Signing away the NHS
Doctor-patient contracts replace treatment and trust with surveillance and suspicion.
A New Labour policy document has proposed doctor-patient contracts for the National Health Service (NHS).
Doctors would agree to provide certain treatments (such nicotine patches for smokers) and to meet certain standards (such as providing appointments within 48 hours). In return, patients would pledge to modify their unhealthy habits (for example, by attending smoking cessation courses) and agree to turn up on time for appointments. Doctors would try to be civil to their patients; patients would promise not to beat up their doctors.
These proposals have provoked a storm of condemnation from the British Medical Association (BMA), the Patients Association and even from the Conservative Party. This is strange, because medical practice has been reorganising along these lines for some time – with the active support of these organisations. The new proposals merely formalise a framework of bureaucratic regulation that replaces relations of trust between doctors and patients with relations of contract.
So the new contract for GPs that is currently under discussion has provoked much controversy over questions of pay (quite rightly, given that the first scheme circulated implied a substantial cut in income for most doctors). But although there have been heated debates about money, there has been little controversy about the substance of the new contract, which proposes a major shift of general practice away from the treatment of patients who are ill towards the regulation of the lifestyles of the population.
In the new order being forged in medical practice in Britain, the patient is no longer an individual seeking treatment for illness. Instead, the patient is a unit of a population in which target quotas have been set for interventions (of highly dubious efficacy) designed to reduce rates of coronary heart disease, strokes, cancers and other diseases. The doctor is no longer an individual skilled in the diagnosis and treatment of disease, but is a bureaucratic functionary, the mere executor of protocols and the follower of guidelines, a ticker of boxes and a filler-in of forms.
It is not surprising to find that, as relations between doctors and patients have become more instrumental they have also become more conflictual. The New Labour proposals remind patients that the NHS is a ‘free but not finite service’, one in which resources must be rationed. After raising expectations of the health service by encouraging public preoccupations about health, New Labour increases pressures on GPs who are required to act as gatekeepers to the grossly overloaded hospital system.
In a recent visit to a local health centre, I counted seven posters in the waiting room indicating, in different ways, the policy of ‘Zero Tolerance’ towards patients who behave in an abusive or aggressive way towards doctors or other practice staff. The impression that this creates, of relations of seething rage and scarcely contained violence prevailing between doctors and patients, is a grotesque distortion of reality.
Yet the ubiquity of these posters – they can be found in every GP’s surgery and every hospital accident and emergency outpatients department – is a powerful testimony to the damage done by the advance of relations of contract in medical practice. The slick but vacuous slogan ‘Zero Tolerance’ perfectly expresses the corrosive cynicism of New Labour policy in the NHS.
Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).
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