I have been troubled by reports and films of the behaviour of some, predominantly young, members of my profession in England. To withhold one's labour and to appear on picket lines, laughing and chanting mindless slogans, to attribute the minimum income to all, while claiming that all of them, trainees, are already highly skilled and likely to be attractive to employers in Australia or Canada, is to deceive the public and cannot be regarded as professional behaviour. It is cynical to wave banners saying 'Save the NHS' when your behaviour has exactly the opposite effect. Much has been allowed to happen to the NHS to lead to this discontent, but for the British Medical Association (BMA) to encourage such unethical behaviour is deplorable.
Members of my family have worked continuously as doctors and nurses in the NHS since its inception in 1947 and have been involved in teaching medicine since before the practice of medicine in Britain was formally regulated under the Medical Act of 1858. I quote from two speeches given to medical students in two eras almost 150 years apart. The first was by my great grandfather, the fifth son of a poor Glasgow handloom weaver, who attended Anderson's University and became a surgeon and ultimately head of the new medical school in Leeds.
In 1869, after describing the curriculum, he said: 'To prevent and cure disease and to alleviate pain and suffering present a field of labour of the noblest kind. In the pursuit of these objectives you must be prepared to exercise much self-denial; to spend anxious days and not unfrequently watchful sleepless nights; to be ever ready at the call of duty however inopportunely that call may come'. He explained that medicine rarely offered rich rewards other than those derived from the gratitude of those cared for.
Five generations of his family have now experienced this in the profession. Their experience, sometimes documented in patient records, shows that the practice of medicine has always been hard, often financially unrewarding, but sufficiently satisfying for some in each generation to aspire to join the profession. And medical students over the generations have been warned – I quote from another speech, entitled
Two words and a man, delivered to the graduating medical class in 2007 in Aberdeen. Having described the inspiring story of their university's greatest medical graduate, Sir Patrick Manson, father of tropical medicine, the speech continued on incentives and professionalism.
'You won't find the word
incentivise in any other than the most recent dictionary, as it is a newly coined verb to describe the process whereby business people are persuaded to work harder by the incentive of a large bonus at the end of the year. The implication is that they have a job that does not bring its own rewards; that money is the main motivation of their industry. It has recently been used with respect to the learned professions, teachers, doctors, academics. The last English Minister of Health has justified his government's agreement to the generous consultant contract in terms of the need to incentivise doctors. Why didn't this word exist until recently? Because there is another perfectly good word with the same meaning,
motivate. And this brings me to the second word,
professionalism.
'In English, professionalism has its medieval roots in the profession of faith and it is now commonly used to denote two contrasting concepts. One is the familiar role of someone, especially a sportsperson, who receives money for their activity in contrast to the amateur who does it for love; the other is the attitude of a member of one of the learned professions. In this sense, it acquired a deeper meaning during the Industrial Revolution as the professional ideal, in order to differentiate the activities of the entrepreneur from those of the doctors and academics, loosely grouped around Jeremy Bentham, whose activities and skills were devoted in a disinterested manner to the service of their fellow man and woman, especially those less privileged than themselves. I am sure that this understanding of professionalism is what motivated you to enter this profession and I hope it will sustain you through your careers.'
Was I being overly optimistic or hopelessly out of date? I like to think not, and perhaps this is borne out by the more sensible behaviour of doctors (and their government) in Scotland and of their many colleagues in England who refuse to strike. But I have another experience that may explain what is happening now.
Like many young doctors of my time, my brother and I spent some time working in the USA. We went overseas to broaden our experience, not to make a fortune. My son went further, to Papua New Guinea and several of my friends went to Africa. We all came back better doctors, to work in the NHS. But in USA in 1969, I was shocked to find many medical students had entered medicine not from vocation but from a desire to make a good living. And this was mirrored in the attitude of the public, that doctors were looked on with suspicion, sometimes justified, that they would inflict unnecessary procedures or operations on their patients for personal enrichment. I am afraid that the present behaviour of junior doctors in England risks driving public opinion in the same direction – and this destroys the concept of the NHS.
