Implicitly, contracts between different units of the NHS always existed since 1948, essentially depending on hierarchies and old-boy networks, with generally passive and uncritical assent from the communities they served. The end of medical unaccountability implies the end of hierarchy and old-boy networking. What can take their place? Contracts between competing units in a market is the entrepreneurial and consumerist option. This is already resulting in promotion of the most readily industrialised and therefore most profitable clinical functions, and demotion of less profitable units serving small but important subgroups, or performing essential functions that are least easily industrialised and most dependent on communication and traditional support, such as psychiatry, geriatric and paediatric medicine. The needs of the market as perceived by managers without clinical experience do not coincide with the needs of populations, either as felt by themselves, or as seen by health professionals in daily contact with clinical realities. It is the continued dual role of family doctors as both purchasers and providers that makes them potentially such effective participants in area commissioning. They know what they are buying, because as junior hospital staff they had personal experience of producing it.
Sir Keith Joseph, the original theorist of Thatcherism, gave us fair warning in 1974. Speaking as Minister of Health, he proclaimed that the NHS would henceforth be run with maximum delegation of responsibility downward, and maximum accountability upward. As a patrician, his natural assumption was that doctors acquire their powers from the State, and are accountable to it for the ways they choose to use them. As a health worker, the truth always seemed to me to be the exact opposite; our power as doctors has been delegated to us by society, most readily represented by the people we serve, and our first obligation must be to them, whatever secondary obligations we may have to managers, the necessity for whom is undeniable. Sir Keith’s principles have now been fully applied in managed competition, with predictable results for staff morale at all levels. “It was hoped”, says Professor Malcolm Forsythe, “that the contracting process would be non-legalistic, non-adversarial, and based on trust and mutual understanding. Instead, it is turning out to be bureaucratic, shrouded in mystery, and potentially damaging”.
The alternative is to use the inevitable and long-overdue death of medical independence to develop accountability downwards at all levels, both individually and collectively. For the care of individual patients, providers of tertiary (super-specialist) care should report back to providers of secondary (District General hospital) care, local specialists should report back to community generalists, and community generalists should report back to their patients as in many important ways their most informed critics. The alternative to medical independence is acceptance by all health professionals of accountability both to a necessary framework of area management for co-ordination and planning (without which no public service can operate) and to the local population, both through individual patients and through elected representatives of the local community.
In both cases, this accountability must reflect the complexity of the work with which it deals. If health professionals cannot work effectively without some kind of managerial framework, managers themselves must be accountable in some ways to health professionals; it cannot be a hierarchical relationship of the Keith Joseph kind. And if health professionals cannot produce positive health outcomes without the active participation of patients and communities in their own care, patients and communities must also accept accountability in some ways to health professionals. For care of communities as a whole, all these levels of NHS staff should be accountable to local representatives of the people, and all should have some share in needs assessment, planning, and commissioning.
AREA COMMISSIONING AND LOCAL GOVERNMENT
Strategies for health are a responsibility of government. Electors must choose whether they prefer governments assisted to power by the minorities which profitably sell tobacco, diesel engines, or superfluous medicines, or by the majority which unhealthily consumes them. Implementation of these strategies must depend on people with local knowledge and loyalties, in units that bring people who plan the job together with those who do the job; not forgetting that, as we have seen, the job is done by patients as well as by health professionals. We want planned production with workers’ control, the workers including all who contribute to health gain.
Community representatives should be elected by local people, not selected by Ministers from their political networks, so that if they cease to represent the people, they can be got rid of. Where can these elected representatives of the people come from? Unlike Canada and the USA, we have no tradition of local directly elected school boards. We could have directly elected members of Health Boards, sharing in area commissioning of health services at all levels, but this would require invention of an entirely new category of elected local government. The parallel with school governing is apt. Except for parent-governors, local school governing boards are at present appointed, not elected. If there were good evidence of majority participation in elections for parent governors (now exceptional, at least in working class areas) encouraging serious plans for directly elected school boards, there would be a good case for directly elected health boards also. Both the NHS and schools are subjects of intense local interest, and a good turnout of voters should be possible for both. However, unless this change occurs, elected local control would have to come from councillors selected (by their fellow councillors) for their specific interest in the NHS, but originally elected for the general responsibilities of local government.
Local government responsibility has been opposed on two main grounds. The first is the weakness of Local Authorities, which have been in perceived decline ever since their heyday at the close of the 19th Century. Since then central government has been enormously strengthened by changes in communication, and the experience of national mobilisation in two world wars. Fifteen years of Conservative government, steadily stripping out public responsibility for public service and replacing it by opportunities for profitable enterprise, have left councils which started with responsibility for schools, housing, and a wide range of other important local services, either without these functions entirely, or with just enough responsibility to make them credible scapegoats for inevitable failure. The real powers of Local Government have gone either to private entrepreneurs, or to the 73,000 or so centrally appointed nominees of Quasi-Non- Governmental Organisations (QUANGOs), more than twice the number of all elected councillors .
