To understand the medical profession it is necessary to understand its history and how it came to be one of the most powerful and respected professions in the land.
When the British Medical Association was founded in 1832 the medical profession was neither powerful nor respected. Surgeons were craftsmen, physicians were domestic servants of the rich and apothecaries were tradesmen. These were the three occupational groups out of which the medical profession was to be forged.
Muirhead Little, in the official history of the BMA, points out that until 1846, with the first publication of the Medical Directory, there was no list of qualified medical practitioners. (E.M. Little, History of the British Medical Association, 1832-1932, London 1932; this was reissued in 1981 as the first volume of a two-volume history.) However the bulk of those practising medicine at that time were unqualified. The 1841 Census gave 33,339 persons as practising one or more branches of medicine, but the Medical Directory for 1853 showed only 11,808 as then qualified.
Even so a medical qualification did not carry the status it now carries. Muirhead Little comments that
[in 1832] the average medical practitioner was a man of little culture or general education. The graduates of Oxford and Cambridge and of the Scottish universities were probably as well educated as the members of the learned professions of the church and the law, but the rank and file of the profession had received its training through the sytem of apprenticeship. It is undeniable that it involved at the best the too early termination of the general education of the lads who, in order to get qualified by the time they reached the age of twenty-one years must have left school at the age of fifteen or sixteen. At its worst, if the master neglected his duties, or the pupil was idle and cared little to learn, the period of apprenticeship too often represented so much precious time wasted.
In 1832 Charles Hastings called together a meeting at the Worcester Infirmary to establish the Provincial Medical and Surgical Association, later to become the BMA, whose role was to be to transform the status of medicine into a profession ranking with the other learned professions.
The first task was to define the profession. From the establishment of the BMA in 1832 it took until 1858 to persuade Parliament to legislate for the establishment of the General Medical Council and the Medical Register, and thereby distinguish in law a doctor from a quack.
From that basis it was possible to begin the public relations exercise of presenting doctors as professionals providing a devoted and disinterested service to the sick, based on sound scientific knowledge and practised with absolute integrity.
The success of that 150-year process can be seen in the status of the profession today.
The Campaign of Professionalisation
The period from 1832 to 1858 was dominated by the campaign for a Medical Act and the establishment of a General Medical Council At least seven unsuccessful Bills were promoted during that period. These and the successful Bill of 1858 were very largely drafted by the BMA, and their promotion was one of its major activities.
The BMA at this time was also concerned with the promotion of public health. It campaigned for improved vital statistics, playing its part in the 1836 Act for the Registration of Births, Deaths and Marriages. A report on vaccination against small pox was the main factor in stimulating the Vaccination Act of 1840.
Tte Association was also concerned with the advancement of medical science and held a series of scientific meetings. In 1840 it launched the forerunner of the British Medical Journal.
We can see in these early activities of the BMA the strands which continue to this day – public-health campaigning, scientific work, publication of scientific journals and the defence of the interests of doctors centred on the advancement of the status of the profession.
In the latter half of the nineteenth century the BMA addressed itself to the exploitation of doctors by the friendly societies and the Poor Law institutions, as well as to the status of doctors in the armed forces and in the Indian Medical Service. It made known its views on a wide range of public-health matters and some of these views, on housing and on factory legislation for example, placed it unequivocally on the side of social reform. Its scientific work made it an increasingly authoritative point of reference on matters of medical science. In 1877 the BMA established a special committee to investigate the use of chloroform. This not only set a precedent for the appointment of special BMA committees to look at scientific matters, but also initiated a programme of BMA activity on the safety of anaesthetics which culminated in the publication of a major report on the subject (the Waller report) in 1911. Early in the twentieth century we find the BMA attacking the sale of patent medicines of dubious therapeutic effect, and, indeed, throughout the period the BMA attacked quackery.
The BMA had found a formula which was very powerful. It had established itself as a major scientific society. It had demonstrated its public spirit by its public-health campaigns. At the same time it campaigned for the suppression of competitors to orthodox medicine, and for increased status for the medical profession.
The formula worked.
The Ideology of Medicine
Out of this historical process an ideology has emerged, in the sense of a way of looking at the world which is shared by the substantial majority of the profession and forms the basis of professional debate and the profession’s collective behaviour. This ideology also shapes the individual thinking and behaviour of members of the profession.
What then are the characteristics of this ideology?
An Embattled Profession
Objectively, the medical profession is a powerful force in health care – probably holding more than half the total power in the health care system and certainly far outweighing any other single group in its capacity to determine the policies, resource-allocation, priorities and practice of the NHS. Objectively, its refusal to share that power with patients’ groups, other professions, other health workers or the democratically elected representatives of the people imposes upon it considerable responsibility for the decisions which are made and casts it in the role of an ‘oppressor’. Resistance to medical power by other groups who have a legitimate claim to some part of the power is, objectively, not anti-doctor but simply resistance to domination by an over-mighty group, which has a right to a share of power but not to a monopoly of it.
