A New Kind of Doctor 6 A CRISIS OF ACCOUNTABILITY

Though most thoughtful and well-informed GPs now accept the need for more staff, equipment and postgraduate train­ing, they are uncertain about what new investment is needed, and even more so about how it should be made.

The only answer fully consistent with autonomy in the Osier paradigm would be that GPs should invest their own money as entrepreneurs, selling their services as commodities in an open market. In Britain, though not in many other developed countries, this had lost majority professional support by the 1920s and after 1948 its few remaining adherents became isolated. So long as the State was prepared to underwrite the cost of providing a service to the whole population free at point of use, return to the private market was bound to narrow medical employment and clinical opportunity. However attractive ideologically, it made no sense at all in terms of income, employment and security for doctors.

Marketed medical care remains the ‘natural’ solution to Margaret Thatcher and the politicians of New Conservatism. As the public hospital service lags further behind advancing medical science, their remedy is to encourage high quality growth in the private sector, leaving the public sector to cope as best it may. The eventual goal is to achieve high-quality marketed care at both hospital and GP level for a core population in stable employment at high rates of pay, with a salvage service for peripheral populations in casual employ­ment, or unemployed, the nature and quality of which will depend on political pressures.

Most doctors have until recently seemed to accept decline of the NHS as inevitable, just as they formerly accepted its permanence. Like any other occupational group, their first concern was to find a safe haven for themselves. If most of them were prepared to look for security in a transitional economy, moving away from a comprehensive NHS toward a frankly two-tiered service even at GP level, the New Conservative strategy would succeed. Judging from the unusual caution so far shown by Conservative Ministers of Health, the government is far from sure it can get away with it. The attitude of GPs to privatization of the health service has not been tested by a frontal attack, and probably never will be. An approach by stealth is already going on which will soften the impact, but an eventual collision is inevitable between public and professional expectations and a govern­ment withdrawing sponsorship for growth in the public service.

On the best-informed and most responsible independent projections of medical school output, NHS career posts, and demographic trends, about half the students now entering British medical schools will be unable to work in the NHS by 1997, even if the rising proportion of medical women and lower GP lists are taken into account. ( Nussey, S.S., Pilkington, T.R.E., Saunders, K.B., ‘Where will this month’s medical school intake go?’, Lancet 1986; ii:977. See also Lancet editorial ‘Medical student numbers and medical manpower’, Lancet 1987; 1:7 23-4)  Most medical students and junior hospital doctors now appear to be adapting to this prospect, but seem unaware of the real nature of the alter­native private medical market. If effective medical care now requires a transformation of the GP service into locally-controlled, population-based, need-orientated anticipatory care, the genteel medical shopkeeping to which these doctors think they might return would conflict far more with good clinical medicine than it did before the NHS. The real nature of a new medical market can already be seen in the USA, though in a much wealthier society which can better afford its extravagance; primary medical generalists as well-paid but strictly controlled cogs in impersonal, for-profit corpora­tions selling medical care to those who can afford high-premium insurance, or have good jobs in growth industries.

We are entering an era of struggle in medical ideology, a battle of ideas arising from fundamental conflicts of interest, pitched not in some hypothetical future when medical care has been restored to its ‘natural’ place as a commodity sold to individual consumers by competing suppliers, but in the present, when all but a handful of GPs earn their living from the Welfare State. Even today, the only realistic point of departure must still be the relation between GPs and the State established by the Lloyd George Act of 1911.

Public Service Privately Administered

For the Osier paradigm, the best alternative to a private market in fees was public funding without public account­ability, public service privately administered. Without noticing this paradox, let alone asking themselves how it was achieved, this is what GPs finally got; so strongly had they resisted public service on any terms, that they hardly noticed how easily government conceded their continued independence to run their practices pretty much as they liked, providing it didn’t cost more money. In fact, Lloyd George favoured the doctors in order to rid himself of the local power exerted by the thousands of small local Friendly Societies which had run the club practices he nationalized. The medical profession and its obsession with autonomy was the weapon he used to break the power of the locally-based insurance societies, and ensure that all lay control would lie with central government. The Insurance Committees which administered the Act were soon dominated by the local doctors and by central govern­ment appointees, and the Friendly Societies, which had represented some degree of local democratic control, were steadily squeezed out.

Despite paranoid BMA forecasts of clinical decision by committee and the end of clinical freedom in 1912 and again in 1948, both contracts were administered with a disinterest difficult to distinguish from indifference. In theory, first the Insurance Committees, then the Executive Councils, now the Family Practitioner Committees (  Allsop, J., May, A., The emperor’s new clothes: Family Practitioner Committees in the 1980s, London: King’s Fund, 1986)   (always the same organization, only names changed) had responsibility for ensuring that GPs provided a good clinical service from adequate premises and that they maintained proper records. In practice, the administration of general practice, even more under the NHS than under the Lloyd George Act, was, and for most areas still is, entirely passive and negative, limited to the organization and supervision of GPs’ earnings and prescribing costs. Though generations of newly appointed chief FPC administrators have wanted to do something more positive, they have never been given the staff or office organization required for an imaginative approach to planned primary care; after a year or two enthusiasm has given way to cynicism, and eventually to entrenched bureaucracy. Providing GPs did not cheat on a big enough scale to guarantee success­ful prosecution for fraud, did not absent themselves from their practices completely, did not certify unfitness for work without even seeing their patients, and did not prescribe more than 50% more per head than their local colleagues, neither excellence nor incompetence, indifference, ignorance or exhaustion attracted administrative action, either supportive or punitive. Administration of general practice had, and for the most part still has, no defined objectives other than containment of costs and minimizing of complaints. Until the 1987 White Paper, the legal definition of GPs’ work in the NHS was contained in the Regulations of the NHS Act of 1977. For the 39 years since 1948 the duties of GPs were:

to render to their patients all necessary and appropriate medical services of the type usually provided by general practitioners.

In other words, if GPs did the same as most other GPs, they’d stay out of trouble. George Bernard Shaw would have been amused to see this definition of medical conscience, confirming his own in his preface to The Doctor’s Dilemma :

Doctors are just like other Englishmen: most of them have no honor and no conscience: what they commonly mistake for these is sentimentality and an intense dread of doing anything that every­body else does not do, or omitting to do anything that everyone else does. This of course does amount to a sort of working or rule-of-thumb conscience; but it means that you will do anything, good or bad, provided you get enough people to keep you in countenance by doing it also.

Shaw’s cynicism was more justified when he wrote than it is now; since the NHS took Shaw’s advice and virtually abolished fee-earning in general practice, many individual GPs have pioneered work which everybody else does not do, and have had the courage to discard much that everyone else still does. Yet up to the 1987 White Paper there was little evidence that either district or central administration was as interested in the outcome of care as Lloyd George ( Anon. ‘The insurance medical service week by week: payment for keeping records’, British Medical Journal 1935; ihsuppl. 174) threatened they would be in 1912, when speaking in parliament on his plan to increase from 6 to 9 shillings per head the proposed annual payment to panel GPs:

If the remuneration is increased, the service must be improved. Up to the present the doctor has not been adequately paid, and there­fore we have had no right or title to expect him to give full service. In a vast number of cases he has given his services for nothing or for payment which was utterly inadequate. There is no man here who does not know doctors who have been attending poor people without any fee or reward at all.

