Tuesday, 15 May 2012

The confusing challenge of learning lessons from the past

I am all at sea this week. I feel like I am being pulled in all sorts of different directions intellectually. Let me set it all out for you, and then perhaps, you can give me some pointers.

Following a suggestion in Paul Corrigan’s blog, I have started reading the second volume of Michael Foot’s biography of Aneurin Bevan, written in 1973. The combination of Nye’s rhetoric and Michael Foot’s prose is a heady mixture - surprisingly so for such a dry subject matter - the formation of the NHS and the nationalisation of the steel industry rarely make for a pacy read, but I am hooked. It’s a solid tome too - praise the lord for ebooks (If you’re not converted, think of the posturing and hand contortions required to read a 700 page book in bed, and ask yourself why you still insist on doing it). 



The book feels like a return to a more chivalric era, when there could be objective satisfaction in an argument well-made, and there was a real appreciation in the performance of politics. Is it me, or is politics a lot more ruthless than it used to be? Perhaps that’s not right: perhaps it’s a bit like rugby in the professional era: the skill levels of modern players are no better than of the best players from the amateur era, but they are certainly fitter than they used to be, and they get a lot more back up nowadays. I want to say modern politicians get more help, and have access to more support than they used to, which leads to a more relentless brand of politics, practiced full-time by people for whom politics is all they have ever done, and will ever do.

The narrative of Bevan’s efforts to win over the medical profession is compelling reading. One’s impression of how people behaved is inevitably tainted by how it all turned out. As a friend of mine says, Harry Hindsight is the best trader in the bank (I bet Jamie Dimon wished Harry worked for JP Morgan right now) and the knowledge of how successful the NHS was colours one’s interpretation of the resistance that the BMA in particular put up against the NHS Health Bill. But it must have been a hugely unsettling time: in spite of the admirable aims to provide comprehensive health care to the country, doctors were faced with moving from a system of practice that they were used to and understood (even if it was inequitable for patients, and difficult to establish oneself in as a young doctor) to one they did not know, that had never been tried before, which was due to implemented at an unprecedented pace. And all the while they had to negotiate with a man who appeared to them to be really good at hoodwinking them, smoothing over their concerns with charm and wit, and probably left them feeling  after every negotiation that they had been duped, but without really knowing how. If I had been a doctor then, I would have been deeply suspicious, and almost certainly, at least a little resistant to the whole plan.

Does this remind you of anything? Are there any more recent health reforms that you have been suspicious of, or resistant to?

The parallels between then and now are uncanny. Will my grandchildren be reading (and enjoying) biographies of how Andrew Lansley revolutionised the delivery of health care in the UK, against a tide of opposition from the entrenched views of a self-protectionist medical profession? Maybe, but I suspect not. But let’s not shy away from the important issue for reflection: that there is the possibility that some of the resistance to health care reforms that has played out over the last few months, may have somewhere within it, the fear of change, and a reluctance to try something new.

But while I was busy challenging myself on this point, I realised that while Nye Bevan reformed the health service on the back of a manifesto pledge, and an unarguable mandate from the British public, those conditions are not met today: we are witnessing the second biggest health care reform in British history on the back of a promise to stop top-down reorganisation of the NHS, by a Conservative party who limped into government by forming a coalition with the third most popular party in the country.

Is it fair of me to challenge Andrew Lansley on these grounds, or is this me desperately hanging on to the idea that we have been done over?

And it gets harder. Just as we embark on health care reforms that I am beginning to believe might just deliver improvements, I read an essay in the BMJ by Arnold Relman, from Harvard Medical School (and former editor of the NEJM) that health care in the USA is being bankrupted by the influence of market forces, and the only way that health care can be adequately afforded and provided is by the genesis of a system defined by ‘a single public payer that provides universal access to comprehensive care.’

Blimey, just as it feels we are moving away from that definition, Arnold argues that the USA should move towards it. And I am dizzy from all the spinning around I have been doing this week.

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