The NHS: new Libertarian Alliance series: “A Doctor writes”

David Rønnqvist

No more “bedside manner”?


Interpersonal altercations were the sort of thing that it was once judged could usually be left to be negotiated by the people concerned. Increasingly, however, minor disputes are coming to be seen as requiring layers and layers of bureaucratic management, changing the nature of the public services we receive and altering the once-pleasant feel of England as a country to live in. We have all heard of the use of home-school contracts in the state education system and of councils that refuse to take away rubbish where the bins cannot be pulled with two fingers. This sort of thing is becoming the norm across society, and I want to focus on how it is altering the National Health Service (NHS).


Doctors used to be esteemed for their bedside manner, but now often behave like faceless bureaucrats who could be working at public expense in any branch of government. I recently joined a new surgery and was very surprised to receive a Patient’s Agreement to sign, promising not be abusive to surgery staff. Apparently these forms are standard now. The covering letter stated that if I did not sign the form and return it within three weeks, I would be expelled from the practice. I wondered how this complied with the requirement under the farcical Patients’ Charter to be respectful to all patients and with the right of patients under the Charter to have a general practitioner. Such mission statements and charters tend to proliferate in the public sector precisely when conflict with members of the public is rising, and can probably be taken as backhanded admissions that such public bodies no longer treat members of the public with respect.


In itself the silly Patient’s Agreement is just a small thing, but family members working in the NHS confirm that the trend within the NHS is towards greater officiousness towards patients. A district nurse has told me that there are altercations every single week in her practice between district nurses and old-age pensioners in their own homes over the patients’ right to smoke. Apparently the NHS believes that all their staff have the right to work in a smoke-free environment. But, rather than leaving such a minor matter to individual negotiation, smoking in front of a district nurse is now sufficient justification for explusion from a practice. The same nurse told me that when she visits patients in pairs, the other nurse will frequently issue an peremptory order along the lines of “put that cigarette out immediately or you will be expelled from the practice”. Such issues “empower” the NHS staff to behave in a bureaucratic and officious manner. No longer are they required to show respect to their patients in their own homes by asking politely for the cigarette to be extinguished.


Another aspect of this agenda relates to “inappropriate” language or behaviour by patients. The same nurse told me about an occasion where a 90-year-old man being catheterised in his own home made an “inappropriate” joke. When other nurses at the practice found out, one of them put in an official complaint against the patient “on behalf” of the other nurse, leading the surgery to consider whether the 90-year-old should be listed as a potential abuser and placed on a list of patients who cannot be visited alone.


Despite the right to care under the Patients’ Charter, patients with “inappropriate” views may be denied care. There are a number of examples in the media where patients with “racist” views have been left without care in hospital corridors. This reminds me of how my dying grandfather, who went through World War II, became disoriented in his final days, and thought the Chinese nurse attending him was one of the “Japanese”. He thought the Imperial Japanese Army was attacking down the corridor. Nowadays, such comments by a less than lucid dying man could in some hospitals be seen as justification enough for denial of care.


Professional behaviour in the NHS requires that all patients are treated, regardless of any “offensive” language or behaviour on their part. Medical care is not something that should be withheld as a punishment for political views. Old soldiers who do not wish to be treated by certain medical staff may be violating the most sacred principles of the multicultural elite, but the issue should be treated pragmatically. Similarly, offensive comments by Islamic extremists, or anyone else, should not be used as an excuse to deny treatment, however satisfying the “fix” of moral superiority such a response would give the NHS bureaucrat involved.


I note that all surgeries are engaged in constant propaganda over violence against their staff-but I believe such violence is very rare in fact. The ambulance service has a list of homes where violence is feared-apparently 729 in Cornwall, Devon, Somerset and Dorset-and are wondering whether to blacklist the homes or mandate the wearing of paramilitary jackets when summoned to those addresses. However, press reports make clear that the inflated number includes houses where staff have experienced “verbal abuse”. Only a minority of these people will have actually assaulted NHS staff. Some of the rest may have simply expressed anger at the treatment of their sick relatives or slow ambulance response times. A recent survey of around 1800 NHS staff by the NHS Security Management Service shows that 41% of NHS staff have experienced verbal abuse, but only 2% were physically abused.


I certainly do not believe that patients should be violent to staff, but knowledge of British society would confirm that violence to NHS staff is very rare. It may be that incredibly minor events are being classed as verbal or physical abuse today. Of those experiencing verbal abuse (in other words, an altercation of words they should be able to deal with themselves), only 54% reported it. An even greater percentage, 66%, of those physically abused did not report the attacks, confirming the view that in nearly all cases what is classed as “physical abuse” is of an incredibly minor nature.


I would expect that abusive or rude behaviour among patients is on the increase, but this is likely to be a reaction to the increasingly bureaucratic nature of the NHS. Contrary to the posters adorning surgery walls, serious violence to NHS staff is virtually unknown. It may be that smug bureaucratic behaviour on the part of the NHS is a reaction to perceptions of rude behaviour among patients. Patients dealt with poorly could become angry and emotional. NHS workers on the receiving end of abusiveness may call for increasingly peremptory bureaucratic controls on patients in a kind of vicious spiral.


It is difficult to know how to respond to the officiousness of NHS staff. Complaints or even polite comments pointing out the insulting assumptions in NHS literature would get nowhere. In the end, as the Libertarian Alliance has pointed out, the increase in bureaucratic jobs in the NHS tends to produce more and more bureaucratic initiatives. Cutting the state, or even giving the individual the ability, whether by vouchers or otherwise, to purchase healthcare would restore a sense of dignity to patients-after all, these people’s salaries are paid for out of the taxes that we pay!


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