Medicine and Labour Chapter 5 Medicine and the NHS

Many on the left assume that the BMA has always been hostile to the National Health Service. In sustaining this indictment they would point to the fact that the BMA was on the verge of taking industrial action to prevent the implementation of Lloyd George’s National Health Insurance Scheme, that 35 years later it rejected the National Health Service Bill and again came close to taking industrial action to prevent the Bill being implemented, and that 30 years later again it actually took industrial action to prevent the phasing out of pay beds.

In defending itself against this charge, the BMA would claim that each of the three conflicts was about detail, not about the principle of a health service. To have taken action about issues of detail which affect its members no more implies lack of commitment to the NHS than does the action of health service unions in 1972, 1978 and 1983. Far from being opposed to the NHS, the BMA actually produced a blueprint for a National Health Service in 1930 in its document ‘A General Medical Service for the Nation’ which was approved by the Representative Meeting with only six dissentients. Moreover the BMA did not only oppose the National Health Service Bill on issues of detail affecting doctors. It also fought very hard, harder than the left did, to have industrial health services included in the NHS (a measure that failed not because of opposition from doctors or employers, but because of opposition from Ernest Bevin who saw the Beveridge Report as ‘an ambulance service for the nation’ and did not want the NHS to get anywhere near ‘hard policy’ areas like industry).

It must be admitted that the defence is strong.

The BMA and National Health Insurance

On 30 July 1910 the BMJ Supplement reports a decision of the Representative Meeting ‘That the Association should promote a centrally organised National Provident Medical Service’.

On 4 March 1911 the Supplement carried a ‘Report on the Organisation of Medical Attendance on the Provident Insurance Principle’. This report pointed out that ‘Medical practitioners constantly complain that they cannot obtain payment of debts justly due to them for medical attendance. It is notorious that, by those who make debt collecting a business, medical book debts are regarded as amongst the least valuable.’

The report referred to the way that provident societies had filled the gap in providing medical services to the ‘wage-earning classes’ but pointed out that provident societies had often exploited doctors. It nonetheless advocated extension of the provident society principle.

The introduction of the Lloyd George Act led to a dispute which the BMA seems to have approached from the standpoint that the National Health Insurance Scheme was just one big provident society and that it must be prevented from exploiting doctors. In pursuing these negotiations the BMA was guided by the principles it had worked out for dealing with friendly societies, which included demands for an income limit, for medical involvement in the management of the society, for special payments for defined special services and for freedom of choice of patient and doctor (a measure which had originally been designed to prevent societies offering all their business to one doctor by competitive tender).

Although some of the demands seem strange in a modern context they are readily explicable in the circumstances of the time, and the BMA probably passes the test of legitimately defending doctors’ interests rather than opposing the scheme.

Pioneering an NHS

On 26 April 1930 the BMJ Supplement carried a report ‘proposals for a General Medical Service for the Nation’. An opening paragraph read:

The Association therefore presents the following scheme to the public and invites the fullest criticism. Such a scheme may be compared to a plan submitted by an architect to a householder who wants to extend the house in which he lives and to introduce all modern improvements. The householder may, on seeing the plan, decide that it would cost too much and that he must put up with the house as it is, or he may make suggestion for the modification of the plan. But the householder knows that if he wants to extend his house he is, as regards essentials, in the hands of architects and builders.

Here the BMA was laying down its view that planning health services is doctors’ work and that those who try to do the job themselves will have problems.

‘General Medical Services for the Nation’ set out the following main points:

  1. That a satisfactory system of medical services must be directed to the prevention of disease no less than to the relief of individual     (The   report   said   ‘… it   must   be recognised that progress in the prevention of disease is much more dependent on the education of the people, on action by the government and the local authorities in the matter of housing, food, pure air, etc., and even more on self control on the part of the individual than upon any action by doctors …’)
  2. That the medical services of the community must be based on the provision for every individual of a general practitioner or family doctor.
  3. That a consultant service and auxiliary forms of diagnosis and treatment should be available for the individual patient, normally through the agency of the family doctor.
  4. That the interposition of any third party between the doctor and the patient, so far as actual medical attendance is concerned, should be as limited as possible.
  5. That as regards the control of the purely professional side of the service, the guaranteeing of the quality of the service and the discipline of the doctors taking part in it, as much responsibility as possible should be placed on the organised medical profession.
  6. That in any arrangements made for communal, subsidised or insurance medical service, the organised medical profession should be freely consulted from the outset on all professional matters by those responsible for the financial and administrative control of the service.
  7. That medical benefits of the present National Health Insurance Acts should be extended so as to include the dependents of all persons insured thereunder.

