One of the constant political backdrops in the months following the general election last May has been the junior doctor’s contract dispute. In essence this is a disagreement over pay and conditions between junior medics and NHS Employers, though it has expanded to become a fight between medicine as a profession and the Health Secretary, Jeremy Hunt. As the dispute has escalated so has the rancour, with some terse and- at times- less than professional comments on social media. For what it’s worth, which isn’t much, I agree with the doctors’ point that the contract seems to be unfair, especially in the way it redefines out of hours payments. I do, however, question some of the junior’s political nous and campaign tactics- which have seemed to lack a clear objective and focus. I’d also add that-since junior doctor’s leaders have been seen on picket lines with the Socialist Worker’s Party and appearing on Russia Today- win or lose, they are going to need a formidable exit strategy. In this current maelstrom, it is not surprising that some medics feel under attack and have begun to retreat into a narrative among themselves that seeks to exclude any outside challenges or scrutiny; in other words the echo chamber of confirmation bias.
It was we these thoughts in mind that I read Partha Kar’s post on his website titled Alternates. I want to explore and challenge some of the points Partha makes about the “uninformed” who seek to offer advice to doctors. Before I do that I just wanted to say that I have a huge amount of respect for Partha, he is one of a new breed of doctor who is trying to modernise his profession and he has done sterling work in transforming diabetes care in his area. With that disclaimer written, let’s move on to Partha’s blog post.
Partha starts his piece by dismissing those that spout “views without basic understanding”, well that’s them sorted! Except that the commentators and “hacks” that he so easily dismisses are- I suspect- policy experts, journalists, managers, patient groups and voluntary & community groups that have a far better understanding of how large systems operate and have the task of looking to the inter dependencies between various settings and organisations rather than just one clinical area. That’s not to say that doctors can’t develop a broad knowledge about the political and socio-economic factors that underpin delivering healthcare- many do- it’s just that it isn’t inherent to their skills and knowledge as medical professionals. In other words; policy makers and managers- among others- have to take a utilitarian approach to healthcare provision, while doctor’s focus on individual best practice. This approach, on the whole, works well and describing one group as “ill informed” is not especially insightful or helpful.
Partha then makes the superficially persuasive analogy between that of fans of a football club (patients) and its manager (the doctor). If only he had read Janan Ganesh’s piece on the rise of Leicester City in last weekend’s Financial Times he may have developed a more nuanced parallel; in the piece Ganesh highlights how a more modern approach to football- particularly in relation to redefining roles and responsibilities within the club- has driven the unfancied team to the top of the Premier League. As a fan of Liverpool F.C, Partha should also know that some football mangers are simply incompetent and it is often that voice of the fans that is instrumental in getting rid of them.
Partha then enters into a long discussion about the changing face of diabetes care in the UK over the past decade or so. I do bow to his superior knowledge here and he is right that policy makers and managers should directly involve clinicians- not just doctors- when developing initiatives in particular services. The success of the Stroke Strategy of 2008- which should be noted had no extra funding attached to it- is testament to this approach. In all his talk of cost and quality however, Partha never mentions the outcome of those two variables’ interplay; namely value.
The changing nature of society- especially the lack of substantial economic growth since 2009- means that we will have to look at the divisions of labour within healthcare and that may challenge some who are essentially rooted in a 1950s model of healthcare, which suggests that doctor knows best. Through all this the notion of value should be our guiding light.
As I have stated, anaemic growth has left us with the challenge of developing and providing high value public services. I believe Larry Summers- Bill Clinton’s Treasury Secretary- is correct when he says we are entering a period of secular stagnation in market based economies, characterised by low growth and shrinking investment. This leaves policy makers with challenges around the payment and provision of public services that will, I believe, mean we will have to pay more in our taxes if we want to see an increased level of spending on healthcare, for example. It will be easier to ask the public for more money if they believe that the NHS is designed to take into account the needs of patients and the public and is not subject to technocratic tribalism, from whatever source that arises.
Partha finishes his piece by warning of excessive arrogance and hubris in healthcare. We are both in accord on that.
First published on Medium