However the medical profession does not see itself in that way. It feels embattled. It actually feels itself to be powerless, pushed around by hostile and powerful forces against which it must maintain relentless hostility in order to have some slight influence on events.
This perception is reinforced every time some other group attacks some aspect of the medical profession’s use of that power; far from seeing itself as having created that opposition, the profession sees its old enemies at work trying to roll back some toe-hold of influence that the profession has gained in its bitter struggle against a hostile world.
This sense of being besieged is very obvious in the speeches of delegates at the ARM. It was even more apparent in the articles in World Medicine, a journal which thrived in the 1970s and early 1980s by allowing ordinary doctors to write articles expressing their ordinary thoughts, thereby creating a very popular house-journal of medical thinking at the grass roots. (World Medicine suffered a major blow when its editor changed after an argument with the magazine’s new owners and many of its regular writers ceased to contribute in protest. It ceased publication in 1984.) The articles in World Medicine brought to the fore a fierce libertarianism, radical in an unfocused, almost unrealistic, way, impatiently dismissive, yet at the same time fearful of administrators, politicians, unions, other health workers or any group of patients who claim to be more than the passive recipients of the profession’s devoted service.
These articles reflect accurately the way in which doctors talk amongst themselves about such issues.
This sense of embattlement does a great deal to sustain the effectiveness of the BMA. The BMA plays public affairs like a game of chess, vigilant not only for the current threat but for anything which might shift the balance of positional advantage. It will cast the net very wide in its search for the hidden manipulations of its enemies. When the Health and Safety at Work Act contained a clause imposing upon suppliers the duty to ensure the safety of their product, the BMA protested that were this to be applied to medical services (a thought far from anybody’s mind and far from the restricted legal effect of the clause), clinical freedom would be in danger.
This paranoid delusion is readily explicable in terms of the profession’s history of struggle to raise its status and influence. Indeed there are many other examples in human affairs of the inability of a group which has struggled against oppression to perceive that the battle has not only been won, but that the group is now itself an oppressor. The most horrific examples of this phenomenon are probably the Afrikaner and Israeli societies.
A United Profession
The main weapon in the medical profession’s battle against the hostile world has always been its absolute unity. To divide the profession, especially under attack, is the ultimate sin. It is out of the concept of unity that many of the restrictive practices, which the medical profession glorifies as ethics, can be seen to have originated.
It also explains the love-hate relationship between the profession and the BMA, in which no doctor seems to approve of the BMA, but every member has some private reason for continuing to pay the subscription.
The idea of’never criticise another doctor’, which causes so much unhappiness to the victims of medical malpractice, runs very deep in the medical psyche. So too does the tendency to band together under threat. I remember attending a Politics of Health Group meeting at which a critique of medicine was being developed by a number of non-medical people into quite a major attack on the way in which doctors behave. The doctors present, each and every one of whom agreed entirely with what was being said, felt it necessary to defend the profession, to the bemusement of their non-medical colleagues who felt betrayed to meet such resistance from people who they thought would share their views.
A Depoliticised Profession
There are two reasons why the phrase ‘no political stance’ had such a deep emotional resonance for the delegates to the 1983 ARM, when it was debating the question of nuclear war.
The first is that politics is seen as disuniting the medical profession. This may seem at first sight to be inconsistent with the sophistication of the medico-political machinery, but medical politics is itself depoliticised. It centres on conflicts between interest groups within the profession (such as juniors vs. consultants) and on the careers of individual medical politicians. It does not primarily involve conflicts in ideas and values.
The conflicts between interest groups are part of the process of negotiating the terms on which the unity of the profession can be maintained. The careers of individual medical politicians are a process of testing the future leaders of the profession – rewarding the capacity to fight for radical ideas as a junior with co-option into the medical establishment when the capacity for compromise has been learned sufficiently to ensure that the boat is not rocked. The vigorous debate, hotly contested elections and sophisticated machinery for resolution of differences of opinion have nothing at all to do with differences in ideas. Which is why the left, in seeking to use them for their ostensible purpose, is seen to commit such treachery. It is indeed treachery to use the machinery of unity to pursue divisive sectional ideas.
But the depoliticisation of medicine does not just serve internal purposes. It is also important for external consumption. Doctors derive their status and power from their perceived independence.
This may seem inconsistent with the openly political behaviour of the great campaigning Medical Officers of Health in promoting social reform, or with the activity of the BMA on such issues as seat-belt legislation and anti-smoking campaigning.
Yet this inconsistency is in fact the expression of a paradox: the power of the Medical Officer of Health derived from the significance attached to a medical opinion, and that in turn derived from the depoliticised perception of medicine. Likewise the power of the profession to intervene politically in matters affecting health is considerably enhanced by the fact that such intervention will still not be perceived as politically motivated, whatever the reality of the situation.
