A New Kind of Doctor 8 Accountability For And To Groups

Doctors are rarely accountable for the average quality of their work in terms of outcome. They have to answer for exceptional events, unexpected disasters lying outside the normal range of experience, but rarely for assessment of average process, and virtually never for average outcome. If disasters don’t occur, or don’t reach the ears of authority, quality of work is assumed to be satisfactory. Even if it is so obviously unsatisfactory as absolutely to demand enquiry, that enquiry will use process rather than outcome measures.

For example, the expected mortality of a planned operation for repair of inguinal hernia in a man of 65 is between 3 and 6 per 1,000 operations (Neuhauser, D., ‘Elective inguinal herniorrhapy versus truss in the elderly’. In, Bunker, J.P., Barnes, B.A., Mosteller, F. (eds.), Costs,risks and  benefits  of surgery, pp.  223-39. New York:  Oxford University Press, 1977.). Death from such an operation is exceptional for an individual, but since not even the best surgeons have an operative mortality of zero, some deaths will always occur. The quality of a surgical unit (allowing for the average age and state of health of the patients) can’t be judged fairly or usefully from the litigation, press criticism, or individual complaints it appears to provoke. Intelligent judgement depends on comparing average results in different centres, and then asking why differences are what they are. Fear of litigation is unlikely to improve the outcome of operations if the real fault is overwork and fatigue among junior staff, a shortage of nurses, or a high proportion of patients in poor health.

Hospital teams with enough pride, interest and confidence in their work to review their results and expose them to peer criticism at clinical meetings or in serious medical journals provide most of the evidence we have on the effectiveness of medical care. These generally show steadily improving out­comes, not because of pressure from litigation and complaint, but because the advance of medical science generates motiva­tion of its own, initially at centres of innovation, later among pioneers at the periphery. Useful studies are based not on exceptionally good or bad individual results, but on the out­come of care in groups large enough to eliminate the confusing effects of chance, and the variable age, sex, and other factors relevant to survival which make individual outcomes so un­reliable as a guide to the quality of care.

No public service has ever had much interest in suspecting, identifying, or advertising its own limitations, but scientists do generally accept that the advance of knowledge depends on precise recognition of their ignorance. GPs as graduates in medical science have been slow in accepting this self-critical stance because of their autonomous status as entrepreneurs in a public service. However, just as there are no zero-risk surgeons, there are no zero-risk GPs. All medical interventions entail some risk, however small, of going wrong. This risk must be multiplied if interventions are applied indiscriminate­ly in hasty 5-minute consultations, where the prescription pad may be used more to speed throughput than to change outcomes intelligently. If thoughtful medical interventions chosen and aimed accurately at selected targets are effective, then their inappropriate omission will also increase risk. If doctors are required to be perfect, they’re damned if they do and damned if they don’t. Many will maintain the greatest possible ignorance about the real results of their work by avoiding objective measurements and denying their value. They can remain comfortable with entrepreneur status, accountable to no one providing they satisfy their customers. Once these customers are sufficiently well informed to make more accurate judgements, however, the always fallible GP may find it better to abandon the omniscience of medical trade, and promise only what can really be delivered; the best we can do jointly with the people we serve, with in­complete information and nearly always less time than we need.

A scientific approach to measuring quality must be realistic rather than legalistic, and can only begin if GPs are allowed and encouraged to search for their own errors. Good doctors are those who are prepared to measure, or let others measure, how bad they are; or, more constructively, are prepared to accept that their work can be convincingly improved only if they are prepared to start by measuring its outcomes, errors and omissions. This in no way contradicts the rule that medical care should not be judged only by what is most easily measured (for example, the proportion of patients whose blood pressures have been measured or who have had cervical smears). Many very important qualities, like friend­liness, approachability, and readiness to listen, are difficult to measure and tend to be ignored in plans for evaluation of care; but this does not mean that they can’t, with imagination and some readiness to ask the patients, be quantified just as much as any other medical process. In practice, however, rude and inaccessible doctors simply will not attain good indices even on the simplest measures of performance. Regardless of status, bad doctors are those who refuse to measure, or to allow others to measure, their outcomes, errors and omissions. And these measures must be repeated; doctors whose poor performance is improving are better than those whose good performance is stagnant or deteriorating.

Perfection for Some of the People Some of the Time, or our Best For all of the People all of the Time?

About 20 years ago a newly appointed consultant visited one of my patients at home. Before his appointment, his specialty did not exist in South West Wales: he brought essential skills for the first time to a total population of nearly a million people. We were both enthusiasts for better clinical medicine, so after the visit we took 10 minutes off for a beer, an exchange of gossip, and for me to congratulate him on the dramatic improvement in the quality of care available to my patients in his specialty. Everything he said suggested contempt for doctors who pursue fees rather than science and public service, so I was amazed to hear he had chosen to work part-time, and after only a year in post had already developed substantial private practice. ‘Why on earth do you do it?’, I asked. His answer (rather shamefaced; he was not yet completely comfortable in his new role) was the typical defence within the Osier paradigm: ‘I feel I owe it to myself to practice really good medicine at least one session a week; without that I’d lose my self-respect.’

It’s difficult to deliver a specialized service to about half a million people with inadequate resources; still, we previously had no service at all in that specialty, so we (the GPs and the population) were more grateful than critical. It is clever, but not nearly so difficult, to see a few who can afford to pay (in another country we would call it a bribe) for more time, more thought, and more courtesy—in fact, better care.

The test of quality applied in the Osier paradigm is a capacity to excel under ideal conditions, mainly more time. The constraints of practice are seen as unchangeable; the good doctor in the Osier paradigm gets out of bad circum­stances as soon as he can, to work better in good ones. Bad practice because of circumstances which preclude good practice is seen as a problem for doctors, not patients, with doctors’ not patients’ solutions.

The test of quality for the New Kind of Doctor we need is measured outcome for the registered whole population at risk, whether that be the 500,000 or so served by a neuro-surgeon at a tertiary hospital, the 100,000 served by a cardiologist at a District Hospital, the 10,000 served by a group of five GPs at a health centre, or the 2,000 served by one GP with nursing and office staff. Simple ultimate out­comes, for example death rates standardized for age, sex, social class and locality, can rarely be applied to populations of less than 10,000, and even then only over periods of 5 years or more, because of chance variability where numbers of events are small. But intermediate outcomes, group average blood pressures in hypertensives, group mean glycosylated haemoglobins in diabetics, changes in the proportions of smokers in different age and sex groups, changes in the hospital-admission rate in child asthmatics, the number of fits in epileptics, and so on, have predictable effects on more serious outcomes and are certainly feasible, particularly now that we have the huge data-handling capacity of micro-computers.

The justification offered for excellent care for a few is that it sets standards for the many. If that is true, it can have a place within the new paradigm, for the average quality of care, measured as average outcome, will rise. Important new ideas often start from individual cases, and the condescending attitude to anecdotal experience often adopted by non-clinical medical scientists is usually though not always un­justified. However, in choosing subsets of the population for innovative and exceptionally excellent care to pioneer general advances, it seems odd to select these according to their ability to pay fees, since fee-payers are not typical of the general population and usually present fewer problems in care. Scientific medicine, which now incorporates epidemiology (the study of disease in whole populations) throughout its fabric, cannot be practised with integrity in a commodity health market.

This argument is becoming of critical importance. In hospitals, more and more doctors and nurses are being forced to work without enough time, without enough staff, without enough space, tolerance, courtesy, or thought for anything but how to cope from one day to the next. The easy answer, permitted in the Osier paradigm, is to get out; out into some part of the NHS which still has adequate resources, out into private practice or agency nursing, out into one of the many hundreds of for-profit private hospitals and nursing homes now going up all over the country—to ‘help’ the ailing NHS, as well of course as their owners and shareholders, or out of your own country altogether, to seek your fortune abroad if there are still any richer countries that will let you in. Beds in private nursing homes and hospitals in England and Wales rose from 25,300 in 1971 to 33,500 in 1981 and 51,000 in 1985, while available NHS hospital beds fell from 526,000 in 1971 to 450,000 in 1981 and 421,000 in 1985. Private hospitals are concentrated around London and the South East, the very areas most subject to NHS cuts.

This process already exists in general practice to the extent that industrial practice remains generally constrained by high demands and low expectations, which some (but by no means all) GPs seek to evade rather than to change, but we are far from a frank division into a two-tier service, with private practice of high quality in the Osier paradigm and a threadbare public service. However, few doubt that in one form or another this is the future foreseen by the New Conservatives, probably by the same process of cutting off resources necessary for new advances which now operates in hospitals. The most probable development is tax-relief for private medical insurance premiums for private GP care. Like private care by hospital specialists, this will be justified by claims that it relieves pressure on the NHS: and the real effect will be exactly the same, that NHS doctors who effectively write their own timetables without official super­vision will have even less time to do NHS work which (they say) is already too rushed to be done well. GPs who do not choose or are unable to enter this minority market will pose an embarrassing question to those who do; precisely what is it that they will give to their private patients, which they do not give to their NHS patients? If private and NHS care are the same, the transaction is fraudulent; if they are not the same, they are clearly doing less than their best for NHS patients. The BMA in 1858 believed that because disease affected people of all social degrees, the same medical skills should be available for everyone; the BMA must still believe this in 1987, for otherwise it has to concede a division in the profession of the same nature as the division in society.

In the new paradigm, the test of a good doctor is that we do the best we can, verified by measurement, for all our patients, in the circumstances we find: and also that if necessary we do our best to change those circumstances. The best doctors won’t look for easier circumstances somewhere else, but join with their patients in changing conditions which preclude good practice, if necessary by blowing the whistle by full use of the newspapers and television. We have the social authority to do that, and no right not to do it, for no one else can. Loyalty to the populations we serve must become more important than our own value in the inter­national professional market.

Doctor-centred Studies of General Practice

Mainly through initiatives from the RCGP and its members, much descriptive data has been collected ever since the 1950s on many aspects of the patients GPs see and what they do for them. Notable examples are the 1951, 1971-2 and 1981-2 National Morbidity Surveys organized jointly by the OPCS and Donald Crombie’s RCGP Research Unit in Birmingham (General Register Office. Morbidity statistics from general practice 1955-6 (vols I-III). London: HMSO, 1958.); (RCGP, OPCS,  DHSS. Morbidity statistics from general practice 1971-2: second national study. Studies on medical and population subjects no. 36. London: HMSO, 1979.) ; (RCGP, OPCS, DHSS. Morbidity statistics from general practice 1981-2: third national study. Series MBS no. 1. London: HMSO, 1979.),Wright’s study of general practices in the South West of England (Wright,  H.J.,  ‘General practice  in South West England’, Report from general practice no. 8, London: RCGP, 1968.) , W.O. Williams’ study of general practices in South Wales (Williams, W.O., ‘South Wales study on morbidity’, Report from general practice no. 12, London: RCGP, 1970.), and the study of 208 GPs in Manchester by David Metcalfe’s group (Metcalfe, D., ‘No excuses’. In, Pereira Gray, D.J. (ed.), The Medical Annual 1985, pp. 184-204. Bristol: John Wright, 1985.). These surveys follow the general pattern of enquiry long established in hospitals; their starting point is doctors and the patients they see, and though the size, age and sex distribution, and some­times the social class composition of their base populations are available, the underlying assumption has to be that states of public health can be studied by looking only at the people who demand care, with little information about those who do not, or (more often) who demand care that is not relevant to their principal causes of ill-health.

