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Sick, thick and dangerous

Inner-city doctors need police protection from thugs demanding prescriptions, says Theodore Dalrymple

23 August 2003

12:00 AM

23 August 2003

12:00 AM

As a conservative, I am against all unnecessary change, of course, but I welcome innovation that improves the quality of life. Thus I rejoice to learn that certain doctors in my neck of the woods are now conducting clinics for difficult and challenging (i.e., violent and dangerous) patients in local police stations. This will improve the quality of clinical care no end.

Naturally, the principal beneficiaries of this innovation will be the doctors themselves. They will no longer sit in fear and trembling behind their desks as their young male patients, decked out in the uniform of modern British savagery, make their unreasonable demands, compliance with which they are prepared to enforce by using their full and extensive repertoire of vileness. Few are the doctors in our cities who do not know what it is to be assaulted: and the rule is, once assaulted, twice comply.

If you had asked me when I first qualified as a doctor whether the nearby presence of policemen would ever be necessary for medicine to be practised properly, I should have thought you mad. Perhaps it was necessary in other countries, but not in ours. However, the English patient is now to medicine what the English football fan is to football.

The radical egotism of young male patients means that they cannot take no for an answer, unless superior physical force is at hand to persuade them of the meaning of the word. So long as there is a possibility that intimidation might work, they will use it; for, having grown up in a world of sluts, slobs, slatterns and psychopaths, they think that all social relations resolve into questions of power, of Lenin’s Who Whom: who does what to whom, or gets what from whom. What they understand is superior force: they may not like it but – like good creatures of the jungle – they recognise it when they see it.


Enclosed in a tiny world bounded by their radical ignorance, their intransigence towards the doctor derives from two ideas: that they are consumers, and that they have rights.

In the marketplace, of which they form the reserve army, the consumer is sovereign: the customer is always right and can do no wrong. Successive governments have sought, with unaccustomed effect, alas, to persuade people that their relationship to the doctor is that of customer to supplier (without, of course, giving them a choice as to their supplier, for that would require the total dismantlement of the NHS, which in turn would require courage). The patient goes to the doctor, therefore, as he goes to the sweetshop, to obtain what he wants; and the doctor’s job is merely to serve him with it. Unfortunately, if the doctor doesn’t have what he wants, or refuses to give it, the patient cannot easily go elsewhere, and so grows angry. Patients whose only experience of not getting what they want is having been thwarted by those with more raw physical power than themselves try, usually successfully, to intimidate the doctor. He reaches for his prescription pad, or the sick note, or both, though he knows perfectly well that there is nothing wrong with the patient other than that he has the soul of an urban savage.

The urban savage has rights, though, of which he is only too aware. The most basic of his rights is to be happy, and happiness, as everyone knows, is a matter of getting everything you want. If a doctor refuses to give a patient what he wants, therefore, he is denying him his human rights. No wonder, then, the patient grows angry: not to be given sleepers to trade on the black market or to space him out during the day is in the same category as being arbitrarily arrested and maltreated by the police.

The doctor in an English slum is like a lone gazelle thrown among lions: there is nothing to protect him, certainly not the law. The police are of limited use, as the following story shows. A man went to his doctor to demand medication that the doctor thought he did not need and – unusually, in the circumstances – refused him. The patient at once became menacing and threatening, and the doctor called the police.

The police arrived. What did they do with the menacing and threatening patient? Did they haul him off to the station and give him a stiff ticking-off? No; they brought him to our hospital, depositing him in the casualty department. There he repeated his performance when denied the medication he demanded, and the police were called again. Did they haul him off to the station and give him a stiff ticking-off? No; they brought him to me, the doctor of last resort. Once again he was menacing and threatening, and this time hit a member of staff. The police were called. Did they haul him off to the station and give him a stiff ticking-off? No; they escorted him from the premises and dumped him at a street corner.

The resistance of the doctors in this case was unusually consistent, but it was almost certainly futile. Before the day was out, he would almost certainly have found a doctor whom he could intimidate into prescription. Doctors have often been criticised for over-prescription, sometimes justly; but in Britain a new reason has been added for this practice.

I think it true to say that a large proportion of prescriptions for antidepressants and addictive tranquillisers in this country are written as a means of ensuring the swift and peaceful departure of the patient from the doctor’s presence. Certainly, I have never spoken to a doctor round here who denied it. Prescription of these drugs is for the doctor’s, not the patient’s good; the doctor feels relieved when he sees the patient leave.

So while it is often said that medical services in prison should resemble those in the NHS, I think the opposite is true: that medical services in the NHS should resemble those in prison. For only the presence of several very large men nearby, ready to intervene if the patient kicks off, to descend to the argot of prison, permits the doctor to prescribe or not prescribe as he ought. Clinics held in police stations are obviously a step in the right direction, though I recognise that they represent a threat to the interests of manufacturers of antidepressants and tranquillisers, whose semi-useless, semi-harmful products would not be prescribed to the millions who do not need them. But job satisfaction in the medical profession would increase enormously, for there is no more professionally demoralising activity for a doctor than prescribing out of fear of patients.


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