Patients and the new contracts

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Abstract
Contracts excluded the patient's voice and lacked an intellectual overview It is said that behind every disagreement there are the bones of an old philosophy rattling around. Surveying the wreckage of the consultants' contract,1 and seeing also that the general practitioners' contract2–4 is floundering in heavy seas—such that even if it is rescued5 it will start life half drowned—has made us wonder what has gone wrong with the process of making contracts for doctors. We want to look deeper, to open out more fundamental debate about what medicine could and should be for, and so what should and should not be in doctors' contracts. Doctors and managers historically have prided themselves on their pragmatism rather than their philosophy. Getting the task done has been more important than asking whether the task is valid in the first place. To the negotiators from the BMA, the Department of Health, and the NHS Confederation, setting out in 2001 to draw up a contract will therefore have seemed a sensible and achievable task, whereas debating the philosophy behind the contract would have seemed an irrelevance. Yet now we see the results of trying to draw up contracts in a philosophical vacuum. In a far sighted editorial, Gillon et al drew attention to the fact that no social contract existed for the practice of medicine.6 They pointed to fundamental disagreements about what people expect from medicine. Fundamental disagreements imply the existence of different values and different philosophies. Perhaps the territory crossed by medicine in 2003 has not been mapped clearly enough for doctors' and managers' maps of reality to align comfortably with each other, or with the ground itself.7 8 Perhaps as doctors we do not understand ourselves fully enough so that, although we want a radically new contract,9 we do not like what we get. The patients have not been represented in the contract negotiations. The Department of Health claims to represent patients, yet it has its own intrinsic interests and limited resources and makes choices that patients may or may not agree with. At no stage of the negotiations of either the general practitioners' contract or the consultants' contract have patients had an independent voice despite the fact that doctors' patterns of working will be fundamental to the services available to patients. The presumption that a group of doctors and civil servants—both with their own valid but necessarily biased perspectives—can really know what patients want or need is an example of the democratic deficit in the United Kingdom. So even if the doctors and civil servants had achieved an agreement on contract, the question remains whether the results would have been acceptable to patients. We can now see that the negotiators on both sides in both consultants' and general practitioners' negotiations have been working too close to the problem, without a sense of deeper vision of where doctors, managers, and patients are going. Walt Disney used to have a strategy in which any project would include a dreamer, a realist, and a critic. The consultants' and general practitioners' contracts feel as if they were drawn up by realists and critics, and the results show the absence of dreaming. Where was the intellectual overview, the setting out of assumptions, the map to the future in any of the contracts? What were the contracts trying to achieve, and what reasons did they give for wanting to achieve these things? These are big questions about purpose that we now need to ask ourselves, whether as doctors, patients, or managers. As Kierkegaard says: “Whoever has a why to live will find a how to live.”10 Specifying work patterns, blood pressure targets, immunisation targets, and such like are the details in all this, not the purpose of the contract. Irritation over too many patients and endless extras are details that inevitably emerge from the current system because we have not mapped out what we should be doing and what we should not be doing. The patients are confused about what symptoms to bring to the doctor and when to bring them. We struggle to clarify their confusion but are not fully sure ourselves. This daily round and common task will not furnish all we need to ask unless set within a bigger frame of meaning. We need now to achieve this frame of meaning urgently. Smith pointed out that a lack of clarity about roles was part of the reason why so many doctors are unhappy.11 The new contracts did not address this lack, and the angry reactions to the contracts may reflect this lack.12 Any new contract has to work at many levels. Most of them have not been explicit in the debate about either the general practitioners' contract or the consultants' contract, and this has been a major flaw in both medical and government responses to these contracts. Until wider attention is paid to the many different levels and contexts at which contracts need to be effective the emergence of any successful new contracts is unlikely.