The British Journal of General Practice., April 1999, p330-1
On the day which happens to be the deadline for this article, I will be going with my wife to a memorial service for my trainer, Tony Danby of Lyndhurst, whose name few will recognise, but who was the best doctor I have ever known. That is my assessment. That is my validation. I could not begin to justify it, quantify it or prove it, the attempt to do so would be absurd, but it is true. No scheme of assessment on earth, however cunningly devised, would change that truth, whether it supported it or contradicted it. That's the sort of thing he taught me, without meaning to of course.
I don't know what he would have made of revalidation, this model of mine, I suspect it would have made him very sad. It certainly makes me very sad, because it means to me that we have lost the battle to uphold the special nature of professionalism which he exemplified to such a high degree. It actually makes me feel that I am not sure I want to be this new kind of doctor, and it makes me fearful for us all as patients in the future.
Which is funny because the whole thing is supposed to be progress. But the fear is shared by almost everyone you meet. In Sainsbury's this afternoon a retired classics master wrinkled his nose - "It's Big Brother isn't it" Yesterday a civil-servant said, "It's what they've done to the teachers". At Monday's rehearsal for our Operatic Society production a health visitor, "I used to love my job so much when we were free . . There just isn't trust any more."
I'm supposed to be being positive about this and God knows I've tried but I can't make it hang together. Why was it necessary to bring it in on a pretext? I am as keen as anyone to protect the public from incompetent, dishonest or, of course, murderous doctors. I believe the recent cases have highlighted a deplorable situation and the tightening and speeding-up of the ludicrously-timid procedures for action in such cases is long overdue.
But that is not what is being proposed. The Guardian got it succinctly on 2nd February, "Doctors who fail new checks to be struck off". But these new checks are going to leave the glaring deficiencies which spawned them entirely untouched.(1)
So are the 'new checks' to be a set of base-line standards? I would have no anxiety about that - a level below which nobody could be allowed to sink. I argued for such a base-line in my book(2) and as early as 1979 in a BMJ Personal View on qualification for membership of the RCGP.(3) These standards would be far lower than ideal standards and we would all, in our different ways, aspire to rise above them. They would be springboards for growth, not mountain-tops we would exhaust ourselves struggling vainly to reach. In this way we could hope to preserve the vitality, initiative and diversity which has been so characteristic of British general practice. For in practice we know that people are best left choosing their own mountains to climb.
But unless we are entirely unlike all the other professionals who have been subjected to external regulation in recent years, that is not what we are going to get. What we are going to get is a set of target standards, set by enthusiasts (acting in good faith - I don't deny that for a moment), which are then raised year by year so that we can be seen to be kept under the inhuman pressure which is central to contemporary management philosophy and so that 'progress' can be demonstrated in boardrooms and debating chambers and on the morning news. Did anyone else wake up this morning to Radio Three and learn, whether they wanted to or not, the name of the 'worst primary school in England'? Just don't try to kid me that we have nothing to fear, we live in an age that likes this sort of thing.
We live in an age that believes in Utopia, attainable through technology. This is in spite of the fact that Utopianism was shown by Karl Popper half a century ago to be a logical absurdity, leading inevitably to authoritarianism.(4) It has, of course, been tried and found wanting in Communist Europe. In practice it doesn't work. You have to give people their freedom, their individual responsibility, the widest possible room to breathe and spread their wings, and let them fly. And you have to accept that whatever level of perfection you achieve, the natural tendency will be to want to take it further.
In fact it is worse than that, as we in general practice know very well, the safer and more effective medicine becomes the more worried people become about the hazards that remain. This is going to go on. We must find a way of coping with that reality which doesn't mean us all having to subscribe to a doomed quest for the Holy Grail of perfection.
I will just have to trust readers to understand that I am not arguing for complacency, or that we shouldn't always be trying to improve. What I am saying is that if you measure progress in something as vast, diffuse and multifaceted as general practice by single parameters like immunisation rates, or the number of books on the surgery shelf, or whether we know what ACE stands for, you will certainly improve those parameters, but at the expense of others which may be, indeed are, vastly more important. What I am saying is that this approach is fundamentally misguided.
That is why thoughtful doctors are worried about revalidation. Which brings me back to Tony Danby, whose highest praise for a doctor was that he was thoughtful. If ever there was a time for doctors to be thoughtful it is now. Perhaps we can even find a way out of this mire of control-freak society that some of our sister professions could gratefully follow. I think he would agree with me that there is no kind of medicine that we could do now which would do more good.
(1) Charlton BG, The ideology of 'accountability', Journal of the Royal College of Physicians of London, Jan/Feb 1999
(2) Willis JAR The Paradox of Progress, 'Rules for Rules', p123, Oxford: Radcliffe 1995
(3) Willis JAR Personal View, BMJ 3 Feb 1979, p339
(4) Popper K The Open Society and Its Enemies, Routledge & Kegan Paul, 1945 RETURN