The NHS is being dismantled, privatised, on that I think most are agreed. There appears to be a groundswell of resistance to this, at least there does if you spend time on Twitter. Here socially engaged, predominantly left wing commentators rally to the cause, but beyond the Twittersphere the story does not seem to attract much attention. The BBC is not interested, the press explore it fitfully. Anger is contained. It looks like a done deal. But what of those who work for the NHS? Surely doctors and nurses are fighting, demonstrating, complaining. I don’t see them. Do they have no loyalty? I’m not out there either. Do I?
The Luminous Bed Test
One way of assessing a person’s attitude to the NHS is to ask, in the manner of a market researcher, how they felt during the Olympic opening ceremony. You would assume that most health care professionals felt proud when those illuminated beds lined up to spell out the letters ‘N H S’ for the whole world to see. For me it was an abstract kind of pride. Perhaps that was because the Health and Social Care Act had already received royal assent, and many had identified it as the beginning of the end. Danny Boyle’s choreography seemed like a cheeky, even subversive attempt to signify national affection for a lost cause. The impression was not helped by the news (released before the Olympics were even over) that Trusts were being encouraged to export ‘the NHS brand’. It was that superficial term that caused me to ask myself – What does the NHS mean to me? To answer that requires an examination of my relationship with the NHS. And, like most employee-employer relationships, it’s complicated.
Aerial view of Olympic opening ceremony
Mixed feelings
Doctors, especially those in training, have not always been treated well by the NHS. Until recently the hours were hellish. Now the hours are better but the team-working ethos has been fragmented. Trainees struggle to find the time to study, and are forever cross-covering each other to free up days for essential courses. Some rotas allow no choice as to when holiday is taken, while others rely on the tradition of ‘internal cover’ by which on-call shifts that are ‘missed’ while on annual leave have to be paid back when the doctor returns. The MTAS debacle (a ‘deeply damaging episode for British medicine’ according to the man who led an independent enquiry into it, and one that I was fortunate to avoid) resulted in doctors leaving the country and the profession. Many complaints could be directed at administrative and academic bodies that are not part of the NHS: Modernising Medical Careers (MMC), Deaneries, the Royal Colleges or Medical Education England (MEE) – but the doctor in training who is struggling to progress cannot be expected to understand the subtle tensions that exist between these bodies, it just feels like the ‘system’ – the health service, the NHS.
Self-sufficiency
Doctors in training flit from employer to employer with great regularity. I think I worked for 9 trusts between qualification and consultancy. This unusual pattern of employment demands two qualities – adaptability and self-sufficiency. Adaptability is crucial, because you have to learn the ropes of a new hospital within days, sometimes hours, if your patients are not to be disadvantaged. Self sufficiency is equally important. The doctor who moves through an ever changing landscape of individual trusts seeks constant reassurance that their trajectory is correct, their educational development satisfactory, their emotional wellbeing monitored. They want to know that someone is keeping an eye on them. The system can meet these demands up to a point, but is designed to identify and assist outliers, the ones who are struggling. The majority will move forward, deal with their own problems and dig into their own resources to work through the crises they are bound to encounter…they will not be feel the warm hand of the ‘system’ at their back. So, when their training is complete and they find themselves reasonably happy with their lot, they will attribute their success to their own persistence and endurance. They will not feel grateful to the NHS for the help and encouragement that it gave. The pride that they feel will be personal.
Where does loyalty lie?
In a consultant interview one of the questions was “Will you work at XXXX, or for XXXX?” It was a good question, because it forced me to express the desire, in advance, to be loyal. I had not worked at the hospital and I did not yet know if it deserved such a commitment. Only a fool would have said, “Oh, well…ask me again in six months and I’ll tell you!” On further reflection the question suggested that there should be automatic loyalty to an employer. I asked myself if I had demonstrated loyalty to my previous Trusts? Had I defended them when they were criticised? Had I made an extra effort at work in order to strengthen their reputation? The answer was no. I had whined and whinged about the conditions as much as my colleagues in the pub after work. I had brimmed with frustration when I couldn’t get away for training days. My loyalty lay with my team, my mentors, perhaps with my department, but not with the institution itself. As the expiry date on my contract approached, as my ID card was automatically deactivated (sometimes a couple of days before I actually left), I recognised that I was another employee passing through. Close colleagues would say goodbye, emotions might run high (the most stressful jobs engender a ‘band of brothers/sisters’ feeling) but the hospital wouldn’t blink an eye. The NHS wouldn’t miss a beat. The day after I and my new friends left, a fresh group entered…and a smooth service was maintained.
