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Sir Donald Irvine (April 2001 JRSM, pp. 162-169) gives two causes for the crisis in the National Health Service (NHS). His first cause is the ‘cultural flaws in the medical profession’. Top of his list is excessive paternalism. He is impressed by the information revolution and gives an example of the change that has occurred. He speaks of a ‘flavour’ of recent improvement, a less pejorative word than anecdote: ‘Holly’ has been transferred by her parents from one teaching hospital to another. Her parents are calling the shots—‘not doctors or managers’. Sir Donald's attack is really on élitism. He doubts whether a lone doctor who has spent his life studying a subject will have the knowledge to advise wisely on treatment. In the place of judgment that might be faulty, treatment should be based on team decisions, protocols, guidelines, accepted good practice and ‘evidence-based medicine’, all leading eventually to directives where responsibility is taken from the doctor, and the medical profession becomes a middle-grade civil service. Ward rounds where a consultant with small team and sister would make decisions on twenty patients in two hours have been replaced by the case conference: the notes without the patient are now studied by a group of doctors, nurses, social workers, physiotherapists, occupational therapists, home finders, dietitians and managers lasting two hours and often coming to no decision. Professor Anthony Smith, President of Magdalen College, points out that Britain has become uncomfortable with the idea that, in a democratic age, there can exist élites and élite institutions. We are more at ease with ‘excellence’, which has acquired ‘a kind of bureaucratized status in all sorts of contexts, partly because excellence sounds not so much as something to be striven for as something that can be handed out in egalitarian rations’.
Sir Donald writes: ‘The principle of quality improvement is that quality is achieved across a broad front by a process of incremental improvement and that, rather than inspecting our defects, one gets things right first time’. If this statement means anything at all, it suggests that we should ignore defects but somehow achieve improvement, whatever one means by improvement. He then deals with assessment and the need for revalidation. Mistakes occur through tiredness, carelessness and other human failings but only rarely through ignorance. Would Lykoudis1, the forgotten discoverer that peptic ulcers are caused by bacteria, have had his revalidation refused until he accepted that the bacteria at the floor of peptic ulcers were the result and not the cause of the disease? Sir Donald only touches on Shipman, the medical murderer, but cannot resist using the Bristol ‘scandal’ to further castigate doctors who have not yet had the controls which he proposes to impose.
George Orwell would have been proud to have produced the newspeak found in this article, and Sir Donald's new world could have been devised by Jonathan Swift. Gulliver in his travels to Laputa found that neither Prince nor people appeared to be curious in any part of knowledge except mathematics and music. If élitism is expelled from medicine, so much the worse for the NHS.