This is a brilliant tract against the times. Tallis records how the traditional vocation in medicine is ceasing to be renewed. What he says has a wider application to all professions and, indeed, to work generally. How can Britain sit casually by as a profession which, under oath, brings a lifetime of learning and dedication to our care is replaced by the highly paid medical salesman? Tallis locates a number of destructive forces at work.
Changes in the practice of medicine reflect changes in the wider society. The idea of vocation is increasingly no longer strong enough to determine what role people wish to play in life. A number now training as doctors may never practise, or, if they do, it will be for only a short period. This is a finding which would have been unimaginable 30 years ago. Being a doctor, and where to practise, is less a vocation and more a lifestyle choice. Ask anyone interviewing for junior consultant positions in London teaching hospitals. A significant number of candidates do not mention their desire to contribute to a team effort which has international status as a reason why they wish to be appointed. They single out instead how convenient the hospital will be for the life they will lead once their contractual hours are completed. The 2002 doctors’ contract was rejected by older doctors on grounds of its entrenching of political interference. Younger doctors voted against as it enshrined from their perspective anti-social hours into their working practices.
Tallis concentrates much of his attention on the rise of consumerism and with it the inexorable rise of political interference and control in matters which he sees as best belonging to the profession. The field of litigation ever more frequently determines how doctors behave. He writes, ‘There can be few doctors practising hospital medicine who have not subjected … patients … to the grisly indignities of futile attempts of cardio-pulmonary resuscitation in order to avoid the accusation by an aggrieved and ill-informed relative that the patient was neglected.’ Tallis testifies to the power of the fear of reprisal himself. In place of an oath which puts the patient’s needs and care first Tallis aptly, if rather crudely, suggests that the first aim now for a doctor is to cover his or her arse.
Attacked on the one hand by patients who see their treatment as no less important than their weekly communion at the local Tesco’s, the medical vocation is also under constant bombardment by politicians. Their attack is on two fronts. The first is a setting of targets, which politicians see as popular with an ever more consumerist electorate. Many of these targets clash with what the profession sees as the best use of still scarce resources.
Second, in order to extend control, those at the sharp end of medicine are subjected to wave upon wave of reporting upwards to their political masters in Whitehall. Tallis cites one academic consultant surgeon who, on top of 22 regular reports to national and university bodies, is required to complete ad hoc investigations of clinical incidents, assessments of individual research projects, the auditing of particular practices, the contribution to national surveys, and the list goes on. No wonder the time available for clinics is so restricted and no wonder the civil service has grown accordingly.
Maybe these trends would be bearable if they were not accompanied by the bile politicians, aided and abetted by the media, empty into NHS politics. Listening to ministers reporting on Alderhay Children’s Hospital, one could have been forgiven for believing they were announcing the closure of a concentration camp, rather than commenting on the work of an outstanding children’s hospital that had saved through its research programme the lives of countless children.
Such ministerial statements set off again those disgraceful Liverpool lawyers who make normal ambulance chasing for trade appear like a WI past-time. It is at this point that Tallis’s message should be read across to other professions. Into my political surgery come the walking wounded, used by lawyers to pursue daft and absurd cases against anybody from whom money may be extracted. Once the legal aid funds are bled dry, these unfortunate individuals often but not always very vulnerable, are spat out in my direction.
The only wonky piece of Tallis’s book is on the Thatcher children effect. In this area only Tallis genuflects to conventional wisdom and swipes at the selfishness that Mrs T let loose. In trying to arrest Britain’s long-term decline, Thatcherism may well have sometimes pushed the political pendulum too far in the opposite direction to its post-war swing. But self-interest is different from selfishness, which is itself different from greed. No politics can succeed if it is not based on self-interest, that most basic of human desires. How self-interest can be directed to promote the public good lies at the very heart of policy.
The medical vocation is not an island. It will be impossible to restore anything like the rule of vocational and professional standards if medicine is thought of in isolation. The tides that have washed away so much of those standards crafted over generations to protect the ill and the dying are causing similar havoc elsewhere in our society. What is required is a tract for the times which begins to set out how best we can pursue the new politics of behaviour. What kind of people we and our fellow citizens should be is far too important an exercise to be left only to the politicians.