As a young doctor I worked in what could be called the “old” NHS founded in 1948 by Labour’s Aneurin Bevan and which lasted until the “new” NHS of Margaret Thatcher’s governments. Though elected in 1979 her reforms did not impact at hospital level until the late 1980s.
When I started in in 1977, the original NHS ethos “to each according to their needs” remained. It was a great place to work. The counterbalance to your 80-hour week was that doctors were well treated, with accommodation, meals while on duty and support at work. If a doctor was ill or bereaved they were looked after. If they were unfairly blamed, the issue was answered by the hospital as a whole.
As part of a team of doctors, you had the advice and supervision of seniors. Along with a tradition of research, this gave you a secure medical apprenticeship. Mentors generously gave career advice. Was the old NHS perfect? Certainly not but its basis was fair, the population supported it and its staff felt part of something worthwhile. As a consultant the same ethos maintained up to my leaving in 1988.
After 20 years as a consultant in Ireland, I returned to work in the NHS in 2012. By then the Thatcher reforms and Blair innovations were well embedded. There were major expansions of staffing and technology. Universal access to health care remained but the manner of its delivery was profoundly different. The NHS seemed to have been transformed into a huge company.
Not only were policy aims and allocations decided centrally but directions on care were also relayed down for local enactment. Senior doctors and nurses felt they had become operatives, pressurised to comply with central directives. This responsibility without power, led many consultants to retire early or leave the NHS. Young doctors emigrated or abandoned their careers altogether. There was a major dependence on medical locum agencies. The staffing crisis had begun.
Staff overruled
My first encounter with the business-consumer model was a questionnaire of visitors to a hospital near London. Among their preferences was continuous 24-hour visiting to all wards. This was strongly opposed by both nurses and doctors, except for gravely ill patients. Their advice was overruled. Noise, poor privacy and distraction of clinical staff resulted. Care of the most ill at night was particularly disrupted. The old NHS adage, to favour the most ill, had been replaced. The new ethos had impacted on patient care and staff had been undermined in their area of responsibility.
The new model had many effects. For junior doctors medical protocols had been introduced. Such guidelines are useful but need adaptation for individual patients’ complexity. However with the abolition of teams in 2005, trainees often did not have ready access to seniors for advice.
In my work the most fundamental change was the new system for acute medical admissions. Previously, most patients were admitted under a team who supervised their care until discharge. The new system often involved multiple transfers during the same admission, whereby the patient might see a different doctor every day, particularly in larger hospitals. Patient trust was jeopardised, while loss of continuity of care was a major medical concern.
The ethos of a health service must be clear in its aims, limits and rules. Otherwise the equity of some patients will be lost and clinical staff will become the interface for a disappointed public.
Staff support
Medical litigation and concerns about it are major factors undermining medical morale. Even if a doctor is blameless, the possibility of litigation has outcomes that can include suicide. Mature handling of complaints and incidents is essential. While candour and apologising for medical shortcomings are professional obligations, suggestions of incompetence, unprofessional behaviour or illegality require fair assessment. Unwell doctors need prompt help away from the workplace.
Regrettably in some countries a practice has arisen of hospitals issuing apologies, before the cited doctors are involved. This can be misconstrued as their being part of the defined “act of saying you are sorry for something wrong you have done”. This could count as an admission of fault. Doctors will leave or avoid such an unsupportive work setting.
Employers also need to avoid creating divisions between staff. Thus it is undermining to allow some doctors, but not others, to work in training posts or to pay some consultants less for the same work. Similarly, to put constraints on doctors who wish to spend time training abroad, suggests a less open and confident health service. Their ambition, new approaches and links would be a loss.
A health system’s ability to attract medical staff greatly depends on the population it serves. If their support is not there, even when deserved, alternative market models will be promoted. My experience suggests that it would be more effective if Ireland could agree and support its own solutions.
David Clinch is a consultant physician in general internal medicine and geriatric medicine