The paradox is that the more politically motivated a particular doctor, group of doctors or medical organisation, the more it has to lose if the depoliticised status of the medical profession should ever be lost. If the left ever took over the BMA we would find that it had ceased to be useful to us. Indeed not only would the BMA have ceased to be useful, but the protection which its non-political mantle throws over anything associated with the profession would also have been lost, so that much of the authority which left-wing medical organisations are able to deploy would also disappear.
A Conformist Profession
Unity of the profession expresses itself in a deep conformity. Views are ‘right’ because ‘the profession holds them’. The norms of the profession are loyally followed, and unquestioningly defended as ‘the way that things must be’.
Doctors protest their independence and individuality but in fact this is only a myth in which, in true conformity, they loyally believe.
A Fiercely Independent Profession
The medical profession is organised along the principle that once you have ensured that people conform loyally to the right ideas you can then allow them a considerable degree of independence of action. Indeed this explains how intelligent people can consider themselves to be individualists when in fact they are extremely conformist. (There are strong parallels here with Maoist forms of organisation.)
This form of organisation is achieved by a very liberal medico-political system and a very libertarian system of organisation of practice coexisting with a very illiberal system of victimisation in the junior grades.
Left-wing principals in general practice and left-wing consultants enjoy considerable freedom of speech and action. Indeed they are feted as free-thinkers, invited to take the floor to demonstrate the profession’s liberalism and sought out to stimulate thought in seminars and conferences. This is possible because the system has ensured that they are an insignificant and harmless minority.
In clinical terms, too, the value attached to individual doctors’ freedom to prescribe the treatment of their choice and to make their own judgements is matched only by the extent to which it is unlikely that this freedom will be used in any way that is remotely unorthodox.
This preservation of independence is part of the laager mentality, and explains the emotional power of support for private practice and the independent contractor status, even amongst those who do not share the powerful economic incentives that a minority of doctors have in preserving these systems.
An Ethical Profession
Ethics are important to doctors.
The profession embodies its restrictive practices in its ethical code, with restraints on advertising and on the poaching of patients. But these restrictive practices coexist in the ethical code with some very idealistic principles about dedication to patient care.
These principles are important partly because they conceal the fact that much of medical ethics is merely a set of restrictive practices but also because they are absolutely central to the profession’s claim to be a dedicated servant of the public, a claim on which the status of the profession depends.
That these principles have an economic basis does not detract from their idealism or from the extent to which they are powerful motivators of altruistic behaviour. Doctors in other parts of the world have faced imprisonment, torture or death in the name of their commitment to patient care, and there is no reason to suppose that the British medical profession would be any the less courageous if faced with the same dilemmas as their colleagues in, for example, Chile.
It may be argued that the profession takes the short-term disadvantages which such action brings as a protection for the long-term interest in its status and respect. But that does not detract from the fact that what is done in pursuit of the ethical code is right – sometimes gloriously so.
The essential principle of this real ethical code is the principle of an overriding commitment to one’s responsibility to the patient. Following on from this is the principle of confidentiality which is important because it guarantees that patients will be able to approach doctors and freely confide in them, unimpeded by fear of the consequences if their identity or the information conveyed should become known.
An Exclusive Profession
The struggle to set up the General Medical Council (CMC) was the first major battle to be fought by the profession in the process of establishing itself. For that reason alone the idea that the profession should control its own composition is an important one, in that it represents an achievement out of which the profession acquired self-confidence and dignity.
For that reason ‘covering’ (professionally associating with unqualified practitioners) is a major ethical offence for which doctors can be struck off, although co-operation with serious practitioners of alternative medicine has become acceptable over the last decade.
For the same reason the General Medical Council has emotional significance well beyond its actual functions. The CMC has quite limited functions. It maintains the Medical Register, it inspects medical schools and recognises their qualifications and it controls registration of doctors qualifying overseas. It has a general responsibility for co-ordinating medical education, although it has very few powers to go with this responsibility, and postgraduate medical education is really controlled by the Royal Colleges. The CMC’s most important function is probably its enforcement of medical ethics, through its disciplinary procedures. It also has power to suspend the registration of doctors who are unfit to practise because of ill-health.
Despite this quite limited role, elections to the General Medical Council attract much more attention than elections to much more powerful bodies, such as negotiating bodies, BMA committees or the Boards of the Royal Colleges and their Faculties.
Similarly, campaigns to reform the CMC have a significance out of all proportion to its actual importance. When the GMC was first set up it was composed entirely of nominees of the universities and Royal Colleges together with a small number of royal nominees, of whom a few were lay. A long campaign was waged to add elected representatives of the whole profession, a campaign that was successful in 1886, and then to increase the number of those elected representatives, until finally in 1979 they became the majority of the Council. Since no University or Royal College has been willing to give up its seat on the GMC, the principle that elected representatives should constitute the majority of the Council meant that it had to consist of 95 members, an absurd size for a body with such limited functions.