It was suggested that the Public Assistance Committee should pay the contributions of the poor, and that administration of the scheme should be in the hands of county and county borough councils, and added: ‘The medical officer of health of the administrative area concerned will be the administrative head of those parts of the scheme which need central administration, guided and advised by a medical committee.’ (The ARM subsequently added a proviso that the medical committee should have direct access to the local authority if they disagreed with the MOH.)

This whole report was endorsed by the ARM with only six opposing votes. It must be remembered that this was in 1930, the same year that the SMA was founded, and in this context there is an interesting mistake in Stark Murray’s history of the SMA. He dates ‘General Medical Service for the Nation’ as 1938 not 1930. The implication of this would be that the BMA came to its ideas after eight years of SMA campaigning, rather than that the BMA was one of the pioneers of the idea of an NHS, and that in the same year that it produced its ideas the SMA was launched to take them forward through the Labour Party.

Grey-Turner and Sutherland, in the second volume of the history of the BMA, claim that the socialists were rather late in the field in the campaign for an NHS.(E.   Grey-Turner and  F.M.  Sutherland,  History of the British  Medical Association 1932-1981, London 1982.) This is not true. Socialists had been the mainstay of the SMSA, as reflected by its collapse when they transferred their energies to the SMA, and the history of the SMA can legitimately be traced back to 1912. But certainly the BMA may claim to be among the pioneers.

There are some aspects of ‘General Medical Service for the Nation’ to which socialists would take exception. The most important was the degree to which the system was to be controlled by doctors, and this indeed was the ultimate point of conflict. The idea that progress should come by extension of National Health Insurance was acceptable at that time, being indeed a view held by many in the Labour Party who believed that it was the quickest way forward. Dr Alfred Salter, the left-wing MP for Bermondsey, for example, held this view. Acceptable as the view might have been in 1930, it was unacceptable when it surfaced again in 1944!

Socialists would welcome the commitment to local government control of the service, although this is a point of view which the BMA abandoned during the course of the 1930s. The method of finance, seen by socialists as a key issue, was clearly regarded by the BMA as unimportant, but contributions were envisaged.

The BMA and the NHS

As it became clear in the early 1940s that a National Health Service was coming, the BMA set up a Medical Planning Commission. An interim report appeared in 1942. No final report appeared and Stark Murray claims that this was because the BMA leadership feared the outcome.

The BMJ Supplement of 15 January 1944 laid out the principles by which the BMA would judge any White Paper on a National Health Service. These principles were to dominate medical thinking for several decades, and indeed still shape BMA policy. Given their importance, and in certain respects their radicalism, it is worth quoting them in full:

  1. The health of the people depends primarily upon the social and environmental conditions under which they live and work, upon security against fear and want, upon nutritional standards, upon educational facilities, and upon facilities for exercise and leisure. The improvement and extension of measures to satisfy those needs should precede or accompany any future organisation of medical services.
  2. The efficiency of a country’s medical services, both preventive and curative, depends upon the available medical and scientific knowledge, upon the character and extent of medical education, upon the sufficiency and quality of personnel, upon facilities for treatment including institutional accommodation, and upon the absence of economic barriers that impede the utilisation of such services. Thus, the sufficiency and quality of personnel and facilities for treatment, including institutional provision, should be assured; in order to improve the country’s medical services the facilities and resources for medical research should be greatly increased and methods devised for their adequate application; medical education, both undergraduate and postgraduate, should be maintained on a high standard, adapted to modern needs, and brought within the financial resources of any suitable student. Wherever economic barriers prevent an individual citizen taking advantage of medical services such barriers should be removed.
  3. Subject to these general and overriding considerations the functions of the state should be to co-ordinate existing provision, both official and non-official, to augment it where necessary and to secure that it is available without economic barrier to all who need it. The state should confine itself within these wide limits, invading the personal freedom of both citizen and doctor only to the extent which the satisfaction of these functions demands.
  4. It is not in the public interest that the state should convert the medical profession into a salaried branch of central or local government service. The state should not assume control of
    doctors rendering individual or personal health service. The profession rejects any proposal for the control of the future medical service by local authorities as at present constituted.
  5. Free choice as between doctor and patient should be preserved as a basic principle of future health services and no administrative structure should be approved which does not both permit and
    encourage such free choice.
  6. It is not in the public interest that the state should invade the doctor/patient relationship. The loyalty and obligation of a doctor rendering personal health services to an individual patient must be to that patient and to none other.
  7. Free choice of doctor should be reinforced by a method of remuneration which relates remuneration to the amount of work done or the number of persons for whom responsibility is accepted.
  8. Every member of the community should be free to consult the doctor of his choice either officially, as when he consults the doctor he has selected under an official service, or privately, as when he consults some other doctor, whether that doctor is a member of an official service or not. Nothing should be done to encourage the splitting of the medical profession into two groups – the official doctors and the non-official doctors.
  9. Consultants and specialists should normally be attached to the hospital. For those persons who wish to be treated in private accommodation, whether part of a hospital or not, private consulting practice should continue.
  10. The central administrative structure should be a corporate body concerned only with civilian health services and should be responsible for all civilian health services. This central administrative body should be advised on medical matters, including personnel, by a medical advisory committee, representative of the medical profession, which should be at liberty to publish its findings. Locally, new administrative bodies should cover wide areas and should be representative, directly or indirectly, of the community served and, in appropriate proportion, of the local medical profession and voluntary hospitals. They should be advised, on medical matters, including personnel, by local medical advisory committees representative of the local medical profession, which should be at liberty to publish their findings. These administrative changes should be regarded as foundation changes to be agreed before other changes are initiated.
  11. All branches of medical practice should be regarded as a single service and it is undesirable that a detailed scheme for general practitioners should be framed and put into operation without corresponding arrangements for other branches of practice.

