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PRACTISING DOCTORS SHOULD NOT MANAGE
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National Health Service PRACTISING DOCTORS SHOULD NOT MANAGE
respond, leaving a minority to have treatment B. Thus, the respond to treatment A were denied the B because A was cheaper; they had an treatment superior and suffered longer for the sake extra treatment unnecessary of the majority-ie, the treatment was linked to the majority’s 20% who did not
not to
A. D. B. CHANT
the individual’s needs.
If clinicians do
Royal South Hants Hospital, Graham Road, Southampton SO9 4PE I HESITATE to say it (but I think it must be said); practising doctors should not be managers. I realise that this statement does not accord with the "modern" view of clinical responsibility’ and also that much of what I say has been said by the "utilitarians" before me, but I believe strongly that the ethics of our profession are being seriously undermined by the efforts of successive Governments to make the British National Health Service work at the expense of individual patients. The ethical dilemma concerns what is best for an individual patient against what is good for all patients. My present interest was sparked off by an overheard comment from a (senior) junior hospital doctor. "I do not think we should give that drug to Mr X. It is very expensive and I do not, on balance, think it will work."
Starting with the choice of treatment, the doctor takes many factors into consideration. Clearly, the appropriateness of the drug, the dose, the means of giving it, and patient tolerance- all play their parts in establishing whether the choice was correct. Fortunately, in most instances (eg, an aspirin for a headache), this is the end of the matter. However, in Mr X’s case the consequences (in this case, financial cost) to society are also being taken into account. With proven treatment the most important factor is the dose-response relation, whereas with a newer treatment the cost-benefit ratio is more important. Unless the patient responds at a low cost the chances of the treatment continuing are low. Again in Mr X’s case, the fact that the dose-response curve also made a good response unlikely finally sealed his chances of obtaining that particular type of treatment. Conversely, of course, had the doctor known that the proposed treatment would definitely work-as, for example, in cases requiring haemodialysisbut, because oflack offunds, he had to deny the treatment, his relationship with the patient would have been even more wretched. Sensing this moral dilemma leads me on to a second point-should that doctor have been put in this situation? I believe not; and further moves to involve practising doctors in managerial decisions will only make matters worse. Traditionally, doctors have nurtured their clinical freedom, but when have they ever had total freedom? Certainly, when doctors’ services were on a fee for service basis they could never have prescribed any treatment, however expensive, since besides the finances their freedom was curtailed by the patients’ and relatives’ wishes, and also by peer review. Clinical freedom seems to have become sacred only when the NHS first allowed all doctors to prescribe practically anything. The main constraint on our clinical freedom is still to do the best for our patient. If doctors
take financial decisions, who should? "Surely," it is argued, "it is better that trained people should take these decisions rather than ignorant lay people." I think leaving it to those who are medically trained does not always give the correct answer, certainly not in ethical terms. Within the past 10 years, for example, it has been argued that in the treatment ofa certain disease it is reasonable to give treatment A to all patients in the first instance, since the majority would are not to
have true total clinical freedom, have responsibility to individual patients, but have a financial impact on society, is it consistent to ask them to be managers? I believe it is not, but there are ways out of this dilemma, some of them radical. 2,3 First, the Department of Health and Social Security should strengthen its resolve to manage the NHS more effectively, and second the principle that doctors treat patients and advise administrators about the types of, and trends in, medical care should be clarified. Encouraging signs from the DHSS are the managing director idea proposed in the Griffiths report, the profession’s dealings with the pharmaceutical industry (eg, generic prescribing), and clinical freedom being viewed as a freedom to conduct ethically controlled trials rather than a freedom to spend willy-nilly. However, it is "at the local level", quoting Norman Fowler, Secretary of State for Social Services, and the Griffiths report, "that clinicians determine and direct the use of almost all resources". This seems to be the mainstay of the argument for clinicians in management. Again, I think there is an alternative; certainly at district level a clarification of what we are all meant to be doing would not come amiss. Local medical committees (despite misnomers such as Medical Executive Committee) are essentially advisory, and they should advise on the medical consequences of administrative decisions; if well served with facts by administrators, they could contribute more constructively to improving the environment in which clinicians operate so that the financial decisions are separated from the immediate clinical decision. However, if practising doctors become the managers, as has tended to happen in consensus management, objectivity is immediately undermined; the doctormanager is at the beck and call of two masters-his patients and the rest of the patients in the district. not
The way out of this dilemma, I believe, is to allow doctors who have had clinical experience and are motivated to move into administration to do so and cut their clinical ties altogether. Thus, the burden of financial and moral responsibility is shifted from the individual doctor and his patient to the medical profession and society at large, where it truly lies. If society spends on other areas of government more than we earn, we cannot reasonably expect individual doctors to bail us out by denying individual patients proper treatment. There are many examples of doctors successfully leaving clinical practice for administration, not the least the present Chief Medical Officer. The spectre of the Medical Superintendent will always be paraded, but I think this antiauthoritarian society with its inbuilt checks and rapid change should be able to contend with the odd dictator! If, however, the present practising doctor-manager ideas are pressed, I fear many of us who should be primarily concerned with our will find our energies dissipated in reallocation disputes with our colleagues for which we have little knowledge, minimum training, and little stomach.
patients’ wellbeing resource
REFERENCES 1. Griffiths Report. NHS Management Inquiry. See Lancet 1983; ii: 1093-94. 2. Illich I. Medical nemesis: the expropriation of health. London: Boyars, 1975.
3. Chant ADB. Stem Doctor
melting pot. Health Soc Serv J 1982 (Dec 9),
1462-64.
