Q J Med 2003; 96: 241-242
© 2003 Association of Physicians
Coda |
The National Illness Service
A few months ago, I had a conversation with a hospital chief executive who was complaining about the unrealistic expectations that many patients have nowadays. He told me that he wished we could change the name of the National Health Service to the National ‘Keeping-Death-at-Bay’ Service. He thought that this would help patients to shed their illusions of omnipotence and immortality. It would also indicate that, in reality, hospitals by themselves have little to do with the production of health.
This struck me as an interesting if somewhat provocative idea. However, I didn't give it much thought until the following month, when I happened to be doing some consultancy work for a mental health team in the south of England. During the course of this, the team leader said how much he disliked being part of something called a ‘mental health team’. He thought this name was quite dishonest and really they ought to be called the ‘Coping-With-Disappointment’ team. After all, he argued, most of the patients they saw were simply struggling to come to terms with lives that had failed to fulfil their hopes. He and his colleagues could usually do little to alter this—but they could still do good work if people were inclined to accept that disappointment is inherent in the human condition.
When you come across an idea like this twice in quick succession, you can be pretty sure that you will soon come across it a third time. So when a friend recently recommended a book called ‘How to be a good enough GP’,1 I wasn't very surprised to find that it addressed exactly this theme, and elaborated it at some length.
The author of the book, Gerhard Wilke, is a social anthropologist and group analyst who has done a great deal of work with groups of GPs in the last few years, trying to help them to adjust to the numerous reforms and reorganizations that have unsettled doctors' lives so much in Britain. Wilke's book makes sense of a great deal that is going on in primary care at the moment, but I have no doubt that it will also make sense for hospital doctors too.
Wilke takes his title from the concept of the ‘good enough mother’, a term coined by D.W. Winnicott to describe mothers who can help their infants to face the emotional challenges of the real world, with confidence and trust. By analogy, a ‘good enough’ doctor is one who helps patients do the same. Wilke argues that the very same ability is also needed by managers if they want to help doctors with their daily work. Here is an example of what Wilke says on this subject:
‘I would suggest that it is necessary to challenge the implicit ideology underpinning such buzzwords as health, team, modernisation, accreditation and audit. The emphasis on health at the exclusion of illness is a denial of a large part of reality of primary care.
‘Healthcare professionals like to think positively as it is too unbearable to stay in touch with the inevitability of decline and death. It is hard to live with the awareness that general practice can do a lot for patients but ultimately it manages the process of patients finding a good enough death ...
Professionals need to create a more balanced discussion in which the emphasis on health is matched by a focus on death and chronic decline. Only when that is politically acceptable will we have a more honest and realistic debate about resources.’
I believe that Wilke is right when he criticizes the rhetoric that has possessed British health service management in the last decade, and when he draws attention to what underlies this, namely a fear of mortality. Reading the book has certainly deepened my own understanding of why my in-tray is brimming every day with those dreadful, neo-Stalinist reports from government agencies and local trusts, full of frothy optimism and photos of multi-ethnic staff groups, all smiling joyfully. It has also helped me to understand the inevitable counterpart to all this managerial mania: widespread demoralization among health professionals and even, in some places, despair.
But I believe Wilke is right too when he points out that as doctors we play an important part in this process. The whole charade of cheerfulness in which we are now caught up both mocks and exploits our own tendency to certain forms of psychological avoidance. It may even echo the reason why we became doctors in the first place, and maybe that is why we find it so hard to confront the charade. Wilke offers us a challenge by suggesting that we will only become ‘good enough’ doctors when we acknowledge that there is a fundamental deception at the heart of the National ‘Health’ Service, and that we are both its perpetrators and its victims.
References
1. Wilke G. How to be a Good Enough GP: Surviving and Thriving in the New Primary Care Organisations. Oxford, Radcliffe Medical Press, 2002.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||