Published: 10/03/2005, Volume II5, No. 5946 Page 21
Dr Theodore Dalrymple has recently announced his early retirement from the NHS. Readers will know him as a regular contributor to a range of right-wing outlets, including The Spectator and the Telegraph, as well as the New Statesman.
He has written fluent tirades on a variety of subjects: teenage pregnancies and paedophilia, prison diet and bad behaviour, the loss of integrity in public institutions and British culture, misguided medical reforms, the failings of human nature.
But his favoured target is NHS management. For him, it is a culture of 'petty vindictiveness and dishonesty' in which 'a miasma of intellectual and moral corruption hangs over every hospital'. There are no half measures in these generalisations and no detailed evidence. For a man of science, he does not like to clutter his mind or his articles with too many facts, but it makes his writing all the more engaging.
Dr Dalrymple wryly compares the NHS to the Bolivian navy - no ships or sea but lots of officers with fancy titles and uniforms, waiting to become naval consultants on their retirement.
Ironically, he blames the demise of the NHS on none other than Margaret Thatcher for encouraging, and then naively implementing, the Griffiths report on NHS management in the mid-1980s.
Since then, managerialism has become a monster. This is a world in which 'it is impossible to point one's finger at precisely who is responsible for what latest idiocy'.
Although a staunch defender of medical professionalism, Dr Dalrymple also blames his colleagues for being supine in the face of surplus, power-crazy, amoral and talentless NHS managers.
As we tend to say when faced with an irrepressible voice to be reckoned with, 'love him or hate him, but you can't ignore him'. Maybe Dr Dalrymple could be dismissed as a quaint, reactionary malcontent.
But the agenda he sets for health debates could also be considered more even-handedly. His generalisations and prejudices could be tested.
His silences could also be interrogated, particularly in relation to the historical price paid for medical dominance. Reasonable questions are thus begged.
Is the NHS now hopelessly compromised by the all too rapid turnover of political interferences?
What is the most cost-effective skill-mix in complex health services between clinical staff and their managers?
Should those trained to treat illness be credited with expertise about health? Has traditional medical authority now been lost and a mature and honourable profession proletarianised? If so, is this outcome good or bad? What are the daily operational norms of probity and leadership?
If management indeed proves demonstrably inefficient and morally dubious, what could replace it? By contrast, if it is already efficient and morally worthy, how do we know?
The research and evaluation questions go on and on, usefully stimulated by reading Dr Dalrymple's hostile laments.
They are begged as much by his medical arrogance and the legitimacy afforded to it by publishing outlets as they are by the content.
The subtext in his columns in recent years has been that not only do medical training and clinical experience provide unique and superior insights into individual morbidity, they also generate an enviable expertise about health, social policy and our whole moral order.
If his stethoscope is now hanging, forlorn behind his study door, his pen will probably continue to flow at the desk.
Our self-appointed social commentator may well entertain and exasperate us all for many years to come - with any luck.
David Pilgrim is honorary professor of Lancashire School of Health and Postgraduate Medicine, University of Central Lancashire.