National Health Service PRACTISING DOCTORS SHOULD NOT MANAGE
respond, leaving a minority to have treatment B. Thus, the respond to treatment A were denied the B because A was cheaper; they had an treatment superior and suffered longer for the sake extra treatment unnecessary of the majority-ie, the treatment was linked to the majority’s 20% who did not
not to
A. D. B. CHANT
the individual’s needs.
If clinicians do
Royal South Hants Hospital, Graham Road, Southampton SO9 4PE I HESITATE to say it (but I think it must be said); practising doctors should not be managers. I realise that this statement does not accord with the "modern" view of clinical responsibility’ and also that much of what I say has been said by the "utilitarians" before me, but I believe strongly that the ethics of our profession are being seriously undermined by the efforts of successive Governments to make the British National Health Service work at the expense of individual patients. The ethical dilemma concerns what is best for an individual patient against what is good for all patients. My present interest was sparked off by an overheard comment from a (senior) junior hospital doctor. "I do not think we should give that drug to Mr X. It is very expensive and I do not, on balance, think it will work."
Starting with the choice of treatment, the doctor takes many factors into consideration. Clearly, the appropriateness of the drug, the dose, the means of giving it, and patient tolerance- all play their parts in establishing whether the choice was correct. Fortunately, in most instances (eg, an aspirin for a headache), this is the end of the matter. However, in Mr X’s case the consequences (in this case, financial cost) to society are also being taken into account. With proven treatment the most important factor is the dose-response relation, whereas with a newer treatment the cost-benefit ratio is more important. Unless the patient responds at a low cost the chances of the treatment continuing are low. Again in Mr X’s case, the fact that the dose-response curve also made a good response unlikely finally sealed his chances of obtaining that particular type of treatment. Conversely, of course, had the doctor known that the proposed treatment would definitely work-as, for example, in cases requiring haemodialysisbut, because oflack offunds, he had to deny the treatment, his relationship with the patient would have been even more wretched. Sensing this moral dilemma leads me on to a second point-should that doctor have been put in this situation? I believe not; and further moves to involve practising doctors in managerial decisions will only make matters worse. Traditionally, doctors have nurtured their clinical freedom, but when have they ever had total freedom? Certainly, when doctors’ services were on a fee for service basis they could never have prescribed any treatment, however expensive, since besides the finances their freedom was curtailed by the patients’ and relatives’ wishes, and also by peer review. Clinical freedom seems to have become sacred only when the NHS first allowed all doctors to prescribe practically anything. The main constraint on our clinical freedom is still to do the best for our patient. If doctors
take financial decisions, who should? "Surely," it is argued, "it is better that trained people should take these decisions rather than ignorant lay people." I think leaving it to those who are medically trained does not always give the correct answer, certainly not in ethical terms. Within the past 10 years, for example, it has been argued that in the treatment ofa certain disease it is reasonable to give treatment A to all patients in the first instance, since the majority would are not to
have true total clinical freedom, have responsibility to individual patients, but have a financial impact on society, is it consistent to ask them to be managers? I believe it is not, but there are ways out of this dilemma, some of them radical. 2,3 First, the Department of Health and Social Security should strengthen its resolve to manage the NHS more effectively, and second the principle that doctors treat patients and advise administrators about the types of, and trends in, medical care should be clarified. Encouraging signs from the DHSS are the managing director idea proposed in the Griffiths report, the profession’s dealings with the pharmaceutical industry (eg, generic prescribing), and clinical freedom being viewed as a freedom to conduct ethically controlled trials rather than a freedom to spend willy-nilly. However, it is "at the local level", quoting Norman Fowler, Secretary of State for Social Services, and the Griffiths report, "that clinicians determine and direct the use of almost all resources". This seems to be the mainstay of the argument for clinicians in management. Again, I think there is an alternative; certainly at district level a clarification of what we are all meant to be doing would not come amiss. Local medical committees (despite misnomers such as Medical Executive Committee) are essentially advisory, and they should advise on the medical consequences of administrative decisions; if well served with facts by administrators, they could contribute more constructively to improving the environment in which clinicians operate so that the financial decisions are separated from the immediate clinical decision. However, if practising doctors become the managers, as has tended to happen in consensus management, objectivity is immediately undermined; the doctormanager is at the beck and call of two masters-his patients and the rest of the patients in the district. not
The way out of this dilemma, I believe, is to allow doctors who have had clinical experience and are motivated to move into administration to do so and cut their clinical ties altogether. Thus, the burden of financial and moral responsibility is shifted from the individual doctor and his patient to the medical profession and society at large, where it truly lies. If society spends on other areas of government more than we earn, we cannot reasonably expect individual doctors to bail us out by denying individual patients proper treatment. There are many examples of doctors successfully leaving clinical practice for administration, not the least the present Chief Medical Officer. The spectre of the Medical Superintendent will always be paraded, but I think this antiauthoritarian society with its inbuilt checks and rapid change should be able to contend with the odd dictator! If, however, the present practising doctor-manager ideas are pressed, I fear many of us who should be primarily concerned with our will find our energies dissipated in reallocation disputes with our colleagues for which we have little knowledge, minimum training, and little stomach.
patients’ wellbeing resource
REFERENCES 1. Griffiths Report. NHS Management Inquiry. See Lancet 1983; ii: 1093-94. 2. Illich I. Medical nemesis: the expropriation of health. London: Boyars, 1975.
3. Chant ADB. Stem Doctor
melting pot. Health Soc Serv J 1982 (Dec 9),
1462-64.