I have got three conditions which I am going to lay down as the result of this increased provision. One is that the doctor who acts on the panel shall agree to give, without further charge, those medical certificates which an insured person will require to enable him to get sickness or disablement benefit. . . Secondly, we shall also ask that those practitioners who act on the panels shall keep simple records of the patients whom they treat, the illnesses from which they suffer, and the attendances given. This is new in respect to the industrial practice of this country. Though we are providing increased remuneration, I frankly admit we are also asking for increased service. We know that doctors dislike book-keeping above all things but we also know that they desire the advancement of medical knowledge, and we feel that they will co-operate with us in this matter. We on our part undertake that the records required shall be of the simplest character that will give the necessary information.

Thirdly, and chiefly, the service must be improved in certain definite respects, as compared with what it has been possible to give in the past. It will be the duty of the Commissioners. . . to see that a proper standard is reached and maintained, not merely in the number of visits paid or the number of times a patient is seen at the doctor’s surgery, but also in respect of the amount of time and attention given, and also that where necessary the practitioner should resort to those modern means of exact diagnosis the importance of which I am advised is increasingly recognised in the profession.

This promised administrative interest in the more easily measured aspects of clinical work was never implemented by Lloyd George or any other Minister, either under the Insurance Act or the NHS. The initial hostility of GPs was not enough to explain this; by the 1920s, the greatest fear of most GPs was that Conservative governments might repeal the Liberal legislation they had once opposed, and had the government wished to press for improvement in the quality of GP service, it had the power to do so. The most obvious explanation for this indifference was that governments were more concerned with economy than with the quality of the service. Concern displayed for clinical effectiveness has as a rule been rhetorical, unless some charitable foundation or commercial interest could be found to pay for material change in some token project. Relatively well-paid doctors running a cheap service remained an attractive formula for all politicians from all parties. If it meant that many practices were nasty as well as cheap, this was seen as a moral problem for GPs, not an administrative problem for government, which concerned itself not with the low standards and expectations of average general practice, but with individual complaints against individual GPs for exceptional acts and omissions.

Better work requires not more exhortation, but more time, more space, more staff, better equipment, time-consuming development of self-criticism and peer-criticism and continued postgraduate education, all of which depend on greater investment in primary care. Investment of public money through the GP’s pocket has proved as erratic and uncertain as would be the standards of schools, if they were funded through the pockets of head teachers. If public work is put out to private contract, the usual way to ensure good standards are maintained is strict accountability to the public body responsible, with process and outcome targets set and regular reports on how far they are achieved. No Family Practitioner Committee (FPC) has ever worked in this way, though there have been a few recent imaginative attempts to break out of the straitjacket by some progressive FPCs. ( Allsop, J., May, A., The emperor’s new clothes: Family Practitioner Committees in the 1980s, London: King’s Fund, 1986)  Such an approach to primary care is essentially neither easier nor more difficult than it is for education, whose administration is concerned with standards and resources as well as teachers’ pay. Definition of objectives and measurement of their attainment would not of itself solve the problem of increasing public investment in primary care, any more than the existence of state education guarantees that a government will consider that educating our children is more important than tax relief for millionaires or organizing the means to destroy life on earth, but it would at least create the machinery essential for future governments with more humane and intelligent priorities.

Hospital consultants are salaried professionals, not independent contractors. Health Authorities are responsible for providing their resources and ultimately for maintaining standards. Weak though they usually are, national and District Health Authority policies and planning do exist in the hospital service, but are almost entirely absent in the GP service. Administrative controls on specialists have generally been used with discretion, and alleged threats to clinical independence have not materialized; nearly all difficulties in this area have arisen from government attempts to reduce costs, and occasionally from attempts by consultants to do private work at the expense of their NHS contract, not from positive proposals with which specialists disagree.

Three Foundations for Independent Contractor Status

There must be few employed people in any occupation who, given the choice, would not prefer to be self-employed, handling substantial funds without a clear division between personal income and service expenditure and with minimal accountability. GPs are the only professionals in public service permitted to retain this curious 18th Century privilege.

As never before, all three foundations are now in doubt. Of course, like all other creative workers, GPs need autonomy of some kind; but thoughtful GPs, even if few can yet conceive of autonomy without independent contractor status, are beginning to consider what their independence is for, and to recognize that it may limit at least some aspects of their work however much it may appear to facilitate others. ( Pereira   Gray,   D.,   ‘General   practitioners   and   the   independent contractor   status’,   Journal   of  the   Royal   College   of  General Practitioners 1977; 27:746-51.)  For clinical initiative and decision autonomy is essential, but even then only within limits set by their ability to explain their actions and omissions to their colleagues, their patients and an interested administration, and either persuade them they are responsible, or think again. GPs have created their own body of independent research and literature, and medical knowledge in general is becoming as accessible to them as to hospital specialists; these, not Ministry directives, should remain the main sources of innovation in general practice. Practice and community nurses are beginning to follow this autonomous but socially responsible path, which needs to be encouraged if appropriate community care is to surpass inappropriate hospital care in effectiveness and efficiency. But autonomy for delegating more work to underpaid assistants, for taking on more better-paid part-time jobs outside NHS general practice, or even in order to remain on a less rigorous scale of income tax, is publicly indefensible, though these are precisely the arguments principally deployed when the question is debated within the profession. The assumption that all GP autonomy is altruistic is no longer credible even to GPs themselves, who know very well that it is at present more often used to justify search for a quiet life than to accelerate clinical innovation. Many GPs are now groping towards accountability, but can’t make up their minds who they can or should be accountable to.

Belief in the cost advantages of general practice is also less sure than it was. General practice is still cheap compared with hospital work, and this accounts for most if not all recent political interest in the subject. For the first time in history, all the major British political parties issued policy documents on primary care in the run-up to the 1987 general election, but at their 1986 annual conference the subject was never debated, it never surfaced during the election campaign itself, and none of the press conferences or detailed political comment in the serious medical press referred to any new ideas about general practice. Though proposals for annual reports by GPs, annual meetings open to patients to discuss them, and elected patients’ committees to assist and advise GPs were all contained in a Labour Party policy document published in the run-up to the election, ( The best of health: charter for the family health service, Labour Party, 150 Walworth Road, London SE17 1JT, 1986)  these were completely ignored by Labour Party spokesmen and shadow ministers, as well as by their opponents and by the medical press. Party political argument was almost confined to rival claims about global support for NHS spending, not about how money should be spent or new directions for health service investment. (Smith, R., ‘The wasted opportunity of the election’, British Medical Journal 1987; 294:1438-9)  Though we must always live in hope, neither ministers nor shadow ministers have as yet appeared to see primary care as a field for expansion rather than cost containment. They face a dilemma; the GPs and nurses most actively pressing the case for primary care also want it to be upgraded in quality and comprehensiveness, better staffed and equipped, aiming at qualitative parity with hospitals. In theory, a better GP service would take over much of the work now done at higher cost by hospitals, but in reality the immediate effect is to duplicate it. Few leading politicians now have the time for imagination, or the stomach for long-term solutions which are bound to present initial difficulties.

