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Getting into a Supermarket Ambulance

The Salisbury Review — Winter 2004

Francis Hallinan

On the 23rd of January 2004 Stephen Parley, a 52 year old family doctor in the Leicestershire village of Ibstock, hanged himself. He had been under investigation by his local health authority for admitting too many patients to hospital. Rutland, Leicestershire and Northampton Strategic Health Authority were concerned that his 'old style' ideas were putting too much strain on the system. They insisted he undergo mentoring. This meant he would have to accept another doctor, skilled in the managerial school of medicine, to sit in on his surgery to supervise him. He found this so humiliating he became depressed and ended his life.

His practice manager said, 'He was a brilliant GP. He spent most of his life in Ibstock — nearly quarter of a century — and he was absolutely loved by all the patients. They have been devastated by this.' There seems little question that Dr Parley was a dedicated and competent GP. A consultant said he had never known Dr Parley to make an incorrect diagnosis. His patients picture him a hard working, kindly man, somebody who was prepared to visit patients at lam when they could not get through to their local call centre. He was also persistent. He sent one patient back three times to the hospital until cancer was diagnosed.

The new managerial culture that has pervaded the NHS began in the early eighties when the Royal College of General Practitioners, having swallowed huge doses of psycho babble and management speak, began a rigidly prescriptive training scheme for young GPs. It is very far from the idea of a liberal profession. The intention of the scheme is to turn out a standardised GP taught to do exactly the same thing as all his colleagues in every circumstance, who can be easily regulated and controlled throughout his professional life. Trainees, subjected to an intense form of mental supervision unknown outside of medieval monasteries, are obliged to attend tutorials in which they watch themselves on video to curb any excessive postures or mannerisms. They learn formalised ways of speaking to their patients, how to open and close conversations, how to put questions and answer them and how to conceal their real feelings behind a professional mask. This form of feedback aims to weed out unusual personalities so that the public is faced with a standardised doctor as bland and unoriginal as a cheddar cheese. It does not always succeed. Many medical graduates dismiss the training as a joke. calling it 'Play School'. However. as Professor Frank Furedi remarked in a recent lecture however much you resist the infantilising effect of this' widespread form of management you invariably internalise its messages. As the generations pass, doctors will become more and more bland and conformist, unit traditional doctors like Dr Parley will be extinct.

The medical culture of the 21 st century will 1 be that of a music-filled aisle of a supermarket with 'products' and 'services' on view for a consumer public Raymond Tallis in Hippocratic Oaths — Medicine and its Discontents describes the doctors who will have to man them.

The patient as client or customer in the shopping mall of medical care will see the doctor as vendor rather than as a professional.... The almost robotic standardisation of the way doctors are taught to interact with patients — even down to when the doctor should move from open to closed questions, when and how often they should use techniques to indicate they are listening, and the bodily posture that should be adopted — will make the professional, with deep compassion and the ability to make and stick by difficult unpopular advice, an ever rarer bird-The doctors of the future will be easy going and friendly conformists, relentlessly reasonable and entirely clubbable.

Dr Parley with his mutton-chop whiskers, count clothes and a big grin on his face, looked more like cheery Farmer Giles than a doctor. He became depressed when faced with the prospect of managerialised medical 'mentor'. Dr Parley, like me of the doctors of his generation, probably went in medicine for the sense of independence it gives you of being responsible for your own decisions, learning there is no single way of approaching the problems of the sick.