These studies show great diversity between GPs in their rates of consultation, organized follow-up, home visiting, prescribing, laboratory and x-ray investigations, nursing referral and hospital outpatient referral, and in their average consultation time per patient. Very high workload is typical in some areas such as South Wales, which are still generally under-researched because their GPs seldom volunteer to take part in surveys. We always know less about what happens in Toxteth, Clydebank and Gateshead than we do about the Thames valley. At high workloads (whether caused by big lists, high levels of sickness and distress, or both) GPs’ work seems to be constrained to a more uniform pattern of short consultation times. Metcalfe’s study of 189 GPs in Manchester (Metcalfe, D., ‘No excuses’. In, Pereira Gray, D.J. (ed.), The Medical Annual 1985, pp. 184-204. Bristol: John Wright, 1985.) showed that below a list size of 2,000, GPs released from these absolute constraints of workload were extremely diverse in their behaviour. This diversity was apparently related to personal characteristics of the doctors rather than to the age or social composition of the popula­tions they served, confirming in detail the more general conclusions of the three National Morbidity Surveys.

The BMA has asked for a target average list size of 1,700 per GP, justifying this by the need for more time if preventive work is to expand and clinical standards are to improve. Metcalfe found no evidence that the extra time released by lower list size led to more preventive work or more of any other indicator of clinical activity of personal care below a threshold of about 2,500. GPs with smaller lists apparently suited themselves, and expansion of preventive work, better clinical standards, or more personal care seem not to have commanded more of the extra time available than GPs’ other interests. Obviously there will have been exceptions to this, but they did not reach statistical significance.

One conclusion to draw from these studies seems to be that GPs as a social group are no more to be trusted as their own sole judges, and should no more trust themselves, than police, popes, prime ministers, presidents or patriots in the marine corps and secret service. There are big differences in health and therefore in potential primary care workload between local populations, depending on their age, occupational and social class composition, the availability of other sources of care, and their morbidity as reflected in local Standardized Mortality Rates. These differences should be reflected in the way GPs work, a reflection which should become closer as list sizes decrease and GPs have more time to show imagination in tackling local health problems, but evidently this is not happening.

The need for smaller lists should not be in doubt, but if GPs are to have fewer patients for the same pay as the BMA demands, the public has the right to expect more time given as better and more personal care. It should not be pocketed by GPs as compensation for conveyor belt work which has remained perfunctory through custom and low expectations long after the pressure of work which originally caused it has gone, while they seek equally mundane but better-paid part-time work outside their practices and even outside the NHS.

More constructively, we might conclude that without defined health objectives, it is hardly surprising if GPs wander off in all directions. Why not develop feasible local target figures for (for example) ascertainment and control of diabetes, high blood pressure, epilepsy, asthma or any other measurable and reversible health impairment? No doubt there would still be a healthy variety of answers, but at least we would know what questions are being asked.

Patient-centred Studies in General Practice

Data obtained from GPs who volunteer to take part in national studies such as the National Morbidity Surveys must inevitably be biased away from practices that are more over­worked, less well organized, or have a smaller social conscience, a problem which has still not been acknowledged by some of the principal authors in this field (OPCS   General   Household   Surveys.   Introductory   Report   1973, annually thereafter to 1984. London: HMSO, 1973-84.). The studies listed above started with GPs counting the patients they saw, perceiving their population at risk (if at all) only as a residual denominator, the ones they didn’t see. Only data obtained from random samples of the general population can give us generalizable information about the quality of care in general practice as a whole.

Few studies have sampled patients randomly from the general population, looking at the GPs the patients happened to have, and thus observing general practice through the public it serves. Data of this kind have for some years been gathered routinely by the General Household Surveys of the OPCS (Hart, J.T., ‘General-practice workload, needs, and resources in the National Health Service’, Journal of the Royal College of General Practitioners 1976; 26:885-892.), based on recall of events over the two weeks previous to interview, but their sample sizes are small and detailed studies of particular problems, for example the care of diabetics or people with chronic lung disorders, are not possible with them.

Ann Cartwright and her colleagues from the Institute for Social Studies in Medical Care have provided the most complete, detailed and reliable series of studies of how general practice relates to its populations, starting in 1964 with Patients and their doctors (Cartwright, A., Patients and their doctors, London: Routledge & Kegan Paul, 1967.), still the best source of data about the nature of British general practice, and ending rather weakly with General practice revisited (Cartwright, A., Anderson, R., General practice revisited: a second study of patients and their doctors, London: Tavistock, 1981.) in 1977. Like the General Household Surveys, these studies do not connect with its clinical content, and are therefore easily dismissed in the Osier paradigm as relevant only to the psychosocial fringe of practice, rather than its clinical care. Two of Ann Cartwright’s studies are exceptions to this; Life before death (Cartwright,   A.,  Hockey,  L.,  Anderson,  J.L., Life  before death, London: Routledge & Kegan Paul, 1973.) and Life after a death (Bowling, A., Cartwright, A., Life after a death: a study of the elderly widowed, London: Tavistock, 1982.)looked at what happened to patients during the year before their deaths (randomly sampled from registered deaths in the general population) and to their bereaved spouses afterwards. These two studies are sited well within clinical territory and should be required reading for every medical and nursing student and every medical and nursing teacher, but judging from the few references to them in the general clinical literature, they seldom are.

Clinical Epidemiology and Audit in General Practice

As we have seen at length in Chapter 5, GPs with registered lists of people for whose primary medical care they are responsible are able, unlike all other clinicians, to measure both what they do and what they don’t do. The inefficiency, ineffectiveness, and for most of the time unreality of the Osier paradigm of episodic salvage can only be fully exposed, and the paradigm fully superseded, on its own territory of clinical practice, and by measuring health outcomes rather than clinical processes.

Both Osier himself and Clifford Allbutt recognized the superiority of public health and preventive measures over episodic care (Seipp, C., The ambiguities of greatness: Sir William Osier, 1849-1919.   Unpublished MS  1981.  Health Services Research Centre, University of North Carolina, Chapel Hill.), but could not in practice bring it to the centre of their clinical teaching because teaching hospitals had no clearly defined source populations, follow-up was erratic, and generally they were producing doctors for self-employed private practice rather than for Public Health Service, and inevitably adapted their teaching accordingly. Less thoughtful than they were, true believers in the Osier paradigm today are not seriously concerned by its ineffectiveness at a psychosocial level, because they see psycho-social problems as optional features at the periphery of their work, bolted on or omitted according to the style and interests of individual clinicians, who can retain their reputations for clinical competence whether or not they accept them. If, however, it can be shown that within the Osier paradigm even the best GPs, who measure their work against a known population base and publish in the medical literature, are unable to deliver effective clinical care to more than about half the people who need it, it can be recognized as an obstacle rather than an aid to effective anticipatory care, though it will remain an effective albeit incomplete method for handling salvage in symptomatic disease.

Bearing in mind that all clinical audit and population-based research in general practice is voluntary, unpaid and very time-consuming, the proportion of practices which have done work of this kind, and the rate at which this proportion is growing, are impressive and compare well with other nations and care systems. Until paid and protected sessional time is made available in all practices for internal clinical audit and planning, it will not involve more than a small minority of enthusiasts, but the rate-limiting factor is already more the social and economic structure of NHS general practice than the attitudes of GPs, which have already in many cases outgrown its entrepreneurial form.

Death of the Medical Officer of Health: Did he fall or was he pushed?

At present, no one is really responsible for local health in concrete terms. If the NHS were organized to enable and encourage primary care teams to take responsibility for the health of their local registered populations, and to make them accountable to those populations, a critical mass of medical and nursing opinion would already be available to make a serious start on a national scale; but it is not there now.

From 1918 to 1974, Medical Officers of Health (MOsH) were employed by and answerable to elected Local Govern­ment authorities for supervision of all aspects of local health other than personal medical care, including enforcement of laws controlling quality of housing and some occupational risks, as well as monitoring of water supplies and sewage disposal. They built up and led teams of sanitary workers, nurses and salaried doctors, varying from very small units performing minimum statutory functions in some smaller areas, to huge organizations with many specialized medical and other departments in large cities. Though the BMA fiercely resisted all proposals for personal preventive work by salaried public health medical officers, failure of GP entrepreneurs to develop planned ante-natal care, to give help in birth control, to help young mothers by systematic personal advice in child-rearing, or to achieve more than sporadic immunization for diphtheria, led to development of Local Authority clinics which did provide these things. In the early years of the NHS these clinics continued to develop, and many salaried medical officers serving them developed valuable skills in preventive and educational work and in early diagnosis and supervision of handicap.

MOsH had wide discretionary powers and considerable professional independence (they could not be sacked by their employing authority, for example), and where both MOsH and local government really wanted to develop an effective public health service, achievements before the NHS were remarkable in some areas, recently reviewed rather optimistically by Sir George Godber (Godber,   G.E., ‘Medical  Officers  of Health  and health services’. Community Medicine 1986; 8:1-14.). Unfortunately for each vigorous pioneer there were at least ten others who sank into bland bureaucratic optimism, well described by Webster (Webster, C., ‘Medical Officers of Health—for the record’, Radical Community Medicine, 1986′, autumn:10-14.):

. . . MOsH as a whole developed a reputation for minimising the problems with which they were confronted. Their scientific judge­ment was clouded by pressures from the centre to present an optimistic impression of the nation’s health, or by local reluctance to incur additional expenditure. . . With so few positive virtues the image of the MOH was shaped by negative factors. To other doctors the MOH was an officious and bullying bureaucrat, presiding over an empire of clinics and institutions. . . delivering services of dis­proportionately small benefit considering the costs involved.

In fact most MOsH still looked to the Osier paradigm, reconciled to their peripheral position in relation to clinical medicine by a relatively well-paid, undemanding and secure job. Between the wars they took on functions as local hospital administrators which had nothing to do with public health or prevention. When the NHS came in 1948 and they lost this part-time role they found, in Webster’s words, ‘no alternative worth contemplating’. When MOsH were abolished in the NHS reorganization of 1974 few noticed their dis­appearance, and fewer still were prepared to defend them.The 1974 reorganization, later reinforced by the Griffiths Report on NHS administration, created a unified administra­tive machinery modelled on the administration of corporate private industry. Business executives with corporate industrial experience were brought in, whose example Community Physicians were expected to follow. Local control by elected councillors from Local Authorities was greatly reduced, compared with their previous powers to appoint, support and receive information from MOsH, a de-democratizing tendency which is now (1987) almost complete.

The background to and consequences of this development have been excellently reviewed by Jane Lewis (Lewis,   J.,   What price   community   medicine?  The philosophy, practice   and  politics   of Public   Health  since   1919, Brighton: Wheatsheaf, 1987.). Detailed public health functions such as control of water supplies and sewage disposal went to engineers, social services escaped from their absurd subordination to a medical leadership which was rarely either interested or informed about the skills of social casework, most GPs were running their own ante-natal clinics and some were running their own baby clinics, leaving only co-ordinating and leadership functions to the MOH. Co-ordination and leadership of staff they did not employ and over whom they had only a moral authority amounted nearly always to virtually nothing.

Such residual energy as still remained in the dying MOsH was bequeathed to their successors, Area Community Physicians, who retained an advisory role to local govern­ment for environmental hazards and occasional epidemic disease, but for practical purposes no doctor now had personal responsibility for reporting on or doing anything about the health of local communities. In fact, just when epidemiology was showing that powerful environmental and social causes underlay the modern epidemics of (for example) coronary heart disease, lung cancer and maturity-onset diabetes (susceptible to environmental and social control and requiring planned environmental and social policies and monitoring which only a public health service could provide) the traditional Public Health machine was being dismantled, its principal staff corps of MOsH being bribed into abdication by profitable early retirement or lucrative posts as Community Physicians ranked as consultants, and theoretically supposed to co-ordinate the work of hospital specialists, but without any real power to do so. The underlying assumption was that the nation was now too healthy to benefit much from public health measures and the monitoring of groups; future advances would come from a powerful system of individual clinical care within the Osier paradigm, which scarcely existed in the 19th Century when the public health idea was born.

