If you want to refresh your memory of the comings and goings in Geroge Eliot’s classic, Middlemarch, then look no further than Professor Rosin’s analysis in the June 2009 issue of Medical Humanities.
http://mh.bmj.com/cgi/content/short/35/1/43?q=w_mh_current_tab
If you want to follow a contemporary equivalent of medical marketplace machinations then you need look no further than what is currently happening to general practice in England and Wales. And specifically to the Orwellian world in which carers and cared for find themselves. A world where government announcements to the national news media of the universal introduction of Cognitive Behavioural Therapy are followed by the systematic reduction of mental health care services in primary care. In my own practice, in the past 6 months, first the PCT provided mental health care worker was removed and more recently the practice counsellor of 17 years standing was ‘let go’. But hey ho, never mind, NICE guidance has after all told us what to do: if a patient is suitable for CBT and it isn’t available (!) we can (and should) tell them to ‘hang on’.
And yet, and yet. In the Orwellian world in which I work, and patients need care, large tranches of money for elective investigations are diverted from the local hospital radiology services to a private contractor (because the former is deemed to be slow and inefficient) only-two years later- for the private contractor to be so overwhelmed that its routine delay- from referral to investigation- now magically mirrors that at the local hospital. The latter meanwhile, in spite of its much reduced budget, has been required to continue providing the rather less glamorous and more resource intensive emergency radiology. I could go on, offer more examples, enough to fill a bookcase with dystopian novels, but you get my drift.
Such talk is of course anathema to the UK government who would doubtless see my thoughts as yet more evidence of the reactionary, self-serving nature of the profession they seek to break. They hold no truck with the claim of so many of us that we actually care, deeply, about what happens to the people who entrust themselves to our care. They are it would seem incapable, too cynical, to accept that the shared professional values and the duty of care that is central to how so many of us practice, is an invaluable safeguard that patients are denied at their peril. The government, put simply, doesn’t get it, doesn’t believe that doctors are or should be anything more than instruments of the State and conduits of scientific progress.
Of course it could be me that’s cynical, bruised by the progressive manner in which the power of doctors has been traduced by the State. First off was the introduction of a system whereby GPs no longer had to provide patient care themselves but instead needed merely to demonstrate that someone in their employ had done so. This heralded the switch over from a system characterised by personal care by a named GP, ably assisted by other employed doctors, nurses, counselors etc, to a system where increasing numbers of GPs take on the role of over-qualified business managers providing little or no direct care themselves. Not all yet of course. So many good doctors struggle on, keep doing their best, refuse to give in. But it’s a struggle and it’s taking its toll.
Then came the seemingly innocuous requirement that GPs demonstrate, objectively, that they were providing a minimum quality of care in a select number of important clinical areas. Except that most already were and the administrative burden of proving they were has taken up an estimated 15-20% of doctor and nurse time, time previously spent on patient care. The added sting in the tail/tale of this system is that those doctors too busy caring for a patient to fully record that they have cared for the patient are financially penalised and are thereby, ultimately, forced to reduce the numbers of doctors and nurses available to care for patients. As counsellors, doctors, nurses, dieticians and phlebotomists are made redundant across the country, ironic just doesn’t do what’s happening justice.
Then of course the coup de grace-mass doctor un- and under-employment: the ultimate weapon of control for any government. By training more doctors than the UK health care system-focussed as it is on ill-conceived and exhorbitantly expensive IT systems, and dystopian systems for enforcing a reductionist model of medicine on a resistant but powerless populace- could ultimately afford, the government must surely believe it’s time has now come, and that finally it can seize complete control of medicine and its delivery.
Like climate change, the pace of this politically driven seismic shift in primary care has surprised both patients and doctors alike. For many the inconvenient truth of where these developments are taking us is hard to accept. It will, sadly, take a little longer before the full extent of that change- of what took so many years to build and then so few to destroy- will be evident. Like climate change it is of course more of a worry for my children than me, which is, of course, why it matters so much to me and should matter to us all.