41. Finding Tannochbrae, and rolling it out.


The NHS keeps being re-organised. This week we have the new GP contract and post-Francis, a splurge of nurse recruitment from the EU. The feeling is, the NHS has taken several bullets, and if this was an action thriller, we’d be waiting to see if it’s going to fall down or turns out to be wearing a kevlar vest. There’s a kind of impasse as people wait for the inevitable closure of smaller hospitals, walk-in centres and stagger-in centres, aka A and E.

The worst way of re-organising an organisation is to consult widely, sit down with ‘stakeholders’ and listen to experts. Instead, we need to reach down into the collective consciousness and find the archetypes of medical practice. We need to find the icons and copy them and work backwards from there. For medicine, we need to look no further than historical medical TV drama to find out how things ought to be, and in particular, the 1960’s shows, Dr Finlay’s Casebook, and Dr Kildare. This is what we should be reading:

‘The new general practice contract is more prescriptive and detailed than people expected. It looks as though there are going to be two doctors in each practice – one old and one young. Both must be Scottish. Only one other employee is mandated, an older female ‘housekeeper’, ideally called Janet.

The doctors must not be married. Beyond a telephone they will not use any modern form of communication device. The younger doctor must keep up to date and introduce anything deemed new-fangled. The older doctor must act as mentor and companion to the younger, specialising in wisdom and wry expression.

Although comparatively wealthy, both doctors should espouse a liberal stance and champion the disadvantaged. Both of them should know their way round a microscope. At times they may use a Motor Car to visit patients in their own homes’.

The model for hospital doctors is slightly different. Whereas the two Scottish GPs are brimming with lifestyle advice – such as proper fish filleting technique – the hospital team’s job is ‘to keep people alive, not to tell them how to live’. The hospital also uses a team of two, again an older and a younger man, but this time they are American. Both of them look good with stethoscopes and know their way around machines that go beep.

In all cases, tweed is de rigueur, no suits.

Both in general practice and in hospital, the teams will need to fight against rogue practitioners. In the community this is likely to be a toff, who works single handed, mainly in private practice and drives a Bentley. For some unaccountable reason, he has something of a way with the ladies. In hospital the main enemy is an autocratic character who calls himself The Chief. He’s in the board room far too much and never in the operating theatre. The ladies don’t like him, apart from one sycophantic, sado-masochistic type.

Both teams like a lot of background music, favouring lavish strings arrangements. But whereas the GPs prefer a jaunty tempo, in hospital it’s strictly andante, to match the steady flow of trolleys down corridors, with tubular bells on the offbeat.

Jeremy Hunt, you used to be culture secretary, so you know all this. Finlay and Cameron would never have sat around on clinical commissioning groups or attended team building workshops. Finlay would never have gone on about strategic aims and driving down operating costs by standardising the infrastructure. If Cameron had to say something like, ‘we need to front-load the front-loading’, he would at least deliver the line in a huge theatrical splutter.

The archetypes are a little different for psychiatrists, being found mainly in movies. These have been well documented in papers such Theory and Practice of Movie Psychiatry, by Irving Schneider.* The actor Patrick Stewart turns up in two pivotal roles along these lines, first as the decent-sort consultant Eddie Roebuck in Maybury, and much later on, after several years in space, as the evil Dr Jonas in Conspiracy Theory.

In the latter role he offers a poor model of practice, specialising in finishing off the survivors of a brainwashing assassins program. Though there are no NICE guidelines on brainwashing, and how to handle it when it goes wrong, Jonas probably missed the short medical ethics course at the end of year 5.

It’s likely that the new template for mental health practice will be more like this:

‘The psychiatrists, who are brothers, seem a little fussy and pompous but mean well. To compensate for limitations in his interpersonal skills, one of them runs a local radio show where patients can phone in, so that the whole community can benefit from his wisdom. For background music, it’s strictly jazz.

Jeremy Hunt, these are our heroes, not the Kings Fund, nor NHS England, nor the Nuffield Trust, nor the CQC. As culture secretary you were the one person in the country never to watch UK Gold, but now it’s time to catch up.

*Am J Psychiatry. 1987 Aug;144(8):996-1002)


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s