Abstract
I agree with Martin McKee 1 that the National Health Service (NHS) is being degraded by systems that are comparable with those which worsened healthcare in the Soviet Union. Central control, bureaucratic expansion and counterproductive target-setting and ‘reforms’ have all been used by successive governments who exercise control on those doing useful work on the front line via a large pyramid of apparatchiks. In the NHS, this is exemplified by the removal of clinical role models from training, the introduction of feldshers by another name, and the denigration of experts by politicians such as Kenneth Clark and Michael Gove, but this malign process affects much of life outside the NHS as well.
The fact that this can happen in Western democracies is not new or surprising. Machiavelli described just this situation 500 years ago. He said: ‘The reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order’. A sadly neglected work of political philosophy, On Voluntary Servitude, by Etienne de la Boetie in the 1570s, brilliantly describes how leaders control those below them by a pyramid of anti-libertarian tyrants and sub-tyrants.
In recent times, I was struck by the words of the recently sadly deceased successful entrepreneur Mike Lynch who described the secret of his success as ‘No bureaucracy. No admin, lots of late nights, lots of cold pizza.’ That sounded to me a lot like the ethos and efficiency of the NHS of the 1960s and 1970s in which I worked as a junior doctor. I wish that governments could think of proper reforms rather than just adding to the burdensome mistakes of their predecessors.