Do the comfortable thing.

I am feeling rather ashamed today. I heard that Asia Bibi was released from prison, after her conviction for blasphemy was overturned, and was relieved with this news. However, after a decade unjustly imprisoned, and much of that time spent in solitary confinement, she is at considerable risk in Pakistan. There have been mass demonstrations and riots demanding that she be executed. This is no idle concern, as previously high-ranking officials who took up her case were indeed assassinated. She has wisely asked for asylum and thankfully there have been some offers and it is likely she will go to the Netherlands.

The reason I feel rather ashamed is that one of the countries from which she requested asylum was the United Kingdom. Given the long association between Pakistan and the United Kingdom this would seem to be a natural choice. Given the obvious need for asylum, and the reasons behind her plight, one would have anticipated that an offer of asylum would have been quickly forthcoming. However , it seems that this has been specifically rejected. Wilson Chowdhry, of the British Pakistani Christian Association, reports that British authorities  have said :-

‘I’ve been lead to believe that the UK government had concerns that her moving to the UK would cause security concerns and unrest among certain sections of the community and would also be a security threat to British embassies abroad which might be targeted by Islamist terrorists,’

Religious freedom and a refusal to be intimidated are core facets of what we consider “British Values”. We should be proud to offer asylum to those fleeing persecution and should do this even if there are risks in doing so. We can not be seen to only help when there is no cost to ourselves. It is shameful to reject asylum because of fears of what those doing the oppression might do. If there are those in our community who object to us giving asylum then it is they that are behaving badly, and against the principles of our country. Indeed, if there are any who think that she should be executed we should ensure she comes here, and is kept safely, to clearly echo the point that we think freedom of thought and freedom of religion and vital, and uncontestable, parts of British society. It is those who think othewise who should consider whether they are living in the right place.

Asylum is something that should not be weighed up against trade deals, nor weighed up against possible difficulties to ourselves, it is something we should offer to prove our humanity and moral standing. I feel a little ashamed that today it seems Britain has said moral duties can be trumped by comfort or safety.  It was said that during World War 2 we spent all our energy and lost thousands of lives in order to protect a few moral principles while now we will loose our moral principles in order to save a few lives.

 

 

Blasphemy laws; here and there.

Blasphemy laws; here and there.

The Irish public are voting in their referendum today as to whether they will jettison their ancient blasphemy law from their constitution. This is found in Article 40 which reads :-

“The publication or utterance of blasphemous, seditious, or indecent matter is an offence which shall be punishable in accordance with law.”

This situation did receive degree of  public attention when attempts were made to use the law  against Stephen Fry on 2017; following his making of blasphemous statement in a television interview.  His case was dropped and thrown out as have all other attempts to use the law in recent times. Indeed it is a largely recognised that this is an “obsolete law“, a view which is also held by the Irish Catholic Bishops conference who are, as a consequence, not opposing its abolition. It will be welcome to see the back of this anachronism, a relic from the days that every constitution used to include reference to God and Faith.

Blasphemy laws are simply an attempt to restrict freedom of speech. They do not protect people of any faith, they simply protect those with power. They are a sign of the wedding of state and church and a mechanism to bolster the influence of both of these institutions. They protect some from offense or distress by removing the rights of others to freedom of expression.

People with religious faith do not require blasphemy laws. It is in the nature of faith that it persists despite what others may say, it persists in the face of argument. It is this steadfastness which makes me admire so many of those people of faith, who have soldiered on against apparently insurmountable odds, because their faith directed them to do what they knew to be right. (Think of the Quakers’ opposition to wars or the Abolitionists in the struggle against slavery). Indeed blasphemy laws are largely a risk to people of faith in the many cases when their faith is not shared by the current state. This is the horrific situation in which Asia Bibi finds herself in Pakistan.

Asia Bibi had been out collecting berries with neighbours and had taken a drink of water from a well. She was told by her neighbours that, as a Christian, she was unclean and should have not used their cup. An argument followed and at both parties made disparaging remarks about the others faith. Asia was charged with blasphemy and imprisoned in 2009.  She has been kept in solitary confinement and subsequently found guilty and sentenced to death.  Seven years later she is still in prison and awaiting results of appeals to the Supreme Court to have her capital punishment decision overturned.

