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- guardian.co.uk, Sunday June 24 2001 00.30 BST
The public can dispense with most helmsmen of old civic life, from vicars to bank managers, but cannot do without GPs. Yet the news that half of them are thinking of resigning from the National Health Service causes barely a flutter of interest. Why should this be?
Partly because surgeries, with their red plastic chairs veined with grime and their composted Reader's Digests have always hinted at frugal decline, but mainly because a new mood of suspicion grows. The image of Dr Harold Shipman, with his tidy beard and phials of powdered diamorphine stashed in his doctor's bag, is hardly a boost for a beleaguered profession. A more insidious destabilising force is at work
As doctors, complained of and complaining, become the new teachers, the Government underlines how lucky they are. The NHS Reform Bill specifies that, by 2004, they will control 75 per cent of the health service budget. The message is that autonomy equals beneficence. No doubt some GPs are grateful. Others may think that if they wanted to count cash, they could have been NatWest cashiers, or that being the procurer for unavailable or unaffordable treatments does not constitute a shopper's paradise. The political message counters such pessimism. Doctors have never had it so good.
Patients, conversely, have never had it so bad. John Major's patients' charter made us strident, and foreign holidays made us envious of those who get treated without spending half a day becalmed in a toxic A&E department. ER, Casualty and media scare stories mean we're experts in everything from small bowel transplants to the side-effects of Zyban. Some seek to sue doctors while others go for summary justice. Attacks on medical staff are running at 65,000 a year. Two in 10 Londoners fail to turn up for booked appointments, but that is our prerogative. Patients come first, the Government is constantly reminding us, as if malign doctors are trying to usurp those rights.
Two new constructs are being fleshed out. One is the doctor from hell, the other the patient from hell. If each protagonist sees the other as the enemy, that divide-and -rule stratagem may suit a government with plenty of other worries. The greatest reminder of recent failure will surface any day now, when the inquiry into the Bristol children killed by bungled heart surgery is revealed in Parliament. Ian Kennedy's investigation, the largest undertaken into clinical practice in the UK, will make Lord Cullen's report on the Paddington rail disaster look like a Post-It note.
It is so shrouded in secrecy that even Sir Barry Jackson, the president of the Royal College of Surgeons, has no clue on its findings about James Wisheart and Janardan Dhasmana, who, with their former chief executive, were found guilty by the General Medical Council of serious professional misconduct over 29 infants who died. Jackson hopes, of course, that Kennedy will acknowledge tightened standards making it 'virtually inconceivable' that there could ever be a reprise of Bristol. Tonight's Panorama will argue, conversely, that a replay is all too likely. As the hype builds over the report, another question might be whether it was necessary at all.
Harold Wilson once said that he saw no need for a Royal Commission that 'would take minutes and waste years'. How fortunate for him that he was spared the current mood for paper-pushing. In the Harold Shipman inquiry, a million pages of information have been put on databases, a video link-up is in place to Hyde, where he worked, and £500,000 has been spent on installing IT equipment.
Where most public investigations are a requiem for official incompetence, this one is also a sleuthing exercise on how 459 patients died. Although few would deny relatives their right to know, only nine people arrived at the shabby viewing-room. One, a pensioner with a bag of sandwiches, could not bear to go in. For all the modish emphasis on 'closure', people don't always want old sorrow excavated, particularly when the aim is slaking public anger rather than personal grief.
The Bristol parents might have found some peace long ago, but for government dithering. The Health Department could have held its own, wide-ranging inquiry at the outset. Instead, it shuffled the case on to the General Medical Council, which, pending yet another reorganisation in July, is still perceived as unfit to hold a stewards' inquiry into a three-legged race at a primary school sports day. Hence the need for the gravitas of Kennedy. His report, two years in gestation, may criticise the Health Department. It is expected to focus on the failures of systems rather than individuals. Undoubtedly it will advocate more audit trails, although how those are to be achieved is unclear when the Government has shown no signs of providing promised money for a computer set-up.
Practical solutions cannot address a deeper ill- will. At the King's Fund president's lecture last Friday, a senior consultant said that he had been billed for several hundred pounds by a patient who had been kept waiting and wanted recompense for his 'professional time'. But where, the doctor asked, was he to find time? It seems the crucial question. British doctors, with annual pay rises of around 3.5 per cent, overtook their European counterparts in 1993 and stay comfortably ahead on wages. There are, however, only 1.8 doctors for every 1,000 Britons, against a European average of 3.4. GPs say an extra 10,000 are needed if government targets are to be met.
To some, this seems a bit rich. Royal College protectionism, decreeing that no one without multiple grade As at A-level was fit to assess the nation's bunions bred a lean élite. Now medical school applications are dropping, from 12,076 in 1997 to 9,700 this year, and the panic is on. While there is some recognition on doctors' part that the clubbishness that helped foster rogues such as Rodney Ledward and Richard Neale was inexcusable, no one has yet worked out how to make health service jobs look appealing. Meanwhile, mutual mistrust and baroque inquiries obscure the bigger picture.
The Government has backed itself into a corner on health. In not much more time than it took Professor Kennedy to produce one report, it has to fix the entire NHS. As a report by the Institute for Public Policy Research will say tomorrow, its plans for private partnerships look flawed. A purely tax-funded service works only if the rich pay more tax.
That leaves either hypothecation or a social insurance model, such as the French one, where 90 per cent of the population pay around 17 per cent of their salary into a sickness fund and the poorest get the same care free. Although Blair dismisses both schemes, the suspicion is mounting that genuflecting to Beveridge must soon give way to something more radical.
As the real battle for a better health service begins, doctors and patients should be fighting on the same side.
