For a few months, one of the teams I worked in was said to be ‘overperforming’ its service contract. This word is often used by managers in the National Health Service. Overperformance really just means that you have done more work than predicted, so telling people that they have overperformed is a bit like saying that the sun has overperformed because the weather forecast said that it would rain. All the same, we were asked to cut down on our work for the remainder of the financial year. We had to close some cases, knowing that we might need to reopen them once the new financial year started in April. We also had to change the review dates for other patients, in order to make sure that they didn’t darken our doorstep again until April had begun. Where two clinicians from different specialities were seeing a case jointly (fairly common in our line of work), we had to explain that only one of us could see them for the time being.
Fortunately – or ludicrously, depending on which way you look at it – all of this only applied to part of our catchment area. People who lived slightly further away, or in some instances on the opposite side of the same road, continued to have no such restrictions. In theory at least, we could even have decided to fill our time by seeing them more often, or with several clinicians in the room twiddling their thumbs and waiting for March to expire.
This phenomenon, and others like it, are now very common in the National Health Service. Broadly speaking, I have noticed three kinds of reaction among my colleagues to these kinds of directives. A few outspoken staff members burst out with indignation or even outrage when one of these measures is announced. It is usually the same people on every occasion, often the ones who seem angry about a lot of things at work anyway. We admire them, but also feel irritated and embarrassed, wondering why they cannot just accept the madness of everyday life in the health service like the rest of us, knuckle under as we do, and get on with their jobs. By contrast, a number of other colleagues seem to buy into the latest managerial demand more or less wholeheartedly each time. While lamenting any temporary difficulties, they are keen to explain to the rest of us the importance of rational planning, workforce efficiency and so on. Things have been unacceptably sloppy in the past, they remind us, and we are paying the necessary price for tightening systems in the right way. We admire these people too – to an extent – but we are also a bit scared of them. If they aren’t already in positions of authority, they probably soon will be.
Most of us, to be honest, fall somewhere in between in our reactions. Our sympathies are with the protesters, and we may even make some tame comments to this effect, but nevertheless we fall in with the modernisers. We take their rebuke to heart, as if overperformance isn’t just an artefact of budgeting, but a genuine moral failing. And we try to convince ourselves that it isn’t as insane as it seems to postpone seeing a referral because it’s March and the patient’s address is in Jubilee Road and not Jubilee Avenue.
As always, I am struck by how these processes resemble totalitarianism. I realise that some people will find this comparison preposterous, and clearly one has to discriminate between degrees of totalitarianism: there is an important difference between being told off for overperformance and being shot for it. Yet all the classical ingredients are there: the idealisation of order, the marginalisation of dissent, the disqualification of compassion, enthusiastic collaboration by some thoroughly decent citizens, and passivity among the rest of us. There is also a certain kind of collusive secrecy. When we change patients’ appointments around, or send letters telling them their files have now been closed, we don’t necessarily tell them the real reasons. Instead, we package these in some other convenient form, somewhere along the spectrum from coincidental half-truths (‘we have decided to close every case where patients have not attended their last two appointments’) to downright lies (‘unfortunately Dr Launer is unable to be present at our next meeting’). Without any discussion, we collectively assume that we cannot be open with our patients. The deceit becomes part of the climate in which we work.
In discussing totalitarianism, the historian Hannah Arendt famously wrote of the banality of evil, and it is indeed banality that characterises these sinister incremental shifts in what is acceptable. After the team meeting where we learned about our overperformance, I probably went to the canteen in my usual way, and then took my cappuccino downstairs to my office so that I could dictate the necessary letters. Fairly soon afterwards, I would have more or less forgotten this latest small assault on my capacity to practise professionally, or humanely. My job and my pension were still intact, so perhaps things weren’t really so bad after all…