At first, I thought my criticism was simply because it was called “The Tony Blair Dictum”. For me, one of the most ‘successful’ Labour Prime Ministers in living history, and this is no time for hyperbole, was very good at knowing the price of everything and the value of nothing. This is what I thought was the heart of his failure to understand how modern business works, and the importance of people in the creation of value in the relatively new discipline of corporate social responsibility. But Blair was a lawyer and politician by trade.

The “Tony Blair Dictum” says “I don’t care who provides my NHS services ‘behind the curtain’, as long as it’s of the highest quality.’ Variants of it include the bit ‘as long as I don’t pay for it’, and indeed this bit is often tagged on to help to demonstrate that the reforms are not privatisation. However, if you include that the majority of contracts will be put out for competitive tendering, to avoid conflict, to the private sector – it is privatisation. It is taking away of resources to run a comprehensive, universal state-run service, and using the monies as consideration for entities running services for profit or surplus.

For ages, I thought my objection to this was purely in terms of my own business training. This training had taught me that increasing transactional costs was bound to magnify greatly the amount of wastage and inefficiency in running the system as a whole. Coupled with the loss of ‘economies of scale’, the likelihood of this process would be a fragmented service which costs money, and which is unlikely to be comprehensive. I don’t think my economic argument is incorrect. Nor do I think it’s somewhat disingenious for private contractors to run their services under the NHS logo, while it is well documented that programmed attacks on the NHS ideologically have taken place in parts of the media. Some parts of the media in an astonishing way have not reported on the ‘reforms’, estimated to cost about £2.5 bn so far, at all.

No, it’s not that. I think I find this Dictum potentially difficult, if it can be a different Doctor each time who sees you, and it doesn’t matter where they’ve come from. It suddenly dawned on me thanks to thinking about why Dr Jonathon Tomlinson (@mellojonny) loves general practice so much. My late father was a GP near Brighton for nearly 30 years, and he loved his job. He was a single-handed practitioner with a list of about 2500 with not a blemish on his professional record, and he did all his own on-calls. This means that he knew his patients (and often whole families) backwards – his families loved him as the community Doctor. He never breached medical confidentiality of course, but the continuity of care was of benefit to patients. This meant, like transactional costs, things would not get repeated to different people at different times, and things were not ‘lost in translation’ through Doctors reading the medical notes of other Doctors. My father knew his patients.

However, given that I have nothing to do with the medical profession, I am struck by how a ‘conveyor belt’ atmosphere had begun to emerge in the NHS, even in the brief time when I was a junior physician in busy Trusts in London and Cambridge. This means that the approach was that of a “production line”, what I would later know as ‘lean management’ (where it is very difficult to know the precise cause of clinical error because the system is literally firefighting all-of-the-time). In this production line, Doctors would never see the output of their combined efforts, the “product”, as the Doctor responsible for writing the discharge summary was invariably not the Doctor who had generated a ‘problem list’ when the patient was admitted to the Hospital in the first place.

This situation I feel is not unique to primary care, and certainly this is not meant to be any criticism of Group G.P. practices where Doctors are very keen to know the histories of all patients in their catchment. It is not meant to be a criticism of NHS Direct or the Out-of-Hours service, though the benefits of a patient seeing his or her own Doctor out-of-hours is not simply an issue of nostalgia. I think there is a clear parallel in the commodification of the legal profession. This commodification has seen law as not having a prominent place in one’s community (“There is no such thing as community” is possibly a more accurate phrase than “There is no such thing as society”), with the death of the high street law centre at odds with the flourishing multinational corporate law firms. Ironically, in the United States which has had a longer time to assimilate the effects of multinational corporates on modern life), there is now recognition from big-brand management consultancy firms that there is more value to be had inter-transactions rather than intra-transactions. This means that the approach of one ‘fee earner’ identifying and solving the legal problem, with that fee earner never to be seen again, is being replaced by a lawyer who is interested in the development of your issues over a long period of time.

This indeed had been the approach of the medical profession too. I remember being witness to some amazing physicians, who admittedly had remarkable memories but, who could remember events from the patients 20-30 years’ ago, which might have direct relevance to the symptom with which he or she was presenting today. Possibly, with the introduction of whole person care, this approach might take a comeback, and certainly continuity-of-care had previously been considered important for the conduct of medical professional life. Whether they intended to or not, my late Father and Dr Tomlinson have made me realise why I do actually find ‘The Tony Blair Dictum’, aside from macroeconomics, potentially very difficult.