Finally, the clinical scope of general practice is growing too fast to be ignored much longer, even by politicians still ignorant of its potential. No GPs working within the NHS contract can do more than begin systematically to do all the simple and effective things that need to be done for all of their patients, but enough have begun to do some of them to show, very impressively, what is possible. Public expectations are rising, and though some who can afford it will be diverted into health-care acquisitiveness in a growing private sector on the North American and West European model, most cannot and will not. Perhaps for the first time, there is beginning to be serious pressure on government for a better primary care service, reflected in the 1987 Report of the Parliamentary Select Committee on Primary Health Care. (House of Commons Committee on Social Services. ‘First Report Session   1986-7:   Primary   Health   Care’,   Paper   37-1.   London: HMSO, 1987.)  The natural tendency of government will be to concede this without cost; at the top by encouraging privatization, at the bottom by stricter enforcement of a contract which may be modified here and there, but will remain orientated to process rather than outcome. Independent contractor status has endured because government and profession jointly agreed on a stagnation comfortable for both. For many different reasons, that collusion is now breaking down.

Limits of Cash-Limits

In seeking a return to the leaner, fitter, more competitive society in which they believe, Margaret Thatcher and her New Conservatives have generally met less resistance than either they or their enemies expected in dismantling the civilizing reforms of a crude market economy achieved by 75 years of struggle and concession, but the GP service has so far been an exception.

When they first won power in 1979, the solution to all social and economic problems appeared the same; privatize the problem, expose it to market competition, let the fit survive and the weak perish. To New Conservative theorists, general practice seemed a particularly suitable subject for this simple treatment. It was still an under-capitalized cottage industry, and many relatively inefficient GPs were there to be shaken out. There were also many energetic GPs impatient to apply new technology to primary care which was already in general use in Western Europe and North America, which was uneconomic under their existing contract. There was a new generation of better paid, better informed, more demanding consumers willing to pay more for better personal care for themselves and their families and eager to pay less in taxes for care of other people. General practice seemed ripe for entrepreneurial expansion into new responsibilities GPs had been unwilling to undertake in a public service funded only for obsolete care, but might willingly provide for fees.

Exactly what happened to this theory we shall never know. At considerable cost, the government commissioned a major independent study on the possibilities for applying cash limits to general practitioner services, so that FPCs would operate within plannable annual budgets. The results of this study, the Binder-Hamlyn Report, have never been published, so the public which paid for it has never been able to see the evidence it unearthed. It seems reasonable to assume that Binder-Hamlyn confirmed that general practice had to remain a demand-led service if its essential buffer function was to be maintained, and that no simple solution was yet feasible for rationing GP access to hospital referral. However that may be, the still secret Binder-Hamlyn Report put an end to proposals for either cash limits or large-scale privatization of primary care, which were publicly buried in the government’s Green Paper on the future of primary care in April 1986, ( Secretaries of State  for Social Services, Wales, Northern Ireland &   Scotland,   ‘Primary   health   care:   an   agenda  for discussion’, (Cmnd 9771). London: HMSO, 1986)  though probably in a shallow grave designed for easy resurrection now that a decisive 44% of the British electorate has voted for five more years of conspicuous personal consumption side by side with impoverished public services and an army of unemployed.

Solution of the problems of primary care by straight privatization evidently failed to survive even the briefest exposure to the reality well known to every medical civil servant: that Britain already had the cheapest and most cost-effective health service in the developed world, consuming the smallest proportion of a dwindling Gross National Product, with the lowest administrative overheads, the cheapest medical profession, and for the most part a still very undemanding public with low expectations by West European and North American standards. Every other country which relied on market forces for distribution of medical care had higher costs, lower efficiency, less compre­hensive coverage of the population and higher expectations for technical salvage. Privatization of the more potentially profitable parts of hospital care was a different matter, but privatization of general practice threatened only to disrupt a cheap but still popular and credible service, which it would be politically and economically suicidal to disturb for doctrinal reasons.

The Thatcher government therefore had to accept that it could not afford any general privatization of general practice, but it also could not afford to ignore the anomalous position of GPs as the only health service workers with a demand-led and therefore unplannable budget, which was largely respon­sible for initiating costs in the hospital service. GPs alone appeared to be in a position to control the demands on specialist care in hospitals, but they remained outside the NHS management system. In an ageing and therefore sicker population, hospital throughput, staff workload, in-patient and out-patient waiting lists, and pressure on community nursing, social services and GPs inevitably increased, given an upward twist by each advance in medical science, always widening the gap between what could and what actually was done faster than it could be narrowed by greater staff effort. In any such permanently overloaded system there must be flexibility somewhere; the traditional and most economic point for this was always in general practice, the interface between undemanding apparent health and demanding symptomatic disease, where response was cheapest and could most easily control entry to hospital services.

The Green Paper

Before the government got the bad news from the Binder-Hamlyn Report, it embarked on preparation of a major discussion document on the future of primary care, known as the Green Paper (confusingly but aptly, it eventually turned out to have blue covers, but discussion papers are traditionally known as Green, final proposals as White). This was promised as the first comprehensive review of general practice since the NHS began in 1948, and was generally expected to contain radical proposals for privatization and market incentives. As two, then three years rolled by without publication, it became an open secret that these ideas had been discarded as impractical; the New Conservative radicals were too ignorant of the realities of general practice, and the DHSS experts too entangled with the welfare tradition, to be able to agree on any fresh practical proposals. The BMA was still much clearer about what it didn’t want than about positive proposals for reform, and found it difficult to admit publicly that there was any serious or widespread problem about the quality of GP care.

For the first time since its birth, there seemed to be an opportunity for the RCGP to use its de facto political muscle, by putting forward positive proposals for better general practice, against minimal professional opposition, with a government which might be grateful for anything that looked like a policy. The General Purposes Committee (GPC) of Council of the RCGP, its main collective policy-making body, began preparing the College’s proposals in 1983. All members of GPC (of whom I was one) and probably all members of Council, shared a common point of departure; that the quality of GP care was generally uneven and often grossly deficient, that reform required material investment in time, staff and equipment, and that the new investment available from the 1966 Package Deal was almost exhausted. Though only 15% of GPs chose to employ the full complement of staff permitted under the wages reimbursement scheme, this proportion had not changed significantly for about ten years. As in 1966, the most innovative practices offering the best public service were generally doing so at high personal cost to the GPs in charge of them.

