Medicine at the centre of the nation's affairsBMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6970.1730 (Published 24 December 1994) Cite this as: BMJ 1994;309:1730
- Maurice Shock, former rectora
The medical profession was shaped a century or so ago by the interaction of three forces. These were a class structure in which doctors were largely held to be gentlemen to whom deference was due, a society dominated by the activity of production (hence the label of the working class for the majority), and the doctrines of liberalism as the guiding star in politics.
Prime Minister Gladstone defined his task as “opening doors and windows.” The outcome was a minimum of government interference and control with the belief that professional self regulation was the way to ensure that practice matched principle. The state (the word was hardly ever used) was self effacing almost to the point of non-existence.
These are ghosts of the past, but it is a comparatively recent past. Within memory, the major domestic preoccupation of politicians of all parties was how, and to what ends, the working class could be absorbed into the political system. Health had a crucial part to play in this task, as Lloyd George and others saw early on. The “panel” was very much a forerunner of the NHS. Indeed, Bevan based part of his case in 1946 on the claim that 21 million people were already on the “panel,” clear evidence of the degree to which society was still dominated by production.
While speaking of Nye Bevan, we might examine his claim that the NHS was “pure socialism.” In fact, it was rather closer to being “impure liberalism” in the consideration with which general practitioners and consultants were treated, the considerable freedom enjoyed by local administrations, and the low profile of government itself. That is why many remember the period as something of a golden age. It suited almost everyone very well.
Health becomes political
Looking back, it is astonishing that in the early years of the NHS health was hardly a political issue at all. For more than a decade its minister was excluded from the Cabinet. Nor can a single reference to health issues be found in the definitive study of the 1959 election -despite expenditure having been kept down; indeed, there had been much less change than we are now inclined to think.
The shake up came after the Conservative victory in 1959 with the arrival of Enoch Powell, determined to breath life into the Guillebaud report on the cost of the NHS and do much else. In getting the NHS moving, perhaps he even deserves a niche in the pantheon with Nye? Since then, there has hardly been a moment of rest: medical advances on a scale without precedence, the rise and rise of the aged population and the triumph of the consumer society over the producer society.
We have scarcely begun to come to terms with any of these individually, let alone in combination. Only think of the score of questions that now buzz so insistently about each of them. But, in combination, their force has obliterated much of an ancient land-scape. Sum it up for your own condition: “The patient is different, the doctor is different, medicine is different.”
But the consumer society? We certainly know who is in it and who is not, since Douglas Black's concern has essentially been with the outcasts from it. The first blast on the trumpet was Macmillan's “You never had it so good” on his way to winning in 1959. In no time at all, almost all politicians were singing to no other tune. They had found a new cause to take the place of the two that had held the stage for so long: coping with the working class and dealing with the Germans.
The consumer—or if you prefer, the voter—was endowed with rights. Instead of the Rights of Man we had the Rights of the Consumer: the Social Contract gave way to the Sales Contract. Above all, the electorate was fed with promises, sometimes elevated to pledges, about what could be enjoyed as a standard of living or delivered as a level of public services. Lemons at half time
Not that there was any escape from much previously acquired baggage. The ghosts could not so readily be put fully to rest. Not so in the Far East, where the consumer society arrived as a kind of Big Bang. If you are inclined to think that much of the future can be glimpsed there, consider that a good deal of primary care is now organised supermarket-style in big urban areas. And who is to say that it might not be right for large, rootless populations?
That was one interpollation, a kind of lemon at half time. May I take a suck at one more? For the past few decades politicians have been able to act as they have because of the perfecting of the two devices of taxation on which their policies rested. These were that there should be no receipt of wage or salary before deduction of tax and no purchase of goods or services before payment of tax; in effect, no living at all without previous deduction.
A turbulent time
In spite of all the twisting, turning, and borrowing, limits soon began to appear and are now clear for all to see. They are set by the imperatives of a global economy, defined for our times by Mrs Thatcher's “You can't buck the market” and the increasing tendency of the consumer (voter) to give priority to private over public consumption whatever he or she may say to the young person from Gallup in the High Street on a Saturday morning.
