The Great War changed the world forever and burnt itself into our language, memory, consciousness, and understanding of life. That’s the argument of Paul Fussell’s marvelous book “The Great War and Modern Memory,” which was first published in 1975 and won the National Book Award. Before the war we had Tennyson, Kipling, Trollope, Conrad, and Hardy, and after the war T S Eliot, Kafka, Joyce, Pound, Proust, and Waugh. The Second World War was important in giving birth to the NHS, but it’s the Great War that seems to be most relevant in current debates over the NHS.

Although it began almost a century ago, even the youngest reader of the BMJ must know the outline of the Great War, the trenches, the frontline running from the Belgian Coast to Switzerland, the stalemate, the loss of life on an industrial scale, the horror, and the pointlessness. Most know as well that this was a war where “lions were lead by donkeys.” You’ll begin to see the links with the NHS.

What bought the NHS to my mind as I read Fussell’s book was his account of the utter disdain that the troops in the trenches had for “staffers,” the “red hats,” the senior officers behind the lines. The troops thought that the staffers had no idea of the conditions in the trenches. This is an account of Lieutenant General Sir Laurence Kiggell being driven close to the front several weeks into the battle at Passchendaele, where hundreds of thousands died in the mud.

“As his staff car lurched through the swampland and neared the battleground, he became more and more agitated. Finally, he burst into tears and muttered, “‘Good God did we really send men to fight in that?’ ”

You cannot understand war if you are not on the frontline. David Jones, who was in the trenches, much later brought this imagery into his account of making art. Fussell summarises his argument:
“To make art one must hurl oneself into it, get down into one’s material, roll in it, snuff it up: know it, in fact, the way troops know fighting, rather than the way the Staff conjectures about it…the artist is overweighed by critics, reviewers, discussants, conjecturers, manipulators.”

I think that many, probably most, frontline (what a popular word) or practising doctors can empathise with this. It may seem insulting to make any comparison between the Great War and the NHS, but doctors—who manage desperately sick patients close to death, must deal with violent and drunk patients in casualty on Saturday nights, and put their fingers into the intimate parts of patients’ bodies—do feel those who oversee the NHS, the politicians and the managers, have no understanding of their experience. Indeed, unless they spend time in the trenches when the battle is on they can never understand. They are, in some sense, lesser creatures: they cannot be artists but only critics, impotent parasites.

But it’s these staffers who are leading NHS reform without any idea of what it’s like for the “poor bloody infantry.”

Interestingly, David Jones wrote in his 1959 book that “Today most of us are staff-wallahs of one sort or another.” It’s certainly true of me, sipping champagne and writing blogs in my chateau way behind the frontline. It’s true of all politicians and everybody in the Department of Health. It’s true of all editors and journalists, including the staff of the BMJ. And many doctors think that it’s true of the officers of the BMA: they may claim to know the trenches but they are not up to their necks in much and bullets like real doctors.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.