The task given to GPC seems in retrospect poorly defined: to produce a discussion document. Should a discussion document provide a range of options together with relevant evidence which could then be discussed by a wider membership? Or should it present a more or less finished consensus policy? This choice was never explicitly made. Almost to the last moment, those who believed in multiple options (myself among them) deceived themselves that full public discussion would be encouraged. In fact what emerged was a single prescriptive view, though no viable consensus existed on anything but the Status Quo.

Before either the Green Paper or the RCGP’s reply were published, two members of GPC published their own inde­pendent proposals. Marinker ( Marinker,   M.,   ‘Developments   in primary  care’,  in A  new NHS Act for 1996?, London: Office of Health Economics, 1984.)  put forward a complex plan ‘based on entrepreneurial competition within the NHS’, in which groups of GPs would be budget-holders exerting consumer pressure on hospital specialists competing for referred trade. This was included, and implicitly endorsed, in a review ( Maynard,   A.,  Marinker, M.,  Pereira Gray, D., ‘The  doctor,  the patient, and  their contract. Ill  Alternative  contracts:   are they viable?’, British Medical Journal 1986; 292:1438-40) subsequent to the Green Paper but before its explosive rejection, jointly authored by Pereira Gray (now Chairman of the RCGP), health economist Alan Maynard, and Marinker himself. It was an unconvincing attempt at a market solution, in tune with the times but wholly im­practical, and would have permanently antagonized the hospital specialists if anyone had taken it seriously. As a ‘Left’ alternative, I ( Hart,   J.T.,   ‘Community   general   practitioners’, British  Medical Journal 1984; 288:167’0-3.)  proposed the creation of a new career option for GPs to act as both personal doctors and com­munity physicians for their own registered populations, giving account of their work through annual reports both to District Health Authorities, and to general meetings and elected committees of their local populations. This gained a little published professional support, (Mant, D., Anderson, P., ‘Community general practitioner’, Lancet 1985; ii: 1114-7)  but none within GPC. Similar proposals were discussed in the intelligent report on primary care of the House of Commons Social Service Committee, which had members from all parties in parliament on the US pattern. (House of Commons Committee on Social Services. ‘First Report Session   1986-7:   Primary   Health   Care’,   Paper   37-1.   London: HMSO, 1987)  It was probably unrealistic to expect the novel idea of locally democratized, public-health oriented general practice to be rapidly accepted or even understood in an election year; the Labour Party is a conservative organization, in which any imaginative proposal is quickly dubbed lunacy by what Aneurin Bevan called ‘the most prostituted press in the world’ and thus transformed into an electoral handicap. In fact there was at that time little real interest in any proposals on primary care from any of the political parties.

The Quality Initiative

While discussions in depth continued on GPC (which seemed to have no effect at all on its final document), the fifty or so members of RCGP Council took back to their own practices proposals for personal audit, the first move in the College’s ‘Quality Initiative’ programme. ( Royal College of General Practitioners, ‘Quality in general practice’, Policy Statement 2, London: RCGP, 1985)  This aimed to improve standards in individual ‘opinion-forming’ practices by encouraging quantified review of what GPs actually did, comparing this with what they thought they ought to be doing, particularly in areas of prevention and anticipatory care, such as population management of high blood pressure, diabetes, cervical cancer and immunization. It was (and still is; the movement continues, though rather uncertainly) essentially an exercise in self-help and voluntary peer review in the tradition of professionalism, pre-empting public accountability by offering self-criticism and peer-criticism instead; ‘If we don’t do it, somebody else will—outside the profession.’

From the College’s point of view, the response was encouraging. An impressive range of often imaginative work was begun, on a wider scale than most had dared to hope. But from the point of view of any administrator concerned with progress in NHS general practice as a whole, the exercise must have seemed almost irrelevant; as usual, most of the initiatives were from areas where relatively good standards already prevailed.

However, even this self-help voluntarism was a brave policy for the College, always in danger of isolating itself from the majority of GPs, in or out of the College membership, who considered themselves already at full stretch meeting individually presented demands, without the added burdens of active follow-up for chronic disease, search for needs, or organized practice intelligence on prescribing and referral which provided nearly all the subjects pursued in the Quality Initiative. Whenever the players thought they were getting somewhere, the College seemed to move the goal posts; right for a body concerned with the advance of art and science, but very wrong for many GPs who still saw themselves as practical men in a small way of business. The possibility of an explosion was always there, and early in 1986, when the Green Paper ( Secretaries of State  for Social Services, Wales, Northern Ireland &   Scotland,   ‘Primary   health   care:   an   agenda  for discussion’, (Cmnd 9771). London: HMSO, 1986.)  was finally published after three postpone­ments, the roof fell in.

The Good Practice Allowance

Despite claims to be the first thoroughgoing review of primary care since 1948, the Green Paper was no such thing. In general, it made no attempt to define either the objectives of primary care or to assess how far they were being attained, and proposed few fundamental changes. It assumed that general practice was effectively co-terminous with primary care, and there was no serious discussion of how the work of GPs was to be co-ordinated with the work of other primary care health workers or Public Health bodies. Its only substantially new proposals were for an increased capitation element in GPs’ pay to encourage competition for patients, vaguely formulated suggestions for ‘health shops’ in which GPs would join other more overtly commercial entrepreneurs (pharmacists, opticians, private physiotherapists, health food shops and the like) to woo the health-care-acquisitive consumer, and the Good Practice Allowance.

The first two of these fell at the first fence. No GP who remembered the pre-1966 Package Deal years wanted to return to the unprincipled competition for patients and bitter intraprofessional rivalry of those days, and none believed that a return to capitation would encourage better quality of care; all historical experience proved the reverse. The ‘Health shops’ idea was plainly ludicrous, typical of other absurd attempts to transplant US commercial culture to a society which didn’t want it and couldn’t afford it. The BMA and the RCGP were opposed to both these proposals, and neither got any significant support or attention from the profession.

The only really novel feature of the Green Paper was the Good Practice Allowance (GP A), but this had clearly emerged not from the Minister, but from the RCGP discussion document. The GPA boldly faced up to the long obvious fact that the service offered by GPs was extremely variable in quality. Like teachers, milkmen, and all other trades and professions, problems existed because there were both good and bad practitioners; pay the good ones more and the bad ones less, and market forces would eventually eliminate bad practice; problem solved. This was not only a matter of quality of service, but had huge economic consequences. According to Donald Crombie at the RCGP Research Unit in Birmingham, data on practice activity from about 1,000 GPs in 1982-3 showed that annual per capita hospital costs initiated by GP referrals varied nearly fivefold between the top and bottom fifths of the distribution (overall mean £257, £106 below the 20th centile, £509 above the 80th centile). ( Crombie, D., Personal communication, 1987)

