Personal views: Has humanity disappeared from the NHS?
Authors: Anthony Toft
Journal: BMJ (2000)

It was Monday 27 December 1999, when I was the first on-call physician for the acute medical admissions unit at the Royal Infirmary of Edinburgh; it was to be the busiest day of the year.


There were heroic efforts from many staff in containing what seemed to be a tidal wave of patients—most of whom were seriously ill. Paradoxically, I enjoyed the 24 hour period, unencumbered by the usual other clinical commitments. It was like the “good old days” when doctors and nurses worked together rather than in parallel. 


I sense a climate of fear in the NHS, preventing the admission of inadequacies in the service



The next day there was a sense of elation: every patient was in a bed. But as I visited the new patients scattered throughout the hospital it became clear that many had not been clerked, many were not in appropriate beds, many had been moved on more than one occasion, and some of that boarding had been instigated by bed managers against medical advice.

My experience was not unique, but what made that Christmas period so memorable was the collective failure of management to recognise or, perhaps more accurately, to admit that the NHS was in difficulties. It was the behaviour of directors, trying to defend the share price of their company ahead of the publication of poor results. Not only did such a stance undermine the efforts of the clinical staff, but it also concealed the true state of affairs from the public.

I sense a climate of fear in the NHS, preventing the admission of inadequacies in the service lest it is interpreted as personal failure with serious career consequences. And that fear has infiltrated beyond administrators. Journalists are frustrated by the “don't quote me” revelations of hospital doctors who are concerned about their financial promotion. There is just a danger that they will lose the independence which characterised doctors in the past—at times counterproductive to progress, perhaps, but a guarantee that patients had effective advocates.

It was Aldous Huxley who said that fear “casts out intelligence, casts out goodness, casts out all thought of truth . . . in the end fear casts out even a man's humanity.”

How else, other than in terms of loss of humanity, can you begin to explain how we have come to accept, as the norm, mixed sex wards, with the delirious drunk adjacent to the elderly spinster in cardiac failure, her life ebbing away; boarding of patients in the middle of the night and possibly on several occasions during a hospital stay; and the inappropriate early discharge to relatives ill prepared to cope?

There would, however, seem to be some good news. The secretary of state for health has admitted that the reduction in hospital beds, at least in England, has been excessive. But what if, as is likely, there is a disparate perception held by doctors and managers of what is an adequate number of beds, and occupancy figures are nearer 100% than the ideal of 85%? It will be unfortunate not only for patients who will continue to endure all that is unsatisfactory with the present provision of health care, but also for medicine as a whole because of the intolerable burden of working at, or near to, full capacity throughout the year.

And what is the cost of this frenetic activity? Doctors will be increasingly forced to cut corners with the inevitable rise in cases of medical negligence. They will not have the time to attend the lunch time clinical meeting regularly, will give this year's specialist conference a miss, will fail to engage in research and audit, and their medical journals will remain unopened.

It is not that doctors are workshy, but they are frustrated that the system does not seem to recognise that time is necessary to reflect on your activities if a high standard of care is to be delivered. There is an increasing anger that they have become the whipping boys for the failure of an inadequately resourced service.

At such times doctors look to the medical royal colleges and the General Medical Council for guidance in trying to maintain a decent standard of clinical practice. However, these potential saviours are on the back foot, greatly exercised by how to counter the seemingly endless criticism of the medical profession. It is all very well to proclaim the merits of revalidation and of clinical governance, but most practising clinicians have little confidence that either of these projects, as yet unfunded and somewhat ill defined, will improve the lot of the patient, or indeed maintain confidence in the profession.

And these independent and potentially powerful bodies have been quiet, at least in public, over the issue of resources. Surely they, too, cannot have become as fearful as the individual doctor or manager of pointing out what has been glaringly obvious to anyone who has needed to be in hospital recently. There is within medicine an enormous talent and within management genuine commitment to the NHS. Think how much better the service could be if fear of failure and of sticking your head above the parapet were to be swept away and intelligence, goodness, truth, and humanity allowed to flourish.