullshit rhetoric about clinical standards when anybody with half a brain cell can see that the HSCB bill is designed to enrich the likes of SERCO, et al.
I was trolling around a few Tory websites/blogs, when I found comments left by their supporters, which read, “It is now up to the Doctors and nurses and all those who work in the NHS, to scupper the implementation of this wretched Bill”.
I find this heartening, this type of comment would have been immediately deleted, moderated, had it been on a Lib Dem site,
and its shows even the Torys are losing their grass roots.
TTFN. Rob.
First on a point of admin: Dr No is on the medical register, but without a licence to practice. The reasons for relinquishing his licence are varied, but do not include ‘leaving patients to fend for themselves’. If that was in his plan, he wouldn’t have started this blog, nor continued it.
The Chamberlain (Pétain)/Churchill collaborate/confront debate is as old as the hills, and if human nature is anything to go by, will probably outlast the hills. Both sides have reason on their side. Both sides can claim moral high ground.
The resolution, at least for Dr no, so far as he can presume to understand these things, lies in an understanding of human nature, in particular its dark side, and what humans are capable of doing when it is in command. History teaches time and again that when motives are base and unchecked, there are no depths beyond which the dark side will not stoop. It also teaches us that the crocodile, be it international tyrant or playground bully, has a big appetite. However much one feeds it, it still comes back for more. Appeasement is never a one-off act: the crocodile’s appetite is insatiable. If more is not offered, then the crocodile will take it, if necessary by force. Those who feed crocodiles should be in no doubt: they too are on the menu, and the day will come when they themselves are plat du jour.
Were the HSCB clearly benign, and have only the interests of patients at heart, we would all heartily embrace it. But even the A&E CN’s ‘anybody with half a brain cell’ can see that behind the liberating window-dressing lie darker intents: commerce greedy for profit; investors envious of government wealth. These are the crocodiles snapping in the background. Appeasement, collaboration, call it what you will, always ends in tears; not, of course, for the crocodile, but for the appeaser. But all is not lost. In the great tradition of WSC (RC – DN ‘wrote’ what follows earlier today, before seeing your comment; the last line of the next paragraph echoes your comment):
When we look behind the brazen fronts of Lanzidom – as we have various means of doing – we see many remarkable signs of psychological and physical disintegration. We see the shortages of integrity and intellect which already begin to hamper both the quality and the volume of their health industry. We feel the hesitancy of divided counsels, and the pursuing doubts which assail and undermine those who count on commerce and commerce alone.
In the bitter and increasingly exacting conflict which lies before us we are resolved to keep nothing back, and not to be outstripped by any in service to the common cause. Let the great hospitals of our cities banish despair even in the midst of their agony. Their release is sure. The day will come when the joy-bells will ring again throughout our health service, and when victorious professions, masters not only of their foes but of themselves, will plan and build in justice, in tradition, and in freedom a house of many mansions where there will be room for all.
That’s right – room for all. Dr No has no wish to banish commercial/private medicine. He simply thinks we must keep its crocodiles in check.
“Greed is your word not mine.”
What did you mean by ‘dark side’ then?
Your quote from Star wars “Come over to the dark side Luke, we have cookies!” is then followed by “and andtogether we will rule the galaxy”
And it implies ‘greed’ due to lack of a strong moral code since would would only be after ‘the cookies’ to the point of stepping over to the ‘dark side’, and ‘rule’ the galaxy from this point?
And that’s not how I regard those who go into the challenge of doing it on their own with all the risks, and satisfaction, involved. For example, I can’t see anything wrong with a doc like you going into private medicine as well as working for the NHS, actually, why not if, like youself, you are able enough to do just that – so there’s no dark side here, but an achievement to be celebrated since you benefit patients who are after your type of service, the taxman, as well as those others you employ too.
But I know that a ‘dark side’ can exist with some doctors, that’s when they use NHS time to go out and have a private business on the side leaving ‘their’ juniors in charge, and it does happen as you know.
Good luck with what you do Dr Phil, no defeatism or opportunism in what you do at all, so long as you are not the dark side, and if anyone becomes envious, let them, the ‘sentiment’ belongs to them after all, and that’s out of your control.
“when motives are base and unchecked, there are no depths beyond which the dark side will not stoop”
Are you saying anyone who goes into business is a ‘crockodile’ who is prepared to do anything for money?! Even a ho**e won’t sink that low, I think! 😀
It depends on one’s morality too, surely! Some of those who dare go it alone enjoy the challenge too you know – and those usually value money much less than those with a guaranteed wage every month, hence they can take the risk, again, and again … and believe me, they don’t have the time to be jealous or envious of anyone either no matter how better off than themselves they are!
