The Changing Relationship between the Public and the Medical Profession
Authors: Donald Irvine
Journal: Journal of the Royal Society of Medicine (2001)

I started medical school in 1953, almost 50 years ago. The new National Health Service (NHS) was just getting underway, and its founding principle—all citizens should enjoy good medical and health care free at the time of need and irrespective of their ability to pay—had caught the public imagination and the professional idealism of many doctors.

Now, 50 years on, we have a crisis in the NHS and we need to understand why. There are two main issues. There are deep-seated flaws in the culture and regulation of the medical profession and serious deficiencies in the management and capacity of the NHS1,2.

The cultural flaws in the medical profession show up, in individual cases, as excessive paternalism, lack of respect for patients and their right to make decisions about their care, and secrecy and complacency about poor practice. These all contribute to a picture which leads the public to believe that many doctors put their own interests before those of their patients3.

The deficiencies in the management and capacity of the NHS have their outward visible signs in the lack of institutional attention to quality and safety—in unacceptable waiting times for treatment, medical and non-medical care of indifferent or poor quality, dirty hospitals, inflexible systems, defensive complaints procedures and so on. There is a serious shortage of doctors. No wonder there is general anxiety about whether the NHS can deliver a service of acceptable quality.

These concerns are shared fully by doctors. I cannot remember a time when so many doctors have felt so angry, undervalued and disillusioned. Public and government criticism of the profession, together with fears of litigation, have added to the demoralizing effect of the treadmill4 — the relentlessly rising volume of service demands that leaves no proper time for establishing effective relationships with patients or for reflective practice review, both of which are fundamental to good quality.

The General Medical Council (GMC) has been rightly criticized for failings that are of its own making, and has acted as a lightning conductor for more general criticisms of doctors' attitudes. Less justifiably, it has been used as a proxy for some of the underlying institutional failings in the NHS. The `blame game' is unhelpful, as is the present tendency to seek simple solutions to complex problems. A recent example was the Government's inappropriate linkage of the new National Clinical Assessment Authority with the detection of murder—the Shipman case.

So we have wholesale change again, as the Government, managers and the health professions get to grips with the situation. Such is the plethora of new proposals that many doctors and the public have difficulty making sense of it all.

Here I deal with two issues that are fundamental to the way forward. These are:



The need to implement the culture and practice of continuous quality improvement and quality assurance across our healthcare system


The professionalism of doctors—their attitudes and regulation, and how these must change to meet the public's expectations today.






Things do not happen in isolation, so let me begin with the background.