Death by erosion

Two of Britain’s largest remaining nationalised industries – the Church of England and the National Health Service – have recently acquired new bosses who have publicly declared that the Nineties will be a decade of major change. This has set me wondering what kind of reaction George Carey might expect if the plans he had in mind for his own organisation were at all like those being implemented under William Waldegrave. Capitation fees and evangelism budgets for individual priests? The chance for churches to opt out of diocesan control? A division between purchasers and providers so that a diocese can draft in the Jehovah’s Witnesses or the Wee Frees if it suspects that the fare in its own parishes is becoming a little dull? A small minority would no doubt welcome these along with other transatlantic innovations, but for most the sheer, well, commercialism of it all would provoke a delicious shudder of horror.

More Britons see a doctor regularly than go to church, but that is part of the problem. Doctors and priests once shared fairly equally the task of helping us to cope with the fact and fear of death, and of minimising the unpleasantness we might face before and, respectively, after the event. Although doctors also do much routine plumbing and maintenance work, the unpredictability and suddenness of illness means that their role as mechanics cannot be separated from their priestly function. The scope of the former role has grown through technological advance, while the need for doctors to exercise a priestly function has expanded as our hopes decline for an ultimate referral to the Great Consultant in the Sky (he opted out some while ago). When they act as our priests, doctors are expected to fight for us and to counsel us selflessly, certainly not to judge us or to treat us as costs in a function to be minimised. And if priests were all they had to be, running a health service on a shoestring, with less attention to management than to purity of vocation, would be an unexceptionable policy. But the priestly analogy breaks down once applied to the substantial resources that a modern health care system commands. This is partly the product of its own success: as death from infectious diseases has declined, so a sturdier population grows to an age where death comes by erosion rather than by conquest, and care of the sick is correspondingly more protracted and expensive. Partly it is the achievement of science in holding that erosion at bay: the technology of soul transplants has not changed much in two millennia (though Americans, as always, find the electronic media helpful), but many other bits of the person can be strengthened and supplemented with chemical or mechanical gadgetry. It’s a losing battle, but even postponement of defeat can feel like an achievement. And the greater ease of monitoring medical progress increases the temptation to intervene, to use newer and more expensive gadgets when the old ones fail, as inevitably they will. But partly the resources problem arises because much medicine is not a technological folie de grandeur: it consists of simple useful things like paracetamol and hip replacements and health visitors, things that genuinely improve people’s quality of life, but are always under threat from the claims of glamour medicine on one side and taxpayers’ meanness on the other. And when resources on this scale follow medical decisions, doctors become managers as well as priests. It’s not a role they can choose to forego: like speaking prose, they do it whether they acknowledge it or not. The current controversy over the NHS reforms is about how, not whether, that managerial role should be fulfilled.

Any medical system in any country faces an insoluble problem. Most decisions about allocating medical care to individuals are made by doctors and patients responding to the needs of a particular case. Their concern for a cure usually dominates most other claims on their resources. But most decisions about investing in health – about allocating resources to the health-care system as opposed to particular individuals within it – are made by people who are well (taxpayers, politicians, individuals taking out insurance policies), and who therefore balance the risk of illness against other claims. Decisions of the latter kind – weighing risks of this against chances of that – are the reasonably familiar province of economics. But decisions about allocation to individuals are characterised by values more typical of the priestly role: urgency rather than cost-effectiveness, need rather than value-for-money. These sets of values are in mutual tension, but the health service needs to live with both kinds. Sometimes contemporary political rhetoric seems characterised by a yearning to abolish one kind of decision-making altogether. Thus the Labour Party’s ‘Better Way for the 1990s’ promises us only priests, no managers, with the literally incredible claim that ‘the only health market which Labour will promote is a medical market in which GPs and patients can make their choice on the basis of the best treatment, not the cheapest treatment.’ Much Tory rhetoric, by contrast, seems to regard the priestly function as just another symptom of the dependency culture, and to long for the day when health care is allocated by managerial considerations alone. It is hardly surprising that voters remain unmoved by promises to make doctors as competitive, dependable and efficient as garage mechanics.

In practice the two main parties are closer together than the rhetoric suggests. Both are desperately anxious about the potential of health costs to leap over the next decade; both are aware that central planning and rationing by queues are even more discredited now, by recent events in Eastern Europe, than they were before. Both realise that the American model is not one to be copied (indeed, the recent reforms in some respects move the NHS in the opposite direction: fee-for-service payments have done much to encourage over-treatment in the US, while fund-holding and drug budgets are feared here because they may encourage under-treatment). Both parties also believe that the recent NHS reforms are of quite momentous significance. A foreign observer might at first be puzzled, since the reforms appear to consist mostly of accounting changes, and will still leave the UK with less of a competitive market in health care than most other industrialised countries. In fact, there is a question here about the commercialisation of the Health Service which both opponents and defenders of the reforms have failed adequately to answer. If, as both main parties agree, there is overwhelming evidence that doctors are individually motivated to a considerable degree by a sense of vocation, why is there reason to think that these reforms will make very much difference – for either good or ill – to the millions of everyday treatment decisions that make up the bulk of the activity of the National Health Service? Why will a greater awareness of profit and cost have much effect on the actions of people who are not particularly sensitive to such considerations by either inclination or training?

