The true nature of health. An open letter to Harriet Baldwin MP.

Recently I signed a petition urging my MP, Harriet Baldwin, to support the National Health Service(Amended Duties and Powers) Bill I received a reply in which she strongly supported the current NHS reforms, particularly the greater involvement of private providers. She voted against the bill, which was a Private Member’s motion and will probably go nowhere.
This is how I replied:

Dear Harriet Baldwin

Thank you very much for replying to my signing the petition regarding the recent National Health Service (Amended Duties and Powers Bill). I noted that you were one of the only twenty five MPs who voted against the bill. In your letter you set out, in a cogent fashion, the reasons why you see no dangers in the increased involvement of private providers and how more money is going in to, and more operations coming out of the NHS and in this you feel pride at what is being achieved.

I think a major misconception is buried in what you write. In your account the NHS is seen as an efficient (or not so efficient) illness machine, an industrial operation whose effectiveness can be measured by things that can be counted – waiting times, costs, operations carried out and the like. It is pertinent for us to remember the old adage ‘Things that can be counted are not necessarily important and things that are important cannot necessarily be counted.’

In this conception the human individual who is in contact with the Health machine is either ‘client’,’customer’ or, worst of all, ‘consumer’. We all become so-called ‘consumers of health care’ endowed with a selection of spurious and sometimes irrelevant, choices. We become acutely conscious of our ‘rights’ and grumble furiously when we think they are being infringed.

There is another way. It has actually been with us for as long as medicine has been practised but it is rarely talked about. To outline it is to describe how, in practical terms, health care could be organised in a way that differs from the model above and how creeping privatisation is an insidious influence.

That way has to do with the nature of health itself. Health is a state of mind where the human individual feels at one with herself, not necessarily free from problems, disabilities or even pain. Not necessarily expecting to be cured, indeed at times expecting to die. She has come to terms with the deal she has been dealt, she is not letting it get her down. There is life to be lived, life in all its abundance.

So what does the Health Service have to offer her. Obviously, at times, highly scientific and controlled intervention where appropriate – the operation to replace a diseased hip for example – or long term drug therapy that can control a chronic mental condition. But she cannot make the decision as to what intervention might be best for her, or where to get it, without some skilled guidance. It is here that we alight on what could be regarded as the heart of the health service, the general practitioner, a medically-trained and competent individual who is in relationship with his patient. Often this will be a longitudinal relationship that may be spread, albeit sparsely, over many years. This contrasts with the vertical relationship that she might have with a specialist doctor which will last for the short length of time that she is under the care of the latter. That is, of course, quite appropriate.

Add to all this a number – 96%. That is the percentage of all contacts with the NHS that are made with a GP. It is a figure that has changed little over the years and it is all the more surprising when we reflect that in many health care systems in the world there are no GPs at all. It is a huge figure which is almost totally overlooked in debates about our NHS, truly the elephant in the room.

This is not to denigrate the 4% of care that takes place beyond general practice. The fact that so much is done within that figure demonstrates how efficient and effective is that care. Obviously there is some crossover between the two sectors, most Consultants will have relationships with the occasional long-rem patient that could be described as longitudinal but this does not detract from the argument.

And so I come to the crucial point. It is about what doctoring and being a patient is all about. It is expressed in this short statement

‘Health is a value that is created by a doctor and patient working together. ‘

There are some subsidiary clauses to that

  • health cannot be measured but its loss or its increase is always perceived by the patient

  • health is not necessarily dependant on the absence of disease. The dying person can have health

  • this health-creating partnership involves no hierarchy nor exercise of power (by either party). It is two human individuals quietly and privately relating at a deep level.

If we were to accept that this is true (and it is, we just seem to have forgotten it) we would want to place GPs and their patients at the heart of the Health Service, not in the spurious way making them ‘Commissioners’. That is an administrative task which is probably better exercised by a competent manager. No, we should empower, resource the 96% and not burden them with chasing futile targets and the like. Neither should we be doing anything that takes away from the one doctor, one patient structure (as for instance has the change of rules that makes a patient a patient of the practice, not of one doctor in that practice, surely designed to undermine doctor responsibility for any one patient.)

Which brings me to where we disagree. Privatisation. The way that the NHS is going makes, in particular, general practice a ripe target for private providers. It does not require much imagination to see how this could destroy all that is good about the Health Service and which has developed over the past fifty years or so. It would imperil the very activity that I have outlined above. It is inevitable that commercial and business decisions would ease out the personal, humane values that have been part of the health service for so long.

So there it is, two fundamentally different ways of looking at the NHS, yours and mine. I do not suppose I can shift you from your party line but I hope I can make you think. My credentials for all this are that I worked as a GP and a teacher in general practice for twenty-five years up to 1997. These are matters that I have thought about for decades.

With all good wishes

Andrew Chapman

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About Andrew Chapman

Worked for 25 years as a doctor in rural England. For the last 15 years has been a writer and composer.
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