As for the grand new conception of the Community Physician, like Mozart’s Arabian phoenix, everyone has heard of it but few have seen it. As always, there are exceptions, but their efforts seem to have been more an embarrassment than a source of pride to most of their colleagues. I have met Community Physicians doing excellent work, excellently trained at the London School of Hygiene, but they were Catalans practising in Barcelona. Though the theoretical training of community physicians in Britain is second to none, it is in practice impossible for most of it to be put into practice in the NHS, a system managed for economy rather than planned to conserve and restore health. The Public Health Alliance (‘Rethinking public  health:   the  Public  Health Alliance’, Lancet 1987; ii:228. The address of the Alliance is c/o The Health Visitors Association, 50 Southwark Street, London SE1 1UN) launched in 1987 by Dr David Player after he was deposed as director-general of the Health Education Council because of his outspoken opposition to socially divisive government policies, is campaigning for a redefinition of Public Health in much the same terms as those advocated in this book. This could be an important rallying point, particularly if it becomes associated with progressive movements in primary care.

Origins of the British Public Health Tradition

The Public Health tradition in England was founded on four perceptions by those with the wealth and power to implement policies:

  • That as industry concentrated population in cities, the health of the rich could not be insulated from that of the poor, requiring control both of communicable disease (above all, cholera), and of its most immediately obvious causes.
  • That as labour skills became more sophisticated and valuable, ill-health in the labour force became a potentially avoidable burden on the costs of production.
  • That military manpower depended on a reserve of fit young men.
  • That charitable care for the poor could endorse the rule of the rich, thus stabilising a divided society.

This is not the authorized ‘on and on and up and up’ version of history taught in medical schools, typified by Sir George Newman (Newman,  G.,  The  rise of preventive medicine, London:  Oxford University Press, 1932), who traced the origins of the British Public Health Service to

. . . the expansion and interpretation of Humanism and an ever-extending Education of the people as a whole. . . the benevolence and altruism of the medical profession; the evangelical revival of Wesley and the Methodists; the humanitarian ideals of Elizabeth Fry, John Howard, Samuel Romilly, and Wilberforce; ‘the greatest happiness of the greatest number’ of Bentham; the broad common sense and understanding of Percival, Ferriar, Haygarth and the medical officers of the Poor Law Commission; the ‘socialism’ of Owen, Cobbett, Place and the Chartists; the co-operative movement; Lord Shaftesbury, Chadwick, Simon, and Florence Nightingale; the far-seeing economy of employers; Mill and the Utilitarians; and the promoters of national registration and insurance.

A bland list of good people with good intentions, borne irresistibly upward by the justice and common sense of their cause; that was not how history happened, nor how it was felt by those it happened to.

More than by any other man, the British Public Health system was conceived and brought to birth by Edwin Chadwick, who started as personal secretary to Jeremy Bentham. His ideas developed while he was secretary to the Poor Law Commissioners, during implementation of the Poor Law Amendment Act of 1834, when he became arguably the most hated man in England. The New Poor Law was consciously designed to reduce the burden of rates on land­owners, and to herd surplus labour from the countryside into the new industrial towns by eliminating all alternatives except the workhouse, and then ensuring (by the ‘doctrine of less eligibility’) that survival inside the workhouse would be more unpleasant than starvation outside. It therefore had the support of both the old landed gentry and aristocracy, and the new rising class of industrialists. The Act, which was largely Chadwick’s creation, was ruthlessly utilitarian in the Bentham tradition. Because it was directed at the propertyless classes, it was a collectivist intervention, contradicting the laissez-faire individualism of the propertied middle class. The stoutest efforts of revisionist historians have failed to scrub out the horror of the workhouse, which has permanently tainted all efforts at authoritarian reform.

Having failed to legislate pauperism out of existence with the Poor Law, Chadwick turned to ill-health as one of its causes. In 1838 he persuaded the Poor Law Commissioners to support a survey of the condition of the people in industrial cities, mainly relying on the Medical Officers of the Poor Law Unions (mostly part-time GPs) as his reporters. Their findings appeared in his Report on the Sanitary Condition of the Labouring Population of 1842. Few men of 50 were still well enough to work; in Manchester the average age at death was 38 in the families of professionals and gentry, 17 in the families of labourers and artisans. Chadwick’s comments on a radical workers’ meeting show how his interest in the health of the working class derived from his perception of the utilitarian interests of employers. He observed that

the bulk of the assemblage consisted of mere boys, and that there were scarcely any men of mature age to be seen amongst them. Those of mature age and experience. .. generally disapproved of the proceedings of the meetings as injurious to the working classes themselves. These older men, we were assured by their employers, were intelligent, and perceived that capital, and large capital, was not the means of their depression, but of their steady and abundant support. They were generally described as being above the influence of the anarchical fallacies which appeared to sway those wild and really dangerous assemblages. (Quoted in Watson, R., Edwin Chadwick, Poor Law and Public Health, London: Longman, 1969.)

Chadwick’s chilly utilitarianism was in a class by itself, but more sympathetic reformers share the same ultimate social allegiance. William Farr, Britain’s first Registrar General and founder of social statistics, sympathized with the popular battle against the workhouse, but looking back from the 1870s concluded that despite its abuses, the Poor Law was ‘an insurance of life against death by starvation, and of property against communistic agitations’.

The highest incidence of disease was everywhere associated with absent or foul water supplies, open drains and filth of every description. It was common for corpses to remain for several days before burial, in all weathers, in the single rooms inhabited by most families. In a supplement on burial of the dead, Chadwick proposed the appointment of Medical Officers of Health whose first task would be to verify deaths, ascertain their cause, and thus build up an information system on the state of public health and what was being done about it. The Health of Towns Act of 1848 laid down the legal basis of all subsequent public health work, revolution­izing the structure of towns, introducing universal safe water supplies and drainage, legal control of housing standards, and the safe distribution of food.

Chadwick successfully overcame the opposition of private water companies, slum landlords, and the innumerable local profiteers from corrupt and inefficient Local Authorities which were still elected by a small propertied class, mainly of landowners. The odium in which he was held by the working class gave him a relatively free hand from the most powerful economic and political interests, but pursuit of the causes of ill-health, even in the name and interest of the Establishment, was bound eventually to lose the support of the comfortable classes once the two fears of revolution and cholera had receded. Chadwick’s enemies combined against him in 1854, when the government’s Bill to continue his Central Board of Health, organizing centre for the defeat of cholera by cleaning the slums, was defeated in parliament. No mass support was available from the poor, who saw him as oppressor rather than liberator. The Times gloated over this easy isolation of an authoritarian reformer:

We prefer to take our chance of cholera and the rest than be bullied into health. . . It is a positive fact that many have died of a good washing. All this shows the extreme tenderness with which the work of purification should advance. Not so thought Mr Chadwick. New mops wash clean, thought he, and he set to work, everywhere washing and splashing, and twirling and rinsing, and sponging and sopping, and soaping and mopping, till mankind began to fear a deluge of soap and water. . . The truth is, Mr Chadwick has very great powers, but it is not so easy to say what they can be applied to. Perhaps a retiring pension, with nothing to do, will be a less exceptionable mode of rewarding this gentleman, than what is called an active sphere. (Quoted in Watson, R., Edwin Chadwick, Poor Law and Public Health, London: Longman, 1969)

And that is what he got; a pension and no further public employment for the last 36 years of his life. Chadwick’s downfall has been attributed to his obstinate, intransigent and uncompromising personality, but that has been said of every energetic reformer who tried to enlighten the ignorance of wealth enthroned. His rise and his influence in fact depended on these same uncomfortable qualities, together with more courage than the Poor Law Commissioners, who initially refused to publish his Report on the Sanitary Condition of the Labouring Population because of its criticism of powerful interests, finally letting it appear only under Chadwick’s own name, leaving him with sole responsibility for it.

Limits of Authoritarian Reform

The same theme has arisen many times in the subsequent history of public health reform, in Britain and in every other country. Reform imposed from above, addressing fears of the rich rather than felt needs of the poor, succeeds only so far as the affluent are willing to pay for even a part of the cost of maintaining the health of the labouring class.

Historical experience suggests that at the top, social con­science depends more on the sound of hammering at the gates than on spontaneous altruism. Once the fears of cholera and revolution receded in the 1850s, Chadwick the authoritarian reformer had no friends.The workhouse legacy remained, to provide most of the buildings and the attitudes inherited by the NHS in 1948. Listen to this interview about life in Wandsworth workhouse, from the Report of the Royal Commission on the Aged Poor of 1895 (Royal  Commission  on   the   Aged  Poor,   1895,  XV,  15, 409-31. Quoted in Hobsbawm, E.J., Labour’s turning point 1880-1900, London: Lawrence & Wishart, 1948.):

  • Q. We have now to ask you about the aged poor; those about sixty.
  • A. They have to go and pick oakum for eight hours a day, twisting little pieces of corded string for eight hours a day until the people nearly become imbecile; they do not know what to do.
  • Q. Up to what age are they kept at this work?
  • A. They are kept at this from sixty-five until—well, there were some there seventy. There was one man there seventy-nine, at least he said he was.
  • Q. And they were all alike, worked for eight hours a day? A. Eight hours a day; they have a quarter of an hour to go out and smoke a pipe.. .
  • Q. Did you find the work severe?
  • A. No, not severe; monotonous. You did not know what to do. You could not go out to write a letter, or to read, or to do anything: you had no time of your own; in fact it was a place of punish­ment, not relief. . .

The thoughtless cruelty of the workhouse system was still forcibly separating elderly married couples when I qualified in 1952. The entire system of gentrified ignorance, hierarchical snobbery and judgemental condescension, run by starched matrons and soaked in a pervasive stench of carbolic, which typified all health service institutions, gave way slowly and reluctantly, not because of a wave of reforming enlighten­ment, but because working-class people with a little money in their pockets and a health service they had voted for and was theirs by right would no longer tolerate it, and the supply of genteel unmarried women with few alternatives to a life of dedicated ingrowing virginity dried up. Of 42,000 residential places in 1949, one year after the NHS began, all but 2,000 were in former workhouses. (Ryan, M.,  ‘The   workhouse   legacy’,   The   Medical   Officer,   11 November 1966; 270-1.) Even in the early 1960s, hospitals for long-term care of the chronic sick and elderly were mostly in a state of undiminished squalor. Here is a description of geriatric wards by Peter Townsend:

This ward is reached up twenty steep stone steps. . . On the wind­swept landing are twelve WCs in two rows of six, with no doors, no wooden seats, and divided from each other only by iron bands three feet high. The stone floors were saturated with urine and one man could be seen groping with his trousers in a confined space. . . The beds are iron-framed and are only two feet apart, each man having a bedside chair and sharing a locker with one other. There are no wardrobes, bedmats, or other amenities. In the day-room part, where the men both sit and eat, there are 41 armchairs crowded close together. All the walls and ceilings are grimy with dust. (Townsend, P., The last refuge: a survey of residential institutions and homes for the aged in England and Wales, London: Routledge & Kegan Paul, 1962.)

