Dr Phil Hammond, broadcaster and GP returner in Bristol

If you have the power, are you using it responsibly?

The central ethical problem in medicine is the responsible use of power.

So said Howard Brody,1 Professor of family practice in Michigan, USA, and I happen to agree. Indeed, you could argue that the central ethical problem in life is the responsible use of power. Perhaps Tony Blair might ponder this in his retirement.

Sticking with medicine, however, this could provide us with a great opportunity to improve our health service. All we have to do is track down those with the power, and then make sure they are using it responsibly. What could be simpler?

After weeks of trying, I can now admit to falling at the first hurdle. I cannot find anyone who will admit to holding the reigns of power in the NHS. Go to the Department of Health and they will tell you the Treasury calls the shots. Go to the Treasury and they will tell you it's the responsibility of No. 10 Downing Street. Go to No. 10 and they will refuse to open the door! However, if you really push them for an answer, a nameless press officer will issue a statement saying that it is a cartel of greedy doctors who run the show and prevent reform. Ask the doctors and we return full circle to the bureaucrats, with a minor diversion for negligence lawyers.

It seems, whoever you ask, power is always 'over the next hill'. So who is telling the truth?

Under current stewardship, the accusation is that political power has been in the hands of a coterie of loyal apostles. But the problem with control from the centre is that it is very hard to predict what effect it will have on the front line. On the rare occasion that a good idea comes out of Downing Street, it can be reduced to anything but, once it has been sieved by countless departments, committees, and civil servants.

Politicians can still lead us into wars without much in the way of consultation and against the wishes of the public majority, but no party has been able to do much about the NHS other than continuously reform it, for no reason, and then watch all that money disappear into a big, black hole.

Patients remain loyal to the notion of the NHS not because politicians tell them they should, but because their day-to-day experiences with healthcare staff are largely positive. Healthcare has always been more about performance art than performance management, with most of the power coming from the therapeutic relationship between healthcare staff and patients. Some call it 'placebo', but I prefer 'the human effect'. It has always been and will always be at the centre of everything we do.

If you agree with me, then it is healthcare staff who hold the aces and who should concentrate most on using this power wisely. However, the human effect relies on continuity as much as anything—no patient wants to keep telling the same story to lots of different people. He or she wants to continue seeing the few people they know and trust to guide them through the idiocies of 'Choose and Book'.

The Government's misguided attempt to auction off the NHS to any plc who wants a piece could represent disaster for this continuity. If as a patient you end up going to five different clinics for your five different conditions, no-one has a handle on you as a person. With the demise of continuity goes the doctor's placebo effect. So, make the most of your power while you still have some, and fight for continuity.

1. Brody H. The Healer’s Power. Yale, University Press, reissue 1993.


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