QJM Advance Access originally published online on February 21, 2007
QJM 2007 100(4):251-252; doi:10.1093/qjmed/hcm011
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Only obeying orders
For part of the week, I work as a consultant on a clinical team that is currently ‘overperforming’ on one of its local service contracts. Overperformance really just means that we have done more work than predicted, so telling us that we have overperformed is a bit like saying that the sun has overperformed this week because the weather forecast said that it would rain. All the same, we have been asked to cut down on our work for the remainder of the financial year. We will all have to close some cases, knowing that we may need to reopen them in April. We will also need to change the review dates for other patients, in order to make sure that they don’t darken our doorstep again until the new financial year has begun. Where two clinicians from different specialities are seeing a case jointly (fairly common in our line of work), we will have to explain that only one of us can see them for the time being.
Fortunately, or ludicrously—depending on which way you look at it—all of this only applies to part of our catchment area. People who live slightly further away, or in some instances on the opposite side of the same road, will continue to have no such restrictions. In theory at least, we might even decide to fill our time for the next month by seeing them more often, or with several clinicians in the room twiddling their thumbs and waiting for March to expire.
This phenomenon, and others like it, are now very common in the National Health Service. Broadly speaking, I notice three kinds of reaction among my colleagues. A few outspoken staff members burst out with indignation or even outrage when one of these measures is announced. It is usually the same people on every occasion, often the ones who seem angry about a lot of things at work anyway. We admire them, but also feel irritated and embarrassed, wondering why they cannot just accept the madness of everyday life in the NHS like the rest of us, knuckle under as we do, and get on with their jobs. By contrast, a number of other colleagues seem to buy into the latest managerial demand more or less wholeheartedly each time. While lamenting any temporary difficulties, they are keen to explain to the rest of us the importance of rational planning, workforce efficiency and so on. Things have been unacceptably sloppy in the past, they remind us, and we are paying the necessary price for tightening systems in the right way. We admire these people too—to an extent—but we are also a bit scared of them. If they aren’t already in positions of authority, they probably soon will be.
Most of us, to be honest, fall somewhere in between in our reactions. Our sympathies are with the protesters, and we may even make some tame comments to this effect, but nevertheless we fall in with the modernizers. We take their rebuke to heart, as if overperformance isn’t just an artefact of budgeting, but a genuine moral failing. And we try to convince ourselves that it isn’t as insane as it seems to postpone seeing a referral because it's March and the patient's address is in Jubilee Road and not Jubilee Avenue.
As always, I am struck by how these processes resemble totalitarianism. I realize that some people will find this comparison preposterous, and clearly one has to discriminate between degrees of totalitarianism. There is an important difference between being told off for overperformance and being shot for it. Yet all the classical ingredients are there: the idealization of order, the marginalization of dissent, the disqualification of compassion, enthusiastic collaboration by some thoroughly decent citizens, and passivity among the rest of us. There is a also a certain kind of collusive secrecy. When we change patients’ appointments around, or send letters telling them their files have now been closed, we probably won't tell them the real reasons. Instead, we will package these in some other convenient form, somewhere along the spectrum from coincidental half-truths (‘we have decided to close every case where patients have not attended their last two appointments’) to downright lies (‘unfortunately Dr Launer is unable to be present at our next meeting’). Without any discussion, we collectively assume that we cannot be open with our patients. The deceit becomes part of the climate in which we work.
In discussing totalitarianism, the historian Hannah Arendt famously wrote of the banality of evil, and it is indeed banality that characterizes these sinister incremental shifts in what is acceptable. After the team meeting where we learned about our overperformance, I went to the canteen in my usual way, and then took my cappuccino downstairs to my office so that I could dictate the necessary letters. Fairly soon afterwards, I had more or less forgotten this latest small assault on my capacity to practise professionally, or humanely. My job and my pension are still intact, so perhaps things aren’t really so bad after all ...
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