Continual reforms will always be a reality in the NHS – a fact which sometimes sits uncomfortably with those in the medical profession. The NHS needs to change and adapt, and doctors must continue to be willing to accept change and be open to reform that drives patient care. Yet reform must be evidence-based rather than divisive and confrontational. Until serious and frank discussions are had regarding the direction it has to move in, the doctor-government antagonism is bound to continue.
NHS reforms are never going to go away. Although the headline grabber has been junior doctor contracts, failing services and privatisation, reforms over the last 20 years have covered everything from how decisions are made about funding treatment to how health and social care should work together. Each government has made an attempt to adapt the NHS to how they believe it will be the best equipped to provide healthcare to the UK population. Whether this is changing incentives for doctors to provide quality care or attempting to create clear accountability with organisational structures, changes have been afoot long before they hit the headlines. These are needed perhaps now more than ever, with the NHS seeming to be struggling continually with huge pressure on structures and staff.
Yet recently these changes have been met reasonably fiercely by healthcare professionals as a whole and in particular by doctors. Although not the largest group of professionals within the NHS, doctors have particular leadership roles within the hospital and have tended to be the most politically active and vocal.
This was most strikingly apparent recently with the widely covered junior doctors strikes at the imposition of a new contract, but this is only the most recent battle. Throughout the last 20 years of reform, doctors have time and again raised concerns and opposition to plans to change the structure of the NHS. The questions that begs answering is “why”? Why do doctors so often resist and resent the changes that the government wish to bring about?
These issues have been simmering away, just under the surface and only recently with the arrival of a conservative government and the changes bought in since then has the frustration been apparent, and the disdain for those bringing about the changes has become vocalised increasingly clearly. Although this could be seen as an argument over pay, it seems to me that there are long standing issues with the way changes are bought about in the NHS that extend far beyond the junior doctors contract.
Perhaps the most fundamental issue that doctors have is a lack of trust in those implementing change. This occurs at two levels: in the very ideas behind the changes and the practical way in which they are undertaken.
A matter of principle?
In principle doctors often struggle with non-medical people dictating change within the services that they run. Doctors are often completely engrossed in the services that they run and the patients that they treat, not infrequently at the expense of other areas of their lives. They know the systems because they live in them; they know the cracks because they have seen their patients plunge through them; and they understand the strengths because they are boastfully proud of them.
For someone without any background of working and toiling within the NHS to tinker and play with the system, and to implement changes feels almost inherently wrong. Doctors don’t really want to be the ones making these decisions. The reluctance to engage with CCG1s is proof of that doctors have voted with their feet – they entered medicine to be clinicians and not to manage. However they do want those to be making them to be versed in the challenges that they and other professionals face.
On the surface this seems contradictory, asking for their perspective to be central but being unwilling to step up when offered the chance. However, I believe there are a couple of reasons that the CCG experiment failed. Firstly, doctors enter the profession because they love the clinical, patient meeting, hands-on aspects which they are be reluctant to give up. Secondly, doctors in these groups often felt out of their comfort zones in business like corporate setting – something which medical school and medical practice left them ill-equipped for.
This may seem to be having it both ways. They don’t want to make the changes yet resist those making them. Yet I suspect there is a healthy middle line to run, in which management and decision-makers have at least some background within a service and listen to input from doctors to make decisions.
For this to happen doctors will have to relinquish some control of the systems and departments that they work in. Although they should expect managers to be familiar with their services and put patient welfare at the forefront, doctors also need to allow these changes to be made – even if at times they don’t fully understand or agree with the reasoning.
We’ve always done it this way?
Inextricably linked to this is that there are aspects in which doctors resistance to change is less principled. Within any established organisation there is an intrinsic resistance to change – a guttural feeling developed by decades of structure. Although doctors have learnt to change practice and structures from evidence of their own, there seems to be a continued reaction against any change to many of the structures.
Doctors have their own ways of doing things and will often resist outside pressure to change. Changes have, however, become increasingly frequently in recent years. From structural change and whistle-blowing from the mid-staffs, to increased focus on the assessment of practice and decision making following the Shipman case.
Yet still, the tradition of the NHS can be more political than this. The default left-leaning slant of the BMA has always led to resistance to conservative-led changes. Although I believe that this is not the biggest factor in recent times, as many staunchly conservative doctors are frustrated and fed up at recent changes. It is an underlying factor that cannot be discounted in an overall picture of this topic.
Do you trust me?
However these problems pale in comparison to the lack of trust doctors have of those decision makers in practice. This is perhaps the most covered aspect of the latent mistrust in reforms, and certainly – in doctors eyes – the most significant. Time and time again over the last 10 years, politicians from across the political spectrum have implemented changes not for their effectiveness or good outcomes, but instead as a political manoeuvre.
Government under pressure due to long GP waiting times? Promise more GPs, irrespective of the difficulty (perhaps impossibility) of this idea. Long A&E waiting times? Set unachievable targets. Still long A&E waiting times? Suggest GPs go and work in A&E. Or more recently, where cuts are needed to be made, the government has opted for cutting haemorrhoids and coeliac prescriptions and keeping homeopathy. Target-setting, doctors’ working ours and direct policy about what treatment should be offered where. In each case the dominantly prevailing view among doctors is that these are not changes primarily to help the NHS, but instead are politicised moves.
Whether to serve a larger underlying agenda or simply as a knee-jerk reaction serving as protection from media scrutiny, these changes provoke mistrust in doctors. Used to changes being driven by evidence and high quality research, doctors have instead been driven by what is perceived as a political agenda. Often this agenda feels more like an attempt to gather votes, as opposed to secure the long term sustainability of the NHS.
Similarly, recently it feels as if the calls for reform have often been an attempt to mask the fact that a service with problems has funding issues. Does it really need reform or just adequate funding? This has driven an increased scepticism for reform, and perhaps now the default position is one of guarded mistrust.
NHS reforms are going to happen. They need to. The NHS needs to change and adapt to the population it serves and to do so in an efficient, effective and caring manner. Doctors need to continue to be accepting of change, open to reform that drives patient care and able to work with organisations to drive healthcare forward – even if those making changes are not governments of their choice.
Yet this is all dependent on reforms being made not from a short term political agenda, or necessarily in response to media provocation. Instead, doctors’ wish is for a government to provide reform that is evidence based, clearly explained and works with doctors, as opposed to being confrontational. Is this going to happen? I feel that this is unlikely. Until honest discussions are had regarding where the NHS is and where it should go the doctor-government antagonism is set to continue.