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The central argument of this intelligent, troubling book is that along the way of the re-invention of the National Health Service since 1997, it has lost something of its core values—compassion and humanity. Those who have lost out through this process are not only the users of the service, but also those who work in it. As someone who did once, but does not now, work in the NHS, it is an interesting hypothesis.
The opening section is in the form of a novel. This unusual device works well at bringing in to play multiple and varied themes in an accessible manner—more than one could imagine covering in a traditional non-fictional account. The flipside is the fact that it is a strange novel in which there seems to be only one topic of conversation. However, the characters and plot are mainly constructed carefully. I particularly enjoyed a section where different characters reflect on a patient forum they have attended, with predictably and accurately varied responses. Only one character, a modern-day James Robertson Justice, seemed too one dimensional. I suspect that the contemporary senior surgeon would find ways of sabotage that are far more covert and concealed beneath a veneer of respectful tolerance.
The second section of the book aims to explore the themes more theoretically, and does so again in a conversational manner. The central accusations seemed to be that: the drive to improve standards through targets has unanticipated adverse consequences; the centralization of the message is damaging; patient involvement as presently configured is missing the point; medicine is more than a series of transactions. Some of these arguments are widely advertised, some less so, but it is interesting to read a book where someone has brought them together in such a coherent way. Mainly it was hard to disagree, even on the subject of MMR (where the difficulties implicit in being asked to describe something as ‘completely safe’, which if true must mark it out as unique not only in the BNF but also in life).
I had two concerns about the book. First, I do not think, as the book seems to imply, that there was ever a golden age. As a medical student and young doctor I remember examples of behaviour that belie the idea of a humanistic, compassionate service—witness the derogatory manner in which patients were dismissed as mere teaching fodder, the ‘myeloma’ in bed 8, and the multiple public internal examinations. Secondly, I think those of us who have worked in the service do also need to reflect on our part in the relative downfall of the NHS in the public estsimation. In all my 20 years in the NHS I am not sure that I ever sat in a meeting where the services problems were not ‘outside the door’, whether this was the general practitioner complaining about consultants, or vice versa, or either group berating managers or patients, etc. Also, I do not remember any change proposed within the service to which doctors in general, often including myself, reacted with any enthusiasm—witness the inexplicable, indefensible resistance to GP appraisal without bribery in the early part of this decade.
Petit Zeman's book is good at describing problems, and exploring the linkages. In general, I think she is perhaps too generous to doctors, and too hard on managers—who after all lose their jobs more easily and often have to implement changes they know to be flawed. Perhaps she is also too hard on government. They constructed a White Paper in 1997 that promised much that was good, and, with the exception of the ruinous multiple forced structural reorganizations, cannot be held solely responsible for the implementation challenges that have ensued. Nonetheless, this is an important, readable and stimulating book that deserves a wide audience and broad debate.