The significance of the GMC, however, is not purely historical and emotional, even if its practical functions seem limited. It plays two important roles in the maintenance of the status of the profession.
The first is that for the medical profession to be seen as a body of highly qualified, disinterested servants of the public, there must be a system whereby the profession is restricted to those who are properly qualified and those who are unfit to practise can be excluded by strict application of the ethical code.
The second is that the GMC enforces the requirement that individuals must have gone through a process of medical education consisting of a medical-school training followed by a year as a house officer. It thus makes compulsory the process through which doctors are socialised into the thought processes and norms of behaviour of the profession. It then enforces those norms of behaviour through the application of the code of ethics.
Reproducing the Ideology
Marxists refer to the process whereby norms of behaviour and thought are passed on as the ‘reproduction of ideology’, and it is important to be aware of what that phrase means in the context of large liberal institutions.
It would be ridiculous to suggest that the medical profession is a large conspiracy to conceal its true interests from the public, and to present instead a face that maximises its power, influence and economic interest. It would be equally absurd to suggest that there is, at the core of the profession, a small band of conspirators who manipulate the rest.
It could be said, without being ridiculous, that doctors are aware of their economic and political interests and consciously behave in a way which enhances them, perhaps rationalising that behaviour for the sake of their self-respect. However I still think that it would be an incomplete, and to a large extent misleading, picture.
In a pluralistic society, human beings form organisations in order to do collectively what they cannot do as individuals. In those organisations they debate their strategy and their objectives and reach a view as to the goals which the organisation must pursue and the methods it must use. If conditions favour the organisation, if it is pushing with the grain of change and it does so successfully, it grows and becomes powerful. It then begins to change from being an organisation of like-minded enthusiasts into an institution which people will become part of in the ordinary course of development of their lives.
As people join such an institution they go through the normal reactions of human beings joining another group of human beings. People are conformist, and have a need to be accepted, so they seek to learn the norms of the group and to model their behaviour on those norms.
Most people who join institutions do so without consciously questioning their norms. That is, indeed, the main difference between an institution and a small group of like-minded individuals. People joining the latter will first of all find out as much as they can about the organisation and decide whether they want to be part of it. The process of adjustment will therefore be slight, or if it is great it will be in welcome directions, since otherwise they would not have joined. In contrast people join an institution because they need to, and if people need the institution badly enough it can demand considerable adjustment to achieve compliance with its norms of behaviour, especially if it is protected by an effective monopoly (either legally or normatively established). People join the complex of organisations which constitute the profession of medicine because they want to practise that profession. This may be out of a wish for a secure occupation, out of an idealistic wish to help the sick or for other reasons. They acquire the norms of the profession as rapidly as possible so that they may fit in and get on with life. They have no wish to change them or even to be troubled by considering change, since they simply wish to live their lives. The norms of the profession are safe with them. They have the power to change them but would not consider the possibility.
Some people, however, have a political bent. They wish to be leaders of the profession and to help shape its destiny. They seek to learn the parameters within which medical politics is played and they become aware of the sacred cows which they are not supposed to challenge. They then stop challenging them, convinced that to do so will be useless and will diminish their power to influence events in other more ‘realistic’ areas. The norms of the profession are safe with them too. They may or may not have the power to change them, but they are convinced that they do not have that power and that it would be pointless to try.
Some of the people with a political bent, a minority within a minority, will be rebellious. They will want to change fundamental aspects of the profession’s norms of behaviour. They will be detested by the non-political for troubling them with issues they do not want to consider. Amongst their political colleagues some will detest them, some will fear them and others will admire them, but all will agree that their ideas are possibly dangerous and certainly impracticable. They will be marginalised.
Some of them will nonetheless earn respect, perhaps as a researcher or a clinician or for contributions that they are able to make to the safe areas of medical politics – as an organiser, a negotiator or a source of ideas. They will then find that they are accepted. Their rebellion is tolerated as an eccentricity. It may fte said, indulgently, of a senior member of the profession, ‘Old Jock always had this thing about patients’ rights’. This conveys respect and love for Old Jock, a mainstay of the profession, licence for his rebellion and a total refusal to listen to him in the areas where he rebels. Old Jock may be very powerful indeed, but the one thing he will not have power to do is anything connected with patients’ rights. He will be no threat to the norms of the profession either. His ideals may be undimmed, his struggle undiminished, but the profession will love him too much to listen to him. For his own good they will respect him for his research, his practice or his educational or administrative contribution, whilst chortling appreciatively at his rebellion.