The second justification is the claim that any increase in responsibilities for local government must mean a reduction in responsibility for national government, and that the Health Service would therefore cease to have a uniform national character. This view has been strongly advocated by Philip Hunt, director of the National Association of Health Authorities & Trusts (NAHAT). Experience of previous nationally planned but locally applied strategies, for example the 1944 Education Act and the post-war Housing Acts, show that this need not be so. A clear and vigorous central strategy, understood by the mass of the people, not only can but must be applied tactically by Local Authorities, adapting central plans to local knowledge.
The only shred of support for the contrary view comes from Nye Bevan‘s unexpected decision to nationalise all the hospitals in 1948, leaving them with only token elected local control, all of it now gone. As we have seen, this decision was overwhelmingly influenced by a perceived need to secure agreement from the consultants, without whom the NHS could not have gone forward at all. Though Bevan thought this a price worth paying, he never believed this undemocratic arrangement could be permanent , and it is totally irrelevant now.
The Local Government share in future area commissioning is now an important subject of public discussion, supported by David Knowles, president of the Institute of Health Services management, the Labour-controlled Association of Metropolitan Authorities, and most vigorously, by the Socialist Health Association .
PRIMARY CARE TEAMS AND THE FUTURE OF GP INDEPENDENT CONTRACTOR STATUS
Ever since Lloyd George nationalised club practice, GPs have been independent contractors – private purveyors of public service. The consequence was cheap but all too often nasty primary care. Because patient care was financed through the same pocket as GP’s mortgages, cars, holidays, and the education of their children, whatever was spent was usually the least which a poorly informed and undemanding population made possible.
As governments were forced (by escalating hospital costs) to recognise the value of good primary care, they began to recognise the risks of a system so cheap that it was positively dangerous; but every attempt to increase investment in primary care ran up against the same difficulty. The health needs and professional difficulties of general practice were always greatest where professional incomes (from all sources) were lowest, and the apparently best, and best paid, practices were mostly in areas of least health need, most attractive to professionals.
The most effective national investment in primary care ever made was the 1966 Doctors’ Charter, devised by the Medical Practitioners’ Union (mainly by a notable and recently deceased SHA member, Dr Hugh Faulkner), and implemented by the late Sir James Cameron for the BMA and health Minister Kenneth Robinson for the Wilson Labour government. It partially overcame the difficulty by earmarking new funds so that they had to be spent on patient care, and were not a part of GPs’ income. However, to limit demand, these were still for the most part linked to some investment by GPs themselves, in what were still regarded as their own businesses. They still had to meet 30% of employed staff salaries, and to make large personal investments in subsidised new buildings, rewarded by huge eventual profits in areas of high employment and rising property values, but an impossible risk in areas of economic decline. This was originally mitigated by a wave of health centre building in the 1970s, but this ceased with the beginning of Conservative rule in 1979.
By 1989, most progressive practices were already working in purpose built premises (NHS-owned health centres or GP-built) and employed their full reimbursable complement of staff. They had used all the resources available for new initiatives. But because of independent contractor status, all these subsidised investments went preferentially to areas where prospects were good – areas with least unemployment and rising property values and lowest morbidity and social need.
Because of independent contractor status, before NHS “reform”, progressive practice where it was most needed depended on innovation by a minority of exceptional doctors, committed in principle to a socialised service even if they had to finance much of this themselves. The “reforms” have enabled enlightened FHSAs to commission specified work from GPs and thus provide resources for innovation of this kind, including work previously undertaken in hospital out-patient departments, but this was more an effect of larger budgets, better qualified administrators, and a general destabilisation allowing greater discretionary powers, than a direct effect of the purchaser-provider split itself. Though independent contractor status made it easy for progressive GPs to give priority to social responsibility rather than the needs of their own families, it made it equally easy for most to do the opposite.
The SHA has always believed in salaried status for all doctors in public service. All hospital doctors are salaried, and until the market “reforms” there was never any example of interference by management in clinical decisions. More importantly, all members of primary care teams other than GP principals are salaried, for whom the self- employed entrepreneurial status of GPs is an anomaly often open to more cynical interpretations than most GPs realise. Independent contractor status is a hangover from the past, when GPs in industrial areas were seldom more, and often somewhat less, than shopkeepers. Opposition to salaried service has come from doctors who fear (now with some justification) loss of clinical autonomy to managers who do not share their objectives or understand the nature of their work, and from the Treasury which fears (also with some justification) a rapid rise in the cost of primary care, as GPs cease to have a personal stake in underfunding the service.