But critics of the new model army of robot doctor trainers accuse them of fearing autonomy and individuality more than Dracula fears the dawn. So it is not surprising that after twenty years of creating an army of conformist GPs, doctors' leaders signed a contract with the government which offers GPs a future in which life will be more like that of a supermarket manager than a doctor. 'Quality points' were introduced into general practice. They are a bit like the loyalty points you get at your local petrol station. Join the herd and you will be rewarded. Quality points are earned for carrying out certain routines such as taking a patient's blood pressure, weighing him, asking how much he smokes, exercises, eats and drinks. Each answer has to be entered on a hugely detailed computer template which allows virtually no room for any type of medical judgement. It is planned that the results will be checked by a central computer at NHS headquarters which each night will extend a ghostly electronic arm and check the templates in every practice surgery. Each quality point is worth £75 and there are 1000 available for each practice. They cover a large range of activities from running diabetic clinics to asking patients to fill in questionnaires scoring their doctor's 'listening skills'. A group practice grossing £600,000 year might earn £80,000 from quality points- While most of doctors' pay still comes from traditional medical practice, quality points are now the only means by which practices can increase their income. Next year the price of a point will be £125. More areas of practice will be covered.

There are benefits to obliging doctors to all do the same thing. Keeping everybody's blood pressure and cholesterol down adds to life expectancy by cutting strokes and heart attacks. Thanks to quality points you will be able to be frail, mindless and incontinent for perhaps an extra two years. But there are precious few treatments whose outcomes can be so confidently predicted as keeping peoples' blood pressures and cholesterols low. However the possible advent of the 'Polypill' combining an anti-cholesterol tablet, a blood pressure pill and a small dose of aspirin available over the counter, will make GP preventive measures for stroke and heart attack largely redundant.

Alongside the new quality points, ordinary medical practice continues. Doctors still see the sick, the worried well, the desperate, the old and the lonely. But underneath it, like a yeast, the new culture of impersonalised, mechanical medicine in which patients are viewed as codifiable items on a supermarket shelf, earning quality points, is at work: How much do members of the doctor's 'herd' weigh, how tall are they, what is their blood pressure, their age and possible shelf live? Nurses now spend their time peering at insanely prescriptive templates for the care of diabetics and epileptics. They are not templates that encourage initiative, they stifle it. Even the individual patient doctor relationship is discouraged. Patients are now registered with practices rather than individual doctors. You can see your 'preferred' doctor if you want, but you may have to wait days rather than the prescribed target — more quality points — of 48 hours. Doctors, especially married women, are becoming more mobile, and called 'gypsies' float from practice to practice doing short bursts of consulting. We are even moving into shelf stacking. In the past when a patient first registered with his doctor, he saw the doctor who was to be looking after him. Under quality points, the initial practice contact can be carried out by practice receptionists who are given brief courses in how to take blood pressures, test new patients await their first automated call for flu jab or smear. Practices can turn away patients who refuse such interviews. By breaking important parts of medical practice down into simple steps, coding them and costing them, and making it possible for semi-trained operators to carry them out, the NHS is creating a market for external private contractors. At the moment the new contract talks of doctors being the 'preferred' suppliers of medical care. It implies they may not always be preferred.

At present most of a doctor's duties remain with him, but there are certain services such as child immunisation, contraception and some specialist clinics that can be contracted out to nurse co-operatives, private companies or subsidiaries of the NHS. Most surprising of all has been the contracting out of night duty. In return for a 6 per cent reduction in their pay doctors can give up answering night calls. A few of the Dr Farley's of this world resisted this for a long time. Night duty was a dreadful burden, but twenty four hour care of the sick underpinned the close personal relationship many GPs, especially in the country, used to have with their patients. The planners' desire to sweep this anachronism away, reflected in their lavish offer of a 6 per cent reduction in income for a reduction of a third of their hours on duty, underlines their anxiety to wrest the power of the individual doctor from his patient.

Night calls can now be contracted out like supplies of baked beans for Tesco's. To make them pay, companies will have to rely on call centres that score your complaints on a computer. Only after a certain score is reached will you be considered for a visit. Like NHS dentistry, many local NHS trusts will simply not be able pay their contractors the luxury of hiring doctors. Nurses will make the visits. For those who object and can afford it the private sector will step in as can be seen in London with tiny cars marked 'Doctor' buzzing about the streets. (Some German doctors fly over for weekends just to do highly paid night calls.) Night duty is not the only thing being cherry picked. Drug companies are now sending out private nursing teams (paid for by themselves) to 'advise' the public on how to take the medications being prescribed under the quality points system, and to urge patients' doctors to prescribe for them if they have not. They refuse to say how much their profits have increased under the new protocols. It cannot be long before an NHS purchasing officer decides to dump one of his badly performing doctors in favour of a ready made team such as one of these.

