Anthony Seaton in his recent articles, Discontent in the profession of medicine (16 August 2023) and The NHS still works (30 August 2023), raises serious concerns. I agree with nearly all his points about current NHS developments, notably his doubts about junior hospital doctor strikes and demonstrations. Pictures of younger doctors chanting in front of hospitals are unlikely to benefit the NHS. Worse, strikes of consultants and juniors are now being co-ordinated to cause near-maximal disruption to elective work (emergencies should be unaffected). I too would not want to be looked after by doctors who withheld care from me.

Surely the way to improve the NHS is via the ballot box and for governments to be forthright and do what is best for the population and not what the population wants (a totally free NHS without increasing taxes to match). That is the flaw with popularism – people will vote for what they want, not what is best for them or for society. Advocates of popularism fail to mention this unpopular notion.

Throughout my medical career of over 50 years, I thought that escalating costs would destroy the NHS. So far I have been wrong but continuously improving healthcare will increase costs. Better preventative care means longer lives, again with increased costs: preventing one disease means that people will survive for longer to develop other diseases and, if these diseases were prevented the same principle would apply, but more so.

The NHS is a national health service and not just a job. Were it to become a job the NHS would be replaced by a private health service run on (very) profitable business lines and a much-reduced public health service funded by taxes and based on what might remain of altruism.

There are several non-financial reasons for the decline in NHS morale. High-technology care requires focusing on parts of people rather than the whole package: this is a sensible business model but dispiriting for doctors and for patients, the latter who might receive care as if they were cases of a disease rather than people with a disease.

Professor Seaton and I regret the current lack of professionalism implied by financial rewards to incentivise staff. But NHS cash incentives are not new. Bevan stated that he had to stuff the consultants' noses with money to get them into the NHS. It seems that consultants were and are still incentivised by extra money as they may receive bonuses (termed merit awards, clinical excellence awards, or distinction wards) that even in 1994 were officially declared to be 'a powerful motivating force'.

Bonuses might create future generations of less caring doctors whose career plans become more associated with spreadsheets than bedsheets. However, some consultants do not want to dance to the tune of tinkling cash registers and there is evidence that some who love their job regard extra cash as irrelevant or demeaning.

Bonuses can be demeaning for consultants, especially those self-motivated to work more than their contracted hours for non-financial reasons (they do not put in more than their contracted hours in the hope of gaining status as bonus holders, because restrictions on publicity ensure that the names of bonus holders are not widely known).

Worse, the process for awarding these bonuses is occult. Awards are allocated in camera by Star Chamber Committees (the original Star Chamber Courts were abolished in 1641) without transparent accountability as to why they favoured one consultant above another. 'It would be extremely difficult, and also undesirable for award committees to attempt to record why individual consultants had or had not received an award' (at that time £104 million) – Department of Health. Consultants desirous of an award were advised to approach an award holder to put forward their case. All this reeks of covert patronage.

Doctors are members of a profession (professions are 'a paid occupation, especially one that involves prolonged training and a formal qualification' – OED) but unlike other professions, we should be primarily a caring profession. And this is what is at risk. I agree with Professor Seaton that 'We need to rekindle the concept of the professional ideal, the motivation of the so far silent majority of British doctors and other professions'. However, times have changed, and we should resist the temptation to indulge in potentially flawed nostalgia for the good old days. As we get older, we remember the good things, but the memories of the bad things fade.

The British Medical Association is a trade union and ought to reflect on its striking image. But it has brought about many good things for the NHS including the demise of ridiculous working hours. As a junior houseman, I was resident on call for half of the time. My wife (also a doctor) had one weekend (Friday 9am until Monday 5pm) continuously on call, 80 hours in total, with only a few hours of sleep.

The NHS is now at risk of becoming solely business-based and everyone ought to ensure we keep it on the right track. Clapping á la Covid will be insufficient.

Philip D Welsby
A retired full-time NHS consultant who eschewed private practice. Whether he received bonuses is not relevant



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