The health of poor people remained appalling. Nearly two-thirds of young men volunteering to fight in the South African war were physically unfit to bear arms. Lord Rosebery, leader of the Liberal Imperialists, observed that:

An Empire such as ours requires as its first condition an imperial race, a race vigorous and industrious and intrepid. In the rookeries and slums which still survive, an imperial race cannot be reared. (Simon,   B.,  Education  and  the  Labour Movement  1870-1920, London: Lawrence & Wishart, 1974. ) 

If this appears, perhaps surprisingly, to anticipate events about 30 years later in Germany, listen to Lord Rosebery’s fellow-imperialist, Lord Haldane, in his rectoral address to the students of Edinburgh university in 1907; after calling on them to recognize the new significance of the State in establishing and maintaining world supremacy, citing the examples of Scharnhorst, Clausewitz, von Moltke and Bismarck, he went on to say:

When a leader of genius comes forward the people may bow down before him, and surrender their wills and eagerly obey. . . to obey the commanding voice was to rise to a further and wider outlook, and to gain a fresh purpose.(Simon,   B.,  Education  and  the  Labour Movement  1870-1920, London: Lawrence & Wishart, 1974. )

I quote Rosebery and Haldane to emphasize the imperial,authoritarian mood of the time which was one important influence, though not of course the only influence, on early conceptions of the Welfare State.

The government was frightened enough to set up an Interdepartmental Committee on Physical Deterioration in 1904 which initiated school medical inspections, school meals, free school milk, leading later to sporadic beginnings of maternity and child welfare, and public nursing and health education services during the next two decades. For the first time, unevenly and incompletely depending on the social attitudes and resources of Local Government and the resist­ance of established GPs, a body of salaried doctors began to deliver personal preventive care.

Lloyd George, more in touch with reality than Lord Rosebery, presented a new idea to a Liberal Party frightened by the recent birth of the Labour Party:

. . . if a Liberal government tackles the landlords, and the brewers, and the peers, as they have faced the parsons [over the Education Act], and tries to deliver the nation from the pernicious control of this confederacy of monopolists, then the Independent Labour Party will call in vain upon the working men of Britain to desert Liberalism that is gallantly fighting to rid the land of the wrongs that have oppressed those who labour in it. (Quoted in Morton, A.L., Tate, G., The British Labour movement 1770-1920, pp. 223-4, London: Lawrence & Wishart, 1956)

With such motives, it is no surprise that despite democratic rhetoric, Lloyd George looked to Bismarck for his model in setting up his health and insurance service. Beatrice Webb and the Fabians differed less from this tradition than their socialist beliefs might suggest. They were authoritarian, indifferent and often hostile to the working-class movement, supported the South African war when all other socialists opposed it, and opposed the creation of an independent Labour Party.

The Webbs’ Minority Report on the Poor Law has correctly been seen as a principal origin of the British Welfare State as it eventually emerged. For example, far ahead of its time, it proposed a comprehensive personal medical service through State-salaried doctors, who could devote themselves

… in practice as well as in theory, to searching out disease, securing the earliest possible diagnosis, taking hold of the incipient case, removing injurious conditions, applying specialised treatment, enforcing healthy surroundings and personal hygiene, and aiming always at preventing either recurrence or spread of disease in contrast to mere ‘relief of the individual(Murray, D.S., Why a National Health Service? The part played by the  Socialist Medical AssociationLondon:  Pemberton  Books, 1971.)

However, the report was actually written at Luton Hoo, stately home of Sir Julius Wember, with his 54 gardeners, 30 house servants, and 10 electricians; here is what Beatrice Webb wrote, in the same Report, on the disposal of the undeserving poor:

Besides. . . the helpless deserving poor for whom Homes for the Aged have to be provided, there exists, we regret to say, no in­considerable class of old men and women, whose persistent addiction to drink makes it necessary to refuse them any institutional provision. For this class, indeed, the Aged Poor of Bad Conduct, out of all the pauper host, it might well be urged that the. . . General Mixed Workhouse, with its stigma of pauperism, its dull routine, its exaction of such work as its inmates can perform, seems a fitting place in which to end a misspent life (Mackenzie, N., Mackenzie, J.,  The   first   Fabians,   London: Weidenfeld & Nicholson, 1977)

Their friends and as they believed principal allies were the radical imperialists of the Liberal and Conservative parties, Lord Milner, R.B. Haldane, Joe Chamberlain, and Robert Morant, men with big social and imperial visions, firmly entrenched on the radical wing of the ruling class, many of them anticipating the later ideas of Fascism. The Fabians’ point of departure (their various destinations were a different matter) can best be understood as one response to an epochal change in the ideas of the ruling class itself, a process described by Hobsbawm in his essay ‘The Fabians reconsidered’ (Hobsbawm, E.J., Labouring men: studies in the history of Labour, London: Weidenfeld & Nicolson, 1964.):

. . . laissez-faire economic liberalism.. . had the force of natural law: a world in which, as in Newtonian physics, prices like water found their natural level, wages, like stones, when unnaturally raised must come down, and pint pots did not hold quarts. It was an orthodoxy which made virtually no provision (at least in the all-important field of production) for state interference, whose effects. . . must be ruinous. Politically it rested on the peculiar compromise of 1832 by which the old political rulers applied the manufacturers’ policy (except in certain fields affecting the social status of a landowning aristocracy), on the absence of a working-class electorate and of any labour movement disposed to, or capable of, seriously challenging social stability. On the military. . . side it rested on the stability of the 1815 balance of power, which left Britain in control of the seas and with a deciding voice in international affairs. The electoral reforms of the 1860s, the unifications of the USA and Germany, the emergence of Japan, and the Great Depression after 1873 undermined all these three pillars.

In consequence the set of theoretical beliefs which dominated mid-Victorian Britain, like the Whig-Liberal-Radical alliance which provided its almost unbroken parliamentary majorities from 1846 to 1874, broke down. A shift from individualist to collectivist thought reflects the necessary intellectual adjustment. . . this was an intellectual problem of liberalism, for no other coherent body of doctrine was available. There were, for practical purposes, no socialists and such conservatives as essayed thinking rather than feeling were, at least in their economic and legal theories, liberals. Hence, not only did the great majority of middle-class (or any other) native socialists of the 1880s revival [of socialism] begin their intellectual lives as Liberal-Radicals, but—more paradoxically—[they were initially influenced by] the systematic borrowing of the Prussian attitude to the State…

The need to find some alternative to laissez-faire, the readiness to define any such alternative as socialism, and the capacity. . . to separate socialism from the working-class movement, therefore provided a very apt background for the Fabians’ peculiar version of it.

The apparatus of the British welfare state, its public medical services and its machinery of Public Health, were completed in outline in the heyday of imperial power and on the brink of its decline. In Britain today the guardians of received wisdom seem to find it difficult to separate the idea of military and economic dominance (imperialism) from the idea of civilization. As our ruling class learns, slowly and reluctantly, to accept third-rate military and economic status, it embraces and rationalizes successive retreats from the civilized social commitments it accepted in the heyday of imperialism.

Bold conceptions of Public Health and organized public responsibility are no longer of interest. The Public Health idea today is an orphan, unsupported by real resources though potentially more powerful than at any time since the mid-19th Century. In the 1960s it was widely believed that mass prevention (which can and should include personalized anticipatory care on a mass scale) had been superseded by technically sophisticated personal salvage. This belief is now wholly discredited among informed people, as a social policy if not as a strategy for their own personal survival. Epidemiology, the study of the natural history of disease in populations, and its response to treatment and to environmental and social change, originally concerned almost entirely with infectious disease, has developed into a powerful research weapon concerned with all forms of disease and all ways of combating it, and Britain has been a pioneering nation in epidemiology as a research discipline. (Jefferys, M., ‘The transition from Public Health to Community Medicine: the evolution and execution of a policy for occupational transformation’, Society for Social History of Medicine Bulletin 39, December 1986, 47-63.); (Terris, M., ‘The changing relationships of epidemiology and society: the Robert Cruickshank lecture’, Journal of Public Health Policy 1985; 6:15-36)   The systems of data collection required to support a national epidemiological information service, so that intelligent planning decisions could be made in a Health Service positively oriented to the solution of health problems, have been earlier and more fully and comprehensively developed in Britain than anywhere else in the world. All British medical students now have some undergraduate training in epidemiology. There is now wide support, particularly among GPs, for integration of personal clinical care into an overall pattern of anticipatory care on a population scale. The conclusions of the Cumberlege Report, (DHSS, ‘Neighbourhood nursing—a focus for care’. Report of the community nursing review (Cumberlege Report), London: HMSO, 1986.)  driven through by a Conservative lady curiously oblivious of the traditional relations between GPs and their favourite Party, set out simple and practical guidelines for planned community care. The only real object­ions to the Cumberlege proposals by GPs have been anticipated difficulties in sharing management decisions with nursing officers, which must appear at least equally great when viewed from the other side of an intolerable divide which simply has to be bridged if we are to see any progress at all, and the fact that registered GP populations are more scattered than the neighbourhoods which Cumberlege correctly identifies as the obvious focus for care. Granted a little patience and flexibility on both sides, the work of primary care teams could be integrated with little difficulty, as most GPs do in fact wish already to set reasonable limits to the areas within which they are prepared to visit (Jarman,   B.,  Cumberlege,  J.,  ‘Developing primary  health  care’, Journal  of  the   Royal   College   of  General Practitioners 1987; 294:1005-8.);(Williams,   E.I.,   Wilson,   A.D.,   ‘Health  care units:  an  extended alternative to the Cumberlege proposals’, British Medical Journal 1987; 37:507-9.).

The registered list system which began with the clubs, consolidated by Lloyd George in 1912, and universalized by the NHS in 1948, make local organization of population-based anticipatory care an easier undertaking than in countries where people generally do not have their own personal doctors or any well-established tradition of referral to hospital-based specialists. But though epidemiology and the Public Health idea are used to question and discount the value of so-called curative clinical medicine, and thus to disarm informed resistance to the growing lag in application of advances in personal medical care, they are not used to provide the structures of a Public Health service truly concerned with the health of the public.

An Orphan Agenda: The Black Report

The Black Report in 1979 showed clearly that Britain still had public health problems of fundamentally the same nature as in the 19th Century, equally susceptible to environ­mental and social change in their broadest sense, though somewhat more accessible to personal clinical salvage. The Report concluded bluntly that in terms of better health and reduced disability and premature mortality, the biggest returns on social investment would come from the following main courses of action :

A. Within the health and personal social services:

1. That government should adopt three principal health objectives :

  • To give children a better start in life.
  • To encourage good health among a larger proportion of the population by preventive and educational action.
  • To reduce the risks of early death in disabled people, to  improve  their quality of life whether in the community or in institutions, and as far as possible to reduce the need for these.

2. That allocation of resources be based on need, using Standardized Mortality Ratios (SMRs) for allocation at Regional level, and other indicators of health care and social needs at District level.

3.That resources within  the  NHS  and  personal  social services be shifted toward community care, particularly to antenatal, postnatal and child health services, and home-help   and   community   nursing   services  for the disabled.