As a consequence of this blasphemy accusation her family have gone into hiding. Salmaan Taseer, the governor of Punjab, who looked into her case and stated that the death sentence should be suspended was assassinated as a consequence in 2011 as was Shahbaz Bhatti, the Minority Affairs Minister, a few months later as he too voiced his support for Asia against the blasphemy laws. Asia’s case has been used to whip up hatred against Christians in Pakistan and to help hard-line religious politicians in their search for support.

As we await the news from Ireland we should recall that Pakistan suggested, in 2009, to the United Nations that all its member states should adopt the very constitutional clause that Ireland is currently considering removing. We should also recall that there are still 71 countries which have blasphemy laws on their statute books. That is 71 countries which have laws which place people of minority faiths at serious danger. It is time that these laws were abandoned for the furtherance of free speech and promotion of religious tolerance.

With all this in mind it is extremely regrettable that the European Court of Human Rights  (ECHR) seems to have taken a backward step.  An Austrian woman was found guilty of “disparaging Islam” and the took her case to the ECHR. They did not uphold her appeal and supported her conviction and fine saying that she made ““an abusive attack on the Prophet of Islam which could stir up prejudice and threaten religious peace” and that this was not covered by the right to freedom of expression. To be clear, this lady had not said anything to foment violence or hatred against Muslims which would clearly, and rightly, be an offense. She had simply been sacrilegious and blasphemous and while this may be upsetting to some should not be against the law.

Churches, states and people in power may need blasphemy laws, people of faith do not and are particularly at risk from such laws. After Ireland, 71 to go !

 

 

 

 

 

Equilibrium (2002)

Equilibrium (2002)

My wife was away visiting the sick yesterday and I had the evening on my own. The demands of milking and feeding the animals mean that it is well nigh impossible for both of us to go away at the same time. It took negotiations, and the coordination of two groups of neighbours, to let us away overnight last year for our annual holiday (to a hotel over 10 miles away). As the sick relatives were closer by blood and marriage to my wife, it was felt best if she was to go to visit.

This left me on the sofa last night, searching for a film to watch. On these occasions I try and find a film that my spouse would not want to watch; it seems wrong to watch a film on my own that she might enjoy too. If I did, I’d probably not want to watch it again so she may never see it, and I’ll miss out on discussing the film, which is a large part of the pleasure of film viewing. She tends to be less keen on Science Fiction than I am so this is often a safe choice. A further factor at play in my choice,  is that I tend not to want to buy a film, spending money is usually a joint activity, so I need to choose from the free-to-air channels or Amazon Prime. All of these factors combined lead me to settle down with a bag of popcorn and watch “Equilibrium

The premise of the film is quite simple : thFWDOJDNSafter the devastation of a third world war it is agreed that the world and humanity can not take the risk of a fourth, it is recognised that emotions fuel the violence that drives wars and therefore society is constructed to ensure people do not experience emotions and feelings.  To curb their emotions and help them avoid feelings (and thus committing “sense crimes“) the people take Prozium regularly, a name obviously chosen to allude to the current antidepressant (Fluoxetine, or Prozac). To police this, and to apprehend sense offenders, the state of Libria (This is the same reason chlordiazepoxide got the brand name Librium) have an organization of grammaton clerics who are trained in the  art of Gun Kata. One of these clerics stops taking his Prozium and, after a convoluted set of twists and turns, ends up leading the resistance towards a finale of the individual overturning the authoritarian state.

The premise in interesting and the camera work, visual effects and story progression are all quiet satisfactory. There is a tendency to be heavy handed on the puns , the underground resistance literally live underground, in the “Nethers”, but the story line is engaging. The cast are able and there are some big names in here, (Christian Bale, Sean Bean, Emily Watson) and they, and the rest,  perform well. But, unfortunately the film tends to fail as a whole.