There are three culprits in this damaging scenario – the UK Government, some (emphatically not all) doctors, and the BMA. The BMA bitterly opposed the NHS at its institution and defended the rights of private practitioners. Then it worked hard on behalf of general practitioners, ultimately encouraging its shedding of house calls, weekend and night-time working.
Now it has apparently been taken over by militant youths posing as downtrodden workers. Many members have resigned from it in protest, as I did decades ago. But those militant youths exemplify a new generation of doctors who don't care if they wreck the NHS and who ignore the effects of their behaviour on their patients. Such people have no place in the profession – would you want a doctor who withheld care from you? If I were an Australian or Canadian, I'm not sure I would either.
The third and most important culprit is the government, or rather a succession of UK Conservative governments. As the employer, they must take responsibility both for the behaviour of their workers and the conditions in which they work. The NHS has aims which by their nature are not fully achievable but are an ideal which can be approached by the efficient use of a determined and altruistic staff. Those two adjectives are crucial and can easily be eroded; without doubt, they have been. They flourish in small organisations but are difficult to maintain in huge ones without imposition of military discipline.
The market approach to healthcare introduced in the Thatcher era in the name of efficiency has been destructive. The diminution of the role of general practice has been destructive. The loss of continuous responsibility for patients in the hospital service and introduction of shift working has been destructive. The steady destruction of social care has been destructive. The progressive privatisation of large pieces of the NHS in England has been destructive. And competition between different units in a system which relies on collaboration and cooperation has been destructive – all destructive of the two necessities: altruism and determination of the workforce.
The loss of the NHS would be a major step in the regression of the United Kingdom to third world status. When I read my great grandfather's speech and my grandfather's clinical notes and photographs from the 19th and early 20th centuries, I see a world not unlike that in refugee camps today, but in a prosperous city in the North of England: scrotal cancer, tetanus, advanced syphilis and tuberculosis, typhoid fever, mutilating injuries. They would not have believed that we, their descendants, would have such wonderful opportunities to care for their patients as provided by the NHS, when all they had was chloroform, opium, the scalpel, and a few other drugs mostly derived from plants.
And let us not forget that the full-time employment of doctors in the NHS along with their academic colleagues has made possible the extraordinary speed with which new treatments and vaccines have been discovered, trialled and introduced. If we lose the NHS, we lose modern medicine in the UK.
Not since 1945 has the UK Government been presented with so great a challenge on the economic and social fronts. The combination of social and economic decline, of which the problems of the NHS are a symptom, with the stresses from war, pandemic and climate change, demand radical action. Slowly the public is beginning to appreciate this and could respond to inspiring leadership. But we need leadership that tells us what their and our problems are and provides a practical way forward rather than making promises on tax that it cannot fulfil. When we get that, we can start to rebuild the NHS. Until that happens, we can expect the selfish and disgruntled doctors to emigrate to countries that tolerate such behaviour and to be replaced in the short term by doctors immigrating from poorer countries, as happened in the 1950s.
The structural problems in the NHS that have led to this are vast and unlikely to be solved in negotiation between the present UK Government and the BMA. The Scottish Government and our doctors have shown a more pragmatic approach but for us in Scotland, and in Wales and Northern Ireland, a united approach to these problems will be necessary to ensure that a sufficient proportion of the national income is devoted to the concept of the health of the population from the whole of our lives. Ultimately this must mean that less money should go to those who have more than enough and more to those who have little.
The national administrators of the NHS and representatives of the royal colleges of medical specialties should now be talking to those who might hold power in a year or two's time to seek a way forward. We must expect the jobs, enterprise and engineering associated with a green future to provide the positive economic background to this rather than the trading of stocks and shares in London.
In historical terms, little time is now left to avoid disaster and that is why the next UK General Election is so important also to those of us who do not live in England. We need to rekindle the concept of the professional ideal, the motivation of the so-far rather silent majority of British doctors and other professions.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own
