Losing
patients Managerialism is corrupting medicine, says Theodore Dalrymple, and keeping sick people out of hospital The corruption of modern Britain is not a matter of money passed surreptitiously under the table; it is much worse and more serious than that. It is the corrosion of our very souls by managerialism that is turning Britain into a very corrupt little country indeed. Moral and intellectual corruption has not only been legalised; in some — perhaps many — cases, it has been made compulsory, a condition of continued employment.
In countries with a tradition of straightforward bribery, corruption may conduce to economic and administrative efficiency. This is so where regulation obstructs all useful activity, or would do so if the sword of subornation were not able to cut the Gordian knot of bureaucratic immobility. In countries with such a tradition of bribery, the bribed are expected to carry out their side of the bargain, if not for the sake of their own honour, at least for the sake of continuing the glorious and precious tradition.
Our kind of corruption, on the other hand, is not only compatible with inefficiency, inertia and incompetence; it actually promotes them. Moreover, by involving everyone in its snares, it ensures that no one is able to take a stand against it: for everyone is implicated, and none can point the finger. I remember a Romanian telling me, just before the downfall of the Ceausescus, that it would take three generations at least to remove the taint of the communist system from the souls of Romanians; it will take at least as long to remove managerialism from the souls of the British, though it has been with us for so comparatively short a period. It started under Mrs Thatcher — but that, as Mrs Hawksbee said, is another question.
The distortion of medical practice by managerialism is well established. A consultant at the Radcliffe Infirmary in Oxford told me recently that, in order to meet government targets with regard to the speed at which patients were examined medically and moved into hospital beds in the casualty department, ambulances bringing patients were not allowed to transport them through the hospital doors until such time as they could be seen within the specified period. As a result, of course, ambulances piled up outside the hospital, which was tough luck on those who needed an ambulance quickly; but they were only patients, and it's the targets that count. Patients are being discharged from hospital not because they are fit to be discharged, and not because they beg to be allowed home, but because targets cannot be met if they are not so discharged. Kindness and decency are no longer permissible reasons for keeping someone in hospital; we must get them out, as the Americans say, 'quicker but sicker'. So what if they come back soon afterwards with the complications consequent upon too hasty a discharge? The original illness and the complication can be treated statistically as two episodes, thus increasing the efficiency (on paper, always on paper) of the hospital.
Sometimes, patients don't get as far as being discharged too early because they are not even admitted in the first place, when they quite clearly should be. I have seen patients who have been misdiagnosed with trivial or less serious complaints when they have serious and even life-threatening ones, not because the doctors are incompetent and don't know what they are doing. but because they are constantly working in conditions in which each new admission to hospital creates a crisis throughout the entire system. If a patient needs admission, the doctor feels terrible tension if no bed is available. Better, then, for his peace of mind, to change the diagnosis to a condition that does not require admission (and diagnosis is seldom so certain that it cannot be doubted) and send the patient home. For obvious reasons of human psychology, this is particularly hazardous for the less attractive members of our society: drug addicts, for example. But since when are doctors supposed to consider the attractiveness of their patients in deciding whether to treat or not? The corruption has gone furthest in psychiatry, the easiest field of medicine to corrupt, of course. So short are beds in psychiatric hospitals that patients are rediagnosed in order that admission should no longer be indicated. Psychiatric patients, according to the traditional summary of psychiatry learnt by all doctors, are mad, sad or bad; increasingly, the mad are assimilated to the bad so that they arc deemed to need no treatment, since there is none for them. The nightmare of trying to find a bed in a hospital — there are none in areas with a population of five million — is thus averted.
Thanks to the shortage of beds, prisons are the new psychiatric hospitals. Prisoners who are quite clearly mad are often sent there after having committed an offence shortly after they have asked for, and failed to receive, asylum in a psychiatric hospital. It is a lamentable fact that such patients are often better cared for in prison than in what we have been taught by constant repetition to call 'the community'.
If this is so, I hear you ask, why do the doctors not cause an outcry? There are two reasons, one understandable though perhaps not very creditable, and the other downright discreditable.
The first is that doctors are interested mainly in their day-to-day work. That is the nature of medical practice, and the result of constant contact with individuals. Doctors are not good at raising their collective voice, therefore, and their leaders, being largely self-selected, often have qualities that are not very far removed from those of bureaucrats.
The second reason I blush to mention. Hospital consultants receive bonus payments according to outstanding service or — increasingly — for good behaviour. These bonuses are pensionable, and can be very considerable. The pension alone can be equivalent at retirement to the interest on a sum ofI million or more.
These bonuses used to be awarded by committees on which doctors were preponderant. No doubt this had its drawbacks, but genuine merit was recognised and rewarded. Nowadays, however, it is the managers who award the bonuses, and they do not want to hear about the shortages of beds, or the deformation of medical practice, that they themselves have brought about because they were only obeying orders. Doctors have to keep their noses clean with the managers if they want to be rewarded.
I need hardly point out the corruption of soul that this system promotes. It is not, of course, unique to medicine; rather, it is the norm and not the exception. From the point of view of the central government (whoever is in power), no better system could exist for keeping control. When everyone feels himself to be tainted, when he knows he has participated in general wrongdoing, his integrity is destroyed and he can resist nothing. Nothing is left to him but to go to a casino, or other resort of distraction, in the evening.
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