It seems unlikely that there has ever been a civilisation that lasted long on a policy of constant change. I'm not talking about the ones that went absurdly to the opposite extreme: the ancient Egyptians, for example, whose depictions of the human form were governed by a bizarre formula that remained unchanged for an almost unbelievable 4000 years. We don't want that. But it is almost as bizarre that our own society has made a fetish of change and built into its systems a powerful bias towards radicalism as an end in itself. ‘Managing change’ has become a discipline in its own right, whose practitioners (dare I call them priests) display an arrogant contempt for consolidation and gradual evolution from tradition, processes that created sensible progress throughout history as they tempered rare, but of course essential, revolutions.
An early critic of my book The Paradox of Progress ridiculed my suggestion that this country needs a Ministry of Leaving Well Alone (MOLWA) and ever since I have been shy about repeating it. But increasingly, as I watch the unfolding events of the subsequent 10 years, I think it was one of the most important things I tried to say:
‘It [MOLWA] would have the responsibility for monitoring and appropriately rewarding people who had the wisdom to maintain successful and satisfactory institutions unchanged. It would allocate knighthoods for services to stability. It would prepare legislation to enforce durability of innovations so that any changes would have to remain in force for a minimum of, say, 10 years except in the most exceptional circumstances. This would encourage a measure of serious thought before new ideas were introduced.’1
Change takes time to assimilate. Those of us on the front line all know that. Broadly speaking, you spend a year in chaos, followed by a year consolidating, and from the third year things begin to run smoothly. But as we so wearily know, changes in the NHS are coming very much more frequently than that. What's more, the interval between changes gets shorter and each tries to be more radical than the last.
Extrapolating this trend some time ago it seemed to me that the moment when the inter-innovational-interval (I-I-I) finally disappeared altogether was going to coincide, weirdly, with the millennium. At this auspicious juncture the NHS would go critical and be engulfed by the legislative equivalent of a nuclear explosion. I imagined something like the closing scene of Götterdämmerung — Valhalla and all the Godlike docs engulfed in flames and chromatic fanfares — saving the expense of attending a performance. Obviously I got my extrapolation wrong; I must have been out by at least a decade.
One of the legitimate changes in modern medicine is that doctors have learned to kerb their traditionally inviolate clinical freedom. The politicians and managers who have now taken over control of medical policy must grow up in a similar way and behave responsibly too. The time when every incoming minister of health can have their midnight wheezes imposed on the nation is over. RIP. Nor can we any longer afford to disrupt our service to accommodate the arcane theories of every passing band of highly paid management consultants.
Two of the many first rules of medicine that every doctor learns are ‘First do no harm’ and ‘If in doubt do nowt’. There may be a lot wrong with the present NHS; there may be many aspects that we think were well in the past and should have been left alone; but what it needs more than anything else now is a period of stability and consolidation. But to do that we must first change the culture that is so locked into rewarding change.
- © British Journal of General Practice, 2005.
