Who is in charge 2: Specialist or GP?

Forget the reform; the GPs are certainly in charge, which makes a change from the old-fashioned view expressed in the 1950s by Lord Moran that GPs were doctors who had fallen off the hospital ladder. In those days most hospital services were planned by hospital consultants and directors of public health. When I started my consultant career the Medical Staff Committee made decisions and expected the administrators to implement them. Now the managers make decisions and expect the consultants to do as they are told. Meanwhile the GPs, who ordered secondary care as required for each patient, are on the one hand saying that they can do a lot of what was deemed specialist care themselves (which may be partly true) while on the other introducing referral management mechanisms that impede hospital referral, largely cloaked under targets. While hospitals depend on the work they receive from general practice, general practice is limiting work – which will inevitably lead to major financial problems for the hospitals.

I am concerned that the powerful consultant voice has been silenced, and it has. Although there are mutterings in hospitals about the problems of the way forward, objectives have been hijacked by managers and those clinicians who have crossed to the dark side pay lip service to general consultation. The role of the MSC has been neutered; consultants work harder and harder to keep the hamster wheel turning and have no time to discuss things with each other, as well as no forum. Indeed I liken many to sheep, unlike the goats of a previous age.

This problem is new, and I date it to a specific event – the closure of “Hospital Doctor”, a weekly newspaper full of country-wide views, opinions and comment. It died when taken over by a new company which saw its financial security undermined by restrictions on pharmaceutical advertising (partly a response to the inability of such advertising to influence hospital staff tied to formularies). I declare an interest; I wrote for it often, and was reported by it more often. But it was a national forum; it encouraged competition (it ran a highly successful specialty Team of the Year competition), whistleblowing, and uprising against authority. Its death was a disaster; revolution and dissent are made very difficult if communication is disrupted, as the Iranian and Libyan people found when their internet access and phone networks were shut down in 2009 and 2011. The BMA’s weekly newsletter has more about working conditions in Northern Ireland and Wales than about consultant working in England. On the other hand “Pulse”, which is a similar journal aimed at GPs, is flourishing and its power is obvious. It is treated with respect from without; one of my emailed rapid responses to a “Pulse” article was quoted by a national journalist. It seems crazy that the whole hospital service can be suddenly disadvantaged by an event totally outside its control, but it happened, and I cannot see a way back without recreating “Hospital Doctor” – at great and probably unaffordable expense. Were I to win the Euromillions lottery I would consider it.

From a clinical perspective, despite the gradual erosion of power of the hospital specialists they are increasingly becoming the first port of call for patients with long-term disease.

Patricia (not her real name) is on methotrexate for her rheumatoid arthritis. It’s convenient for her to come to the cottage hospital for her bloods (to which results her GP has access. One came back showing a typical iron-deficient picture. My secretary had a phone call to tell us this and ask us to sort it out.

If we are supposed to discharge all our patients after two appointments who will look after them? I have noted this before (see the new:follow-up bit). Some GPs have neither the time nor inclination to embark on yet more long-term disease management for which they are not trained. They won’t look at bloods; they sometimes won’t prescribe; they ask constantly for advice; they won’t manage acute flares. We provide a responsive service which meets their needs. Why fix it if it isn’t broken (except for the money thing, and there’s a way out of that).

Despite much huffing and puffing on the sanctity of whistleblowers there has, in parts of the NHS, been a fairly ruthless suppression of dissent. I was threatened with disciplinary action when quoted in the local press expressing a view considered to be contrary to my hospital’s policy, and subsequently ignored when I raised some serious matters of concern over a directive that would severely curtail my ability to prescribe (the GMC supported my contention that the directive was unacceptable, but the Trust took no notice when I sent it the GMC opinion). I have seen overt and crude threats made against colleagues. When medical managers have made decisions about specialist services without consulting the relevant specialists it seems reasonable to me that these latter should protest, but on doing so one was told they would be removed from their clinical lead position if they continued to make a fuss.

Such suppression has echoes from the past.

“The former social order was reversed. The “nobodies” of yesterday became the “big shots” of today. The former scum and dregs of society, such as ex-convicts, gentleman-crooks, swindlers and well-known failures became the new elite, riding high in official favour and power.”[1]

“German and Japanese carpetbaggers who had achieved little status or respect in their own societies became proconsuls in their nations’ new possessions” continued Max Hastings in his masterful account of the Second World War – and later, talking about the beginnings of Hitler’s Final Solution for the Jews he writes “It was hard for victims, accustomed to lives in ordered communities, to grasp the implications of their absolute impotence.”[2]

This is where the hospital doctors are today. Those Jews who foresaw their potential fate, and got out, were the lucky ones; those who could not conceive that such things were possible in a “civilised” society, and stayed on, reaped the whirlwind. My advice to hospital doctors with any sense of duty and morality is either to resist (and, like me, face isolation – or punishment or a coronary) or get out.

[1] Chin Kee On, a Chinese Malayan citizen, writing on the Japanese occupation in “Malaya Upside Down, Singapore, 1946, p.190. Quoted by Max Hastings in “All Hell Let Loose: London, Harper Press, 2011, p.499. Christina Lamb, a foreign correspondent, comments on a similar process in Afghanistan (“Small Wars Permitting”, HarperCollins, 2008)

[2] Ibid, pp 500-1. Frank Binder’s novel “Sown with Corn” (Farthings Publishing, 2010) describes his own experience in Germany at the beginning of the rise of the Nazis in identical terms. As Christian Wolmar puts it in his review in “The Oldie” (which prompted me to buy the book) “Hitherto insignificant local people, disaffected plumbers and penurious school teachers suddenly appear wearing a uniform and exercising power over their neighbours.”

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