The film doesn’t really get to grips with the importance of emotion and feeling to the individual. When it does try to deal with emotion in characters it tends to end up being mawkish or kitsch (One cleric is lead off the straight and narrow by looking into the big eyes of a puppy). While it is visually well made it pays homage to many better films. The clerics and firemen are from Fahrenheit 451, clothing and fighting styles are from The Matrix, the architecture and landscapes are from Metropolis. Even the major plot devices are echoes of better films : the imperfect human fighting the state was handled better in Gattaca and 1984 was much more effective in discussing the state’s control of the individual even though it only had a ‘Big Brother’ rather than a ‘Father’ figure.

As you watch ‘Equilibrium’ these visual and plot devices remind you of much better films and lead to a growing feeling of dissatisfaction. All the elements are there but they do not coalesce into a good film. Indeed sometimes the handling of elements is quite jarring. This is a film whose target demographic is young men, I’d imagine, and thus the stylised and  choreographed fighting plays a central role. This and the copying of fascistic imagery in the outfits and architecture lead it to the edge of glorifying violence and the strong man. There can be a fine line between  parody and glorification (see Leibach) and this film sometimes crosses this line.

So overall, a lot of able cinematographic work has been  has been hammered together in a rather heavy handed fashion rather than thoughtfully crafted. The end result is passable rather than good. The same ingredients, in a cook’s kitchen, can produce a great meal which in the fast food store merely make something to ‘fill a hole’. This film filled a hole but, either it or the popcorn, left me with indigestion. However, I can feel confident my wife would have enjoyed it even less.

 

Thoughts while shearing

Thoughts while shearing

I have found that I have mixed feelings after the annual shearing. During the year any dagging (removing the soiled wool at the rear end) or crutching I do myself by hand, but for the annual shearing of the fleece I rely on a young lad on the next farm to do the work.

He has all the equipment; a shearing trailer (which acts as a holding pen while the work is going on), the electrical shears (which give a neat trim) and moccasins (so that he might hold the sheep with his feet without hurting them). But more importantly he has two other advantages. Firstly he has the strength and stamina; shearing is hard work, grappling 50kg of reluctant, wriggling ewe or ram and trying to operate heavy electric shears at the same time is a young man’s job. It is difficult for an old codger like me. Secondly, and most importantly, he has the skill. Knowing how to hold the animal, how to turn them as you shear, how to avoid cutting the animal and managing to take off an entire fleece intact is a hard earned skill. Watching someone who knows their craft is very impressive.

DSC_3212

I usually like to use the least technology possible, to try and find the most natural way to do a task. However, there is no way to shear a sheep without tools and modern tools make this easier. Primarily they make it easier for the sheep. The procedure is painless but it alarming to the animal, it has no conception of what is happening and is afraid. There is no way to share, with them,  the knowledge that they will feel better during the summer and be at less risk of fly-strike, lice, ticks and a variety of other plagues. It is always stressful and therefore anything that shortens the time it takes is good news. Hand shearing by an expert takes about 15 minutes, hand shearing by me takes about an hour, electrical shearing by our neighbour takes about 2 minutes. There is really little contest, electrical shearing wins hands down.

So why then do I have mixed feelings about it ? Well, this time it started when another neighbour, who was helping, recalled shearing when he was a boy. On the shearing days up to 20 men would sit in a line on benches at the edge of the field and shear the flocks by hand. During the season many hands were needed to do the work. Now one or two men, with good machinery, can do the same job with less effort and stress. It is the reason that agriculture, though it produces much more than it ever did, uses less labour. It is why there are few jobs in the countryside and why the population has shrunk. Though there are less jobs in farming this mechanisation has created its own jobs – there is now a need for factory workers to work the lathes and milling machines that make the equipment. There is less call for young men to learn how to shear in Wales but the demand for young men to work in factories, often abroad. With less people living and working in the countryside there is less call for shops, schools, churches, doctors and the like and this is why we see that now the majority of people live in urban areas.