4.That the quality and geographical coverage of general practice   be   improved, particularly in areas of high morbidity and poor social conditions. The distribution of GPs should be related not only to population but to medical need as indicated by SMRs and other indicators, and  GP  payment  by  capitation  should  be  modified accordingly.B. Measures to be taken outside health and personal social services:

  1. Abolition  of  child  poverty  should  be  adopted  as  a national goal for the 1980s, with an immediate increase in child benefits to 5.5% of average gross male industrial earnings (£5.70 at 1979 prices), progressive introduction of larger increases  for  older  children,  an immediate increase   in   maternity   grant  to  £100   (1979  prices), and an infant care allowance.
  2. Provision of free school meals to all children as a right.
  3. A staged introduction of a comprehensive disablement allowance for people of all ages, beginning with the totally disabled.
  4. Government, unions, and employers should agree on minimum   conditions  at work, and the Health and Safety Executive and Employment Medical  Advisory Service should be more active in preventive health work.
  5. Local Authority spending on housing should be sub­stantially increased, and LAs should widen their respon­sibilities to provide all types of housing need. Public and private housing  policies  should be co-ordinated. Special housing for the disabled should be improved by joint funding schemes by Local Authority housing and social service departments.
  6. The   health   implications of public policies in many different fields should be considered by interdepart­mental machinery at Cabinet office level, with local counterparts.
  7. A Health Development Council should be established with an independent membership to play a key advisory and planning role in relation to a collaborative national policy to reduce inequalities in health.

Everything possible was done first to limit the circulation of the Report, and then to discount its conclusions. Secretary for Social Services Patrick Jenkin contributed a foreword to the Report, in which he said:

… the Group has reached the view that the causes of health in­equalities are so deep-rooted that only a major and wide-ranging programme of public expenditure is capable of altering the pattern. I must make it clear that additional expenditure on this scale which would result from the report’s recommendations—the amount involved could be upwards of £2 billion a year—is quite unrealistic in present or any foreseeable economic circumstances. . .

Subsequent authoritative reviews including new evidence (Fox,   A.J.,   Goldblatt, P.O., Jones, D.R., ‘Social class mortality differentials: artefact, selection, or life circumstances?’, pp. 34- 49   in,   Wilkinson,   R.G.   (ed.),   Class   and  health: research and longitudinal data, London: Tavistock Publications, 1986.); (Wilkinson,    R.G.,    ‘Income   and   mortality’,   pp.    88-114   in, Wilkinson, R.G. (ed.), Class and health: research and longitudinal data, London: Tavistock Publications, 1986.)  which have broadly confirmed its conclusions, have also been ignored and discounted by central govern­ment. The only academically respectable supporters for the government view are Prof. Raymond Illesley and Julian Le Grand (Illesley, R., Le Grand, J., ‘Measurement of inequality in health’. Discussion Paper  no.   12,  London:   Suntory-Toyota Centre for Economics and Related Disciplines, 1987.), who still argue that widening health inequalities are a statistical artefact, and that class-based measures of in­equality are no longer useful. Interested readers must make up their own minds, comparing the evidence offered by these authors with the material in Wilkinson’s book, bringing together a wide range of expert authors, and the rebuttal by Nicky Hart (Hart,  N.,  ‘Class,  health  and  survival: the gap widens’, Radical Community Medicine, Spring 1987; 10-17.), statistician to the Black Report.

In contrast with the complacency of central government, there have been many local area-based studies by District Health Authorities and City Councils (for example Bristol (Townsend, P., Simpson, D., Tibbs, N., Inequalities in health in the City of Bristol, Bristol: University of Bristol, 1984.), Glasgow (Howe, G., ‘London and Glasgow: a spatial analysis of mortality experience   in   contrasting  metropolitan  centres’,   Scottish   Geo­graphical Magazine 1982;119-127.); (West of Scotland Politics of Health Group, Glasgow, health of a city,   Glasgow:   WSPOHG,   1984.   Available from  John Boswell, 469 Tantallon Road, Glasgow G41.), Manchester (Manchester    Joint    Consultative    Committee    (Health), Health inequalities and Manchester, Manchester: MJCC, 1985.), Sheffield (Thunhurst,   C.,   Poverty   and   health   in   the   City  of Sheffield Sheffield: Sheffield City Council, 1985.), Merseyside (Ashton, J., Health in Mersey: a review, Liverpool: Department of Community Health, University of Liverpool, 1984.),Newcastle (Leinster,   C.,  Primary   health   care,   Newcastle:   Newcastle   Inner City Forum, 1982.), Belfast (Ginnety, P., Kelly, P., Black, M., Moyard: a health profile, Belfast: 1985.), and six different areas of London (Golding, A., Health needs and social deprivation, London: Camberwell Health Authority, 1984.); (Curtis,  S., Intra-urban variations in  health and  health care: the comparative need for health care survey of Tower Hamlets and Redbridge, London, London: Queen Mary College, 1984.); (Betts,  G.,  Health  in  Glyndon:  report of a survey on health in Glyndon Ward, London:  Greenwich Community Health Council, 1985.); (Catford   Community   Health  Project,   Wells  Park   health  survey, London: WPHP, 1986.); (Tower Hamlets Health Campaign, Taken bad: the state of health in Tower Hamlets, London: THHC, 1985.); (North   East  Thames   RHA,   ‘Patient   census  study:  social  factor analysis’. Management services report no. 1249. Also ditto, ‘Further analysis of patient census data with respect to social development’. Report no. 1259. London: NE Thames RHA, 1983.)  which have used the ‘Black approach’, well reviewed by Betts (Betts,   G.,   ‘Area-based   studies   of  health’,   Radical  Community Medicine Spring 1987; 22-31.).

Since 1979, government actions relevant to this agenda have included:

A rise in the number of people claiming means-tested supplementary benefit from 4.6 million in 1979 to 7.1 million in 1983, and in those entitled to benefit but not claiming from 2.1 million in 1979 to 3.3 million in 1983. By 1983, about 9 million people (Becker, S., MacPherson, S., ‘Poverty reaches record levels’, Labour Research, July 1986; 75:15-18.), and about 28% of all children (Townsend, P., ‘Why are the many poor?’ International Journal of Health Services 1986; 16:1-32.) were living in families with incomes at or below Supplementary Benefit level.

Levels of child benefit have risen only at the same rate as inflation, even this is now in doubt, and there is now wide discussion of an end to unselective child benefit as a right. The aim seems to be to make all social benefits subject to means tests.

Of a total of £4.17 billion cuts in income tax since 1979, the richest 1% got 44% and the poorest 25% got 3%. (Becker, S., MacPherson, S., ‘Poverty reaches record levels’, Labour Research, July 1986; 75:15-18)

A tax on employees for their employers’ contributions to workplace nurseries, although only 20% of British 3-year-olds have any nursery provision, compared with 42% in the Netherlands and 88% in France (‘The   fall   and   rise   of   workplace   nurseries’,   Labour Research, December 1985; 74:309-311.)

Abolition of maternity grants as a right, replacing them with a means-tested benefit. Abolition of maternity allowances for about 25% of mothers who received it before 1987 (‘Fowler’s second stab at social security’, Labour Research, February 1986; 75:17-19.)

Annual construction of new Local Authority houses for rent fell from about 140,000 throughout the 1970s to 43,000 in 1985. Private sector housing construction stayed about the same as in the 1970s at 154,000 a year. Demolition of slum houses fell from 64,000 a year in the early 1970s to 12,000 in 1985. The number of homeless families recognized by Local Authorities rose from 83,000 in 1981 to 109,000 in 1985. The number of houses repossessed by building societies because of mortgage arrears rose from 2,500 in 1979 to 16,800 in 1985. (Central Statistical  Office, Social Trends 1987, no. 17. London: HMSO, 1987.)

Regional allocation of resources, already in operation at the time of the Report, has continued, but allocations at District level have generally not been related to other indicators of need. Allocation of resources to community rather than hospital services has increased by about 1-2%. Child health services have not been developed actively in any direction, and home help services have been reduced, in some areas drastically; in my village we now have 8, where we once had 16. Community nursing services have been expanded significantly, more or less in line with a reduction in hospital beds and shortening of the average duration of in-patient care. Nothing has been done to increase the number or quality of GPs serving areas of high morbidity, or to modify GP pay to encourage selective improvement in care. Of 16 other more detailed recommendations made for action within the NHS and Social Services, only one or two seem to have led to any widespread action.

The Black Report, though a well-documented and scholarly argument chaired by a President of the Royal College of Physicians, has been rejected on political grounds, with little attempt to marshal any serious scientifically-based argument against it. Equivalent studies in Sweden, where even con­servative groups are more humane (Dahlgren,   G.,   Diderichsen,   F.,  ‘Strategies for equity  in health: report   from  Sweden’,   International  Journal  of Health Services 1986; 16:517-37.), have been much more fully developed with wider research, and are now being implemented. There are real problems about the further development of the liberal welfare state within capitalist economies, even where humane political traditions are much tougher than in England (Therborn, G., Roebroek, J., ‘The irreversible welfare state: its recent maturation, its encounter with the economic crisis, and its future prospects’, International Journal of Health Services 1986; 16:319-38.) ,  but the Scandinavian experience shows that disintegration of the NHS, and abdication from previous public health commitments, is not inevitable; it is a clear political choice today, as was the creation of work­houses in the early 19th Century.

Official Attitudes to Information

The decennial reports on occupational mortality of the OPCS, the main source of data on disease in relation to social class, have increasingly been discounted by the OPCS itself, and are now issued in such a way and at such a price (micro-fiched tables without summarized commentaries, at a total cost of £55) that they are accessible only to a few scholars, not to the public at large or its elected representatives. (Editorial.   ‘Lies,   damned   lies,   and  suppressed statistics’, British Medical Journal 1986; 293:249-50); (Editorial. ‘The occupational mortality supplement: why the fuss?’, Lancet1986; ii:610-12.) The Health Education Council, which under Dr David Player began to take its independent role seriously, has been sacked and reconstituted as the Health Education Authority, subject to the DHSS and with more docile nominees (Editorials: ‘Inequalities and the new Health Education Authority’, British Medical Journal 1987; 294:857-8.); ( ‘A poor start for the Health Education Authority’, ibid., 664.); (Editorial. ‘A mockery of health promotion’, Lancet 1987; i:489.). After giving partial and hesitant support to experiments in GP microcomputers, the DHSS has abandoned general practice data collection to commercial firms offering powerful free microcomputers with sophisticated software, in return for data which can then be sold to pharmaceutical companies, an extraordinary admission that commercial interests which derive most of their profit from the NHS need to take planning decisions based on evidence, while those leading a public service can continue to grope in the dark.

The definition of unemployment used for compiling official statistics has been changed several times since 1979, each time in a way that reduces the official figure, publication of health and health service statistics generally has been delayed and reduced, production of national and local propaganda material glorifying the government’s record on health services at public expense has increased steadily, and health service employees have been disciplined for drawing public attention to shortcomings in the service. Unlike the USA, Britain has no tradition of open government in the sense of legal requirements to expose its work to un­restricted public criticism, but we have had a strong tradition of systematic statistical monitoring of social trends and free criticism within the politically less dangerous circle of scholarship. Even this is now being steadily eroded; unlike its predecessors, who had enough wisdom and social confidence to value informed academic dissent, the New Conservatism sees no advantage for itself from informed criticism, nor danger from secret government.

British Public Health was imposed on the rest of society by ruthless men acting for a brutal but confidently advancing class. Public Health measures were done always to, sometimes for, but never by the people; yet they were done, with energy, confidence, and faith in the idea of social progress, and a concept of civilization which demanded a decent minimum of social investment. All this is now being abandoned.

In the absence of central action to develop a real rather than rhetorical public health programme, the initiative has been left to whatever parts of the periphery are prepared to assert some self-respect and autonomy: Health Authorities of exceptionally independent mind, Local Government Authorities with enough imagination to reach beyond their now very restricted responsibilities for health, and general practice, at the levels of Family Practitioner Committees and of GPs themselves. Enough of these exist to develop several models for more effective planning and care, but these do not constitute a national policy ; in fact without exception the pioneers who have built up these projects are hostile to current Government policies.