The politicians rushed into the new world with zeal. A frenzy of government activity ensued. A perpetual St Vitus's dance gripped Whitehall and Westminster, and only rarely because Brussels was cracking the whip. Rules and regulations poured out in profusion, accompanied by the setting up of a whole new shadow system of government consisting of quangos and regulatory bodies of all kinds. The outcome has been control and interference on a scale that the Attlee government would never have contemplated.
The most obvious consequence has been the enormous expansion of the professions ancillary to legislation: lawyers and accountants. Indeed, historians may come to see this as the most enduring effect of unprecedented effort and activity by government. However that may be, I mention the phenomenon here because it was certainly the final nail in the old view of class equating the professions with gentlemen.
There was a longish period in which the medical profession thought that the turbulence would largely pass it by. It marked a failure to read the social and political signs, which were only too evident, and a consequent slowness to press for the reforms needed to adapt the NHS to rapidly changing circumstances. Consider an economic and social sign, obvious to all of us who have shopped at our local Marks and Spencer: the total obliteration of the once dominant Co-op. And yet much of the NHS remained in the mould of the Co-op from which it had sprung, though the lessons to be learned from Marks and Spencer had been visible for years.
Something of a vacuum had been left in the directing of what was probably the largest, and certainly one of the most expensive, organisations in Europe. In the main, doctors had failed to seize, or even to recognise, the opportunity. That charge of sluggishness must be extended also to include the snail's pace at which the profession was willing to change itself. For many of its members, an appropriate motto might have been, “The status quo is the way forward.” It may be that doctors had been lulled into thinking that any threat lay on the left. What else could have led to reliance on the argument that all that the NHS needed was more money? It was a red rag to a government that had amply demonstrated its state of reforming ferment.
It was hardly surprising, then, that the profession was thrown into such confusion when it was struck by the blitzkrieg from the right. It was blitzkreig with little consultation, indeed not much discussion, even with civil servants let alone those outside Whitehall. And there was appropriate accompanying propaganda about selfish doctors and their grasping trades union and about rights and charters for patients and how the government would be fighting for them. It was almost a textbook campaign. Particularly to be admired was Panzer General Clarke's handling of the decisive weapon, money.
No escape for doctors
Where does this leave doctors? I fear that there is no escape. Doctors are not like the clergy, who have been by far the leading profession during the past 200 years, and now inhabit what some of them doubtless call a niche market. But medicine and those who profess it are at the centre of our affairs, in the eye of the storm. What follows are a few reflections about the position in which doctors find themselves and what might be done about it. It is by no means exhaustive but is aimed at stimulating debate.
There is no point in trying to swim against the tide, against what has already changed our society and altered the ways in which we conduct our affairs. This is an age of regulated capitalism, in which the consumer is cossetted and protected, encouraged to be articulate, and persuaded of his or her power. Not, of course, that any of this should be taken at its face value. We are only too aware that the media, public relations, advertising, and politics have made this an age of mirrors. But the basic point is not affected: public support is essential. That must always begin with the patient, but doctors will also have to pay an entrance fee to the hall of mirrors.
There is as yet nothing on the horizon to challenge consumerism. It will be dented sooner or later, probably by a fit of morality, but that will not change the nature of the problem, only make it more complicated.
The potential remit, even for the leading profession, is a very large one, in terms of the range of activities that the way we live now requires. Forming alliances with other groups in health, and taking the lead when appropriate, seeking support from major external bodies like the Confederation of British Industry and the unions, maintaining close contacts with the media, dealing with parties and politicians at all levels from the constituency upwards, influencing government and not just the Department of Health—most of that is now conventional enough for a major lobby and is doubtless in hand, in need only of regular review and intensification where required.
But is it enough? One example takes us back to the fatal vacuum. Under the new arrangements many clinicians are involved in management but very few have become the managers. There is a need to ensure that more doctors, and young and good ones, become career managers and are properly trained for the job. How much interest has the profession taken in who teaches health services management and what it is that is taught?
