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Sir Donald Irvine got a number of things wrong in his Lloyd Roberts Lecture (April 2001, JRSM pp. 162-169). He was, I think, most wrong and most dangerously so in his understanding of Mrs (now Baroness) Thatcher's ‘reforms’ of the late 1980s: ‘Mrs Thatcher...signalled that patients...had to come first’. The prospectus for the ‘reforms’ was indeed titled ‘Working for patients’, but practically all doctors and nurses knew well that for the past forty years that is what they and their predecessors had been doing or trying to do. The prospectus was so named in order to disguise the intent of the changes—namely, by privatization to relieve the State of much of the burden of maintaining a health service. Not all doctors perceived this at the time: some were persuaded by the prospect of advancement to give their enthusiastic support; others were glad of the opportunity to make money offered by the encouragement of private practice; others were so much terrified by the power of management that they abandoned their role as patients' advocates; many others had by then had enough, and just gave up the struggle.
Meanwhile, the advance of Thatcherism persuaded many in this country that there was indeed ‘no such thing as society’, and many others that the highest good was to be found in the accumulation of money. In the National Health Service, these changes, together with the subordination of the clinical to the managerial ethos, seriously damaged the standard of service offered to patients. Prospects for managers and for ‘chief executives’ in particular have, in contrast, greatly been improved.
Sir Donald and his colleagues must, I think, recognize that improvement in the quality of the service offered to patients will not be achieved by further regulation or by the creation of a new regulatory body every time something goes wrong. It will be achieved only when the primacy of the clinical ethos is restored, when doctors learn again to regulate the conduct of their affairs, when undergraduate teaching and graduate training are reformed, and when management is restored to its proper role of facilitating clinical objectives. It may well be impossible to achieve all this within the Health Service as at present constituted, just as it is now plainly impossible to restore the efficient operation of the railways without radical reform of their administrative structure.