In these respects the medical profession is no different from any other human institution in an advanced capitalist society. It is powered not by a political will to stay the same but by the lack of a political will to change. It rests on human conformity, on the human desire to remain part of the anonymous crowd. The ideas of an institution will probably represent values and interests that are important, for the original organisation would not otherwise have grown into an institution. But they may be outdated, they may represent past priorities which are no longer relevant (perhaps are no longer relevant precisely because the original organisation was so successful in tackling them).
When norms of thought and behaviour become irrelevant they will start to fade away. One generation will pay less attention to them, the next will therefore see them as less important and admit the legitimacy of another point of view, the next will debate them and the fourth will abandon them. In the meantime they will be rationalised in a host of ingenious ways.
Education
I remember on my first day in medical school sitting in a lecture theatre with the other new students, most of us fresh from school, hearing a pep talk from the Dean. One of the things that he stressed was that we were different from the other students of the university. We were junior members of the profession, and need not concern ourselves too much with events across the road in the students’ union. This may, of course, have been no more than an attempt to insulate the Faculty of Medicine from the gathering storms of student rebellion – it was indeed 1968. But similar pep talks are given today. They have their effect. In medical schools such as University College Hospital (London) or the provincial medical schools which are part of a multi-disciplinary university, there is a considerable tendency for medical students to associate more with the medical school than with the university. In those London medical schools which (apart from their position as part of the amorphous University of London) have no link with other disciplines, there is a tendency for the students’ union not to be affiliated to the National Union of Students. Although the NUS has a Health Students’ Section, medical students tend to disregard this as their representative body, and recently the Associate Members’ Group of the BMA has been established and made a strong bid to be seen as the main representative body of medical students.
During their first two years, the preclinical years in which anatomy, physiology and biochemistry are taught, medical students (except at Oxford and Cambridge) learn facts rather than how to think.
It is not surprising, therefore, that doctors are accustomed to think in terms of a factual body of knowledge and a correct view of things, rather than in terms of uncertainties and value judgements.
The divorce of medical students from the rest of the student body is accentuated during the last three years of their course, the clinical years in which students are taught the principles of medical practice. The place of education now shifts from the lecture theatre to the hospital ward. The times of clinics and ward rounds no longer fit so easily into the life of the university and the terms are longer so that the students who form friendships outside medicine would be left alone when those friends went down for the vacation. In any case most of the non-medical students who came up to university with the new medical student leave two years before the end of the medical course. Medical students are thus thrown back onto friendships with each other. At the same time they move into the alien environment of the hospital and have to learn how to behave. They begin to model themselves on their teachers, learning their clinical skills as, in effect, their apprentices. In doing so they learn more than clinical skills. The ward round is an environment for conversation about medical affairs and ethical concepts as well as patient care. Students are in the vulnerable stage of anticipatory socialisation and it would be intimidating to disagree openly on a ward round with the views of their teachers. Gradually they pick up the messages as to the way that doctors are supposed to behave and to think.
After qualification doctors spend at least three years as junior hospital doctors — one of them as a pre-registration house officer and two of them as a Senior House Officer (SHO). Doctors who are to specialise will spend much longer.
Junior hospital doctors work long hours – an 80-hour week is regarded as normal – and in their spare time they study for higher examinations. Life is therefore almost exclusively oriented around medicine. Many of them actually reside in the hospital. The inward-looking exclusiveness of the medical profession, which began with preclinical students being encouraged to see themselves as different, and continued with clinical students being separated from the rest of the university, now develops into junior hospital doctors actually being separated from the rest of the world. Add to this the anxiety of doctors who are faced with life-or-death responsibilities for which they are not yet prepared, the insecurity of doctors being employed on short-term contracts and the vulnerability to socialisation of those who are at the outset of their careers and anxious to conform. The circumstances are ideal for this new cohort of doctors to learn the ways of the profession, internalise them and believe them. Indeed concentrated exposure to new ideas in situations of anxiety and isolation is the basic technique of brainwashing.
Victimisation
To this psychological vulnerability must be added fear of victimisation. Junior hospital doctors are employed on contracts which last for six months or a year. At the end of the contract it will not be renewed – another job must be found. Only at the higher grades of registrar or senior registrar do doctors receive contracts for a period of years, but even then they know that when they become ‘time expired’ it will be necessary to move on – indeed not just on, but up, since a time-expired registrar must find a senior registrar post, not just another registrar job. Add to this the fact that in the popular specialties there is a pyramid in which doctors compete for a number of jobs which diminish as they climb the pyramid, so that some must fail – a sort of gigantic musical chairs with careers as prizes and with those who lose having to go back to the beginning of another game in another specialty or in general practice.
It is well known, within and outside the profession, that doctors who make trouble have difficulties in climbing this pyramid.
This victimisation, however, is subtle. Those who are good, who pass their exams at the first attempt and are excellent at their specialty, are allowed to proceed even if they deserve to be victimised. These are the doctors from whose ranks will be drawn the free-thinkers and dissidents who are the living proof of the profession’s liberalism.
