DOCTORS, PATIENTS AND OTHER NUISANCES

The Government claims it has introduced the rigours of the market into the NHS. This is a lie, says Dr Theodore Dalrymple FIVE YEARS ago there were three offices for nurse administrators in one of the hos- pitals in which I work. Now there are 26, filling two corridors. When you enter one of these offices unannounced, you sense the same blind alarm as when you lift the bark from a damp rotting log and the woodlice and other small creatures scurry for humid cover. I do not think it an exag- geration to say that guilt and bad faith are written on the faces of the inhabitants of these offices: the guilt and bad faith of peo- ple who draw a salary to perform a task which is unnecessary and quite possibly harmful, but who must neverthe- less pay their mortgage like the rest of us.

Another of the hospi- tals in which I work has recently increased the staff of its finance department from three to twenty-one (without counting their secre- taries). Moreover, one of the original three mem- bers of staff has been made redundant and given a generous golden handshake. In the National Health Service, even reducing expenditure is a very expensive business.

Now there may be some among you who see the influx of financial controllers, finan- cial accountants, finance managers, man- agement accountants, management accountants' assistants, exchequer services managers and cost accountants into our hospital (to name but a few) as a sign that at last the Health Service is taking financial matters seriously, and also that its profliga- cy is being curbed; that at last some sense of the importance of what things cost is being instilled into those who work in the service. When demand so far outstrips sup- ply, after all, financial discipline is of the essence.

This view was expressed to me by a chief executive at the headquarters of a nearby health authority (not my own), who told me that we all had to live henceforth in `the real world'. But I wasn't interested so much in what he had to say as in the building in which he said it. It was large, on three floors; and it was as protected from the malign influence of the outside world as a bathyscape from the pressure of the ocean. One entered through a kind of airlock arrangement, visitors communicating with the doorkeeper by means of microphones and loudspeakers. All the windows were triple-glazed to keep out the noise of the real world, and were sealed so that they could not under any circumstances be opened; the temperature was eternally con- trolled to within a degree or two and the ventilation was by means of a faintly hum- ming draught, expelled through aluminium grilles in the polystyrene ceilings. There were fire doors every ten feet in the corri- dors, suggesting either a surfeit of potential arsonists or an excess of timidity among bureaucrats. The atmosphere was monas- tic, calm and other-worldly; but, instead of illuminated manuscripts, the bureaucrats were producing pie and flow diagrams, and tables of such vital statistics as the propor- tion of women in the district between the ages of 16 and 35 with intrauterine devices, or of men over the age of 75 who required Zimmer frames, analysed by electoral ward.

What these bureaucrats of the health authority could not explain to me was how their financial interests could be reconciled with those of my own hospital. I have a patient with a frequently recurring illness who is usually treated in my ward: a service for which, under the new arrangements, the health authority has to pay. Therefore the more frequently the patient is admit- ted, and the more intensively he is treated, the better for my hospital but the worse for the health authority, which frantically tries to deflect this patient to an inferior facility on grounds of cost. So much energy now goes into shifting the cost of treatment from one part of the health service to another, with no thought of reducing the cost to the service as a whole, and certainly none with regard to the convenience of the patient.

Information, we are told, is the key to effi- ciency. Maybe so, though I suspect that, in the absence of intu- itive perspective, infor- mation is but a higher form of ignorance. To know what proportion of hospital porters have shoulder-length hair or tattoos on their necks, for example, is not to improve the survival rate in the coronary care unit, though it is undoubtedly infor- mation of a kind. But to help us gather allegedly 'relevant' information, we now have in one of the hospitals in which I work no fewer than nine medical audit facilita- tors, two audit supervisors and one director of medical audit. Their salaries and other costs must be at least £500,000 per annum. One cannot help but wonder what audit facilitators did before they were employed as such. Or is there now a four-year univer- sity course leading to a B.Med.Aud.Fac. degree?

According to one government publica- tion, medical audit is 'the systematic, criti- cal analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient'. Participation in medical audit is now an obligation placed on hospital doctors by the Government. According to my contract, for example, fully one-tenth of my time must be taken up with evaluating what I do in the other nine-tenths of my time.

There is no doubt that medical audit can be useful, especially when answering highly Specific questions, such as whether it is nec- essary or not to do routine chest X-rays on Young people before operations. But the vaguer and more general the questions asked, the less certain the answers, and the more room for bureaucratic overemploy- ment.

Sonic problems do not require audit facilitators for their elucidation, but are a matter of constant, everyday experience. In my department, for example, it often takes four weeks to get a letter typed to general practitioners about our patients. This is because we have too few secretaries. More- over, the computers in our department were bought not by the hospital, which claimed, at the very time it was recruiting audit facilitators and handing out manage- ment contracts for hundreds of thousands, that it had no funds to do so, but by a pub- lic-spirited physician. If he had not bought them, we should have been able to send no letters at all, ever.

Whether one should spend the hospital's limited money on audit facilitators or on word processors and medical secretaries is, of course, a question for medical audit. Thus the need for medical audit is logically Prior to any other activity whatsoever. But who audits the auditors? No one: audit is now a matter of blind faith, against which the urgings of common sense are quite use- less.

