Book of the Month: The Autonomous Patient: Ending Paternalism in Medical Care
Authors: Julian Tudor Hart
Journal: Journal of the Royal Society of Medicine (2002)

Angela Coulter's The Autonomous Patient1 is the sort of lucid, well argued, readable and important book we expect from her. But it is only the first half of what it could be. The work develops her John Fry lecture of 2002, following a pattern remarkably like that established by the late John Fry himself. Both recognize the essential components of rational National Health Service primary care within the dominant assumptions of contemporary society; they isolate the many irrational customs impeding effective work, and then focus on what can most easily be done to clear the decks. They ignore everything outside currently dominant assumptions, confining their work to expelling old irrationalities, without considering possible new ones. The big difference between them is that, whereas it probably never occurred to John Fry that his own common sense might contain some internal contradictions, Angela Coulter seems to have decided to clear out the past without posing choices for the future.

What are these currently dominant assumptions? One of them is that personal medical care follows essentially the same economic pattern as other services—skilled professional providers transferring a service commodity to consumers wanting it. To fit known facts, this first assumption has to be modified in many ways. Angela Coulter discusses these fully and interestingly, but it remains her bedrock assumption. Once made, it leads to a simple and useful historical analysis: in the past, the rights of consumers in this transaction were smothered by the paternal authority of professional providers. If this can be stripped away, consumers become kings and queens in medical care, as everywhere else in the global marketplace. Kings and queens are certainly great consumers, but what do they produce? Is it really asking too much of people to take themselves seriously as citizens, rather than kitsch royalty? Angela drops a nod to the notion of patients as co-producers, but only in the extremely limited sense of consumers acting more intelligently in their own personal interest. Her message is consumerism.

I said her historical analysis was useful. Useful to what? Not to eliminating already vanishing independent professional trade but to accelerating corporate provision of public services as the fastest-growing new field for multinational investment. She quietly accepts that There Is No Alternative. My mind goes back to the early 1990s, when Kenneth Clarke made it clear that the special relationship between top doctors and government was dead; politicians no longer feared doctors. In 1994, to set limits to their loss of authority, courtiers from the BMA and Royal Colleges held a summit meeting on core values in the NHS. Sir Maurice Shock, former Rector of Lincoln College in Oxford, opened the conference. The BMJ reported this key passage:


‘British doctors were unprepared for the Blitzkrieg from the Right whcih overwhelmed them at the end of the 1980s... They seemed to imagine that they were still living in Gladstone's world of minimal government, benign self-regulation, and a self-effacing State.... [now] instead of the rights of man we have the rights of the consumer, the social contract has given way to the sales contract, and, above all, the electorate has been fed with political promises... about rising standards of living and levels of public service... Doctors cannot swim against the tide and must recognise that this is an age of regulated capitalism in which the consumer is courted and protected, encouraged to be autocratic, and persuaded of his or her power... Doctors must be willing to get their hands dirty with making decisions on allocation of resources, must speak authoritatively and sensibly to the consumer... If [doctors] organised themselves in these ways the government would have to work with doctors, because a Blitzkrieg can conquer, but cannot occupy.’2


Sir Maurice's choice of metaphor reveals extraordinary indifference to the lessons of history. Blitzkrieg did indeed conquer, and with active support from the political and corporate establishments it occupied all Europe for four years. The price of their cowardice was the disgrace and exclusion of an entire generation of right-wing politicians and industrialists from direct political dialogue for the next forty years. For the people it meant four years of degradation, and it could have sent the whole world back to mystic barbarism. However, Sir Maurice carried his audience, and their consensual armistice set the context within which we now live and work, and the prevailing assumptions.

Angela Coulter does a good and necessary job of rubbishing paternalism, and introduces many interesting indications of how patients can become more actively engaged in decisions about their care. These references will be useful not just to dig the grave of paternalism, but to start building something new and better. But before burying it, we need to look carefully at what we might lose, if we accept the consumer-driven NHS now on offer from both Alan Milburn, for New Labour, and shadow minister Liam Fox for the Conservatives.

For thirty years I actually practised paternalism. Having no choice but to own what should have been public property, I did what I thought was best for my patients and for our community. It was a despotism in which I tried to be enlightened. I employed about twice the average number of staff; we held regular whole-team meetings to consider clinical policies; patients had access to their records and listened to referral letters as they were dictated; and we had an elected patients' committee which considered proposals for research and teaching. But all this was conditional on my continued assent. I hired and fired and initiated almost all policies, including these steps toward democratization. A real phoney if ever there was one, but better than running a little business to maximize my own income.

That was the down side. What about positive features? Like other general practitioners before the 1990s, I visited my patients often enough in their homes to be well informed about their lives on their own turf, not mine, I always saw patients on the same day as their initial complaint. I tried as often as possible to visit them when they were in hospital, and to attend their post-mortems (not funerals) when they died. I see no indication that features of this sort are included in the menus now offered to consumers. Our GPs for the most part seem reconciled to the entirely office-based care long familiar in USA.

Medical practice is not at a crossroads. That would be easy; just watch where everyone else goes and follow straight down the middle of the road, turning neither Right nor Left to extremes. No, we have reached a fork in the road. There is an alternative, so far without any media-recognized signpost—a rough track, with no free rides, towards an NHS pursuing rational goals set by public health, with patients developing themselves as informed and responsible citizens with our professional assistance. Something along these lines may be beginning to happen in Wales since we had an elected Assembly with independent powers over NHS policy (though not over Treasury policy). Fortunately this has been beneath the notice of London newspapers, so Government remains hardly aware of this danger that a socialized NHS may survive and even grow within the cracks of UK Inc. Given informed leadership, there's plenty of potential support for this in both public and professional opinion; but I really mean public opinion, not the consumer greed and credulity attributed to the public by newspaper editors (tabloid or broadsheet, there's little difference now)—and I really mean professional assistance, a social alliance speaking the European language of solidarity. Or we can carry on down the road to marketed care mapped out by the World Trade Organization General Agreement on Trade in Services, the fantasy land of Alan Milburn where in five years' time every patient will be able to choose their surgeon and the time and place of their operation, inside or outside the NHS (it will make no difference)—despite deficiencies in medical and nursing staff that will take at least a decade to remedy. Market choice depends on superfluous provision. Without an increase in staffing and hospital resources beyond all possibility, this could occur only within a two-tier service, somehow limiting demand from substantial parts of the population. This road leads to unlimited repairs to the body and dopes for the soul, with public health goals wholly replaced by measures of process.

Angela Coulter tells what to get out of, without helping us choose what to get into. The more difficult but necessary second-half has yet to be written, but it's bound to come.