Medical Policy Association Briefing on the BMA referendum November 1946


Hon. Sec.: Dr. BASIL STEELE.

Bulletin No. 16. November, 1946.


In Bulletin No. 15, The Rape of the Hospitals, published last April, immediately after the publication of Mr. Bevan’s National Health Service Bill for England and Wales, the latter was described as “an Enabling Bill, arming the Minister of Health with supreme power, etc.” This description, although not officially used, is now generally accepted as correct, In plain words, it means that Parliament has decreed that the Minister should direct into his employment, as soon as the transference can be conveniently arranged, every member of the medical profession in England and Wales, and take possession of all the hospitals and other institutions which are necessary for a doctor’s work. Further, Parliament has not laid down the conditions under which this transformation is to take place. It has left this entirely to the Minister, saying in effect- “Give what directions and orders and issue such regulations as you think necessary to make the new service a success” (not necessarily for the patients’ or the doctors’ point of view). That is, Parliament has given the Minister a free hand to fabricate the structure, direct the working, and lay down the conditions of the new service. The task which the Minister has undertaken is undoubtedly a difficult one, and the responsibility of achieving success, by bureaucratic standards, rests solely on him. It is, therefore, a a priori unlikely that the Minister can consent beforehand to bind himself not to issue specific regulations, now or in the future, which practical experience and possibly unforeseeable problems. and occasions may suggest as the best solution. No Minister could be expected thus to tie his hands, particularly one of the character of Mr. Aneurin Bevan. Yet this is what the B.M.A. negotiators seem to expect; at least the B.M.A. Executive believes that it can make its members think that the negotiators can influence the Minister and, more than that, bind his successors also. The thing is folly. A referendum, indeed, may be necessary, asking the doctors, for example, whether they intend to enter Mr. Bevan’s service or not, but a referendum asking whether the luckless negotiators shall discuss future regulations is naive in the extreme.

The recent so-called victory of the Insurance Acts Committee in securing an alteration in the form of words under which it will discuss the Spens Report with the Minister of Health may blind many doctors to this truth, for now the Minister has been given dictatorial powers by Parliament. He is now able to say whether or not a doctor may practice his chosen profession; able to prevent him from practising it where he chooses; able to control his equipment and his methods; and to fix his income, to fine him or send him to prison. For all the brave words and promises doctors will be slaves if they join the service.

That they may be starved if they don’t join is uppermost in the minds of many, and thus professional solidarity and the expression of their true feelings are prevented and undermined. Here we touch problems raised by man’s relation to society. In every man there must be assumed a desire to live “the good life,” striking a balance between the development of his own powers as a personality, the claims of family and dependents, and the adjustment of his life with reference to the society of which he is one member, viz., in this instance, his profession. There are times, e.g., in war, when so much is at stake-and this also is one, as we have emphasized in Bulletins and other publications throughout the years-that neither private convictions nor personal obligations, on a long term point of view, can be set up against the objective system of rights and duties according to which the profession as a community has hitherto been built. The problem is how to blend the two. It is a problem that becomes acute only in times of crisis, such as the present, but a crisis always has its term. Victory comes to the longest stayer and with victory the appointed plan of one’s life, under better auspices, can be pursued in peace. In practical life, a doctor’s duties even to the State largely depend upon his professional functions, and the optimum conditions under which these are best exercised presume self-responsibility and freedom.

Everyone will admit that some forms of professional organization are better than others, and we submit that this superiority consists in the wider opportunities, the fuller freedom, that they afford to their members. Any system, whether State controlled or otherwise, which fails to afford this freedom fails also to give the individual member adequate scope for his own development, as a man and as a doctor, and by so much hinders him also in achieving the optimum environment for his children. In actual fact, not only should the bribe of “security” within the service be rejected, even if genuine, but it should be borne in mind that it is not likely to be genuine. The insecurity of having one’s livelihood subject to the will of a political dictator surpasses by far the insecurity of private practice.

Every doctor on the register will shortly receive a plebiscite form, the object of which is to get a YES or a NO to the question-” Do you want a committee, drawn from the B.M.A., the Royal Colleges, and the Medical Officers of Health, to discuss with the Minister the regulations under which those of you who join the service will work?” From what we have said this is a trap and must be avoided. The Act (National Health Service Act) is primarily one to get control of doctors and so to control certification in the interests of totalitarian government. The Act is an Enabling Act and the regulations can be altered by the Minister at will. The medical profession will, if it disregards all its training in objective reality, only be allowed to help the Minister to frame the First Set of regulations. After that it will be in the same position as any other disciplined force which is subject to authority. It will do as it is told as regulations are altered or introduced From Time to Time or suffer the consequences.

The Minister will have power; the Minister should have responsibility. He has his officials. He has his medical advisers; he has, in the Socialist Medical Association and kindred bodies, doctors who are sympathetic to his aims. It should be left to him to frame the regulations. If well-meaning but muddle-headed (politically) members of the various medical bodies discuss them with him, he will be in a position to say-” I gave them every chance to be helpful. It was they, not I, that really framed this Act.” Even Dr. Guy Dain said recently-” if the profession decided by a sufficient majority to take no part in negotiations the Minister’s regulations would be useless, because the Act would have no doctors to work it. The profession could perfectly well stand together. Patients would be treated. From the economic point of view the average doctor’s income in this country was derived at least to the extent of two-thirds from private practice. They would not be faced with an enormous economic disaster. They would continue to treat the members of the public as private patients, as the majority were treated to-day. He did not think they should enter upon this with trepidation. If they stood firmly together no real harm could come.”

(B.M.J. Supplement, 2nd November, 1946.)

No possible harm can come to any doctor who votes against discussion or negotiation with the Minister on regulations. Not having had part or lot in their creation he will be able to look at them objectively when they are published and then say whether or not he will join the service. To vote for negotiation is to agree with the Minister’s aims because you cannot honestly discuss means unless you are in agreement with the ends.

All Socialist doctors should, of course, vote YES because they agree with the regimentation of both the patient and the doctor.

Non-socialist doctors should vote NO and confidently await events.


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The objective of the Medical Policy Association is to preserve freedom for doctors as individuals. This implies rejection of any form of organization by means of which control of policy is centralized under any authoritative body invested with statutory or other powers to alter the private contractual relationship between doctor and patient, either by means of Regulations having the force of law, or through control of the moneys constituting in the aggregate either the whole or the greater part of doctors’ incomes.

On the positive side, this objective implies the widest possible extension of private practice, preserving a relationship between doctor and patient that is subject only to processes of Common Law and to the ethical traditions of the medical profession.

On the technical side, this objective involves investigation into the removal of economic barriers which, at present, prevent access by a proportion of the community to the existing Medical Services, which have themselves evolved in organic adaptation to the demands of the community considered as individuals.

Survey of Medical Policy, Part 6, ready shortly.

Vail & Co., Ltd., E.C.l