More than any other creation of the post-war Labour Government the National Health Service has been regarded with veneration and satisfaction by those on the left. And indeed, confronted with the vicious medical anarchy which prevails in the United States, no generous person can fail to regard with some gratitude the effort to provide adequate medical care for the whole British population, to raise the ethics of medical practice above those of the market place. Nonetheless such veneration and satisfaction has blinded those on the left to the immense faults of the nhs, considered in a socialist perspective. An earlier article, in New Left Review 34, attempted a definition of health on socialist principles; in the article which follows a number of crucial factors have been selected which dramatically illustrate the failure of the nhs to care properly for those for whom it was set up, and how this failure has affected the doctors around whom, and despite whom, the nhs was erected.
Both doctor and patient showed no awareness, had been given no indication, of how the new Health Service might embody an entirely fresh approach to ill-health.
The doctor/patient relationship has been the subject of innumerable edulcorations on the radio and television. Time and again we are shown the doctor as an altruistic, humane healer, above the vulgar influence of cash and business interest; and the patient, ready to co-operate with him for his own good. Why such falsification? The doctor/patient relationship is pitted with conflict; the lie merely repeated to dull our suspicions.
What generates this conflict? The kind of medicine which the doctors practise and the nature of sickness itself. The new diagnostic and therapeutic techniques, extraordinarily potent by comparison with their predecessors, entail much greater risks to the patient. To use them safely the practice of medicine requires ever greater precision and order. Rules have to be imposed and applied: to enforce them hierarchy and discipline are needed. But doctors are trained as decision takers, their education teaches them adulation of professional independence, of full medical responsibility for the patient, of continuity of care. The form which the scientific revolution in medicine has imposed on the actual structure of the practice of medicine has engendered conflicts between the doctor and medicine itself, conflicts which the doctor cannot act out because of his professed ethic and his attitude to medicine and the patient. The strains burst forth in jets of anger and frustration, in autocracy, abruptness, the imposition of the doctor’s will on his patient, as his right.
In practice it is unusual for anyone to claim that there is privilege; though in one sense it is obvious: the doctor is well, the patient sick. This confers a wide range of advantages, in particular mobility and freedom. In addition, the sick man has had imposed upon him a dependent role, he has asked the doctor in, he has asked his advice, he is willing to take it; this is the contract he has entered. Then there are the demands of society. Society does not want people to be sick. This is the reason for the institution of medicine. The doctor has to protect society from excessive sickness; a sickly society is inefficient and may die out altogether, as the early settlers of Greenland did. At the same time society is continually on the watch for fake sickness. People appreciate that the environment can produce sickness in them, but that they, in their turn, can protect themselves from their environment, their society, by the production of sickness. The reality of such sickness is disputed, though conceded by the common idiom. We say we are sick of work, of this district, etc. For such cases society needs doctors as policemen, to protect itself against the skrimshanker, the malingerer, the lead swinger. And the doctor resents this role for through it he is brought into conflict with his professed loyalty to the patient. This is why doctors resent certification. If a doctor refuses to concede the right of his patient to take time off work by signing the certificate, he exposes his role as health policeman, his loyalty to the other side, an