We are loyal to people and to places. The great mobilization of energy by staff and community in Lewisham, south east London, to defend the downgrading of their local hospital, is a case in point. Loyalty is an emotional response, fed by proximity and constancy. Medical trainees are rather like journeymen of old, moving from Trust to Trust, trading their nascent expertise for a salary, and for the training that ensures ongoing growth, then moving on. Such journeymen do not develop loyalty easily.
Tangible and intangible rewards
Hasn’t the NHS rewarded its staff for the demands it has made? Of course it has…senior doctors are well paid, and risk opprobrium when they moan about conditions on salaries that approach or exceed 6 figures. But money is not the issue, because the changes that are being made will not take it away – and of course, doctors working in the private sector will not be excluded from the financial benefits that its expansion may present. There are deeper, more subtle rewards for working as a doctor in the NHS, but they require us to step back and appreciate how amazing our jobs are. It is easy to forget that working within the huge, impersonal structure has allows us to pursue a vocation. It facilitates the practice of skills that we competed to acquire, and provides the protections and guarantees that come with state sponsorship. Although progress through the system feels random and unplanned, it is at least guaranteed to those who pass their exams and maintain standards. Patients trust us with their lives. Why don’t these benefits engender loyalty? They do…but to the job, to the vocation. Not to the administrative structure within which we work. Perhaps we have been spoilt. Perhaps we will only notice how well we have been treated when that structure crumbles. To really appreciate that structure we need to look up and out, beyond the personal to the societal.
A higher level of concern
If the defenders of the NHS are not motivated by personal loyalty, what is it that gets them up in the morning? It must be because they are looking at it not as providers of healthcare but as sociologists. They are concerned about access, equality, disenfranchisement, the creation of two tiers… These concerns require a higher level of understanding. The problem, I feel, is that most of us are not influenced by these socio-political issues. We are relatively apolitical, we go with the flow, we allow changes to wash over us and hope that our lives will not be disturbed too much. Only social campaigners fight for others. The rest of us just get on.
The one thing that most healthcare workers would respond to is a threat to patient safety. No one can see into the future, no one knows if the gradual privatisation of the NHS will adversely affect the care that patients receive. The full NHS risk register was not published, but it is hoped that the very act of reading the warnings it contained allowed preparations to be made to minimise potential harms. Only as mistakes occur will the case against privatisation grow, but by then we will be reacting to downstream events, not reversing the cause. There are signs. Recently, NHS Direct pulled out of the 111 service for financial reasons. We have been reassured that patient care did not and will not suffer, although an undercover reporter said,
‘Halfway through the training a manager in the call centre admitted to me and the other trainees that on the weekends the service was ‘unsafe’ because they didn’t have enough staff to handle calls.’
Serco, a private contractor for out of hours primary care services in Cornwall,
‘falsified figures on its performance 252 times, making it look better than it was, so that serious failings in the service only came to light thanks to whistleblowers.’
On the other hand we know that many harms were done to patients before the Health and Social Care Act came into being. The Francis report into Mid Staffs has demonstrated that all was not well with the current system. The NHS and safety are not synonymous. So I, as an individual doctor, with a small view, must accept that I am not in a position to know what is right . I am a worker. I see the decisions being made around me and I may feel comfortable or I may feel uncomfortable… but that is as far as it goes. I do not feel particularly sad to see the NHS changed. For the reasons explored above, loyalty to it is not woven into my DNA. But I do worry that the decision to take it apart was made for the wrong reasons. I worry that public representatives with vested interests voted in favour of privatization because they saw the opportunity to make profits. I worry that providers will walk away when promised returns to do not materialise. I worry that patients will be disadvantaged or put at risk… but these objections are hard to define and shrouded in uncertainty. Perhaps my middling, rather anaemic reaction to these changes is a typical one. That might explain the failure of the medical and nursing professions to rise up.
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Illusions of Autonomy 
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