This article appears in the May 2002 edition of the Catholic Medical Quarterly
Why are Doctors Unhappy?
The current cries for reform of the NHS ignore the undoubted fact that doctors and indeed nurses are unhappy. Why is this? What has happened to change a service once described as 'the envy of the world� into a service from which most of its principal operators are seeking early retirement?
Doctors graduating from medical schools after prolonged training in pathophysiology, and the diagnosis and treatment of disease, now find themselves spending more time thinking about issues of management, audit, finance, law, ethics, and communication. A service established on the basis of an implicit compact between the government, the medical profession and the public is found to be weakening. There appears to be a change in this psychological compact of employers, patients and society in that the job now differs from doctors expectations. It has seen a significant reduction in medical autonomy and increases in accountability as a result of the growing evidence base of medicine and along-running attempt to bring it under managerial and cost control by governments, payers and employers. Such a system has resulted in the growing use of guidelines, audits, protocols, regulations and inspections that many doctors see as eroding their control over their own professional lives. Although there are benefits from these changes, having control over work is important for the job satisfaction of clinicians. Medicine has always been based on a model in which doctors are trained to deal with individuals, not organisations; to take personal responsibility rather than delegate; and to do their best for each patient rather than make trade-offs in a resource-constrained environment.
On the other hand government ministers look down on the health service and don�t quite understand. Their cry is that resources are being increased in real terms. They live in a world where escalation of promises is routine. In their attempts to gain improvements in efficiency, a gentle administration which graced earlier years has changed to a hardnosed management: managers seeking greater productivity and doctors feeling they were on a conveyor belt in which the number of patients seen mattered far more than the quality of care.
Then there is the negative media coverage. Dr. Kildare, or Dr. Cameron, according to which generation you belong, has been replaced by Dr. Shipman. Certainly there has been well publicised evidence of failures of performance at both individual and organisational levels, such as the retention of organs without consent at Alder Hey Hospital and the deaths of children after heart surgery at Bristol: one wonders how far doctors now stand in the popularity scales.
The main instrument of reform, proposed by the Chancellor, is a hike in National Insurance contributions. But whereas the public sees a difference between tax and National Insurance, the government does not. It is a common public belief that insurance contributions go specifically to finance the state pension and to make a worthwhile contribution to NHS funding. What is not realised, ac cording to Frank Field, a former Minister,(1) is that the contributions have built up the heftiest of surpluses, which the government has refused to payout for long term care or to raise the basic pension. The National Insurance Fund, as it is called, is compelled to keep a surplus of one-sixth of its expenditure to ensure there is always enough cash in the fund to meet possible fluctuations in income and expenditure. That surplus this year stands at almost 8.5 billion Yet, on top of this, the fund is now running at an additional surplus of a staggering 15.8 billion, set to rise to almost 19 billion next year. There are many interesting and doubtless extremely popular programmes for the distribution of this pot of gold; but, if a large part went on health, our expenditure would be raised to European standards at a stroke. Instead, as Field points out, the government spends it on other programmes. Which ones it never says.
The case for a National Health Service remains convincing: a tax-financed service free at the point of delivery. Reform must include an end to insensitive monitoring, national standardisation and persistent political exposure.
Health authorities are encircled by targets and performance monitoring emanating from Whitehall. The front line professionals, including managers, must be freed from this scrutiny and made answer able to hospitals and patients. At present they answer to the Audit Commission, the National Care Standards Commission, the National Institute for Clinical Excellence, and to national service frame works for diabetes, carcinoma, heart disease, and renal treatment. Leadership and responsibility must be restored to them: for it they have been trained. Admittedly this in certain circumstances may involve them in the painful task of rationing health care; but it should be done with the knowledge of Frank Field�s pot of gold.
1. Frank Field, The great Labour Tax con, The Spectator, 2 March 2002.