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
Because there are social pressures to be normal, most people do not want to admit that they are sick; this is not merely because sickness is penalized by a diminution of income and the curtailment of freedom. There are social pressures which force a person who falls sick ‘to act sick’; to go to bed, to take medical advice, in fact to undergo the archetypes of illness—the harrowing process of restriction, fear, and submission to unwelcome procedures. If you are sick ‘you owe it to others’, ‘you owe it to yourself’, ‘you ought’, even (in the case of certain contagious diseases) ‘you must’ go to bed, see a doctor. Most sick people don’t want to, they resist, and so when at last they do get to see their doctors, their mood is one of resentment, as well as of fear.
The resentment which patients feel towards their doctors is partly the consequence, too, of the conditions which are imposed upon the patient by the system through which medicine is practised. The doctors and nurses have to play a part too—we shall come to that later—but the script has been written for the patient and the doctor/director is not likely to allow much freedom in the patient’s interpretation. In essence the patient is helpless, he has admitted it by calling on the doctor and so contracting to accept his advice; he needs the doctor’s help and for it he is ready to co-operate with the doctor for his own good. The extent to which a sick person signs away his rights and responsibilities as a citizen is hardly recognized. In hospital no patient expects to choose where he should sleep or in what company. He will take the food he is offered. He will not question the treatment meted out to him, submitting himself to the most unpleasant—and frequently medically useless—procedures in order to ‘get better again’. His contact with the outside world is restricted—he can see his friends and relatives only during visiting hours, which are short and at compulsory times. If he is lucky and mobile he may have access to a telephone, but he may not. The radio or television in the ward is likely to be tuned to one programme; if he is fortunate enough to have earphones his listening is optional, if there is a loudspeaker it is not. The point about these restrictions is that they are generally just accepted as part of the set-up, the way they do these things, part of the system. (The most poignant example of such dumb acceptance is the way relatives meekly hang about sister’s office at visiting time in hospital to learn what is the matter with X and what may be expected. Then they pass on the edited scraps to the patient.) Consider the doctors’ resentment of patients who will not abide by ‘their side of the bargain’. The difficult patient, strangely enough, is not the patient whose serious illness poses most problems to the doctor (he is an ‘interesting case’ and is so frightened and so weak that he cannot resist the discipline imposed on him). It is the patient who is nearly better, or the patient who refuses to realize how ill he is, who makes the most trouble for the medical staff. Again, there is the patient who does not appreciate the importance of medical etiquette, the patient who goes to his medical practitioner merely for help in getting an