This specialisation is at the core of capitalism and it is the great irony of the twentieth century  that it has been capitalism, not socialism,  which has pulled many people out of poverty. Through mechanisation and specialisation great increases in wealth have arisen. This increase is so great that, even when it is badly and unevenly distributed, the majority of us benefit. In the west, going back 100 years, no-one could have anticipated our current wealth. The idea of personal transport by automobile, central heating or air conditioning, personal computers and telephony would be unimaginable to people who thought that books and electric light to read them by were a luxury. So it seems I cavil , especially as I post this on the internet, when I cast doubt in these changes. However, I’d argue that not all of this progress has been without cost and, although agreeing that a market economy is the best way to ensure efficient production, I’d propose we have to be careful that we know where we’re heading as individuals and as a society.

It was often said that these mechanised and specialised changes would benefit us because they are “labour saving“. Each new gadget, from the washing machine to the smartphone, has promised to save us time and to leave us more leisure time for ourselves. This should lead to increased pleasure as we do things we enjoy rather than need to do.  However, our pleasures are relative. Once we become accustomed to something it changes from a luxury to a necessity (People will not venture outside now without their phones). Thus the prior luxuries become part of our life and, if missing, a source of our unhappiness. There is no evidence that individually we are any one jot happier than people 100 or 200 years ago. The Victorian got just as much pleasure from his night at the music hall as we do from an evening at the 3D IMAX cinema. The Victorian felt as euphoric when his lover agreed to become his partner as we do now (Well possibly they had greater pleasures in this area as society was more restrictive on the whole).

Our luxuries don’t seem to bring us pleasure but perhaps they at least give us time. It would seem unfortunately this is not the case. As we have more, we need more and want more and thus we work more.  In his book Sapiens Yuval Noah Harari notes that the time we spend as a species working for others has always increased and certainly if one were to look over the last two generations this trend is evident. 50 years ago a skilled manual worker, working well, could expect to provide for his family to the standards of his day. Now both parents will have to work outside the house to provide for their family with all the consequent changes that we have seen in child rearing and family life.

It seems that once we have escaped scarcity, once the basics (hunger, thirst, safety, warmth, etc) are dealt with we do not know what is “enough“. We are good at acknowledging what is too little, we have built in warning systems in our biology when there is too little food, or water, or heat. However, we don’t seem to be able to determine what’s enough in term of what is “too much”.  Consequently in our post-scarcity world, in the west, our major problems are those of excess – obesity  or substance abuse as individual problems for example and global warning and the plastic pollution of our seas as global examples.

This is possibly the reason that all the major religions had as an important focus the advice to avoid excess. Gluttony, avarice, lust and covetousness are sins to be avoided and all the main religions advice that we should try and control our desires.  Going back to the stoics, they advice that we should try to have and want less, to not be controlled by our desires. It is possibly a perfect storm in the developed world, that as the productive powers of capitalism reaches its zenith the advisory power of religion  plumbs its nadir.

Thinking about the changes that have occurred in how we shear sheep has made me think that if we want to survive we need to change. As individuals we have to learn to rein in our desires which I think will require a rebalancing. We will need to rediscover localism so that our wants and needs play out on a smaller stage. We need to reduce the size of the states we live within so that they are no more than is necessary and allow individuals to create small communities on a more human scale. We have to learn when enough is enough and this going to be difficult. As individuals we are going to have to break out of the role of being primarily consumers and reclaim our private lives. This is no easy feat but as Tolstoy said “In order to land where you wish, you must direct your course much higher up.”

Drifting towards the rocks.

Drifting towards the rocks.

It is increasingly apparent that the left has abandoned its originators. It was through the struggles of the working class that many of the present left wing organisations were born. These movements had their roots in the organisations formed by the working class to protect their interest and promote their advancement. The trade unions were the stalwarts of the Labour Party in Britain, and to a degree remain important today, but few on the left today have more than a vague awareness that the other strand which pushed the development of the left was Christian thinking. As Morgan Phillips, when General Secretary of the Labour Party said “the Labour Party owes more to Methodism than Marxism“. In any event, any link between the Labour Party and working class organizations and culture has largely atrophied and disappeared. Now, like many organisations on the left, is more concerned with identity politics and intersectional theory than with any class struggle.

