Constant concern about the state of the NHS is wearing. In the background, there is a danger of unwittingly creating a sort of public nihilism, a belief that all is irredeemably lost. I am particularly concerned about deterring the young from entering medicine, and more especially psychiatry. The current crisis is real, but the medical well is not poisoned. There are still reasons for optimism. We should acknowledge this from time to time.
I have just had a particularly enjoyable weekend. On Friday, I went to Telford’s Warehouse in Chester, where the splendid Chupa Cabra had a launch gig for their second single Mouths To Feed. Notwithstanding that a few months ago I wrote that rock music was “mined out”, it was really uplifting to hear a group of musicians just out of their teens unselfconsciously play witty, obnoxious, high energy garage rock to an appreciative audience. It is hard to lose hope while the young continue to do this sort of thing.
Saturday was a completely different sort of gig altogether. It was in a barn out in the Clwydian Hills. I played support to the Suitcase Dwellers. At the end of the evening, we did a short set together. We have played joint gigs before. We are playing a Music Train gig in a few weeks. I have no idea why the combination works, but it does.
I mentioned to someone in the barn that I am a psychiatrist, and it turned out that her son is a medical student who is seriously thinking about a career in psychiatry. It was a random encounter, but it pleased me a lot because it reminded me that medical students still get inspired and still find psychiatry exciting.
Despite everything, I enjoy my work. I could retire, but I choose not to. I am stretched intellectually and emotionally by what I do. Patients recover, and it is fantastic to be part of it. My attachment to the core values of medicine is deep-seated. Even now, I find it difficult to leave work earlier than six p.m., although no one expects me to linger after five. It is driven by an anachronistic inner imperative to be available, should other staff need me. I think that this implicit awareness of medical values is true of a large proportion of the profession, irrespective of age. Medical values give a central role to patient and public benefit, to scientific evidence and to personal integrity. Naturally enough, we all struggle from time to time to meet these high demands, but most of us do hold to them as aspirations.
To me, the current struggle by doctors to preserve the health service is evidence of the salience of these values. Wholesale privatisation in the face of a medical labour shortage would be bound to increase doctors’ incomes, so financial self-interest for doctors would mean dismantling the NHS, not defending it. Generally speaking, people become doctors because it is a worthwhile way of spending your life. We should not let our cynicism dismiss the extent to which people are attracted to the prospect of using their abilities to preserve life and to relieve suffering. There are less demanding ways of generating a comfortable income when you have high qualifications and capabilities, as the majority of doctors do. Despite its challenges, I cannot think of a job that could be more engaging. Admittedly, not everyone thinks so. I had a friend who became a senior banker. He could not understand why anyone would choose to help people rather than make ‘serious money’. The friendship did not survive.
In the Soviet Union, doctors earned two thirds of the average industrial wage. Soviet ethics determined that doctors owed their first allegiance to the proletariat (represented by the Soviet state), not the patient. Nonetheless, the social construct of ‘doctor’ and underlying medical values were not eliminated, even if they were severely undermined at times. For example, Dr Anatoly Koryagin was a Russian psychiatrist who did more than anyone else to expose Soviet political abuse of psychiatry. He did this in the knowledge that he was likely to experience the full repressive force of the Soviet state, as he did in due course. Amongst other things, he was sentenced to seven years of hard labour for anti-Soviet activity (read this contemporaneous letter about him from the BMJ).
I was lucky enough to be the trainee representative on the Royal College of Psychiatrists Special Committee on the abuse of psychiatry when he came and met with them after his release and exile in 1987. I have known several doctors who have shown amazing courage in resisting state power. Like them, what was striking about Dr Koryagin was that he was a doctor with a very similar set of values to the rest of us. These were unaltered by growing up and training in the peculiar moral environment of the Soviet Union. What makes these doctors stand out is their willingness to uncompromisingly live by those values.
Even in good times, the lifestyle of the average doctor is not easy. I never learned to relax when on call, despite doing it for more than thirty years of my life. Awoken at three a.m., I could never get back to sleep. A difficult lifestyle is the price you pay for doing something that matters. All doctors understand this. It is one of the factors that generate so much anger over Mr Hunt’s forced introduction of a contract that will turn a difficult lifestyle into an impossible lifestyle, especially for some women.
We cannot ignore growing evidence that in NHS England, the previously unthinkable has become routine. Medical and other staff cannot be recruited at any price and gaps in medical rotas are left unfilled. Medical Royal Colleges are making calm but clear warnings about the situation. These are not organisations that are prone to histrionic statements. There is definitely a big problem. Nonetheless, I do not believe that the current crisis will break that which is strong about medicine. If Marxism-Leninism could not destroy the values of medicine over seven decades, I am certain that the moribund doctrine of economic neo-liberalism will also fail.
Times are difficult, but I do not discourage young people from coming into medicine and psychiatry. These dark days will pass. As a profession, we will always need some of what Chupa Cabra have, the restless energy of youth. We need young doctors who are willing to challenge the likes of me. We have to resist damaging and inappropriate change, but we need young doctors to champion healthy, and sometimes radical, change. It is usually young doctors who can tell the difference between the two. We need them to expose the myth of a lost golden age. It takes youth to recognise that beneath the paving stones, there is a beach.