Description
How would you one advise an ambitious Secretary of State for Health who wants to see the ‘overpowerful’ doctors brought down a peg or two? A working group might well identify certain themes that are likely to lead to success over a period of time. The most important one is to take away the strong sense of self-worth and group identity by making doctors into just another group of employees to be hired, fired and bullied just like everyone else.
You would then f lesh this out with some specifics. Creating a fear of unemployment; getting people to clock in and out of work; forcing them to obey rules – whether relevant or not; using pay and contracts as a weapon; taking away any areas where doctors think they control their own destinies.
Looking at this list we can at last to make sense of some of the NHS changes over recent years – almost all of which were instituted by Alan Milburn. For example, a huge increase in the number of the number of medical graduates is coming without a commensurate increase in training opportunities after House Jobs (not to mention re-badging the early years as Foundation programmes to create confusion). Also allowing a pool of nearly 10,000 international graduates to be in the UK having passed the PLAB Part II exam and allowing all EU graduates to work here without any formal tests whatsoever. It is no wonder that some SHO jobs now attract up to 1,000 applicants.
The European Working Time Directive has created tremendous openings to de-professionalise us: almost all junior doctors are now used to diary monitoring exercises and also understand the importance of leaving when a shift is over. This is so close to clocking on and off that we cannot really see a difference. It also takes away one of the cornerstones of the doctor’s role which is to always put the patient’s interests before your own. That no longer sits with shift work and limited hours.
Contracts are another area where we have been caught out for short-term gain. GPs have received a decent pay rise but for many of them it has meant becoming State employees instead of independent contractors; this will prove troublesome in time. Hospital doctors have had a more modest pay rise but at the cost of a hugely increased amount of monitoring of weekly job plans by management. In addition managers have been given much wider powers to alter work arrangements through the annual review.
Command and control (‘do as you are told’) are entering our vocabulary now because of ever increasing pressure from political targets. No-one now pretends that clinical priority is still the main determinant of who is admitted and when. In addition we have seen patients hived off to overseas surgeons and healthcare companies in a way that was unimaginable a decade ago. We mostly do as we are told because the hassle is so great otherwise.
The downgrading of the Royal Colleges as guardians of training standards by the creation of PMETB was also a masterstroke. This has been coupled with the MMC programme to create confusion and stress all round. By downgrading the Colleges, the government has succeeded in neutering a powerful set of critical voices. Any complaints from this source can now be easily portrayed as the rantings of ‘forces of conservatism’.
One more development we must study carefully is the idea that surgeons will be credentialed for individual procedures. This could easily lead to a cadre of tonsillectomy only surgeons. One needs a broad range of skills to cope with the unexpected and to deal with changes in the way diseases are managed. Just look at the changes in urological surgery or cardiac surgery for a glimpse of the future for other specialists.
To some this article may look like an outburst of paranoia; we would suggest that it is only when you put all these reforms together that you can really see what is going on. We are in danger of slipping into de-professionalism without even noticing. We are sleep-walking to disaster.