But most doctors are not brilliant. It is those who are part of the ‘average’ mass, who will require understanding of their faults and their exam failures, who form the bulk. They will receive that understanding and mercy to some degree if they conform, but not at all if they do not conform. The left is excluded not by overt victimisation, but by the denial of a second chance.
Probably only a handful of doctors suffer victimisation each year. Like all forms of terrorism, career victimisation is important not in the numbers it hurts but in the numbers it intimidates. While writing this book I wrote to the secretariat of the Hospital Junior Staffs Committee asking for evidence of victimisation. They supplied me with the names of two members of the committee who had not sought re-election in 1984 because of fear of victimisation. What is important is not that these doctors’ careers were damaged, for they weren’t, but the fact that they conformed in order to avoid that damage.
There are well documented cases of victimisation, and it is tempting to cite them to ‘support’ the ‘allegations’ made in this section. But to do that would be to be sidetracked from the real issue, which is not that victimisation occurs, but that it is part of the folk knowledge of medicine, conveyed from generation to generation by anecdote in the bar, by threats from consultants, by friendly advice to dissenters and by the way in which doctors use it as an excuse for failure and find the excuse accepted. This situation would terrorise whether or not victimisation ever actually occurred.
The Institutions of Medicine
The major institutions of the medical profession at national level comprise the General Medical Council, the BMA and its related committees, the Royal Colleges, and the protection societies.
General Medical Council
Elections for the CMC take place every five years and are a major medico-political event. The CMC is responsible for undergraduate medical education in the sense that it decides whether or not a particular medical course should be recognised for registering doctors. It also sets examinations for registering doctors who qualify overseas (although some overseas qualifications are recognised directly for full registration and EEC qualifications are recognised under European law). It exercises disciplinary powers. It also has a statutory responsibility for co-ordinating all aspects of medical education, including ‘postgraduate education’ (a phrase which covers the training of specialists and the updating of the knowledge of existing doctors) but this is a new power which it has possessed only since 1979, and it has no teeth comparable to those which it possesses for undergraduate education.
British Medical Association
The British Medical Association is a voluntary organisation. The general public often confuse the BMA with the CMC and assume that all doctors must belong to it. However membership is entirely voluntary and in the mid-1970s fell to a trough of around half the profession. It has since recovered to over 70 per cent, a more typical figure when the whole history of the Association is considered.
The BMA is a company limited by guarantee, recognised by the Inland Revenue as a learned society and registered as a trade union although not affiliated to the TUG. It is governed by an elected Council, which until the Tebbit laws was elected by the Annual Representative Meeting (ARM), but from 1986 has been elected by postal ballot, as indeed it used be until the mid-1970s.
The BMA is divided into Divisions and half the membership of the ARM is drawn from Divisions. The other half is drawn from the ‘craft committees’ which are the bodies recognised to negotiate for the medical profession. They are not BMA committees. On the other hand they are BMA committees.
In legal terms there is no doubt that the craft committees are part of the BMA. They are established under its by-laws and have no legal existence independent of the BMA. The complexity arises from the fact that their basic purpose is to negotiate for doctors and so the basis of their recognition for bargaining is at least as important as their legal status. They are recognised as ‘representatives of the profession’ and the basis of that recognition is that they are elected by all doctors whether or not they are members of the BMA. In the case of the committee which represents general practitioners, the General Medical Services Committee (GMSC), there is a further complexity in that it is not only a committee of the BMA but also the Executive Committee of the Conference of Local Medical Committees (LMCs), and it has never been clear whether its recognition derives from that status, especially since LMCs are the statutory representative bodies of general practitioners.
The complexity of this situation allows non-BMA members, and even rival trade unions, to participate in the craft committees, which are thereby representative of the whole profession, whilst at the same time keeping the whole structure within the broad ambit of the BMA.
The craft committees include the GMSC, the Hospital Junior Staffs Committee (HJSC), representing junior hospital doctors, the Central Committee for Hospital Medical Services (CCHMS), representing consultants and the Central Committee for Community Medicine and Community Health (CCCMC^p, representing community physicians and doctors in community health, child health and family planning clinics and the school medical service. The Medical Academic Staffs Committee (MASC) is also treated by the BMA as a craft committee, although the BMA holds full negotiating rights in its own name in the universities and has no need to enfranchise non-members if it chooses not to. For this reason the Medical Practitioners’ Union does not participate in MASC, even though it participates in all the other craft committees.
In addition to the craft committees the BMA has a powerful Ethical Committee, and a Board of Science. The BMA publishes the British Medical Journal and a range of other specialist journals. It maintains an insurance finance brokerage, BMA Services, in conjunction with a firm of financiers, and operates a network of industrial relations officers to provide normal trade union services to members.