Computerised inventories, fragmentation, competitive bidding, tendering and short contracts are the commercial soil on which (he great supermarket chains have built their business with such success over the past thirty years. However Joanna Blythman in her book Shopped— The Shocking Power of British Supermarkets is scathing about them. While they are 'Wonderfully streamlined, highly efficient machines, sensitively tuned to deliver a very specific objective — a share price to keep their investors happy' their effect on our quality of life has been terrible. A supermarket's shelves may look like a cornucopia of products from every corner of the earth, but what you are looking at, concealed behind the pyrotechnic effects of advertising and artful store layouts, are the results of a relentless search for the bottom; bottom prices, bottom quality and bottom taste. With 80 per cent of Britain’s food now being supplied by a handful of chains, it is not that we have never eaten so badly, it is we could be eating far, far better. Supermarkets have chewed and spat out every advance in food quality and originality in favour of price and advertising.

Blythman's book is relevant to the crisis in general practice because general practice is a supermarket, a dispersed shop front spread right across the country, a huge enterprise selling billions of pounds worth of drugs and services each year. The problem is that general practice does not sell discounted bananas. It is about language and relationships rather than products, the non-technical side of medicine that is often more important than drugs and tests. Modem managers recognise these values but their aim is to 'objectify' them so they become products rather than shared moral values. For example, the ability of a doctor to listen to his patients can now be scored on a practice questionnaire and quality points awarded for high scorers. Doctors are now offering a product called 'listening' which, if it fails the quality control test, may be subcontracted out to a new supplier, along with the rest of his work.

Is there anything wrong with applying such efficient methods to the care of the sick? Raymond Tallis in his chapter 'The end of medicine as a profession?' quotes Sir Maurice Shock, former Rector of Lincoln College Oxford: 'Doctors need to recognise that society is changing and that 'The social contract' and 'The rights of man' have been replaced by the ‘Sales contract' and 'The rights of the consumer'. But doctors can only do this says Tallis, 'By developing an exercise in feigning the values of the past (still expected of a doctor) while acting in accordance with the new values that shape the expectations of the present. The non-technical aspects of the relationship between patient and doctor will be a meeting of the naked consumerism of the patient and the consumerism of the doctor, concealed under a thick carapace woven out of the verbal signals of 'caring for the person beneath the consumer'. He comments later, 'The more ill the patient is the less satisfactory a business relationship will be.... The seriously ill will find that 'have a nice day' does not easily modulate to 'have a nice death'.

Medicine is about truth, telling the unpalatable facts as they are, of being able to face them day after day. Everybody will die, everybody has to be looked after. The doctor has to be steady, to be there all the time. The supermarketisation of medicine does not aim to tell more of the truth but to avoid it. Being there all the time is often a one year contract. A high score in listening may be nothing but a meaningless and empty formula, as tasteless as a supermarket tomato. The elimination of all mistakes by a stifling rule book means nobody learns. What has happened to food will happen to general practice, bland but barely adequate, all differences paired down by cost cutting, fears of the litigation bogey and consumerism.

I asked several people if it would worry them if, having had a heart attack, they found a supermarket ambulance at the door. Everybody gave a slight twitch of fear and began to laugh. Suddenly they could see themselves as a commodity, the weekly groceries being taken away as it were in reverse, to face the same treatment of being priced, examined for quality and then discounted. Is this what is happening to general practice? In a real crisis, who would you trust, the manager of your local Biggamarket or Dr Farley?

Francis Hallinan is a practising GP.
See Hippocratic Oaths, Raymond Tallis, Atlantic Books, 2004 and Shopped: The Shocking Power of Supermarkets, Joanna Biythman, Headline, 2004.