Ben Hoban is a GP in Exeter.
We are all familiar with the idea of a contract, not least as employees or service providers in general practice. Binding agreements between parties specifying their respective rights and obligations, as well as the penalties for their breach, are ancient: we have copies of treaties between near-eastern rulers and their peoples from thousands of years ago.1
The social contract is even older, going back to the first human social groups. In this case, however, the agreement in question is less formal and not made between parties sitting on opposite sides of the table. Instead, the members of a group undertake their duties towards the group itself and expect the same benefits from it in return. In effect, each person gives up a part of who they are individually and receives back an equal share in the society that results from this pooling of selves. We exchange our personal agency for a collective one.2
For most people today, the social contract involves paying taxes, keeping the law, and doing what they’re told in an emergency. The state reciprocates by providing public services, enforcing law and order, and representing the national interest. Even though it is natural to refer in this way to the state as an agent in its own right and distinct from the people, it is technically a construct representing the delegated collective agency of those same people, based on the social contract. The state is a Leviathan: a giant and long-lived decision-making mechanism which we have built to take care of us according to certain rules. It is not a thinking machine, though, and acts blindly in obedience to those rules, enforcing them on society if needed.3
…each fresh challenge inevitably leads to others, as new structures have to deal not just with their allotted task, but also with other… sometimes incompatible structures.
Modern states are of course much larger and more complex than earlier societies, and their inhabitants are almost infinitely differentiated and interconnected according to their roles, privileges, abilities and needs. If we consider how successful societies meet the requirements of their growing populations, it is easy to see this complexity arising through a gradual accumulation of adaptive changes in response to the various pressures and strains they encounter over time. Within an increasingly complex society, however, each fresh challenge inevitably leads to others, as new structures have to deal not just with their allotted task, but also with other existing and sometimes incompatible structures. The social contract on which any state depends therefore eventually produces diminishing returns, as successive adaptations achieve less and cost more. Most states are too big to fail, and so instead of collapsing under their own weight, they enter a half-life, in which everyone still turns up to work, but nothing really gets done, and people start to look for help wherever they can find it.4
Although states are perhaps the most obvious example of this phenomenon, other Leviathans include healthcare systems, governed by their own version of the social contract, which exchanges the liberty of the individual for membership of a group.5 For doctors, this means submitting to professional regulation and the various directives, restrictions, and protocols which shape our working lives, and which allow us in return to lay claim to the resources of the state on our patients’ behalf. For their part, our patients are free to access NHS services, although it is expected in return that they will look after themselves properly and participate in vaccination programmes, health screening, and campaigns intended to pick up early symptomatic disease; more recently, commercial access to their health data has also become part of the bargain. On one level, it may be true that a consultation is the meeting of doctor and patient, but on another, we can observe that it is also where the system interacts with the population. If healthcare has become generic and impersonal, it is therefore not because it has lost its way, but because it has shackled itself to a Leviathan, accreting complexity like a barnacled crust.
Similarly, the idea that healthcare has become more complex because people are living longer and have more wrong with them confuses cause and effect. A system that expects to deal only with illness in its full flower can afford to be simple and patient-led, while one that aspires to nip diseases in the bud or prevent them entirely must go further afield to find them, look for them more carefully, and sometimes lead patients instead. Which of us has seen someone whose condition was both obvious and beyond cure, and not wished that they had consulted us sooner? And yet, every such case that we avoid requires additional layers of activity and complexity. People have been living longer and with a greater burden of disease precisely because this complexity has enabled us to identify problems which would otherwise have remained hidden and led them to die sooner.
The crucial question is therefore not how the system can keep pace with the complexity of disease, but whether its own adaptive complexity has now reached the point of diminishing returns…
The crucial question is therefore not how the system can keep pace with the complexity of disease, but whether its own adaptive complexity has now reached the point of diminishing returns, or even decline, as all Leviathans eventually must. The twin embarrassments of long waiting lists for specialist appointments and poor continuity of care in general practice, the growing number of patients seeking private healthcare as a result, and the displacement of established treatments for the many by expensive new drugs for the few all suggest that it has.6
The normal behaviour of any Leviathan is to carry on regardless, even when this becomes counter-productive, and the NHS is without a doubt a Leviathan: large, complex, rigid, anonymous, and increasingly built around specialisation; and yet it is what we have made it. The social contract on which the health service is based now requires people to delegate too much of their decision-making to a system that works well in a crisis but routinely fails to meet their ongoing needs because it confuses them with its own, and because it cannot relate to individuals as anything other than interchangeable members of a group. General practice, where on a good day previously patients have been seen as people first, and flexible, holistic care has trumped structural complexity, is part of the same system, and has been affected by the same problems. If it is still possible to rewrite healthcare’s social contract, though, this is surely where it must happen. We cannot do without such a contract, but it must be framed in a way that gives back agency to patients and doctors, enabling people to look after other people, rather than simply creating systems of ever-increasing complexity to deliver care which is mechanical and ultimately disappointing.
References
1. George E Mendenhall, Law and Covenant in Israel and the ancient Near East, Biblical Colloquium, 1955
2. Jean-Jacques Rousseau, The social contract, first published in French in 1762
3. David Runciman, The Handover: How We Gave Control of Our Lives to Corporations, States and AIs, Profile Books, 2023
4. Joseph A Tainter, The Collapse of Complex Societies, Cambridge University Press, 1988
5. Arthur W. Frank, Confronting the Medical Leviathan: reading a report from the front lines, Perspectives in Biology and Medicine, volume 67, number 3 (summer 2024): 470–481
6. Huseyin Naci, Peter Murphy, Beth Woods, James Lomas, Jinru Wei, Irene Papanicolas, Population-health impact of new drugs recommended by the National Institute for Health and Care Excellence in England during 2000–20: a retrospective analysis, The Lancet, Volume 405, Issue 10472, 4–10 January 2025, Pages 50-60
Featured photo by Nicholas J Leclercq on Unsplash.
