William House, Retired GP; Chair of the BHMA

Published in JHH13.3 – Saving the NHS

In late 2007 I travelled to London to contribute to Lord Darzi’s Next Stage Review about making improvements to the NHS. I had been a GP for 26 years and had never been asked to contribute at this level before. I sought out the ugly building on the south bank of the Thames, opposite Tate Britain. After the coffee and pastries about 100 of us sat in a very large room at tables of six including a facilitator. I was uneasy about the obvious expense of the occasion. Still, ever hoping for real reform I was eager to say my bit! We were handed sheets with questions. To my dismay, none of the questions seemed even slightly relevant to the serious systemic problems obvious to me. I tried to be positive as we chatted around the table and the facilitator wrote things down.

Later, at a plenary session, questions were invited from the floor. The panel included Lord Darzi with the NHS Chief Executive, David Nicholson, and some other bigwigs. I took my chance and asked why it is that GPs’ professional development received no state funding. I reminded them that, whatever the claims otherwise, the default drug company sponsorship was biased in favour of medicalisation and this is unsustainable. It is part of the problem. Nicholson briskly invited another question and no attempt was made to answer mine. It was as if I had not spoken. No one said anything, even over the tea and cakes afterwards. On the way home I pondered on the silence, the failure to challenge the system. It’s either stupidity or groupthink! They are not stupid people, so it’s groupthink. I don’t mean the bigwigs: I’m sure they are fully aware, but they are in Big Pharma’s bubble, so no change there. It’s the 100 silent and docile people in the room. That is the problem.

So what is groupthink? The word was invented by research psychologist Irving Janis in 1972 to represent a common tendency for doubting individuals to stay quiet when most others in a group seem to agree with a proposal or course of action. This might be fear of being the odd one out or of retribution for stepping out of line or some other upset in the harmony of the group, but whichever way, it leads to persisting with flawed practices, or making bad decisions, sometimes disastrously so. Indulging in collective rationalisation of the events follows on. Linked to this is blame. The group closes ranks and points at someone else, often stereotyping and penalising vulnerable others for daring to be different (see articles about David Zigmond in this issue). In that very large room in 2007 it was really the 100 people who were groupthinking their way to the deteriorating situation we now find ourselves in.

If you can control information, you can control people.

Tom Clancy

There are several reasons why groupthink is common in the health service, but the principal ones are stress and the narrowing of knowledge. The latter is interesting. Among the storm of reporting on the recent Trump and Clinton campaigns was an article in The Guardian by historian Timothy Garten Ash (Garton Ash 2016). One of his points is the polarisation of the press and other media. Supporters of each candidate can easily spend all day every day reading or watching news and comment that reinforces their own particular inclinations. Effectively, both candidates had their own media outlets – their ‘bubbles’. Voters read copy that reinforced their own viewpoint. Balanced reporting was very hard to find. The result: groupthink.

Much the same has happened in the NHS, but for different reasons. The volume of publications relevant to medicine is breathtaking. In 2010 there were 25,400 journals in science, technology and medicine In 2009 they published 1.5 million articles. A very substantial number of these are relevant to healthcare. Another huge number of articles and books in the humanities are potentially relevant to medics who try to take a broader view, especially GPs. Busy clinicians have no hope of keeping up in their own field, less still to read more broadly.

Gods don’t like people not doing much work. People who aren’t busy all the time might start to think.

Terry Pratchett

For most the solution is to rely on summaries and guidelines provided by others. These ‘others’ have their own agendas and live in different bubbles – someone else’s bubble. Without broadening your knowledge and dipping into very different worlds, groupthink becomes almost inevitable. You shrink into your small space and feel threatened by the unfamiliar; and nothing changes.

References

• Garton Ash T (2016) Do you live in a Trump bubble, or a Clinton bubble? The Guardian, 29 September. Available at: www.theguardian.com/commentisfree/2016/sep/29/trump-clinton[1]media-left-right-democracy (accessed 16 November 2016).