Thoughts on this subject were stirred last night MV5BMzc1MDY3NDIwMV5BMl5BanBnXkFtZTgwNzkwNzU0MzI@._V1_SY1000_CR0,0,674,1000_AL_when I went to see the Swedish film “The Square” which won the Palm D’or Award at Cannes. I’d heartily recommend this film to anyone who has not yet seen it as it is a biting, vicious satire which is genuinely funny but also very thought provoking. Although the main target is the “Art World” it also takes aim at the progressive elite who run our charities, government quangos,  health boards, government enquiries and generally wield a large part of the day-to-day power in our society. These people talk the talk of inclusion, accessibility, sharing and caring and empowering the powerless, but rarely do they walk the walk. As the film reveals they often have a deep seated fear of the poor and have much more interest in satisfying their own needs. In the film they create art to show they care for their fellow man but fail to recognise their fellow man in need when they pass them in the street.

On the left the politics of identity and intersectionality may have been able to help some groups. Although the womens’ struggle and the fight against racism seemed to be being fought with success before this new theory took the high ground, and it is arguable how much added benefit these theories have had in advancing the causes of women and minorities in western societies. Sometimes the focus on cultural issues, and cultural identity, has indeed been counterproductive when one considers the struggles of women, or homosexuals,  in Islamic countries where a blind eye has been turned to horrific events and support has been denied to those struggling for liberation. But there has been also an unintended negative  consequence of these theories. Now there is a problem of what to do with white working class men and boys.

These individuals have found that ‘class‘ does not count in the hierarchy of victimhood. Poverty and powerlessness do not, in themselves, interest the left. Their struggles are no longer what drives the progressives and their culture no longer has any interest to them. When they think of white working class men they think of brutes, loud scary people with opinions they reject, the wrong ideas on Brexit and immigration. often with attachment to old fashioned cultural constructs and morals. They just don’t fit. In the world of the media and the arts they have all but disappeared. Working class men make up a third of the population but they will not be seen in our plays, films or television series except as in small roles as bigot No#1 or possibly as a wifebeater. In between the programmes on television, the adverts will show every demographic possible with the exception of white working class men. They are an embarrassment which will hurt sales, best to hide them away.

We have a culture that despises them, as Frederick Mount in his book “Mind the Gap” reported they have been “subjected to a sustained programme of social contempt and institutional erosion which has persisted through many different governments and several political fashions”. They have no political project promoting their aims and therefore is is no surprise  that as a group they are suffering badly.   In education, according to the 2016 report by the Sutton Trust, white pupils on free school meals achieve the lowest grades of any ethnic group. In employment and housing they are also steadily failing. These effects should have been anticipated.

The final, probably unintended, consequence of these changes should worry us all. These people who have a proud tradition of fighting for equality and for the moral good have shown themselves able to transform society. Their rejection by the left and progressive movements creates a vacuum. We can hope that new movements will form and pick up the struggle for social improvement. However, recent experience in Europe and America makes me fearful that other political movements will move to fill this vacuum. I fear it is easy to sell a project based on hate and anger to a group that has been marginalised, alienated and held in contempt. Vengeance is a powerful motivating force !

We need a progressive movement that includes everyone, particularly the majority of working class men and women who make up our society. We need to stop defining ourselves into smaller and smaller groups and trying to create our power bases and start defining what we want a good society to look like. We have to start to think we can change society and that we all have something to gain in the future. As Vance wrote in Hillbilly Elegy “We hillbillies need to wake the hell up.” – we all do  – because if we don’t Trump, Orban, and Le Pen are only the first glimpse of our future. We still have a chance to stop it.

 

Liberty + Responsibility = Freedom

Liberty + Responsibility = Freedom

It can be quite messy when you find you are and anarchist or libertarian. The is a great deal of good writing on the subject and many fora in which to debate the issues of individual freedom and the dangers posed by the state.