A new body
It almost goes without saying that to achieve action on such a scale will require the leading professional bodies to surrender some of their independence to a new representative body which in its turn would be guided by a cabinet, serviced by a small but first rate administration. The remit of this top body should be clearly defined within a federal structure and largely confined to strategic and high political matters. Most of the functions that I shall be mentioning would naturally fall to the constituent parts of the federal framework, but without the top body the profession will be unable to punch its weight.
It is crucial that such a body, in discharging its task, does not take government at its own valuation. Here, as elsewhere, by “government” I do not mean this or that particular government. Any government is less powerful than it would have us believe, principally because it cannot guarantee a given level of economic performance or satisfy the expectations that have been raised in the consumer/voter. The genie can't be got back into the bottle, and whatever may be said about doctors being in thrall to a service industry is even more true of politicians.
As we all know, voters have become more and more cynical and sceptical about what politicians say and do. There comes to mind an Irish saying of some wisdom: “This pig doesn't weigh as much as I thought it did. But then I never thought that it would.” This has a bearing on the right's blitzkrieg and how it caught the profession off balance. A blitzkrieg can certainly achieve conquest but it cannot ensure effective occupation. It is tempting to say that guerrilla warfare is the answer, but it is not so. Building up support, forging alliances, giving out the right messages, with an eye always to long term objectives, can, however, recover much lost ground.
As to government itself, if it is wise it will see that there are benefits to be derived from cooperation with the profession—in effect, that its own ability to command and direct is limited and that it is itself in need of support for which a proper price has to be paid. But that is unlikely to happen unless the government sees the necessity, the requirement for which is having to face a strong and undivided profession.
It has to be admitted that this balance between acting simultaneously on the inner and outer tracks of politics is a delicate and difficult one to achieve. To be on the inside is essential, but so is being able to nip a politician's ankle when necessary. Politicians, amiable as they can be over dinner, understand that; but they are ready to knock you down after breakfast and kick you when you are down.
The danger ground, as ever, is money, with images of a profession with its hand forever held out, organised in a union presented as a conspiracy against the public interest. Exactly the opposite picture must be the aim, belief by the patient/consumer/voter that the medical profession speaks authoritatively and sensitively on medical matters and can be looked to for advice and guidance. But that will be hard to achieve if there continues to be a washing of hands whenever priorities and resources are at issue. The implications of participation in such matters are considerable but the choice is clear: be willing to get your hands dirty or risk the charge of too often being for taxation without responsibility.
A wider agenda
The profession's agenda should also become wider and more ambitious in other ways. I have taken three examples chosen almost at random. Firstly, it is of the greatest importance to get across the message that research and training are the keys to better medicine. But that will necessitate much closer attention to the selection and training of doctors with much upset to many vested interests. What sense, for example, does it make to preselect most doctors from 16 year olds who have chosen to do a narrow range of subjects at A level?
Secondly, the main engine of medical advance and also therefore the source of associated costs seems likely to continue to be the United States. We need not only a better early warning system but more systematic monitoring and assessment of the implications of what may be ahead, a task which should fall to the profession, though doubtless in association with others.
And, finally, Europe. Should Britain become a full member of a developing European Union, the profession would find itself grappling with a legal and bureaucratic construct for which little of its previous experiences will have fitted it. Rather necessary to be prepared and soon.
I have tried to show that the old ways have served their time. Thirty or so years ago, health and the NHS were still a slow running backwater. Now we have a torrent of a mainstream. Even though occasionally an outstanding individual can almost succeed in making us believe otherwise, it has to be faced that what served then will not serve now.
What, then, of core values or, as I prefer to think of them, the ancient virtues which have been distilled over time from the practice of medicine at its best? They remain the profession's greatest asset as it prepares to tackle the tasks that lie ahead. But core values or ancient virtues, necessary though they are, will not be sufficient in these turbulent times unless they are made relevant to the problems we face now and are backed by an organisation fit for the purpose.