In practice, I have not found the audit facilitators to be of immense use. This is not entirely their own fault. About three months ago, I asked one of them to provide me with the number of patients from one of my clinics who had failed to attend for their appointments. A simple matter, said the facilitator enthusiastically. Two weeks later, she returned to me, slightly downcast, to tell me that the figures were not avail- able because in the meantime all the hospi- tal computers — £900,000 worth — had been stolen, actually for the third time, and this time the loss was uninsurable. Unfortu- nately, the back-up disks had disappeared along with the hardware, but she had every hope of recovering the information from elsewhere. Three months later, I still don't know how many patients failed to attend for their appointments, and in reality I don't much care. I had only asked because I had to ask something. But the facilitators, informationless, are Still employed: our hospital thus suffers from a variant of the London Transport • Syndrome, in which automatic ticket machines are installed but ticket inspectors and collectors are retained.

A colleague of mine runs four out-

patient clinics a week, which he administers himself with the aid solely of a diary and one nurse. He thus sees vast numbers of patients weekly. The hospital administra- tion is unaware as yet of any of this clinical activity, as they would no doubt call it. But when they do get to hear of it, they will demand, in the name of efficiency, that it be organised through the normal channels, which are so bureaucratic that the clinical activity will have to be reduced by three quarters, and the numbers of staff to do it tripled. My colleague will find his time filled up with such essential procedures as putting requests for appointments in writ- ing to outpatient clerks who will then write — or fail to write — to the patient. This procedure alone takes — when it works — more than two weeks. Thus my colleague can either provide the administration with the information about his work which it requires, or he can see many patients — but not both. There are no prizes for guess- ing which option the administration will choose.

The Health Service is presently suffering from a form of medical Leninism. The assumption is that if decisions have to be made about the allocation of resources (and apparently they do, since demand out- strips supply), they are best made explicitly and 'rationally'. This, of course, is precisely what the Marxists thought about the econ- omy as a whole, with what results we now appreciate. The Health Service is probably bigger and more complex than the entire Russian economy was in 1917, yet health economists and others assume that it can be organised on a wholly rational basis, its output for use rather than for profit — or, indeed, public benefit as defined by doc- tors.

Increasingly, the Health Service resem- bles the Soviet Union. The managers are apparatchiks (down to their bad suits), and will arrogate more and more privileges to themselves. It is not in the least surprising that the bill for Health Service company cars has risen so dramatically of late. Fur- thermore, it is not implausible to see infor- mation-gathering as an excuse for the development of a Health Service NKVD: again, it hardly surprises me that a hospital consultant recently had his telephone tapped by a hospital manager. This is the wave of the future.

The public-spiritedness which undoubt- edly existed in hospitals will soon be destroyed utterly, just as public-spiritedness was destroyed in Russia. In my experience, most doctors and nurses do far more throughout their careers than they are paid C 'mon baby, I may be president some day.' to do; but their attitude will change if they are asked to account for and justify every task they perform.

Of course, the Government will claim by way of refutation that it has introduced the rigours of the market-place to the Health Service. This is a straightforward lie. The customer in the new Health Service is not the patient, but a bureaucracy allegedly acting on behalf of the patient. I mean no personal disrespect to professional bureau- crats, but it is simply not in their nature to act in the interest of others. Doctors and nurses often do so act (though not always), because they have direct contact with peo- ple, and natural human sympathy prevails.

What the Government has done is not so much to introduce market relations, with all their efficiency, as to introduce a system in which two monstrous and uncontrolled bureaucracies speak to each other, with all the incompetence and rigidity which bureaucracies usually bring in their wake. The goal of the present Health Service is not to serve the patients, but to eliminate them altogether as an unnecessary compli- cation in the running of hospitals. Indeed, hospitals themselves are increasingly super- fluous to the need for offices.

We are often told of the alleged need for professional management. In all the myriad circulars I receive — several pounds avoirdupois every week — the word profes- sional is invariably used as a term of appro- bation. But nothing could be further removed from the truth than the need for professional management. On the contrary, what is needed is amateur management — by which I do not mean, of course, that it should be amateurish No: I mean the run- ning of public institutions such as hospitals should, as far as possible, be deputed to retired colonels and commodores, bank managers and accountants, businessmen and surgeons, who, for a very small emolu- ment, would be prepared and indeed delighted to devote themselves to the pub- lic good.

Such people would have no careers to make, and no ambitions requiring the employment of scores of underlings; they would have no vested interest in mistaking activity for work; they would not imagine that the production of circulars, with flow diagrams running from users' and carers' needs to resource implications, service agree- ments, client information systems and aligned operational co-ordination (an actual example taken at random), was in itself productive of anything except profound irritation in the recipient; and they would have a great fund of experience of running important undertakings, private and public. Moreover, a return to management by amateurs would do much to restore public spirit and civic pride, which vast public expenditures and the absurd attempt to put everything on a supposedly rational basis have done so much to destroy. It is charac- teristic of our age that in the name of rea- son we have created absurdity.