Podium: The Kafkaesque world of the NHS

From a speech by the doctor and writer to the Social Market Foundation in London

FIRST LET me say at once that I do not believe there was ever a golden age in which everyone who worked in health care was perfectly contented and satisfied with his conditions of work. I think everyone who reflects on the question of morale accepts that there will never be as much money as desired. Morale undoubtedly exists, but it is rather an intangible quality and it is therefore somewhat difficult to measure. As such, it is completely unimportant to managers, though of course it is vitally important both to staff and to patients.

Because morale is somewhat intangible, what I shall now say is itself somewhat unsystematic. I shall give you a few reasons why morale is low. Some of them, superficially, appear to be connected with the question of money, but there is far more to it than that.

Take, for example, the question of St Bartholomew's Hospital. It is one of the oldest hospitals in the world, having been founded in 1123. Admittedly its history is not really continuous, but it is nevertheless justly known as the Royal and Ancient. It has a glorious history - among many other things, it was the hospital where Harvey, one of the most momentous discoverers in the whole history of medicine, practised. It has been for centuries part of the fabric of the City of London; it is universally loved by the population it serves. Everyone who works there is proud to do so.

To effect relatively paltry savings, it was proposed to close it down. Words fail me to describe this proposal, which would be an act of such cultural vandalism that words fail me. Indeed, it could be contemplated only in a country governed by philistine fools, the kind of people who would make a Gradgrind seem a man of large views and moral grandeur.

Up and down the country, hospitals with a considerable history, whose very corridors are lined with portraits of distinguished past physicians, have been closed without a moment's thought to the cultural consequences. A narrow utilitarianism has reigned.

My wife, also a hospital consultant, works in a district general hospital which is about to be closed down, allegedly for financial reasons, but quite possibly for reasons of the corruption - moral, intellectual and financial - which has undoubtedly seeped in.

Let me move on to describe the almost Kafkaesque atmosphere in which doctors in particular now have to work in the NHS. We most of us feel, like Joseph K, that someone must have been telling lies about us. At any rate, the need to justify our every act, as if we were under a nameless accusation, has become oppressive.

I am not arguing for complete impunity or for absolute power for doctors. But there comes a time when people have to be left alone to get on with things as best they can. Trust is a necessary condition of high morale, and if no one - however senior or eminent - is trusted, then morale collapses.

There is a mania for information-gathering in the present-day NHS which reminds me of the operation of the Securitate in Romania - which I visited - in the last days of Ceausescu. The gathering of information is not carried out so that relevant facts will be known - every telephone in Romania was said to be tapped, and far too much information was gathered for even the large numbers of security men to analyse - but to intimidate and emasculate.

While on the subject of Big Brother, I should like to add that a truly Stalinist school of statistical manipulation is developing in the Health Service in response to centralised targets laid down by the Government. For example, every patient who arrives in casualty should be seen within five minutes of arrival. Presumably the authors of this diktat meant that patients should have some kind of medical attention within five minutes, but in fact they receive only bureaucratic attention, so that the target merely appears to be fulfilled. Do not take at face value any statistic concerning the Health Service.

I think pay is not a very important factor in boosting morale, at least in present circumstances. I have rarely heard doctors complain about their pay. I don't mind working more hours for the NHS than I'm paid to work (as I in fact do, along with many colleagues), but I shall certainly mind if I constantly have to prove, by means of filling in forms, that I am working hard.

Where bureaucracy thrives, morale is always low. I admit I am not sanguine about the future since, in my lifetime at least, all attempts to decrease bureaucracy have increased it. I confess to being one of the majority of hospital consultants who would retire if he could.