The GP as Community Physician

David Mant (Mant, D., Anderson, P., ‘Community general practitioner’, Lancet 1985ii:1114-7)  and I (Hart,   J.T.,   ‘Community   general   practitioners’,  British  Medical Journal 1984; 288:1670-73.) have both suggested that the MOH function could and should be performed by GPs, each group practice being responsible for individual and group health surveillance in its own registered population. GPs are in touch with a known local population, and groups of GPs generally serve somewhat loosely defined neighbourhoods. Though these do not as a rule coincide with the tightly defined patches suggested as planning units by the Cumberlege Report on community nursing, there is already a tendency for GPs to rationalize the boundaries of their practices to reduce travelling time, and with flexibility and good will there is. no reason why GP groups should not eventually serve the neighbourhood units of 10,000 or so envisaged by Cumberlege (DHSS, ‘Neighbourhood nursing—a focus for care’. Report of the community nursing review (Cumberlege Report), London: HMSO, 1986.). This happens to be roughly the size of the average electoral ward, so the possibilities exist (ignored in the Report and specifically rejected by Julia Cumberlege when I wrote to ask her about this) of creating locally elected machinery of accountability.

Primary care teams can obtain intimate knowledge of local health hazards and are then well situated to initiate Com­munity action to control them. Mant lists five principal Public Health tasks which could be undertaken by GPs:

  • Monitoring the state of the practice health; an annual report with local data set in context with regional and national statistics, with a commentary drawing attention to particular problems and suggestions for tackling them.
  • The drains function; surveillance of local environmental hazards and infective disease.
  • Planning tasks; varying ‘from the bizarre (medical care in the case of nuclear war) to the pedestrian (how many chiropodists are needed?)’. These would include liaison with social services, education depart­ments and voluntary agencies; maintenance of chronic disease and handicap registers; and ‘a saintly patience and a freedom from other practice commitments in order to cope with the tedious bureaucracy of local government’.
  • Auditing the effectiveness of preventive programmes; monitoring screening and immunizations, and recording prevalence of disease risk factors in the community.
  • Evaluating population effects of medical intervention. Mant suggests local randomized controlled trials to evaluate practice diagnostic and treatment procedures. In the light of my own experience of running several such trials in my own practice, he seems to under­estimate the limitations of small numbers in population units of 10,000 or so, and the time, skills and resources required for valid trials. However, a national network of Public Health practices would be able to undertake powerful nationally or regionally administered multicentre trials.

Some of these elements have always been included in the work of GPs in many fairly remote communities in Norway and Northern Sweden (Distriktslekke), and in most of Scandinavia this is a tradition which is already beginning to be seen as a portent for the future rather than a survival from the past.

In my own practice in Glyncorrwg, socially isolated and with a ‘Public Health’ orientation in the whole staff developed over 25 years, we have had experience of action (sometimes triumphant, usually successful, occasionally a failure) under all of Mant’s headings. Examples have included public discussion of and sometimes action on repeated fatal or near-fatal road accidents at the same danger points; licenced Public Houses which serve more alcohol to people who are already drunk, to children of 14, and at 2 o’clock in the morning; shopkeepers and school bus drivers who sell cigarettes one at a time to children; tipping of vegetable peelings and other food refuse into the river where they maintain the rat population; derelict industrial buildings which have been the site of serious accidents to children; and a large leak of raw sewage into a river used by children for bathing. This last case was interesting. It occurred in the late 1960s, when we still had a Medical Officer of Health. Until he was shown a coloured photograph of faeces flowing from the broken pipe he refused to accept that any real problem existed; even then his immediate response was that it was against the law for children to swim in the river!

These are all examples of negative action, but our Health Centre Committee has also made positive proposals and organized public pressure for their adoption, for example development of jogging and cycling tracks away from main roads, and real rather than rhetorical provision of facilities for mothers to stay with their children in hospital. Positive screening procedures for detection of high blood pressure, smoking, obesity, diabetes, airways obstruction, alcohol problems and cervical cancer have been applied to the whole population at risk for more than 15 years, and these policies have been backed by the Patients’ Committee. The practice has worked closely with the preschool playgroup and with teachers in the local primary school to integrate brain­ damaged children and to compensate positively for inadequate parenting.

Primary care teams can review local causes of death, drawing attention to practical lessons which can be learned from them in a way that was never possible at the impersonal, large-population level of traditional Public Health. We have done this in Glyncorrwg, circulating the results to the local population as well as publishing them in the national medical press (Hart, J.T., Humphreys, C., ‘Be your own coroner’, British Medical Journal 1987; 294:871-4.). Clinical targets can be set for local communities which are comprehensible to local people, and for which action lies within their imagination, for example the elimination of measles and cancer of the cervix, or reduction of the population of smokers to 25% of all adults aged 20-64.

Annual Reports

Annual reports by GPs are not a new idea. In Northern Ireland,  Ballymoney Health Centre, which serves about 13,000 people, published its 17th annual report in 1986, of particular interest because it literally looks back to the Dawson Report of 1920. The Dawson Report set out a conception of health centres on a cottage hospital model, with autonomous GPs and specialists jointly providing care in much the same way that actually occurred in small towns in the USA in the ’40s and ’50s. It was used by the BMA to head off proposals for salaried service, which soon evaporated as post-war plans for a land fit for heroes were discarded. It was then virtually forgotten until the 1966 Package Deal, with its extensive programme for health centre building, when renewed interest in health centre building required more respectable origins than the Socialist Medical Associa­tion’s wartime campaigns for health centres based on salaried team practice.

Dr Burns’ team at Ballymoney Health Centre is based on one of the few surviving GP hospitals, and its report has the traditional form of a hospital report, extended to include an account of work done by GPs, practice nurses, health visitors, community nurses, social workers for the elderly, physio­therapists, dieticians, a radiologist, a psychologist, in its various special clinics (ante-natal, cervical cytology, immunization, family planning, eyes, well babies, speech therapy, chiropody, dental, child psychiatry, geriatrics, well men and paediatric surveillance), and of undergraduate and postgraduate educational activities. An annual medical meeting is held with a visiting speaker, and an annual obstetric meeting with a visiting expert assessor to discuss the statistical results of the year’s work.

Apart from its obstetric review, the report does not relate its work quantitatively to its population base, but this could be done if one member of staff with some epidemiological training (not necessarily a doctor) were made responsible for developing and using an information system. Though this would have revolutionary implications, it would probably be acceptable to the apparently conservative (but also very progressive) group of doctors who account for 9 out of 13 members of the Health Centre’s Committee of Management (the others are a dentist, the director of nursing services, the District Administrative Officer and the Health Centre Nursing Superintendent). In 1984 the 8 GPs at the centre worked with 4 trainee GPs, 5 office staff, 3 practice nurses, 3 health visitors, 4 community nurses, 1 social work assist­ant, 5 physiotherapists, 1 community midwife, 2 speech therapists, 2 chiropodists, 1 dentist, 1 dental therapist, 1 community dietician and 1 psychologist. The Osier paradigm remains firmly in place, with no direct input from any member of the public. Addition of population-oriented statistics could introduce a necessary element of criticism and change into what has been a pattern only of incremental reinforcement of things as they are, and this is likely to happen as the group moves into organized screening for hypertension and other coronary risk factors. Ballymoney is of great interest as an impressive example of the best that has been achieved (under unusually favourable conditions) within the old paradigm, and therefore the least that should be achieved by any new alternative.

In contrast are annual reports describing the work of radical teams moving consciously towards objectives defined in terms of population need as well as demand. Dr Brian McGuiness has been producing annual reports since 1977 at the Weaver Vale practice at Runcorn, with an obvious effort to relate local to national data. Other examples are: Dr Martin Walsh’s team at Birley Moor, the first health centre built in Sheffield, serving 11,000 patients; Dr John Robson’s team at South Poplar Health Centre (Chrisp Street) serving 8,900; my partner Brian Gibbons‘ reports on work at the Blaengwynfi medical centre serving 2,000; and my own reports on the Glyncorrwg Health Centre serving only 1,700. Two teams I know of have also produced printed newsletters aimed mainly at the populations they serve. Dr Laurie Pike’s group at Handsworth in Birmingham, and Dr Cyril Taylor‘s group at the Princes Park Health Centre in Toxteth, Liverpool.

There are large differences in style between these reports, some with a traditionally dry statistical approach resembling the old MOH reports and apparently aimed mainly at pro­fessional colleagues, others with a simpler, more self-critical, anecdotal or campaigning approach aimed chiefly at involving the local population. In practice the active readership (that is, those who talk to members of the team about what they have read) for all these documents seems still to be almost entirely within medical and perhaps nursing peer groups. No one, so far as I know, has had much response from patients, apart from uncritical praise for making the effort. Perhaps in the eyes of local people, any attempt to take accountability seriously is such a huge step forward that they see little to criticize in either approach. This judgement seems to me to be probably right; at the point we are now at, any attempt by doctors to give an organized account of their work, however traditional or even complacent in form, should be welcomed. We should be careful not to apply to our colleagues the sort of destructive criticism made wearily familiar by medical sociologists over the past two decades, few of whom seem able to imagine what it is like to be responsible for actually providing care, rather than acting as a full-time chairborne critic.

Logically it is difficult to deny the need for an annual report on any public service, though in fact few schools (for example) have done this until recently. Having produced such a report, who is it for? In Glyncorrwg we have sent copies of all our reports to the local Community Physician and Family Practitioner Committee, but have never received any comment, positive or negative, from either. I suspect they have no idea what to do with them. Though annual reports certainly should be circulated to local Community Physicians and FPCs in the hope that they will be taken into account in local planning (assuming such planning really exists) their principal target audience should be patients themselves, the neighbourhood population.

There are problems about designing an annual report detailed and comprehensive enough to meet the require­ments of Community Physicians and FPCs (if these had a serious and positive planning function) yet sufficiently simple and short to encourage local people to read it, express their own opinions, and supplement it with their own exper­ience. My own conclusion is that these two functions can’t be combined; it would be better to produce two reports, a comprehensive one in a fairly traditional style for peer review by medical and nursing colleagues, and a popular version concentrating on one or two key issues for change in the coming year, though obviously both should be made freely available to anyone who is interested.

Annual Meetings

Whatever the difficulties, and these are bound to be great where there is no tradition of community accountability and participation, the logical way to present an annual report to the local population is at or immediately before an annual general meeting open to all registered patients, and the logical way to act on its findings is to use that meeting to elect a patients’ committee.

Relatively few annual reports seem to be presented to open meetings of patients, and when they are, turnout and response are generally disappointing. Practices which attempt this have tried to attract larger audiences by inviting outside speakers, ideally local hospital specialists prepared to discuss their work directly with the population they serve. This was very successful in Aberdare, only a few miles from my own practice. Our experience in Glyncorrwg is that few consultants are willing to do this, but where they are, we have big turn­outs and none of the destructive criticism specialists seem to fear. Because all doctors have so much autonomy, there are big differences between different localities, and it is dangerous to generalize from local experience, good or bad. Consultants in many areas seem to be more willing to meet the com­munities they serve on a more equal footing.

Patients’ Committees

Patients’ committees, or patient participation groups, began in a few centres in England and Wales in the mid-1970s, reaching a total of perhaps 80-100 groups by 1986; 63 of them have been surveyed by Ann Richardson and Caroline Bray (Richardson, A., Bray, C., Promoting health through participation: experience of groups for patient participation in general practice, London: Policy Studies Institute, 1987.). Some are composed entirely of delegates representing organized groups such as pensioners and the Red Cross, others of a mixture of delegates and self-appointed volunteers. All surviving groups seem to have begun on the initiative of GPs; the only exception I know of, in which patients took the first initiative, collapsed fairly quickly. All groups in which GPs do not attend regularly have collapsed.