There are still loads to business people out there who believe still that life is not all about money but about inner contentment too, believe it or not – but they’ll still take an opportunity, when it’s reasonable. This they can’t help, because once ‘in it’, it then runs in their blood …
Why don’t you have a go Dr No? But beware, it’s addictive! 🙂
The cookies reference is to a well known nerd t-shirt: http://nevernotanerd.com/darkside-cookies-nerd-shirt-day/
I do not recall Darth Vader offering refreshments as an inducement, but it is a while since I saw that film.
More seriously: the analogy with feeding a crocodile is an imperfect one. In the USA, Canada, Australia, most of Europe and indeed most of the rest of the world health care funded by governments is delivered by private practitioners being reimbursed by the government. I would not be willing to say that all these are working for the dark-side. I do not think that doctors in all these countries have lower ethical or professional standards than our good selves.
Rather than retire as soon as they can, doctors in these places are keen to stay in their work far longer than UK doctors. It is hard to find a GP over 55 years of age in Borsetshire. Neither do doctors in these places seem so embittered by being forced to be agents of the state.
If there is a crocodile consuming doctors it is an NHS crocodile. One of the pleasures of being ones own boss is one can practice how one chooses, and as long as one chooses.
I am sorry for saying you have left the register, when you are on, but without licence to practice, it is an important distinction.
Boots
Was going to post here and then it got too long. Here’s my thoughts on this;
http://juliemcanulty.blogspot.co.uk/2012/03/of-conscience-compromise-and-oaths.html
Your too right, Dr Phil, there are crocodiles in the NHS.
The crocodile eggs were hatched in 1984 and these initially cuddly and amusing little reptiles were nurtured and given a huge growth spurt when it was considered that the business men and women who had sold shoes, telephones and spectacles had the competence to run the huge NHS “business.” It became old fashioned for a while to use the word “patient.” Client was a better word. They said it was less patronising. And of course we all had to have “mission statements” that eventually fell off the walls because they were unrealistic. I could go on for hours about all the little Creeps that took us to where we are now. It is not even government driven. It is bigger than that because all governments in power since 1984 have found it necessary to develop the Creep. Perhaps Julie has some answers in her recent post.
I am not demeaning all managers within the NHS in any way. Many are my friends and are enthusiastically trying tomake things better for patients. But some of them eventually take on the appearance of crocodiles. Some doctors have developed scales and a mouthful of sharp teeth too.
But I see waste and lack of prioritisation within the NHS. I see how the NHS could better serve patients and at the same time save taxpayers money. I can also see how many doctors enjoy the freedom and time with patients that the private practice of today offers. But the Book of Spells tells me that the private practice of tomorrow will not be so kind. Nevertheless, the NHS crocodile could be rendered edentulate tomorrow if doctors learned to recognise these little insidious Creeps and said “no” when the time was right. They could make a start by insisting on a consultant delivered service and refusing to participate in the bizarre referral systems that were introduced as a precursor to handing over the NHS to big business.
After that they could try to mend the divides that have subtly and intentionally been introduced and festered between doctors and nurses and between consultants and GPs.
The NHS, in spite of the “Staffordshires” can be mended and turned into the best health care system in the world. I truly believe that and it is the sole reason I blog. It is very unlikely the HSCB will succeed. It is a big, big, gamble. But we are doctors (and are or will all be patients too). We are not gambling bankers.
https://mobile.twitter.com/RoyLilley/status/184411152476934145
mr Lilley has the risk register on his twitter. Interesting but not surprising.
Boots
Boots – Dr No has just been reading it too. What curious ways of governing we have these days. Donor Parties for cronies (though we haven’t – yet – seen private health care cronies on the guest list); and now an early (Oct 2010?) RR leaked via Lilley (and Hammond, but his copy is in .xlsx format so not a few people will have trouble viewing it). Another link via here.
The Guardian have picked up on it:
http://www.guardian.co.uk/politics/2012/mar/27/health-reforms-damage-nhs-risk-register?CMP=twt_gu
but – surprise surprise the BBC’s ‘flagship’ radio news programme hasn’t yet (and DN isn’t holding his breath either):
http://news.bbc.co.uk/today/hi/today/newsid_9709000/9709181.stm
Hope the Queen is being kept informed of The Big Health Gamble! The Bill is due to be given Royal Assent today apparently. I imagine HMGs don’t half give monarchs a headache.