Royal Colleges
The Royal Colleges (The full list comprises; the Royal College of Physicians of London, the Royal College of Physicians of Edinburgh, the Royal College of Surgeons of London, the Royal College of Surgeons of Edinburgh, the Royal College of Physicians and Surgeons of Glasgow, the Royal College of Obstetricians and Gynaecologists, the Royal College of Psychiatrists, the Royal College of Pathologists, the Royal College of General Practitioners, the Royal College of Radiologists, the Faculty of Anaesthetists, the Faculty of Community Medicine and the Faculty of Occupational Medicine. A Faculty of Pharmaceutical Medicine is in preparation and there have been talks about establishing a Faculty of Community Health and a College of Family Planning. There are also Royal Colleges in the Commonwealth and in Ireland) are the bodies which are responsible for the training of specialists, setting specialist examinations and issuing certificates of accreditation which declare individuals suitable for consultant appointments. There is no legal back-up for either the examinations or accreditation – theoretically any registered medical practitioner can practise any branch of medicine and could apply for any medical job, including highly specialist consultant posts. (Paradoxically, the only exception to this principle is in general practice. It is no longer possible to be appointed a principal in general practice without having undergone vocational training) A doctor who had not passed the specialist exams and achieved accreditation would, however, be highly unlikely to be appointed consultant.
The Royal Colleges are consulted by government about ‘professional’ matters, and have joint committees with the BMA and craft committees – the Joint Consultants’ Committee in the case of the hospital service, the Community Medicine Consultative Committee in the case of community medicine, and the GMSC/RCGP Joint Committee in the case of general practice.
Protection Societies
The protection societies are essentially mutual insurance societies which insure doctors against legal claims for negligence. They also provide advice on ethical and legal matters, and represent doctors when claims are made against them. There are three such societies – the Medical Defence Union, the Medical Protection Society and the Medical and Dental Defence Union of Scotland. Doctors working in the National Health Service are required by their employer to belong to one of these societies.
Local Bodies
Locally there will be local branches of the BMA and of each craft committee. The LMC is the local unit of the GMSC. The junior doctors’ Mess is the local unit of the HJSC, although recently the HJSC has tried to separate itself from the essentially social Mess, by establishing separate District HJSCs, a move which has had only limited success. Neither the LMC nor the Mess is part of the BMA. In addition there may be a local medical society and there will certainly be a Postgraduate Medical Centre, providing a meeting place at the local hospital, a series of lectures to allow doctors to keep up to date, and a library. (Postgraduate medical centres derive part of their income from the pharmaceutical industry. The industry sponsors meetings, providing food and drink for those attending in return for the right to display advertising material at the entrance. The pharmaceutical industry also sustains the medical press through advertising. This central role of the industry in funding the process of medical debate and medical updating helps shape the profession’s perception of medicine as drug-oriented. The medical press is shy of attacking the industry, alternatives to drugs are not promoted and anti-drug meetings would be unlikely to be sponsored.)
There will also be the medical advisory machinery, comprising divisions for each specialty (each containing all the consultation in the specialty plus representatives of other grades), a Medical Executive Committee consisting of representatives of each division, and a Medical Advisory Committee which brings together the MEG (for the hospital service) and the LMC (for general practice) to produce a united voice. The medical advisory machinery is extremely powerful within the functioning of the health authority.
Through these complex interweaving organisations the medical profession conducts its affairs. The very complexity of the system, coupled with the powerful tradition that the various parts consult each other and do not conflict with each other, is a force that militates against rapid fundamental change.
Socialist Views of Medicine
The Labour Party and the trade union movement are also institutions and, like the medical profession, they have their ideology, their means of reproducing it, their methods of testing the loyalty oi those who aspire to influence, power or leadership and their methods of marginalising their rebels.
As with all institutions these ideas derive from the history of the institution. It is true that in a harsh political climate the scope to say the unspeakable is broadened, and the luggage of the past can be jettisoned more quickly than would otherwise be the case. But the cold wind that blows away some cobwebs will make others cling more tightly, and the area of health may be considered to be the area in which the labour movement has the least need to review its ideas, for it is its most successful political area.
The National Health Service is the jewel in Labour’s crown. Of all the 1945 reforms it is the one that captures the imagination of the British people still. Of all the elements of the social wage it is perhaps the only one where people still accept without doubt that it is better to have the service and pay the taxes, than to cut taxation and forget about the service.
Health is the only area of politics where the Labour Party still has the overwhelming confidence of the people. In 1983, at the most disastrous of general elections, the only successful chord Labour struck was on the issue of the National Health Service. After the election, when the Labour Party was in the depths of despair, a Tory Chancellor of the Exchequer, putting machismo before common sense, made a token cut in the budget of the NHS and gave the Labour Party a perfect platform on the one issue on which it could still mobilise with confidence, could still capture the hearts and minds of the British people and could still go to the doorsteps to expect a welcome as the people’s representative. Opinion polls even showed a majority of Conservative voters favouring Labour on health issues.