One way of reading Medical Choices, Medical Chances is as a study of how commercial pressures affect professional ethics, and thereby the actions of those who do not normally see themselves as responding to commercial pressures. It is a collection of case-material, narrated as the experiences of a fictionalised doctor in Boston. It portrays the pressures for overtreatment as manifesting themselves, not in any direct perception that that is where doctors’ interests lie, but in an attempt to deny the uncertainty that inevitably attends any treatment, and a consequent fear of doing too little for a patient. The most striking and appalling case in the book is that of a two-year-old boy who was literally tested to death in a Boston hospital. He had been admitted with malnutrition and a number of recurrent infections. The malnutrition was due to troubled domestic circumstances which had led him to refuse to eat. But the routine testing to which he was subjected, as well as the daunting environment of a medical ward, set in motion a vicious circle in which his increasing refusal to take nourishment was met by progressively more invasive medical procedures. Too much treatment and not enough love eventually killed him, about as unpleasantly as could be imagined. The authors discuss this case, not as an isolated if appalling error of judgment, but as a symptom of a much deeper failing in the medical profession. The quest for certainty: more tests mean more information, which must be better, even if the information we acquire does not help the patient; the fear of not being seen to ‘do something’, of leaving stones unturned; the tendency to treat illnesses rather than whole people – all these conspire to add treatment onto treatment whether the patient needs it or not, and people may die under the impressive weight of medical science even while everyone’s conscience remains absolutely clear.

Professional codes of this kind come into existence, the authors suggest, because of an insecurity we all feel about coping with uncertainty. Much of ethics (like much of the popular conception of science) deals with actions and events as though no serious uncertainty attended them: the right medical treatment is the one that is appropriate for the condition the patient is most likely to be suffering from; if we don’t know which one that is, we do a test to find out. In fact, most important decisions do not have this character: decisions about treatment simultaneously affect the information we shall acquire, and we often have to trade off large risks of small dangers against smaller risks of more serious outcomes. People are often insecure about making these trade-offs, and so are easily influenced by economic incentives into making them in one direction rather than another. The fear of malpractice litigation, for instance, makes doctors afraid of undertaking less than comprehensive treatment – ‘doing everything you can’ cannot be construed as negligence, even though it might be much more damaging to the patient than taking a calculated risk to ‘let nature take its course’. It is not that doctors are consciously maximising profits, but that financial incentives send potent signals about professional pride and shame.

The authors present much of their argument in the form of a clash between two opposing scientific philosophies, which they call, somewhat grandiosely, the Mechanistic Paradigm and the Probabilistic Paradigm. I have long thought there should be a tax on the use of the word ‘paradigm’, and nothing in this book has persuaded me otherwise (the philosopher Hilary Putnam, who contributes an interesting preface, describes how new theories are continually claiming to represent ‘Copernican Revolutions’ in their discipline, and warns that ‘we would be in a better position to determine what is and is not a real insight contained in any one of them if we stopped discussing them in such grandiose terms’ – advice the rest of the book cheerfully ignores). Little is added by this to the important message that learning to live with uncertainty, consciously accepting the gambles that medical treatment involves, and – most important – sharing the awareness of these gambles between doctor and patient, is the best way for any health-care system to attend to patients’ needs as complete human beings.

This is what good doctors have always known and practised, and a better way to interpret this book is as a manual of good, sensitive practice, though it bends over backwards to assure its readers of the fundamental decency and professionalism of those very doctors whose behaviour it deplores (it is an intriguing mark of the lack of ambivalence surrounding the notion of professionalism in the United States that it should be considered much less offensive to accuse the majority of one’s colleagues of enslavement by a philosophically warped world view than merely to suggest that not all of them are uniformly good at their jobs). As a manual of good practice it adds to rather than radically supplanting other such works. Michael Balint’s The Doctor, his Patient and the Illness, first published in 1957, makes many similar points about the importance of treating the whole patient rather than the single ailment. Its focus is on the doctor-patient relationship as an important part of the therapeutic process, a view very sympathetic to that of the authors of the present work. Balint’s book can be found on the shelves of many doctors’ practices, and although it does not make quite the same points about the way in which doctors cope with uncertainty, there is no doubt that doctors who have absorbed it will be much less likely to be classified as Mechanists by the present authors.