The flaw undermining this simple logic, which few of its original supporters seem to have recognized, is that GPs not only create their practices, but are created by them. The problems faced by GPs seriously concerned to provide an effective service differ from one place to another as much as the mortality and morbidity levels they should be aiming to reduce. Points of departure are hugely different, and innovations that are relatively easy in one area may be extremely difficult in another, above all where needs are greatest but pressure of demand seems to preclude planned development of anticipatory care. As originally proposed in the RCGP discussion document, (The front line of the health service; College response to ‘Primary health care: an agenda for discussion’, Report from general practice 25, London: RCGP, 1987)  and elaborated by Pereira Gray, Marinker and Maynard ( Marinker,   M.,  Pereira Gray,  D.,  Maynard,  A.,  ‘The  doctor,  the patient,  and  their contract.  II.  A good practice allowance: is it feasible?’, British Medical Journal 1986; 292:1374-6)   in the British Medical Journal, the GPA was to be a reward for achieving certain minimum standards of practice, measured in terms of premises, equipment, information available and accessibility to patients, delays between requests for consultations and their achievement, flexibility of consulting hours, special clinics, group activities, annual reports, and evidence of innovation; a consensus description of the practice nearly all of us want to be in, whether as doctors or patients. The GPA was obviously an additional reward for attaining such a practice or being in one already, but it was not at all clear how it would help the GPs in greatest difficulties to get there.

British GPs have a long and robust tradition of hostility to all proposals for stratification of primary doctors into superior and inferior grades, either by income or authority. It cannot be described as egalitarianism, because grossly unequal partnership agreements whereby established senior partners exploit their juniors are still common, though much less so than before the NHS. GPs have always opposed grading by quality of either training or performance. They rejected several million pounds of additional income offered as part of the 1966 Package, rather than accept Merit Awards for better practice.

Much of this hostility is based on GPs’ view of consultants who can double their incomes with Merit Awards (Distinction Awards), devised when the NHS began to compensate consultants for expected loss of private practice. Every year £50 million is paid to consultants in awards ranging from £4,890 for a grade C to £24,930 for an A+. Once given they are never taken away whatever the quality of the consultant’s work, and they go on after retirement as higher pensions. (McKee, I., ‘A proposal without merit’, The Physician 1986; 839.)  Beneficiaries are chosen-in secret by anonymous committees of current Merit Award holders, using secret criteria. It has always appeared to outsiders that the principal quality sought must be resemblance to themselves. Sir Russell Brain, President of the Royal College of Physicians, said secrecy was desired only by those of insufficient merit or distinction to obtain an award, in order to protect their own reputations, but a survey in 1973 showed that secrecy was favoured by 67% of award-holders, compared with 29% of those without awards. ( Bourne, S., Bruggen, P., ‘Secrecy and distinction awards’, British MedicalJournal 1987; 295:393)  Consultants in unglamorous but socially necessary specialities like geriatrics, psychiatry and the non-clinical diagnostic specialties, are consistently under-represented among the chosen, and cardiologists, neurologists and other prestigious specialties are consistently over-represented. For example, in England and Wales in 1984 less than a quarter of all geriatricians got them, compared with over half of all general surgeons. Merit Awards were originally introduced to compensate consultants for their expected loss of private practice, but abstinence from private practice is not a criterion for selection. It is a corrupt system which, whatever its original intentions, discourages imagination and criticism of established practice in young consultants and fails to ensure industry in old ones. GPs wanted none of it, nor any­thing like it.

The College in Crisis

The Government Green Paper, and its central feature, the Good Practice Allowance, were endorsed with uncritical enthusiasm by the Secretary and Chairman of the College within hours of publication. In an editorial in the RCGP Journal, Chairman John Hasler ( Hasler, J., ‘Supporting good practice’, Journal of the Royal College of General Practitioners 1986; 36:394-7)  made belief in the GPA a test of loyalty to the College and commitment to good practice:

Modern general practice of a high standard provides care which is second to none. The arguments for providing increased resources for those practices which are innovating and striving for improvement are unanswerable. Nevertheless, we must recognise that a significant increase in resources for general practice (as in the mid-sixties) is highly unlikely to be provided without some demonstration of improved patient care and greater accountability. To reject a quality incentive equation is to reject the new resources that modern general practice now needs and our patients deserve. . . The important decision now facing the profession is whether or not to accept and endorse the principle of encouraging quality and rewarding personal investment. The government’s proposals for a Good Practice Allow­ance go some way to achieving that objective. Whatever the profession decides ultimately about the allowance, it must not lose sight of this underlying principle.

Though over a third of all GPs are now members of the College, a large majority are passive and rarely attend meetings or take part in College activities. The same is true of the other mass organization for GPs, the BMA, and there is a large overlap in membership. The BMA, centrally and in the elected Local Medical Committees which are its real voice and local organization, was furious, both because of opposition to the GP A itself, and because the College appeared to be usurping the General Medical Service Committee (GMSC) of the BMA’s function as principal professional body for all negotiations on terms of service in the NHS. ( The GMSC is the most important body representing GPs in negotia­tion with government. Its composition is extremely complex, but understanding of it is essential to anyone who wants to understand the politics of the medical profession.  An excellent account is given by  Steve Watkins in his book Medicine and Labour: the politics of a profession, London: Lawrence & Wishart, 1987.)

Within three months the Chairman’s view was thrown out and the College was in greater disarray than at any time since its foundation. Simultaneously, war broke out between College Council and its large panel of examiners for the College Membership examination (MRCGP), prompted by the sacking of chief examiner Dr Andrew Belton, a bellicose character more in tune with many peripheral GPs than were the College officers. The two issues, independence of examiners and the GPA, not only coincided in time, but reflected the same grievance; the College was seen as ‘too political’, in other words more political than the member­ship was willing to be at the time. After a few weeks of bewildered defence, the leadership’s position was clearly untenable; Chairman John Hasler resigned, and a new Chair­man, Dennis Pereira Gray, took on the difficult task of back­tracking on a policy he had fully supported and apparently still believed in.

Good Practice Allowance or Bad Practice Allowance?

To GP entrepreneurs who had most successfully used the terms of the 1966 Package Deal to improve the quality of care, it appeared self-evident that if more practices were to join the pursuit of quality, good work should be rewarded and bad work penalized by a new contract, in which GP incomes would be related to performance; hence their faith in the Good Practice Allowance. To the concerned public it was even more obvious that the first priority for investment should be the practices which had failed to use the 1966 Package, and continued to maximize GP incomes by extend­ing their practice lists and their commitments outside the care of their registered populations; in other words, some kind of Bad Practice Allowance.

The source of this paradox is simple, and clear enough to anyone willing to see it. Bad practice needs investment in more staff, more time, better equipment and better buildings, and more thought about effective service to patients. Since at present few even of the best practices seldom deliver more than about 50% of any reasonably defined target for the services people need (as measured by monitoring the care of common chronic disorders such as diabetes, high blood pressure, asthma, epilepsy or schizophrenia), virtually all practices are in need of a ‘Bad Practice Allowance’, but the best practices need it least. The barrier to such a policy is independent contractor status, which tends to channel all investment through the GP-entrepreneur’s pocket, where some of it naturally tends to remain; if more investment goes to bad practice than to good, independent contractor status ensures that the doctor in charge earns more from bad work than from good.