Ours in Glyncorrwg was elected at an open community meeting of about 60 out of 1,000 adults at risk in 1975, with reserved places for some groups which I thought needed to be represented; mothers of young children, a local teacher, local health workers, a pensioner, a shift-worker, and so on. In practice, it probably makes little difference whether such groups, without statutory rights or powers, are elected or more or less self-appointed. Those which survive more than three or four years become autonomous groups of interested local people, not subject to real popular control, but certainly having a viewpoint different from doctors, though this will seldom be pressed to the point of conflict. Ours meets once a month, discussing and taking decisions on such problems as frequency of GP visits to the housebound elderly, provision of sleeping accommodation and meals for mothers accompanying their children in hospital, collection of data on patient opinion about the practice and on the effects on patients of prescription charges, training in resuscitation, campaigns for a local swimming pool (which failed) and for safe cycle and running tracks away from main roads and against closure of the local ambulance station (which succeeded), hospital waiting lists, and a more or less permanent process of explanation and discussion of how the NHS is supposed to work, how it actually works, and how it might work in the future.

In 1986 the Labour Party’s National Policy Committee on Health and Social Services nominally accepted annual reports, annual meetings, and elected patients’ committees with an advisory function, as necessary reforms for general practice. It is doubtful whether these aims were really accepted, under­stood, or even remembered by the relevant shadow ministers, and they were not included among the twelve key points listed in the Labour Party’s Charter for Health which was supposed to be the basis of its campaign on health in the 1987 general election. I don’t know of any moves to include these reforms in the policies of other political parties, though they are consistent in principle with the official aims of all of them, even the Conservative Party. A majority of the National Committee for Patient Participation Groups remains opposed to legislation to establish groups as a civic right, on the grounds that GPs as independent Contractors can’t be told what to do. The logic of this escapes me; it takes two sides to make a contract, and there is no reason why a new contract should not be negotiated which would include this provision. Most GPs who have initiated groups seem to see them as having very limited advisory functions, without any wider potential for organized accountability. Many soon come to function mainly as (usually very effective) fund raisers for equipment the government considers itself too poor to provide.

A more or less universal experience is that patient participation groups steadily increase workload for GPs and others on the team, at least by adding yet another evening meeting once a month, much more by finding new tasks which need to be done and old tasks incompletely done. Justified fear of this additional workload, more than reflex despotism, may account for the general reluctance of GPs to encourage such committees, even when they approve of them in principle.

The rate of formation of new patient groups is only slightly greater than the rate at which old ones collapse, and few that I know of claim to have a really vigorous life with a wide local population base and an assured future, even if the initiating GPs were replaced by more average ones. Several vigorous, progressive, and otherwise successful group practices in central urban areas of great social need have failed to create viable patient participation groups, despite dedicated efforts sustained over months or years. The problems seem to be the same everywhere in the industrialized capitalist world; Mullan  (Mullan, F.,  ‘Community practice: the cake-bake syndrome and other trials’, Journal of the American Medical Association 1980; 243:1832-5.) reports similar experiences from community-oriented groups in USA. My guess is that progress would be quicker if we gave higher priority to organizing special interest groups addressing practical tasks, for example diabetics and hypertensives and their spouses, child asthmatics and their families, and other chronic disease groups who face immediate material problems at all levels in the NHS, giving an immediately credible, concrete and practical agenda for patient participation, which might later be extended to more general participation.

Despite this generally rather negative experience, the principle of organized, representative patient participation in the work of primary care teams is of critical importance if we are to move seriously into planned anticipatory care of local populations with minimal bureaucracy, fear of which is the main argument advanced by GPs against salaried service or any other form of regular positive accountability.

Local Public Health: Amateur or Professional?

Substantial protected time is essential for any serious commit­ment to a Public Health function for general practice. In Glyncorrwg this work has taken the equivalent of about two full sessions (8 hours) of working time each week, one hour of which has had to be at evenings or weekends. There would be some economies in a larger unit, but judging from my experience a serious government policy would require an absolute minimum of three sessions a week for each Public Health professional to service a group practice serving a population of 10,000.

This work could be done either by a doctor or by a fully qualified nurse, but each would need both specific training and remedial education. Selection of candidates should be based on evidence of capacity for informed confidence and sustained enthusiasm, and ability to transmit these to the whole primary care team, from doctors to office staff and cleaners. Training should as far as possible be by people who have experience of this work themselves; academics whose field experience is limited to research surveys will know more about statistical handling of data, but they are seldom credible to GPs or nurses who already have a lot of coping experience with less structured, more demand-sensitive work in real communities, and the first task of  trainees will be to become credible advocates of a Public Health function in their probably sceptical home teams. The main statistical skills required are awareness of common sources of error in data collection, elementary trial design, simple sampling methods, and some idea of appropriate sample size, all based on examples of real work done by similar workers under similar conditions to those already experienced by the learners. Other essential skills are ability to organize contact with the local population, to run public meetings and produce local health education literature, awareness of the strengths and limitations of various levels of NHS administration and Local Government in local terms, and ability to use and eventually contribute to local, national and international medical and nursing literature with simplicity, boldness and imagination.

There is no way this can be done both well and quickly; we are talking about an agenda for the next hundred years. The Public Health movement of the 19th Century took about 100 years to become legislatively complete and ideologically exhausted, but nobody denies that it was effective. There is no reason why even now, in an economic and political climate more discouraging than at any time since the 1930s, a start should not be made everywhere by those GPs, Community Physicians, community nurses and Nursing Officers who understand the need for it, with or without material support from higher administration. Excellent work has already been done in Oxford by just such a combined force, together with an imaginative and pro­gressive Local Authority (Health Education Authority & Oxford  City  Council, Healthy Oxford  2000:  a   healthy   city   strategy,   Oxford   City Council, 1987.). More than a start is not possible without support from a radically new central government policy, but with the acceleration added every week by the literature of medical science and examples of work already begun in cities like Oxford and Sheffield, once this idea begins to roll it could become an irresistible force from below.

Salaried Service

David Mant (Mant,   D.,   ‘Community medicine and general practice’, Radical Community Medicine, autumn 1986; 28-30.) concluded that the immediate limiting factor on implementation of the GP community physician idea was the hostility of GPs to salaried service, without which planned and protected work in sessional time is difficult. GPs accustomed only to the breakneck pace of their junior hospital posts and of general practice, particularly industrial general practice, are generally unable at first to understand and therefore respect the slower and apparently inefficient pace of sessional work in Public Health and School clinics. They have learned to measure their work not by health out­puts achieved, but by their own exhaustion in meeting demand. If GPs are to move seriously into anticipatory care and prevention, most will need a remedial education which is difficult to obtain as self-employed entrepreneurs.

If GPs remain independent contractors, they cannot share fully the loyalties, understand the anxieties, or perceive the full possibilities of a team composed of other salaried office workers, community nurses, health visitors, mid wives, and the many other health workers who for the most part do not now exist, but are badly needed—community dieticians, physiotherapists, sports instructors and more or less specialized lay counsellors of every kind. They may satisfy themselves that, as first among equals, they accept the team, but does the team really accept them? Doctors have hitherto had too much autonomy, all other health workers have had too little. What seems boldness and enterprise to GPs may look like arrogance and recklessness to salaried staff, and what seems only prudent recognition of administrative reality to community nurses, looks to GPs like unimaginative servility. There is some truth in both perceptions, suggesting that what we may need is a team in which all are salaried but all have greater confidence and autonomy.

Apart from simply leaving things as they are (always the most popular answer), there are five possible solutions for this problem of primary care teams which exist on paper but do not function. First, there is the Cumberledge solution; forget about the GPs, who are and will remain independent entrepreneurs, and construct a new neighbourhood-based team of salaried health workers employed by the Health Authority, led by nurse-practitioners, who will do the job on their own. There may be an underlying assumption that GPs will eventually join the team, once they recognize their own isolation. This scenario is probably not viable: because it has given no serious thought to the existing content of primary care, and little to the training requirements for nurse-practitioners; because of a growing excess of doctors and shortage of nurses; and because there is not even potential majority support for such a development, either among the public, the politicians or any of the health professions. However, some enterprising Nursing Officers are beginning to set up (for example) diabetic clinics in health centres with only passive acceptance by GPs, possibly a first step in the Cumberledge scenario.

Secondly, Prof. Dennis Pereira Gray once proposed that health visitors and community nurses should be independent contractors like GPs. This is scarcely a serious option (it has never had any significant support or even interest from health visitors or community nurses themselves), but there is a real need for greater professional autonomy for all health workers, though this need not be inconsistent with salaried service. As a practical proposal it seems to have lapsed.

Thirdly, and at present most importantly, there is a trend slowly to increase the proportion of primary health workers employed by GPs under the 70% wages-reimbursement scheme. Just over 50% of staff-time available under this scheme is actually taken up, and the quickest and easiest way to expand primary care teams under present legislation would be for all GPs to employ staff to their full entitle­ment (Hart, J.T., ‘Practice nurses: an under-used resource’, British Medical Journal 1985; 290:1162-3). As a short-term solution this is attractive to the minority of GPs who show active concern for the effective­ness of their population care, because it bypasses the some­times considerable difficulties of obtaining lasting agreement from Health Authority Nursing Officers on stable allocation of nursing staff and imaginative job-definitions permitting real team autonomy in setting objectives and deciding on means to attain them. Like other Health Authority staff, nursing officers have been accustomed to leading their troops from behind, and are not always sensitive to the needs and the mood of nurses in the frontline. However, both GPs and nursing officers have hitherto been accustomed to defensive action against disease by reactive care, rather than the pro­active offensives against disease implied by population-based anticipatory care, so both have much to learn about how actually to work in teams, rather than write and speechify about them; there is no evidence I know of on whether GPs or Community Nurses prove more adaptable, but I wouldn’t bet on the doctors. As this learning process proceeds, it seems unlikely that progressive GPs will want to be employers of the teams they want to integrate into. Pressure for employ­ment of practice nurses, rather than agreement with Health Authorities on attachments, will in the future reflect either a business orientation among GPs, or failure of Nursing Officers to approach their work realistically. Either way, it is an attractive short-term solution, but is probably not a good formula for sustained progress.

The fourth option is for Community Physicians to give a lead by employing facilitators and deploying more attached community nurses to group practices in which one GP is paid sessionally to accept responsibility for planning and evaluation of anticipatory care and prevention in the group. This system is already operating in the Oxford region with great success. This principle of giving protected time by sessional employment, ultimately controlled by the District Community Physician who must be satisfied by evidence from clinical audit that progress is being maintained, is easily reproducible in all Districts and would certainly be more immediately acceptable to GPs than salaried service. The only obstacles to it appear to be that it would require money, energy and imagination, all three of which seem to be in very short supply. Certainly in my own Health Authority the Oxford experience has so far been greeted with a deafening silence, and this seems to be typical though not universal. We need to hear a lot more from Scotland, where every dimension of primary care seems to be a generation ahead of England and Wales; the Scottish Home and Health Depart­ment maintains a large-scale GP computers scheme using standardized software, over half of Scottish GPs are using A4 records, and big prevention and anticipatory care schemes such as the Good Hearted Glasgow project are based on attached Community nurses rather than GP-employed nurses.

