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Br J Gen Pract. 2007 February 1; 57(535): 168.
PMCID: PMC2034194

Aiming for the Tsars

I smile watching my son emptying the kitchen bin. His antics are a welcome distraction from the GMC document I'm struggling to digest. He seems as enthusiastic about his chore as I am at finding out what my 14 duties as a doctor should be. He holds the bin at arms length, his nose deeply wrinkled and his head turned to avoid gazing on its distasteful contents. I realise, too late, that we haven't kitted him out in a full hazard suit for his dangerous mission. I expect a midnight knock from social services shortly. I feel as if I've blinked and a boy we once had to stop picking up and eating anything and everything in his path has transformed into a comically fastidious 8 year old.

Finding an elusive happy medium, a balance point between two extremes seems to be all around. The French poet Paul Valéry said ‘Two dangers constantly threaten the world: order and disorder’. The burgeoning regulation industry, however, doesn't seem to recognise the danger of too much order. During another blink of my eyes regulation of doctors seems to have swung from trust in self motivation based on one's own professional standards and pride, to mistrust, suspicion and a compulsion to name and shame.

Like Valéry I think that there are dangers in this attempt to order the world. Heavy handed authoritarian regulation reaches a critical mass which crushes good will, belief in your own standards, professionalism and the enjoyment from doing something to the best of your ability. When those go you lose something priceless. Demoralisation often affects the good, the ones who least need regulation. Just as the ‘worried well’ pay more attention to health promotion; regulation will often have a disproportionate effect on the ‘concerned capable’. The main targets, the Shipmans, Aylings and Ledwards will still be motivated by whatever dark forces drive their deviant behaviour and will often find a way to play any system. Also, creating a misguided belief in an unattainable perfection increases distress when things still happen to go wrong. The natural consequence of this is an increase in the blame culture. Modern medicine has brought unparalleled improvements in treatment and quality of care, yet complaints are also rising. More regulation and monitoring often bring more discontent.

I see much more good than bad in my colleagues. I regularly learn from the mix of wisdom and pragmatism they bring to the rich variety of bemusing and baffling, protocol-defying problems that real patients produce. The band of various advisors from inside the profession should be celebrating this. They should be trying to shape regulation through promoting the good and developing the energy that is already there, not giving their blessing to the confrontational approach of their political masters. I don't want to mention names as Chief Medical Officers and Primary Care Tsars deserve respect from this Journal. Isn't the relish with which those with a mission to monitor adopt the title Tsar revealing? The allusion to an intolerant authoritarian system that demanded unquestioning obedience from the serfs sends a clear message of intent. The Tsars are fond of using star ratings as a measure of perfectibility but another philosopher, and occasional football manager, had a better understanding of stars and the quest for perfection. Bill Shankly put it pithily ‘Aim for the stars and you might hit the ceiling’. Having high standards is important but not achieving them fully isn't necessarily failure. Sometimes being good enough is … well … good enough.

Meanwhile, back at the GMC document, the first commandment is ‘You must make the care of your patients your first concern’. Another counsel of perfection that troubles me. What does it mean? I want to be a good doctor but it doesn't define me completely as a human being. What about all the other values I have — my family for instance — which make me a better human being? I'm ashamed at some of the times that, through too much pressure or pride in my job, I've put work before my family. I don't want to blink and miss other transformations in my children as they grow up at an alarming rate.

Better human beings make safer, caring doctors, and no set of 14 commandments or 44 recommendations can adequately convey that. Any system of regulation that ignores it will not produce ‘Good Doctors’ or ‘Safer Patients’.

Articles from The British Journal of General Practice are provided here courtesy of Royal College of General Practitioners