It is on the whole a sensible idea that GPs who work harder, more imaginatively, and more effectively should be better rewarded than those who do not, but this cannot be done within independent contractor status without further widening the gap between the best and the worst practices, with a steady slide back to a two-tier service. A quality-related contract which retains and develops social equity is possible only in some kind of salaried service, in which the GP’s pay is entirely separated from the costs of practice, and all staff, equipment, premises and further training are paid for directly by the employer, the State. It is certainly very stupid to continue as we are now, when the most conscientious GPs have to innovate at their own expense, and further innovation is no longer possible within the 1966 framework.

Tactical Retreat

Still unable to face this obvious conclusion, the College sought more tolerable reasons for its crisis by turning its back on reality. The official diagnosis was poor communica­tion between the centre of the College and its periphery, and improved communication with and dispersion of power to the Faculties was proposed as its remedy. This treatment could do little harm, because peripheral initiative is always more important if there is any; but was there then any real peripheral initiative to prefer? Wherever there is disagreement between centre and periphery failure of communication can be blamed, but what evidence is there that the Faculties had positive policies for NHS reform to communicate in the two or three years preceding the crisis? From 1983 to 1986, I can’t recall a single example of any positive proposal for reform of NHS general practice from the periphery which was opposed or ignored at the centre. The truth is that most GPs were reasonably satisfied with things as they were. For most GPs, investments in buildings were extremely profitable and were therefore being made, but only a minority were investing heavily in ancillary staff, computer systems and diagnostic equipment, and felt any urgent need for more money to pay for them. If the price of more government investment in general practice was more accountability, most GPs, in or out of the College, preferred to do without the investment and carry on as they were. The predominant mood was and still is conformist complacency; doing most things that other doctors do, and little that they do not do. There never was a mandate from the mass of the membership for a serious policy of reform in any direction, and once any proposals got beyond the talking stage, and involved the whole membership rather than the small active minority, they would have aroused the same grassroots opposition.

It is said that the College antagonized its membership by venturing into negotiations on the structure of the service, which are supposed to be the province of the BMA, but in practice it is impossible wholly to separate structure from function. Any group genuinely interested in the quality of care must concern itself with terms and conditions of service, and where the line is drawn between medicopolitical and academic functions must be a matter of judgement according to circumstances.

The year before this crisis of confidence the government launched its plans for a limited list of drugs prescribable on the NHS. The idea had been floated many times before, and had always been rejected out of hand by the BMA as an attack on clinical freedom, with apparently vigorous support from the BMA membership. The BMA and, to its shame, the leadership of the Labour Party, rushed to the defence of medical independence, without bothering to find out what GPs actually thought. In fact, GPs had become steadily more sceptical of the claims of the pharmaceutical industry, and more hostile to the way it enriched itself at the expense of the NHS; they were ready to agree to common-sense pro­posals which might limit the burgeoning power of the multi­nationals, though they knew very well that this was only a cost-cutting exercise, without any larger purpose. In those circumstances, and backed up by a postal ballot of the whole membership, it was possible for the College leadership to take the membership undivided in a socially responsible direction, and to prove itself a more sensitive and adaptable vehicle for professional change than the BMA. This success seems to have led to intoxication; though the GPA proposal had far less support than the limited prescribing list, it was driven through without a membership ballot, and only abandoned when the position was clearly hopeless.

As for the examiners, the MRCGP was drifting irresistibly away from its original function as a ticket of entry to active membership of the College, towards its present de facto status as an elegant ticket of exit from vocational training. An exit test is necessary and will continue as one relatively unimportant part of training for general practice, just as the MRCP examination is a necessary but relatively unimportant part of the training of consultant physicians, and I think there is a strong case for making it mandatory, though this is still a minority view. The examiners were addressing them­selves successfully to this task, but it had little to do with the general direction being taken by College Council, increasingly (and rightly) concerned with structural reform of general practice as a whole, rather than with verifying what young GPs knew at the end of their training. The potential for a dangerous split is still there.

The 1987 White Paper

Although the specific proposal for a GPA has collapsed, the search for some means of improving ‘bad’ doctors by reward­ing ‘good’ ones has not been abandoned, either by the government and the DHSS, or by the College. The final reply by the College to the Green Paper ( The front line of the health service; College response to ‘Primary health care: an agenda for discussion’, Report from general practice 25, London: RCGP, 1987) still claimed that ‘The key issue now is the way of achieving a link between the general practitioner’s NHS contract and the quality of services that a practice offers.’ How this could be done without raising the same issues as the GPA was not explained. It looked very much as though some leaders of the College (and probably some leaders of the BMA) regarded a two-tier service as inevitable in a two-tier society, and were simply waiting for the troops to catch up with the realism of the general staff.

As I completed the final draft of this book the new health minister, John Moore, launched the government’s White Paper on primary care, ( ‘Promoting better health’, Cmnd 249, London: HMSO, 1987.)  with some proposals to be in­corporated in a Bill to come before parliament as this book goes to press. Most of its proposals, however, will have to be negotiated with the General Medical Services Committee of the BMA, and this is likely to be a very prolonged battle, probably setting the main agenda for the next two or three years. The White Paper claims to be the biggest shake-up of primary care services since 1948, but though it certainly is a turning point in government and perhaps in professional attitudes to GP autonomy, it is not at all clear what strategy will replace the present incoherent jumble of unaccounted resource and unresourced accountability.

The White Paper is a profoundly contradictory document. It drops the Good Practice Allowance, but states that it has not abandoned the idea of performance-related pay for GPs. As the terms of the White Paper come to be negotiated with the BMA, with the RCGP still a potent force on the sidelines, all the issues raised by the GPA and the Green Paper will resurface. The White Paper does attempt for the first time to define some fragments of a boundary to a verifiable GP contract for proactive care in specific terms of health maintenance, though the bits it has chosen (cervical smears, immunization, developmental assessment in childhood, ‘health checks’ for the elderly, blood pressure screening and so on) are a ragbag of what is measurable rather than what is important, hastily prepared by people without personal experience of anticipatory care in the community and un­aware of the real constraints and difficulties faced by all primary health workers who take this work seriously.

Targets are to be set for immunization rates and various sorts of screening, verified by Family Practitioner Com­mittees which are to be encouraged to take on positive functions in health care planning. There are to be inducement-payments for success in achieving these targets. Though obviously this will be more difficult in high-workload, high-morbidity areas such as inner cities and areas of high un­employment and industrial decay, other incentive payments are proposed to improve recruitment of young GPs to these areas, which are presumably intended to offset higher earnings in areas where high rates for preventive care will be more easily attained.

The limit of two Whole-Time-Equivalent staff to each GP is to be removed, and a wider range of staff can be employed, including physiotherapists, interpreters and other social link workers and counsellors. However, reimbursement of wages for these additional staff are to be cash-limited, presumably implying that the most progressive practices which already employ their full quota and want more staff will get them, but the most backward practices most in need of more staff are likely to find the cupboard bare when they get there; ‘buy now while stocks last’.

