The NHS has never been doctor centred.

The 'Carry On' series of documentaries accurately depicted the 'innuendo-centred' NHS of the 60s and 70s.

This government is a nasty combination of arrogance, incompetence and mendacity. One piece of mendacity that it and its henchmen and advisors try to get away with (and which credulous PCT minions are stupid enough to try quoting at me) is the statement, “The NHS was originally very doctor centred, now we’re going to try and make it patient centred.”

The subtext is that doctors are never patient centred, and indeed as “vested producer interests” must be actually against the interest of patients. However if you are an ill patient a good doctor (competent, caring) is the most patient centered creature imaginable.

It pisses Dr Rant off to see people spreading so much bullshit, especially those who are so “Patient centered” that they never actually see a patient, but they want to tell those of us who do how we should do it in a Patronising middle class solicitor Hazel Blears please take note.

Let’s start with some history. The NHS has never been centered properly at all, whether on doctors, patients or managers. Indeed there has always been an uneasy tension between these three poles and at various stages one or other has come to temporarily claim dominance. (Three cornered scenarios are always unstable as Hegel’s thesis, antithesis, and synthesis reminds us. Dr Rant might use the earthier example of the husband, the wife and the mistress.)

In health policy terms the triad was described by decent illness treatment services, even after its increased funding.

For much of the NHS’s history the focus has been on trying to get services set up and delivered. And to try and get some of the geographical anomalies ironed out.

Doctors have actually helped and adapted to this process. Indeed we have put in a huge amount of work to make the whole NHS thing work at all.

Let’s look at what doctors in the supposedly doctor centred NHS of say 10-40 years ago got in their “doctor centred” NHS.

They got long hours as junior doctors. 1:1 rotas (i.e. 168 hour weeks) were not unknown. Now at that stage the doctors might have not been bleeped by junior nurses, and might have had the hospital porter deliver a drugs chart for signing to their door, but the poor junior doctors then were working very long hours. They may have had the protection of an experienced sister running the hospital at night. They may have had access to the dining room and hot food available day and night.

But they were still working exceptionally long hours, and very hard.

Things improved slowly with rotas moving to 1 in 2 and 1 in 3 by the late eighties. Let’s be clear what such a rota means. It meant working Monday to Friday 0800 to 1800 and every third night as well, and every third weekend, covering many wards, from 1700 to 0800 the next morning. In other words weeks of 83-100 hours per week. Oh and these rotas included prospective cover so that 1in 3 dropped to 1in 2 when a colleague was away. So the doctors in the great doctor centred NHS were getting such a great deal.

The consultants were not doing a lot better. They had had to endure about 15 years of junior doctor life before getting anywhere near their consultant post. They had enjoyed brutal competition for posts, and had to put up with grumpy bosses, nurses getting the hump, annoying juniors, and remain tactful in case they heard the dread, “You’ll never work in this town or speciality again.” In short they had been hammered into submission and conformity. The ones who were resilient enough to get through the ordeal tended to have a certain amount of character either innately, or acquired!

So the final half of their career was theirs to enjoy, and if they could earn some decent private practice income (or get a merit award if they were academic) then they saw it as merited rewards. Most of the old school consultants were workaholics, and they gave more to the NHS than they ever got rewarded for. Many consultants paid for their efforts on behalf of patients with alcoholism, burn out, depression and divorce. Their wives realised that they were just there to keep hubby looking after everyone else.

The GPs got a great deal from the old doctor centred NHS as well. Huge workload, their own on call (which became steadily more onerous over time). Then the joys of tyrannical senior partners, and unfair profit sharing arrangements for 3 years till “parity.”

So although in its early days the NHS may have been doctor focused in terms of thinking mostly about how and who would deliver medical services, the NHS never really cared too much about its doctors, and for example did nothing to stop, and everything to encourage, 25% of UK medical graduates to emigrate during the 50s and 60s. A combination of lack of opportunities at home, and better salary and support abroad lost the UK many good doctors. MTAS and MMC have effected the same process for recent graduates.

The NHS has never really provided a wholly satisfactory combination of salary, satisfaction and support for doctors. The salary and satisfaction are reasonable, but the support is severely lacking, and getting less. In particular government advisers calling us “knaves” and “vested producer interests” curiously gives doctors permission to live up to such descriptions.

The NHS has never been doctor centred, and indeed has always consumed more out of doctors than it has ever given back to them. Patients say thank you us and mean it. Politicians sometimes say it, but always add in a “But….” Which negates it.

By the same token the NHS has never been patient centred, and it is currently management centred, on targets, commands and control.

Dr Rant’s plea for the NHS is to give doctors a fair deal, and to trust us to give a fair deal to patients. No amount of regulation has ever made anyone good, in any field of endeavour. If you do not trust us, please do not employ us.

And if anyone talks about the “Old doctor centred days” remind them that they involved screwing a huge amount of unpaid work out of people’s good will. Some economists think this is a good policy…and should have been continued-the NHS after all was getting something for nothing.

The NHS has not been, and currently is not doctor centred.