The messiness arises from a variety of factors but two are particularly important. The first is a problem of nomenclature. The words anarchy and libertarian mean very different things to different people. In particular there is a problem in that the words have quite different meanings depending on whichever side of the Atlantic Ocean you find yourself living. (Debates on the internet often cross this divide without participants knowing and taking the different vocabulary into account).

Here in Europe anarchy has a long an established tradition with its roots in the writings of Mikhail Bakunin, Peter Krotopkin,  Pierre Proudhon,  and Rudolph Rokker among others. Anarchists split from the socialist tradition because of obvious incompatibility over their views of the state but they shared the socialists concerns for the poor, their egalitarian impulses and their opposition to discrimination and unfairness. Their tradition is seen in America in the writings of such luminaries as Emma Goldman or Benjamin Tucker. It is not unusual to see the term “libertarian socialist” or “anarchosocialist” in Europe, as the dividing line in Europe is the role of the state and personal autonomy rather than the other aims of socialists.

In America such  groupings  (e.g. libertarian socialist) would be seen as unusual and even a “contradiction in terms” as the origins of libertarian thought  are different and follows the works of early writers such as William Godwin and Lysdander Spooner, and later the works of Murray Rothbard, Ayn Rand and Robert Nozik. The philosophical base is also individual liberty but there is an acceptance of the capitalist economic system as the best way to deliver material prosperity to people. In Europe these groups would often be considered “Classical Liberals” , or unflatteringly “Neo-liberals“.

This difference in terminology often leads to messy confusion and  one needs to know a lot more about a someone who calls themselves an ‘anarchist’ or ‘libertarian’ before you can guess at their opinions or moral view of the world. Hence, the proliferation of adjectives to try and explain their positions : left-libertarian, anarcho-capitalist, libertarian socialist, agorist, etc. etc. However, this problem is relatively easily solved. A bit of reading or discussion will normally clarify what the persons views are and how they see the world. A much bigger problem and mess arises when people discuss liberty.

Most people view individual liberty as an obviously good thing. It is something to be fostered and promoted, and when we see attempts curtail liberty most of us try to stop this. However, it is impossible to promote liberty without recognising the need at the same time to promote responsibility. Liberty without responsibility is impossible. Indeed as George Bernard Shaw said “Liberty means responsibility. That is why most men dread it”. Many people are happier to feel safe than to feel free; they would happily subject their freedom to the authority of the state if the state keeps them fed, warm and free from crime.

If a society was going to give up the role of the state as the guarantor of safety then it requires that individuals ensure that safety themselves. They may behave as they wish, but if we are free to pursue our own aims then we must be responsible for our actions, we must accept and deal with the consequences that follow. This responsibility will replace the state. Responsible individuals will want to work cooperatively with their fellows to their mutual advantage. Responsible individuals will want to curtail some of their desires today for safety and security tomorrow. Responsible individuals will want to make friends and allies, will wish to help others, as it may furnish the social capital that they might need to all on in the future. In short, if there is no state then there needs to be a big and effective society. If we need an effective society we need responsible individuals. In the past religion has, in part, provided this, in the future, it appears, we are going to have to find this on our own.

A failure to recognise the essential unity of liberty and responsibility has lead to the many rather sad and tawdry aspects of anarchist and libertarian writings. Often liberty has been mistaken for libertinism and calls for equality of opportunity have been barely concealed brutalism in furtherance of injustice. Libertarians and anarchists must by necessity hold themselves to higher standards, they cannot call on the excuse of duty or law, they must be responsible for their actions. However, being free and responsible is the essence of living as Viktor Frankl  recognised when he wrote the following in his book “Mans search for Meaning.

What was really needed was a fundamental change in our attitude toward life. We had to learn ourselves and, furthermore, we had to teach the despairing men, that it did not really matter what we expected from life, but rather what life expected from us. We needed to stop asking about the meaning of life, and instead think of ourselves as those who were being questioned by life—daily and hourly. Our question must consist, not in talk and meditation, but in right action and in right conduct. Life ultimately means taking the responsibility to find the right answer to its problems and to fulfill the tasks which it constantly sets for each individual

Indeed he proposed a Statue of Responsibility on the East coast to remind us of we need both sides of the equation :-

RESPONSIBILITY

+ LIBERTY

= FREEDOM

Freedom, however, is not the last word. Freedom is only part of the story and half of the truth. Freedom is but the negative aspect of the whole phenomenon whose positive aspect is responsibleness. In fact, freedom is in danger of degenerating into mere arbitrariness unless it is lived in terms of responsibleness. That is why I recommend that the Statue of Responsibility  on the East Coast be supplemented by a Statue of Responsibility on the West Coast

 

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Getting out while I still could.