FPCs will be responsible for setting targets for preventive work and verifying their achievement. It is not at all clear how this will be done; FPC budgets have just been cut and further cuts have been officially forecast for next year, though at the same time more money is promised to assist these new functions. The White Paper mentions the possibility of annual reports by GPs as part of their contract, but does not seem to see this as a major area for innovation, and naturally ignores the possibility that these could be a path­way for direct accountability to patients, the development of democratic control, and the means of creating a counter­balance to the risks of central bureaucracy in any future salaried service.

In apparent conflict with all these proposals, the minimum list size to qualify for the Basic Practice Allowance (the salary element in GP pay) is to be raised from its present level of 1,000, and the proportion of earnings from capitation is to be increased. The policy makers seem inclined towards the pattern of care long advocated by Geoffrey Marsh, ( Marsh,   G.N.,   Channing,   D.M.,   ‘Deprivation  and   health   in   one general practice’, British MedicalJournal 1986; 292:1173-6)  an extended team of nursing and other supporting staff, with a smaller number of GPs with large lists, concentrating on their traditional task of dealing with established symptomatic disease and diagnostic and therapeutic puzzles. These larger lists would be attained by more vigorous competition, assisted by simpler procedures for patients who want to choose a different GP, and by moves towards advertising the range of services offered by different practices.

The White Paper proposes an immediate reduction of the salary element in GPs’ pay with a corresponding increase in capitation, to encourage competition and larger lists, and warns that further increases in capitation and reductions in salary are planned for the future. It is interesting that despite the entrenched hostility of GPs to a fully salaried service, both the College and the BMA are fiercely opposed to increases in the capitation element, rightly believing that this will encourage competition for patients in terms which will certainly address consumer satisfaction, but will equally certainly fail to address population needs. The most probable scenario for any shift of British general practice to salaried service is that this will occur not in one single dramatic leap, but by incremental shifts away from capitation and fees-for-item-of-service and towards a proportionally larger salary (basic salary plus salary increments for further training, seniority and difficult areas of practice), together with a more positively planned and verified local contract with proactive rather than reactive FPCs. It is difficult today to conceive of BMA negotiators openly embracing the form of a salaried service, but it is entirely conceivable that they could, faced with uglier alternatives, accept its substance.

A Menu Without a Meal

Though it implies a substantial extension of the scope and responsibilities of general practice, the White Paper proposes an increase in expenditure of only 5% in 1988-9, 2.5% in 1989-90 and 3.5% in 1990-91, all in real terms. The only immediate new money available for this is to be £170 million from charges to patients (for the first time) for examinations by dentists and opticians, a step which obviously contradicts the government’s claim to be promoting prevention. FPC budgets are for the first time to be cash-limited in respect of all this proactive care, as opposed to reactive demand-led care, which remains open-ended because even this government has not yet thought of any way of closing it. The White Paper’s menu does contain many interesting items, particular­ly to progressive GPs accustomed to baked beans every day for the last 39 years, but when we come to who pays, it turns out that this meal is to be more a literary than a gastronomic experience.

In strategic terms, the White Paper is a dog’s dinner, an incoherent jumble of measures promising something for everybody, but which on the day it was presented to Parlia­ment apparently pleased nobody. It is interesting that the Right was probably more angry than the Left. The White Paper gave a ritual curtsey to The Market (‘The Government sees no reason why private primary health care should not be developed in ways that provide both an alternative source of care and means of comparison with NHS services’), but the Director of the Social Affairs Unit (a New Conservative think-tank) writing in The Times (Anderson, D., ‘The great health collision’, The Times, 26 November 1987 ) the next day on ‘The great health collision’ saw ‘no substantial differences’ between the policies of the Labour and Conservative Parties, and was clearly disappointed at the failure even of the third Thatcher administration to break with the tradition of welfarism in the NHS:

The ingredients are all there: scientific and medical progress making available a host of new treatments, rising public expectations that the treatments are a ‘right’, and cost of treatment rising faster than the general rate of inflation. It is a collision course. . . We are now seeing the acknowledged rationing of health care. Unless something is done soon, there will be much more. . .

It is certainly true, as the [White Paper] suggests, that the quality and effort of GPs varies enormously. But, again, this is to be corrected by the politicians and bureaucrats deciding what constitutes a good doctor and giving slightly increased incentive payments for him to do the things they want. . . the overall question of what suits the varied needs of the 750,000 who visit the GP each day is not reflected in these broad objectives. True, the customer is to be given a little more information about the rival merits of GPs but not to the extent that it might inconvenience the GPs, or that trade union, the British Medical Association, that Thatcherism has yet to put in its place. ..

True radicalism would involve facing up to the central problems that health services need a lot more money and it cannot all come from raised taxation, that we need an innovating health system with true competition, and that ‘inefficiency’ cannot improve unless true costs and preferences are revealed by a market.

True radicalism would not restrict its use of charging to outside the GP service—as [the White Paper] does. It would consider whether innovation, efficiency and consumer satisfaction might not be better served by returning to each family of four who wishes it, the £560 it has contributed in taxation to the nationalised system. . . and letting them spend it on private care. All the evidence shows that many families are willing to add such a sum and spend more, provided they know it is going to the family’s health care, not to the general tax coffers.

The contrast between rationing and the market is instructive. Wartime rationing gave us a better-fed nation in war than we had in the peacetime of the 1930s, when markets ruled. The Radical Right never seems to notice that if people have money to spend on private medical care or to contribute to charities, this money could equally, and more efficiently, have been spent on higher taxes for better services which would not have to depend either on the poorly-informed demands of consumers or on humiliating appeals for charity. The fact that many people love themselves more than their neighbours and want to spend their money accordingly seems a poor base for what claims to be a moral argument.

The same issue of The Times contains the reports of the White Paper’s reception in parliament under the headline ‘FURIOUS PROTESTS GREET HEALTH WHITE PAPER’. The fury came not only from the opposition, but from the Conservative back benches, including such Thatcher stalwarts as Dame Jill Knight, Mr Robin Maxwell-Hyslop, and former Conservative Health Minister Sir Barney Hayhoe, who protested at the continued under-funding of the NHS and told his own front benches that if in the next budget possible tax cuts were foregone in order to provide more money for the NHS, the Chancellor of the Exchequer ‘would be cheered equally in all parts of the House’. Between its raucous un-elected advisers and its more cautious MPs, the Government has little room for manoeuvre.

As I write, there has not been time for either the College or the BMA to respond to the White Paper. The minister is probably confident that no real alternative, a planned service accountable for health outputs as well as measures of process, has yet been developed or even contemplated either by professional bodies, or by the opposition parties, and in the absence of positive proposals he can negotiate the details with the BMA with an effectively bipartisan policy behind him in parliament for his positive measures. The Labour Party might well prefer the Conservatives to take the blame for any incursions on GP autonomy, while congratulating themselves on the useful precedents set for a future administration.

