Book of the Month: Friends in Low Places
Authors: Denis Pereira Gray
Journal: Journal of the Royal Society of Medicine (2001)

If you might enjoy some lateral thinking about the modern State, try Friends in Low Places, by James Willis1. In the middle of the book there is a key sentence: a challenge for modern society, he declares, is the proper use of central authority.

Willis, an experienced general practitioner, believes that the State is increasingly controlling public services with a new kind of authoritarianism, in search of a utopia that will not be achieved. He stands up for those in the front line of public services—teachers, nurses, general practitioners—who relate face-to-face with their patients and clients. He believes this is an essentially human process, and that the judgment of front-line professionals is being progressively eroded by a modern management more concerned with models and measurable outcomes than with a caring service. Much of his book is a polemic against management, with its models, rules and timesheets.

Willis considers that management is essentially impersonal and does not relate directly to individuals in need. Instead of evidence-based medicine, which he dislikes for similar reasons, he calls for an understanding-based medicine that takes into account the patient's personality and feelings. He judges that, if professional men and women are deprived of their independence, medicine will lose diversity, flair and richness: loss of independence takes away ‘an essential element of what it means to be a doctor’. The bottom line is trust, an old-fashioned word but still with modern meaning. He contrasts the power and potential of the human mind with the limitations of machines, even modern ones.

Willis's targets, such as the blame culture and the increasing trend towards litigation, are now fashionable, but his central thesis—that ever-increasing control of professionals may have serious adverse effects, particularly in loss of morale—is persuasively argued. His solution is stark and simple: ‘put humanity back at the centre of things’ and accept that human life is not a mathematical equation. Fieldworkers must share uncertainty with their patients. Life cannot be made risk-free and it must be recognized that ‘GPs like other front line workers quietly take risks all the time’. He makes a plea that, just as doctors have had to learn not to prescribe a pill for every ill, so legislators ought not to produce a Bill for every ill.

Friends in Low Places encapsulates wisdom born of experience with real patients, with real problems seen in real time. Willis is right in declaring that the best care for patients will ultimately depend on doctors who know them as people, who care for them as people and who integrate the successes of science into individual care. This care, moreover, must be what the patient understands, has discussed, and feels appropriate. The book is an elegant summary of the case for the experienced professional, a generalist, in the front line of a public service. However, what it does not address is the other side of the coin. Doctors have many privileges, enjoy high status and, in comparison with many occupations, are well paid. They are the most trusted of all occupational groups and have unusually interesting jobs. The matter Willis does not fully face is accountability. The privileges and power of the medical profession stem from Parliament, which through numerous Acts has devolved professional regulation to the General Medical Council. It must also be right that doctors, as key professionals in a modern society, should be accountable to the society they serve. Willis does not mention paediatric cardiac surgery at Bristol or organ removal at Alder Hey. Public enquiries into the Bristol and Alder Hey events have revealed that systems were not in place to protect patients properly. Leaving all power to the professional does not always work. On issues such as consent and explaining risk, there is good evidence that the opinion of some medical professionals has fallen behind what many patients now expect. In a democratic society which has devolved power to the profession through Parliament, and in a National Health Service funded by the State, it is appropriate that power should be properly shared and the State's objectives reasonably considered.

All this demands the wisdom of Solomon and the most subtle balances that can be devised. A pendulum is swinging from almost unbridled freedom for professionals to what may soon become irksome control. Willis must be right that there will be a high price to pay for the latter. His book appears at a time of unprecedented change in the National Health Service, when central institutions such as NICE and CHI in England are in full swing and numerous other controls such as revalidation are on the way. The commitment of an individual doctor to an individual patient or family is Willis's theme, but it needs to be balanced by the collective responsibility of the medical profession to patients in general and to society through Parliament. How those balances are now to be struck is one of the great questions of our time, but all those interested, whatever their perspective, will benefit from reading this radical challenge to current systems.