Getting out while I still could.

I recall that about half-way through my medical career I had a premonition of the problems with patient dissatisfaction  that we are now see. It was therefore with dismay, but no real surprise, that I read the results of the British Social Attitudes Survey on patient satisfaction with the NHS and social care. This has shown that growing dissatisfaction continues; now only 57% of people were satisfied with their healthcare while nearly a third (29%) were dissatisfied. These were significant changes, and deterioration, from previous reports and there was a particular drop in satisfaction with General Practice services. Primary Care had previously been the jewel in the crown of the NHS but now was viewed little better than other areas of the NHS. Some areas barely managed a majority of the population feeling satisfied (A&E for example at 52%) and these are generally worrisome figures.

These rates of satisfaction should alarm us. We often hold up the NHS as the “envy of the world” despite its relatively lacklustre outcome measures. We are now watching it slip to the bottom of league tables, of developed European countries, in public satisfaction as well as in performance. Why is this ? It does not seem that it is due to sudden increases in public satisfaction with other European services (though they have generally modestly improved their scores on this matter). It is because of an increase in dissatisfaction with the NHS’s provision and people cite unhappiness with inadequate staffing, delays in being seen, and poor quality of care. They tend to view this as a consequence of inadequate funding and government interference.

These two factors will, without any doubt, foster and magnify dissatisfaction but I am unsure that these factors are as important as they might initially seem. European healthcare funding has been squeezed in all countries but other countries have not witnessed the deteriorations in satisfaction we have observed, indeed, some have even seen slight ongoing increases. It is difficult to quantify government interference but it is a safe bet that this has not been absent in any of our comparator countries. But could there be another factor underpinning this dissatisfaction ? I thought I felt the start of this change many years ago, and this premonition, lead me to leave the practice of medicine earlier than I might otherwise have done.

When I finished University and started working as a practicing doctor I was full of enthusiasm and keen to learn and use new skills. I saw myself as a medical technician; the better I could be at various techniques then the better my patients would fare and the more satisfied I would feel. This was a useful approach, it spurred my education and learning. When a young doctor I had little time for the “professional” hokum that my seniors espoused. It seemed to me to be a way of holding onto power in the face of technological change and advancement they seemed to be using calls to “professional standards” as ways to obstruct needed change. I was certain that I would never become an old reactionary like them.

But time progressed and I learnt my craft and I started to realise that technological skill was only one aspect of healthcare. There was also a large number of other skills that were necessary, political ability for example, to effect change. I also learnt through my successes and, more importantly, failures that there was an art to the practice of medicine which was as important as my knowledge or technical ability. I know that the times that I failed patients it was rarely through ignorance or ineptitude but rather because of a failure to relate to the patient equally and fairly. I recognised that when I failed; it was the times I rushed, did the job but little extra, and paid inadequate heed to the opinions of the patient or their wishes. I started to recognise that I needed more in order to be a decent doctor and began to discover the importance of professionalism.

I grew to learn that professionalism was an asset for both me and the patients I worked with. The NHS was changing around me, a culture of target setting and central planning was reducing the autonomy of clinicians and reducing the choice for patients. It is often said that patients have difficulty in making healthcare decisions due to the knowledge deficit and that they are almost wholly reliant on their medical attendants in order to make these decisions. This is not the case. I grew to be very aware that one skill that patients have is the ability to distinguish between good and bad doctors. They are much better at it than fellow professionals, they know who is good at the job and who is not. But unfortunately they do not get to make that most basic choice – the choice of whom to see, whose advice to seek and with whom they will work to improve their health. In the NHS these decisions are removed; you see the GP that covers your area and the specialist contracted for your area, the patient has little or no say in the matter. If they are lucky they will be paired with the best, on average they will receive average care, and if they are unlucky they may be stuck with the underperforming. You could be referred to the best doctor for people with Parkinsons  disease but if your problem is diabetes then this might be less than wonderful. Patients would rarely make this kind of mistake, systems often do.