The White Paper probably defers a clear decision in any direction. GP accountability is to be increased, though how this will be done is not at all clear. In general steps forward towards a more continuous, anticipatory and socially responsive service are roughly balanced (and for the most part contradicted) by concessions to consumerism and competition (inevitably impairing continuity), fees-for-service (which may be inflationary and will certainly increase bureaucracy), and direct patient charges (though not yet within the GP service). Though nothing has been actively done to promote private general practice, pressure from the Radical Right will continue, restrained chiefly by the wish of Dame Jill Knight and other Conservative MPs to be re-elected next time they face the voters.

Doctor-centred or Patient-centred Service?

I have dealt at length with the Green and White Papers story because it is the most recent and dramatic example of the unresolved conflict at the foundation of the health service in Britain, and in sometimes more, sometimes less obvious forms in all other market economies; hospital services cannot work effectively without a primary care base of GPs, the primary care base cannot work effectively without more public investment in medical, nursing and office staff time, and public investment will not be made without public accountability; but GPs are reluctant to accept public accountability and as yet unable to imagine it in terms of local participative democracy rather than central bureaucracy. None of these developments can therefore occur on a mass scale, and governments anxious to hasten as slowly as possible will be satisfied to keep this situation going as long as they can, unless and until escalating hospital costs force them to look again at fundamental changes in primary care.

The GPA, and the quality-related pay proposals in the White Paper, attempted to solve problems of clinical squalor concentrated above all in industrial and inner-city practice, by rewarding already-innovating practices almost none of which are to be found where these problems are at their worst. ‘The arguments for providing increased resources for those practices which are innovating and striving for improve­ment are unanswerable’, said RCGP Chairman John Hasler. No doubt they were; but even more unanswerable were the arguments for providing increased resources for practices which were not innovating and not striving for improvement, because these resources were needed for patients, not doctors.

There is only one means of escape from this dilemma; GPs’ practices belong not to them personally, but to the communities they serve. Left to themselves, GPs will never accept this in reality, though they may occasionally be willing to talk about it. But in the real world, they are no longer being left to themselves; they are entering a stormy sea, in which secure and well-rewarded mediocrity will no longer be on offer from any political party. At the time of the Green Paper in 1986, the most the College could realistically have hoped to do was to make the various options for reform clear to the membership, together with such evidence as we had, and leave them to make their own choice through their own traditional negotiating bodies, the Local Medical Committees and the BMA. There was, and as yet there is, no consensus support for any major move in any direction; it was folly to believe it could be otherwise, until it becomes obvious to a critical mass of the membership that the status quo is no longer an option. The historic push had to come from the outside, and with a little patience would soon have done so; it is probably doing so now. It was wrong to risk the unity of a socially valuable organiza­tion in a vain attempt to lead GPs where they did not want to go, at a time when they were not yet convinced that they had to move at all.

After the election of 1987, Mrs Thatcher and her New Conservatives believe they have a popular mandate to impose radical change throughout society, and general practice will ultimately be no exception. Under the slogan of Parent Choice, ‘good’ schools are to be encouraged to expand at the expense of ‘bad’ ones, ignoring the obvious question; why will any parents choose ‘bad’ schools? The government is gambling on its belief that a vocal minority of parents will believe that their own children will gain from a two-tier system, and that most parents will continue passively to accept whatever schooling is locally available, thereby return­ing to an educational system which even in childhood deliberately reinforces the division of society into winners and losers. All the arguments for widening the gap by reward­ing good schools and pauperizing bad ones, rather than making effective investment where difficulties are greatest to improve standards for all neighbourhoods (because it is tidy or rough neighbourhoods we are really talking about), can be applied to arguments for a two-tier GP service. Individual GPs are likely to be scapegoated for bad general practice in the most damaged parts of our society, just as individual teachers have been pilloried for bad schools, and individual social workers have been sacrificial victims of their permanently overworked and undermanned service. Invited to act as jurors, exasperated patients may serve as willingly as disappointed or frightened parents. Mrs Thatcher knows how to economize in already impoverished educational and social services which have to cope with the results of divisive economic and social policies and drastic cuts in central funding, while blaming the consequences on those who have to operate them. GPs are likely eventually to find themselves in the same line of fire. The easy options will be gone, and GPs, in the College and in the BMA, will have to look for new allies and consider active policies for change.

From Investment without Accountability to Accountability without Investment

The prospect now facing (but not, as yet, faced by) GPs is that having so long refused to pay the price of public accountability for increased public investment, they may get the accountability without the investment. It is not too painful to rationalize distribution of effort within an expand­ing service, but in a cash-limited service squeezed between the growing needs of an ageing population and the rising expectations of continued scientific advance, it is going to be very painful indeed, not only to patients, nurses and other health workers, but even to doctors. A minority of doctors and patients will solve some of their own problems by moving backward in history to the private sector, but a frankly two-tiered service for patients will also mean two-tiered quality of care and two-tiered careers for doctors.

Increasingly, doctors will question the value of the social components of the Osier paradigm. Gentlemanly status is a waning asset, and the possibility of a different social align­ment may become more attractive. Once compelled to accept that we must be accountable to someone, we shall begin to understand that we have a choice, if we have the courage and imagination to make it. Apart from accountability to the individual patient, the only forms of accountability ever considered within the Osier paradigm have either been accountability of the profession to itself (which is what we are supposed to have now, and has generally meant no accountability at all) or accountability to some higher administration, without recent personal experience of the everyday realities of practice, with its own bureaucratic objectives, and its own allegiances to yet higher and more remote authority.

Of course, some central, regional and district administrative control and leadership are essential to any fully effective primary care system, and even at practice level administrative skills are essential. The proviso is important, because the whole medical tradition, and especially the tradition of general practice, is (in its middle-class way) anarchic, contemptuous and intolerant even of obviously necessary administration; ‘if they would only leave us doctors and nurses alone to get on with the job, we could do twice the work in half the time’; an ignorant and condescending attitude to health service administration of which we should be ashamed. But the hatred and mistrust of bureaucracy felt by so many doctors, and particularly by GPs, has real foundations. The withering effects of bureaucracy on initiative have been obvious in our own Public Health and School Medical Services, and in many under-funded but over-administered public primary care services abroad. The counterweight to bureaucracy is not cocksure autonomy for clinicians, but participative democracy: the only people besides ourselves who can really know the nature of our work are the populations we serve, and they are the only people who could and would defend us and themselves from bureau­cracy in a planned and accountable service.

Just as doctors in the USA are ending up as salaried employees of for-profit medical corporations because of their obstinate refusal to accept a socialized health service, ( Starr, P.,  The social transformation of American medicine, New York: Basic Books, 1982)  British GPs could end up as Poor Law doctors serving a pinchpenny bureaucracy rather than the needs of their patients, if they refuse to develop real partnership with their patients in a people’s service.