A terrible way to treat our doctors
By Martin Wolf
Published: September 7 2007 03:00 Last updated: September 7 2007 03:00
"Modernising Medical Careers" is a suitably Orwellian name for a Stalinist new system for training doctors in the National Health Service.
The phrase is a perfect example of newspeak. To oppose a "modern" system is to be a conservative, if
not a reactionary. Yet, like all systems of centralised planning,
this one has proved inefficient, inflexible and inhumane. It is an object lesson in the dangers of the ever-growing capture of hitherto autonomous professions and institutions by the state.
Like most outsiders (and many insiders), I find it impossible to understand precisely what has happened, but having a daughter-in-law at the sharp end
has helped. The outlines at least are clear. They also offer a classic example of how a government-run monopoly behaves.
What, then, lay behind the fiasco that Modernising Medical Careers
has become? There appear to be
First, the department resolved on seizing control over medical training from the professional colleges and consultants, who happen to know what doctors can (and should be able to) do.
Second, the bureaucrats made a mess of manpower planning: in England, for example, 29,200 doctors have been competing for the 15,600 training places they arbitrarily decided to create.
Third, they chose this moment of upheaval to introduce an inflexible and characteristically defective computerised system (the Medical Training and Application System) to allocate doctors across the country.
As always, reasons existed for the shift to central planning: critics complained that the traditional apprentice system was riddled with favouritism; and the European Union's working time directive sharply cut hours for junior doctors, which not only necessitated a greater number of them, but also reduced the experience each would gain from a given period of training.
Some reform was presumably necessary. But this one is an object lesson in what happens when the government introduces a "big bang" shift to a centralised, computer-driven system. A bureaucratic monster replaced what had been a moderately flexible, albeit imperfect, system.
In the old system hospitals hired senior house officers; now they are sent them like a parcel of slaves. In the old system, if doctors did not get a job first time they could keep on applying; in the new system, they were to be given just one chance a year. In the old system, if they made a wrong choice it was relatively easy to change; in the new system, doctors must decide early and are then stuck with the consequences. In the old system, hospitals could change the mix of junior doctors relatively easily; in the new system, nobody knows what flexibility will exist.
Allocations to training posts are within huge geographical areas. But doctors are dispatched, like so much meat, to one hospital. Do they live hours away? That is tough luck. Do they have a partner, or even children? That is just tougher luck. Do they wish to switch hospital or sub-speciality? They must be joking. Do they wish to know the terms and conditions of their employment before arriving? They must really
To put the point bluntly, these highly trained professionals, on
whom you may depend for your
lives or those of your loved ones, are being treated with contempt. Do you want to be looked after by someone
To make the computerisation manageable, the doctors were allowed only very limited choices - far too few to eliminate random factors. As the chaos mounted, people were offered just one interview each.
The result was that those most likely to fail to get a job were the best, because they made the most desirable options their first choice. To make the computerised system "fair", much of the detail of people's careers and the detailed knowledge of those they worked for were also eliminated.
Centrally planned systems always eliminate latent knowledge, ignore human motivation and destroy flexibility. It was predictable that this Gosplan for the training of doctors would end up just as it has. It could not do anything else. This is a superb example of how the combination of centralisation of power with a belief in rationalistic planning works in the real world.
No less predictable is the fact that those who made these blunders are still in place. One might have expected resignations, starting with Sir Liam Donaldson, chief medical officer. But bureaucrats are far too grand to be held accountable. It is doctors whose lives are disposable. Who cares that they have devoted up to a decade to the acquisition of knowledge and experience? Who cares that patients will be worse served? What matters is that the Department of Health is firmly in charge.
So is the NHS suffering from an excess of free market zeal, as many on the left believe? Hardly. Where it matters, the planners are in charge. As always, they are making a big mess and, as almost always, they look likely to get away with it unscathed.
Copyright The Financial Times Limited 2007