This prompts the question how much worse is the problem they diagnose in the United States than in Britain – and, more topically, the question whether it could be made worse by changes in medical practice being undertaken here. Without question over-treatment has been exacerbated in the US by fees-for-service, by the widespread insurance system and by greater medical specialisation (which has weakened the power of general practitioners, who have a relationship with their patients that outlasts particular illnesses). These are features of the American competitive market, but not necessarily of any competitive system. In Britain, too, there has been greater medical specialisation and a tilt in the balance of power away from GPs towards consultants since the Second World War. But one of the more hopeful arguments in Donald Gould’s Examining doctors is that in the coming years ‘general practice will become the major instrument for the delivery of medical care, and GPs will provide more and more of the technical services now centred in hospitals.’ This development can only be welcome, and in theory the purchaser/provider dichotomy and the availability of fund-holding for GPs should facilitate it. Gould points out, though, that for these changes to work a large number of other changes need to occur as well: doctors’ training needs reform, doctors need to be willing to acknowledge explicitly the various economic and administrative constraints on their clinical judgment (and employ specialist staff to help manage those constraints effectively), and the risk of exacerbating regional and social inequalities in health needs to be squarely faced. There are certainly grave risks in the NHS reforms as they stand. Competition could raise costs as well as lower them, as the NHS’s monopoly buying power over medical services is broken up. Again, requiring hospitals to produce lists of prices for treatment may highlight ways of reducing costs, but unless purchasers have information on variations in the quality of treatment they cannot judge what these prices really mean. The answer is not (as opponents of reform sometimes imply) to continue to allocate resources on the basis of no information at all, but to ensure that the information covers the main things that matter to patients.

Most of all, changes in the way given levels of resources are allocated among competing claims within the health care system can make only marginal differences to problems that arise from inadequate funding for the system as a whole. This last is an issue the reforms barely begin to address: it is not primarily a medical problem, but a problem of political will; a problem of negotiating a settlement between the sick who need resources and the healthy citizens, politicians and taxpayers who provide and allocate them. It is possible that the widespread perception that health is underfunded in Britain is a reflection of priestly values inadequately tempered by managerial reality: the fact that we spend 6 per cent of national income on health while most comparable countries spend percentages in double figures does not, after all, result in comparable disparities in mortality and morbidity statistics. But the explosive growth in private medical insurance is almost certainly an indication of the strength of the feeling that we have not got the political settlement right. And the nature of the political process gives us reason to doubt the adequacy of the settlement in which it results. Just as every generation condemns its elderly to impoverishment because they have no political bargaining power (they will not be the ones to look after the retirement of those currently in power), so it abandons its sick, in the vain hope that the healthy of the future will not reason in the same way. Private insurance in these circumstances is best seen as an attempt by individuals to ensure by contract what they do not trust political consensus to deliver.

Gould’s book is a chatty, brisk read that covers many of the crucial questions that health policy must address, and begins at exactly the right point: by asking what we think doctors are really for. He points out that ‘there is a wide range of different kinds of doctor,’ and therefore doubts that the question is capable of a single answer. One virtue of his book is its repeated stress on the undesirability of expecting single individuals to combine within themselves all the different human skills (pastoral, managerial, analytical) that modern medicine requires – so that, while he supports the more explicit attention to management and resource allocation that characterises the NHS reforms, he wisely points out that this need not imply that all doctors must become primarily managers. On the contrary, ‘most kinds of doctor should concentrate on helping people – one to one. They should be content as members, and not necessarily always the leaders, of health care teams, and should not assume’ that they have a right to ‘control all health affairs’.

David Widgery’s Some Lives! is not directly about medicine, though his profession as a GP is what provides his perspective on the East End of London whose neglect and decay during the Eighties he angrily records. Most of his book is tightly-written, staccato, harsh and often comic. It chronicles the combination of poor housing, inadequate education, alcoholism, unemployment and racism that so often underlies the individual histories which appear in a GP’s surgery. Widgery is at his best in the immediacy of personal detail, in venting his anger at the closure of a hospital ward or a municipal swimming-pool, rather than discussing how to reach the political accommodation that might allow these things to be provided on a more generous scale. In another incarnation Widgery might be a liberation theologian, and the priestly role of doctors is one he has no wish to see overlaid with managerialism. His view of the future of the NHS under the reforms is much bleaker than Gould’s:

Prevention for populations, service according to need, the family doctors’ very idea of themselves as people who had time to grieve with their patients, to share the joy of childbirth, the crisis of illness and the time of day in the corner shop, are swept away. The New Model GP is hunched over the computer screen calculating uptake and turnover, auditing not clinical skill but fiscal returns and acting as an accountant, an architect, a travel agent, a manager: almost anything but a doctor. What is happening to the human relationships between GP and patient is a part of the same process which is making the quality of life so much worse for the urban have-nots: the old, the jobless, the overcrowded, the giro-dependent ... And what is being lost is something infinitely precious, that sense of neighbourhood, community and mutual solidarity which has given London its special character.

Whether or not this romanticises the past, doctors in general practice are probably the people with the greatest capacity to impart some sense of community and solidarity to those on the economic and social margins. As it moves into a more managerial decade, the National Health Service cannot afford to alienate its local priests. And yet, in spite of the quite reasonable hope that the reforms will strengthen the hand of general practice, the British Medical Journal of 10 November 1990 reported ‘a precipitous fall in applicants’ to GP training schemes throughout Britain: ‘this year, for the first time in 20 years, many vocational training schemes could not be filled on the first advertisement ... By far the greatest fear expressed by young doctors is their perception of a changing ethos. They are concerned that a career in general practice will not now fulfil the sense of vocation that drew them to medicine.’ If the vocational role of GPs is really to be strengthened rather than weakened by the current reforms, the Government is failing to a startling degree to get the message across.