To have told the Labour Party at that time that its health policy needed radical review would have been like taking away from a drowning man the straw through which he might still succeed in breathing.
The Labour Party has since recovered considerably, but the emotion attached to a successful straw may be no less than that attached to it at the time of emergency. The man saved from drowning by a straw may well frame it and hang it on his wall.
In 1984 Michael Meacher set up a network of think-tanks to review and update Labour’s health policy. But he set them up outside the official party machinery, and indeed as a reaction to the disbandment of that Labour Party committee which previously dealt with the revision of health policy.
Labour’s views of health are derived from the struggle of the British people to win for themselves the right to health care irrespective of means. And so a dual vision of medicine emerges.
On the one hand medicine is ‘a good thing’. It must be a good thing or we wouldn’t have fought so hard to get it. And if medicine is a good thing, the jewel in our crown, the inalienable right of the working class, then doctors must be a good thing too. Nowhere is the status of the medical profession more secure than in the hearts of the labour movement. If medical demigods can trail their clouds anywhere it is in the gatherings of the organised working class.
But therein lies the paradox that so few doctors actually take up that opportunity for the receipt of adulation, which is a bit surprising since the BMA really ought to show some loyalty to the sector of society which has most totally swallowed its propaganda.
Indeed, far from seeing the labour movement as its natural ally, the medical profession has tended to support the other side. The battles of 1911 and 1948 were fought with the medical profession ranged against the introduction of, first, the National Health Insurance Scheme and then of the National Health Service. To complete the sorry picture Barbara Castle in 1975 tried to phase out pay beds and lost the battle with the profession.
Thus the BMA acquires a special significance in the thinking of the labour movement as an interest group that is reactionary and implacably opposed to the Labour view of health. And since it won in 1975 and drew in 1948 it must be seen as powerful, ‘the most powerful trade union in the land’. The demigods are hostile and organised, and cannot be defeated.
With this image of medicine a Labour government’s approach to health is defeated before it starts. Its exaggerated vision of the powe< of medicine leads it to back off from any confrontation whilst its excessive emphasis on the importance of medicine leads it to downgrade the other forces for change which exist in the NHS, and its unduly pessimistic view of the hostility of medicine leads it to neglect the compromises it could make and the allies it could turn to.
All that is left is to defend an unchanged National Health Service, to stand on platforms demanding more resources for the demigods, in the name of the people. It really is the basest ingratitude of the medical profession not to recognise that the labour movement is its greatest friend and most loyal ally. Indeed I sometimes think the Labour Party supports the medical profession even more than it supports the United States of America.
Contrary Chords
Of course contrary chords exist. The NHS trade unions see consultants as the dominant power in the health authority and therefore see them as the employer (or almost so) and the enemy. The medical profession fosters this antagonism by its disdain for other health service staff. Those doctors who treat other health workers as their colleagues receive in return a powerful and pathetic loyalty which speaks volumes for the way other doctors treat their fellow workers in the NHS.
Distrust of experts is a deep strand of labour movement thought, especially at the grass roots, although it diminishes as the top of the movement is reached. This strand of thought has been strengthened by the women’s movement and by the pressures for democratisation, and is probably most noticeable in the field of psychiatry. However despite this body of feeling the Meacher think-tanks are almost entirely composed of experts, despite the protests of several of the experts themselves.
Many policies on health which would not have support in the medical establishment have great support in the labour movement especially ideas on priorities and on prevention, and ideas about the distribution of power within the NHS. Additionally, of course, the labour movement remains implacably opposed to private practice.
However these contrary chords are definitely subsidiary in their actual effect on the behaviour of the labour movement and of a Labour government than is the theme of support for the demigods.
There are two main reasons for this. One is that the Labour Party attaches very much more significance to the defence of the NHS than to its development and reform. Every cut, every closure, every curtailment of service is wrong, however inadequate that service, however much better the alternative that is being provided and however true it is that the change is part of a desirable pattern of development. The most ill equipped, crumbling and underused hospital must be propped up at whatever cost, even if it takes the money that could have been used to develop the much needed community services that keep people out of hospital. This attitude raises the cost of developing and changing the NHS beyond the price that Labour governments have hitherto thought that the taxpayer is prepared to meet.
The second reason is that the Labour Party, even where it disagrees with the medical profession and is prepared to state a policy about priorities or about power distribution, is not then prepared to fight that policy through against the resistance of the leaders of the profession. Sometimes this may be a valid assessment of the political strength of organised medicine. But so inflated is the labour movement’s perception of the strength of organised medicine that it will not fight the leadership of the profession even on issues which command little real support at the grass roots, or on which differences of interest exist within the profession which could be decisive if skilfully exploited.
So the contrary chords to the slavish support of the demigods are a matter for conferences in opposition not for ministers in government. Again, the parallel with America comes to mind.