The fifth and final option is that GPs should accept salaried service, probably under a Primary Care Authority fusing the present community functions of District Health Authorities and FPCs, as recommended by the Cumberledge Report and the Royal College of Nursing. The BMA and the RCGP have persistently refused to encourage serious and informed discussion of salaries within their membership. In the only articles ever to appear on the subject in the British Medical Journal in the past 30 years (a well-documented paper in favour by John Robson (Robson,   J.,   ‘Salaried   service—a   basis  for  the  future?’,  British Medical Journal 1981; 283:1225-7.), and a wholly undocumented one against by BMA under-secretary Michael Lowe (Lowe, M., ‘No future for a salaried service’, British Medical Journal 1981; 283:1227-8.), Lowe did not refer to any real experience with salaries anywhere (not even to the fact that all hospital medical staff are salaried) but relied entirely on abstract argument. There is now considerable experience of salaried service by GPs in many countries with social systems and economies broadly similar to our own, including France (Porter, A.M.W., Porter, J.M.T., ‘Anglo-French contrasts in medical practice’, British Medical Journal 1980 ; 280:1109-12.), Norway (Bentsen,    E.G.,    ‘A    revolution    in    primary   care   of   Norway’, Scandinavian Journal of Primary Health Care 1985; 3:53-4.), Sweden (Law, J., ‘Swedes stick to salaries’, Medeconomics, October 1986, 69-70.),Finland (Scally, G.J., ‘Taking primary care seriously: the Finnish experience’, Public Health, 1984.), and Spain.

The idea that GPs could be paid by salary naturally occurs to salaried junior hospital staff because all their consultant and nursing colleagues are salaried. They generally forget this as part of their professionalization into the GP role. This probably accounts for the hilarious events at the National Trainee GPs’ Conference in Swansea in 1986. I was an invited speaker on planned anticipatory care in general practice, and referred in passing to my opinion that effective care was limited by a business approach and would eventually require a salaried GP service. Later that day an amiable doctor employed as a full-time negotiator by the BMA spoke to the trainees about pay structure, and a number of voices from the floor raised the issue of salaried service. One young man who seemed to speak for many said he was excited by the opportunities of primary care, more so than by anything else he had seen in his medical training, but he was repelled by the need also to be a business entrepreneur; he was trained in medical science, not business; had he wished to be a businessman, he would not have gone into medicine; why should he not be paid a salary to work as a community  medical generalist, just as his consultant colleagues were paid salaries to be hospital specialists? Someone suggested that a vote be taken; the chairman, overtaken by events, agreed, and in no time at all Independent Contractor Status was laid out on the floor, apparently breathing its last. By a large but uncounted majority the trainees had voted for salaried service, so far as I know the first politically un-selected gathering of GPs or would-be GPs ever to do so.

At the inevitable dinner that evening I met the BMA man, who was most friendly. ‘Well, that was one for the books!’, he said. ‘What was the majority then’, said I, for the chair­man never told us. ‘Oh, a good two to one at least; I wonder, would you care to come and speak to our quarterly meeting of negotiators sometime in the new year? I’ll drop you a line in a week or two.’ When not being trampled by mobs of their own rousing, BMA officials are intelligent and flexible men, readily adaptable to changing circumstances. Of course I never heard from him again, the BMA knowing well enough that one swallow doesn’t make a summer. The dignified journals, the British Medical Journal and the Lancet, ignored the incident; the free journals paid for entirely by advertising, generally referred to by GPs as ‘the medical comics’ (Pulse, GP and the like) but far more widely read than the heavies, ran angry editorials claiming that the meeting had no elected delegates, was over-run with suspect enthusiasts who had taken the trouble to go to a national meeting rather than the sound average chaps who let other people do their thinking for them, and was probably swept off its feet by emotional speeches. The chairman and secretary of the national com­mittee of trainee GPs wrote a solemn letter to all these journals disavowing the display of subversion at its annual meeting, and claiming (without any evidence) that a large majority of trainees stood four square behind independent contractor status. At the 1987 national Trainees’ Conference the next generation of aspirant medical politicians went one better, resolving that the previous year’s conference had been stampeded by impassioned speech making into an un­constitutional and unrepresentative vote, a decision head­lined in one of the comics as ‘Trainees were duped’. Why the 1987 Conference was more representative than 1986 they did not explain.

In sober fact, it was a straw in the wind. Unwillingness of GPs to accept the accountability inherent in any salaried service is only one of the obstacles to such a development, and from international experience, particularly in Scandinavia and Spain, not the most important. Salaried service starts where GPs are badly needed but cannot otherwise be found, and in those circumstances recruitment is not difficult if salaries are realistic. The question has been raised several times in relation to inner city practice in Britain, and other areas such as the South Wales valleys where there are exceptional loads of sickness and great difficulty in recruiting young doctors with good training and an imaginative interest in clinical medicine rather than small business. The possibility has been ignored in the 1987 White Paper, probably to ease negotiation of its terms with the BMA.

A more serious obstacle is the increased cost of a salaried rather than independently contracted service, not only because of the cost of the salaries themselves (including payment for work outside normal hours), but because once general practice stops being limited by what GPs can afford out of their own pockets, they are likely to press harder for extension of its scope and resources. Rational planning for health objectives is also likely to lead to a larger, certainly more labour-intensive service. Such a service would probably be more cost-effective, but it would also be more costly. One admittedly subordinate reason for the intransigent opposition of the BMA to GP salaries is its historically justified suspicion that such a service would be even more underfunded than at present; that it would increase respon­sibilities, while grudging the means to carry them out. Salaried service under a Conservative government, a not unimaginable consequence of a two-tier service if things continue as they now are, would certainly present serious dangers of this sort.

Bureaucracy and Sloth

However, the main reason given by GPs and their professional organizations for opposition to salaried service is their fear of bureaucracy and loss of initiative. Though these reasons are often advanced to conceal opposition on entirely different grounds (people who are able to run public services as private businesses are on more comfortable tax-scales with some scope for evasion, and enjoy all the other spin-offs of small business), they are real and deserve to be taken seriously.

The claims are that a salaried service in general practice would necessarily have the following four consequences:

  • Individual GPs would no longer accept personal responsibility for the care of individual patients, or for continuity of care, but pass these responsibilities on to an anonymous administration. Care would become more impersonal and therefore less efficient as well as less human.
  • Being paid at a flat rate unrelated to registered patient numbers, GPs would no longer have an economic incentive to be pleasant or conscientious in their care, and there would be a general decline in professional behaviour.
  • 24-hours a day, 365 days a year cover would require a big expansion in medical staffing, which is not feasible.
  • Clinical objectives would be set, and their attainment verified, by a non-clinical bureaucracy of medical officers, with a career structure leading up and away from personal responsibility for patient care, towards chairborne and probably nepotic hierarchy.

There is some historical justification for all these fears, both from British and foreign experience, but not much. Salaried primary care in Britain has not yet been permitted (by the medical profession) to have the clinical scope of general practice; fusion of the preventive and curative traditions has not only not been encouraged, for most of our history it has not been allowed. There has never been any evidence that work done in British Maternity and Child Welfare Clinics, School Clinics, or Family Planning Clinics is inferior in average quality to equivalent work done by GPs. The fact that these clinics were all set up because GPs generally were not doing consistent work in these fields testifies otherwise. Continuity of care and personal respon­sibility is a real problem under any system, and is generally recognized to have got worse in many large group practices. This is to a large extent a function of increasing unit size, and the reasonable demands of GPs and their families to lead a more normal life, with recognized hours of work and arrangements for deputizing. Some large group practices discourage continuity of care and thus evade personal respon­sibility for their patients, a trend which is deplored by a majority of their colleagues and much resented by most patients. Bureaucracy can develop both in independent contractor status and in salaried systems; whether it actually does so depends on attitudes of care givers, above all of senior doctors who usually dominate the team. If they want personal lists and personal responsibility they can have them, with measurable improvement in the quality of patient care. Though theoretically implied by the present contract, personal responsibility for care has never been enforced. I can see no reason why personal responsibility could not be included in the job-definition of salaried GPs, with possibly greater continuity than there is now in many group practices. There can be problems of unequally divided labour where one doctor is more sought after by patients than another, but these will arise under any system. They should be solved by seeking causes and putting them right, not by pooling and thus depersonalizing the work, as is often the case in group practice today.

Any salaried service in British general practice would have to begin from the traditions and styles of work already customary with independent contractor status, and in the end we shall probably reach it simply by building up the salary elements (Basic Practice Allowance, Seniority Pay­ments, Area Inducement Payments and so on) in the present contract (which account for about half of current GP earn­ings), diminishing capitation and fees-for-items-of-service payments, better enforcement of a more clearly defined contract, and development of properly trained and properly paid planning teams in the Family Practitioner Committees.

Some growth in bureaucracy is certain, because general practice is at present almost completely unplanned and unmonitored, both these functions are essential to effective work, and there is no way they can or should be done wholly by GPs or nurses on their own. Like any other industry, there is a minimum level of administration at every level in the NHS essential for optimal performance. Contrary to the assumptions of virtually all fieldworkers, the NHS is not, by world standards, over-administered, and there is no evidence that NHS administration contains more deadwood than either consultant or general practice. All of us can think of people with secure tenure in all three fields who would do patients a service by retiring in name, as they have done long ago in fact. It is true that implementation of the Salmon Report on the staff structure of nursing has led to a career structure which penalizes continuing responsibility for patient care by forcing nurses to choose between poorly-paid clinical and better-paid administrative careers, but the logical conclusion from this is to stop modelling NHS staff structure on the undemocratic traditions of corporate industry, and start paying more attention to the unique opportunities in health services to combine administrative responsibility with continued clinical experience.

Malignant growth in bureaucracy is a possibility, but if (and only if) GPs develop regular and organized contact with their registered populations as groups as well as when they consult individually, we have a powerful weapon with which to keep it under control. We should also remember that many Community Physicians now miscast as economic managers with few opportunities for imaginative work, could develop in new and positive ways in a system of population-based anticipatory care.

The last word on salaries should be left with perhaps the world’s most expert observer of health care systems, their effectiveness, and their practical feasibility, Prof. Brian Abel-Smith of the London School of Economics (Abel-Smith, B.,  Value for money in health service: a comparative study, London: Heinemann, 1976.):

Under any system of payment it is the ethics and social commitment of the doctor which matter most of all. Where standards are low in these respects no financial structure can induce doctors to be what they are not. But where standards are high, salaried payment best indicates to the public the ethical stance of the doctor as a servant of the public, as a priest of medicine.

It is a pity the BMA has hitherto had so little confidence in the ethics and social commitment of its members. If we ever do have a salaried service, we shall need negotiators with well-informed and imaginative ideas on the subject; there is little evidence of that now.

Epidemiology is Accountability: Accountability is Democracy

British general practice already has the solution both to verifiably effective medical care, and to socially responsible professional autonomy. Because it has registered populations, it has denominators for its clinical numerators, and a listed local electorate of a size permitting participative democracy. It has the solution but has not recognized it, and has there­fore been unable to use it. Within the Osier paradigm general practice has perceived only the care of complaining individuals, not the care of populations, and commodity production by experts for patients whose only active contribution is to demand medical action, which otherwise does not occur.

The basic population units of general practice, around 2,000-10,000 people centred in neighbourhoods with increasingly well-defined boundaries, could in an organized system of anticipatory care be basic units both for monitor­ing of national health and the effectiveness of care, and for democratic control of the NHS, a popular counterweight to bureaucracy. The methods of epidemiology take into account and demand the co-operation of all the people in a popula­tion; one person, one vote. Rescued from academic isolation, epidemiology could become a new field for participative democracy.

Until this is understood, the medical profession will continue to provide politicians with all the excuses they need to keep health at the top of their agenda in rhetoric, while leaving it last in practice.