This lack of patient choice was worsened by another aspect. The patient didn’t chose the doctor and the doctor increasingly didn’t feel that they worked for them as an individual. The central planning and target setting meant clinicians felt that their employer was the NHS, in its various bodies, not the patient per se. Targets were set at Health Board meetings not by patient-doctor discussion. Many times targets could be thought of as useful but a target which pays doctors to increase the number of people on statins might mean that the elderly man who went to see his GP because of loneliness and poor mobility might find himself on the bus back home with a prescription for a statin he had never thought he wanted. It may be beneficial for him, and it might reduce the cardiovascular morbidity of the group, but that had not been his issue and it is possible that the time taken to discuss the statin left less time to talk about the poor mobility and their fears about this. Taking a professional approach meant that, while we would try and meet the targets put forward by my employer, my first loyalty was to my patient and we had to address their concerns first, agree a plan of action with them, and only secondly try and mesh this with the central dictats which were aimed at improving the group.

Without this professional approach there was a great danger of starting to practice a little like a veterinarian. When you take your hamster to the vet, the vet assesses the hamster and discusses with you how you would like to proceed. If the vet informs you that you will have to sell your car to pay for the hamster’s surgery, or forgo a holiday, it is quite likely that the hamster’s days are numbered. We will all grieve for the hamster and agree that it was for the best. Increasingly I found that patients came to me for advice, for example with Alzheimer’s Disease, and I would consider whether we should start a cognitive enhancer. But I would not discuss this with the patient, who is now in the role of the hamster, but with the NHS prescribing group who was in the role of the hamster’s owner. They (Hamster owner/ Prescribing Group) often decided that economically it was for the best that we didn’t prescribe and while this was true at a group level (in health economic terms) it may not have been at the individual level.

These are always difficult decisions but they are difficult decisions that should be taken openly, after discussion, with the patient. The patient should be able to trust that the advice they are being given is the best advice for them as an individual not simply the best decision for the community. When patients choose their doctors they are seeking the best source of advice, advice they can trust because it is not skewed to meet a third parties interest.

In the NHS patients lack the ability to choose who they see. Doctors and nurses are  becoming increasingly micromanaged and their professionalism, and thus their independence, undermined. Together this leads to patients unable to work well with their medical attendants and unable to be certain that the advice given is the best available. It sets up distrust and discontent, they see that other European countries, with similar healthcare budgets to ours, do better by patients with common serious medical conditions. Patients read that survival rates for breast cancer in Britain are poorer than elsewhere and that we have more infant deaths than the European average. No matter how many politicians tell them that there are more doctors or nurses, or the NHS is doing more than ever before (which is quite possibly true), will counteract their experience of impersonal healthcare and poor quality outcomes. They will become dissatisfied and this dissatisfaction will continue to grow until the primary problems are addressed.

Until individual patients are again at the centre of how healthcare is delivered it is likely that even if we throw much more money at the system (which will probably be the electoral strategy) this discontent will grow. When we look back, we see the Tredegar Workmen’s Medical Aid Society made a great influence on Aneurin Bevan and influenced the development of the NHS. Unfortunately we seem to forget that the workmen in the Medical Aid Society chose and employed their doctors – they voted on who would be employed and sacked those that were felt inadequate to the job. I am sure this choice greatly enhanced the likelihood of patient satisfaction and is something that we need to rediscover.

Before my career had arrived at its natural end, I had premonitions that dissatisfaction by patients would be inescapable and lead to dissatisfaction in  clinical staff also. I could see the first changes in morale and attitude and felt I had to leave. I hope that I will be proved to be wrong in this prediction, as I have been on many others, but recent news has not given me cause for optimism.