Sooner or later, any government that is serious about developing a more rational, and therefore more cost-effective NHS, will have to face up to the need for a salaried service for NHS general practice. To minimise opposition and for natural justice, this must be generous enough to maintain incomes at least as they now are. This will entail a large additional investment in primary care, but as a much larger investment in primary care is already necessary on other grounds, which cannot be targeted on the areas most in need without separation of earnings from investment, this must be seen as a necessary consequence of any serious step toward a more rational, and therefore more cost- effective, NHS.
We have good evidence that though only about 7% of GPs say they would prefer a salaried service to independent contractor status, another 44% would consider the possibility seriously; less than half (48%) are now definitely hostile to salaried status, and among GP trainees, 73% would either prefer or consider the possibility of salaried status . There is more support for salary now than at any time since 1948. Introduction of such a service could be at least initially selective, in areas of highest health need, with the worst problems of GP recruitment, where support for salaries is greatest and where most experience of locality commissioning has already been gained. There is already long experience of generally successful salaried general practice in Quebec Province and Oslo, and more recent experience in Finland, all in countries with medical and social cultures similar to our own. Plans at least for widespread experiment on these lines are certainly feasible , and should be a part of Labour’s next election programme.
PRIMARY CARE TEAMS OF THE FUTURE
Rational reform of the NHS depends above all on reform of its foundation in primary care. Scattered all over the UK, there are now primary care teams already attempting to deliver the full fruits of medical science to all who can benefit, not as a business but as a free public service. They remain exceptional, but there is no Region without them. These are areas already liberated from commerce, so far as that is possible in a consumerist society. Their experience is the best guide we can have, as we grope forward to a better, more sharing society of the near future – feasible socialism.
From 1961 to 1987, I was in charge of a mining village practice in South Wales uniquely fitted to serve as a descriptive, and to some extent an experimental model of the basic production units on which the NHS is built. Relationships with other practices and home care units in the Afan valley, and routine referral patterns to local hospitals, were simple and easily accessible to analysis. We had the first health centre in Wales in 1966, and began systematic audit of an increasing range of clinical and economic indicators from 1968 onwards. By the early 1980s, we had a very substantial body of data, which though limited to a population of only about 2,000, covered an exceptionally long period, and included records of people who had moved away or died. From 1983 onward, we tried to interest various health economists and independent health policy foundations in this data set, as a model from which we might learn useful lessons about the audited, rational, continuing anticipatory community care of the future . We failed; most health economists believe they have emancipated their subject from political economy, to achieve a value-free methodology valid throughout space and time, so they are not attracted by real human material which makes such beliefs difficult. However, even without skilled economic assistance, we learned a great deal.
First, we learned that in the early 1980s, although the NHS economy was in a remarkably healthy state by any international standard, nobody knew the price of anything we used, except prescribed medication. Neither our Regional hospital laboratory, nor the X-ray Department, could supply any even approximately priced menus from which to cost our demands on them. They knew their global costs, but were unable to break them down into any of the units relevant to our clinical decisions. All they could suggest was that we look at the tariffs used by the British United Provident Association or by hospitals in USA, to charge their private patients, but these included a large profit component, absent at that time from the NHS.
Knowing that money always represents somebody’s labour, and knowing the value of our own, we were concerned to provide an economic service. Wasteful medicine is not just expensive, but dangerous, and bad science. To discover what was actually going on in our practice, we had to apply more and more measurements – blood pressures, weights for height, smoking consumption and blood carbon monoxide levels, tablet counts to measure compliance, glycated haemoglobin to assess diabetes, peak flow rates to assess asthma, patients’ diaries to assess epilepsy – you name it, we measured it. The more we measured real health values, the less we needed to concern ourselves with price, because the result was the same; extravagant care is not only expensive but dangerous, thoughtful care is not only safer, but cheaper in all respects but one – it needs more time.
Second, we learned that planned, audited continuing anticipatory care of whole communities almost certainly does produce much greater health gain than unplanned care which simply reacts to presented demand, within customary expectations. Comparing death rates under 65 for our health centre with those for another serving a similar population in the same valley over the same period 1981-6 , ours were 68% lower than for the control health centre. All the main health risks we targeted (cigarette smoking, blood pressure, weight-for-height, and glycated haemoglobin in diabetics) showed substantial falls. These health gains were achieved in a community ranked fourth from the bottom on the Townsend index of social deprivation, out of 55 Local Authorities in West Glamorgan, which since 1970 has probably had the worst male unemployment figures in Britain.
Finally, we learned that this all takes time, and sustained personal commitment. For community generalists at least, virtually nothing can be achieved in less than five years; but equally, there is almost no reasonable target that cannot be reached in a working lifetime of 30 years.
Similar lessons could be drawn from the experience of many other progressive primary care teams following similar paths. The morale, goodwill, and sense of vocation of health workers of all grades was the most valuable of all NHS assets, and its near- destruction is the greatest crime of the market “reformers”.