The report went on to call for the immediate extension of National Health Insurance to the poor and to dependents, and to cover consultant and specialist services, hospital services and laboratory services, as an interim measure until the NHS could be introduced. It also called for experiments in group practice, health centres and GP hospital units.

The Representative Meeting that endorsed these principles also carried a number of resolutions. It voted by 200 votes to ten against the creation of a full-time salaried state medical service. It voted by 149 votes to 37 for a resolution saying that ‘a comprehensive medical service should be available to all who need it, but it is unnecessary for the state to provide it for those who are willing and able to provide it for themselves.’

It also voted for a resolution that all practitioners on the Medical Register should have the right to participate in the NHS.

The first two principles would be unexceptional to socialists, and would constitute a powerful statement, as valid today as it was then, of the case for a National Health Service. The remainder laid down the BMA’s challenge to the threats to autonomy of the profession. It wanted doctors to control the new service and to continue to practise very much as they wanted to. All it wanted the state to do was pay.

There are two concepts of a National Health Service. One is that it is a way of paying doctors’ bills – of ensuring that health care is available to all irrespective of means. This the BMA favoured, and had a long history of favouring. This is not surprising, for it is very much in the interests of the profession -remember how the 1911 report on provident medical services opened by drawing attention to the problem of bad debts.

The other concept is that a National Health Service is a way by which a society pursues health as a social goal. This position must emphasise the control of the service by the community. This the BMA did not favour, in 1944 or before or since. Hence the conflict.

If this principle underlay the conflicts of the 1940s it equally underlies the conflicts over private practice and independent contractor status today.

Private Practice

The area of private practice is the area in which the profession has most obviously come into conflict with the labour movement.

There is a lack of clarity of thought within the Labour Party as to the implications of its wish to rid the country of private practice. The predominant view is probably that private practice represents the purchase of privilege in health at a time when the nation has decided to make health care freely available to all irrespective of means.

If this view were to prevail there would be no basis for stopping short of a complete ban on the private sale of medical services. But such a ban would be seen as oppressive by a large part of the nation and no other Western nation in the world has carried through such a measure. In fact, private medical treatment can be bought in the Soviet Union from special polyclinics, albeit state-owned. It also raises serious practical difficulties in respect of alternative medicine. Is alternative medicine to be available on the NHS, or is it to be banned, or are alternative practitioners to have a freedom to sell their services which is to be denied to qualified practitioners?

For these pragmatic reasons it has been accepted that it is politically impractical to ban private practice. Two com­promise positions therefore emerge. One is that private practice should be harassed, and the other is that private practice should be separated from the NHS. The former is a pragmatic application of a philosophical opposition in circumstances in which the political requirements of a pluralistic society limit the extent to which that philosophy can be given full rein. In any free society things happen of which the government does not approve, but which it would be oppressive for it to ban, and it is legitimate for governments to find ways to control and limit the development of such activities. To harass private practice is therefore an honest political position consistent with the philosophy of the Labour Party and its acceptance of the legitimacy of alternative viewpoints. Unfortunately the scope for harassment is limited. Tax provisions and planning controls have their place, but on the whole it is difficult to evolve methods of harassment which do not become arbitrary or oppressive.

And so the idea emerges of separating private practice from the NHS. This can be a form of harassment if it is believed that separation will destroy private practice, or it can be an alternative philosophical position based upon the idea that there is nothing wrong with private practice so long as it does not damage the NHS.

As a pragmatic expression of the idea of harassment, separation of pay beds from the NHS has been a disastrous misjudgement which has given new strength to the private sector by forcing it to build its own hospitals. It has thereby separated itself from the point at which it could most legitimately have been harassed, limited or controlled. Separation of pay beds has not only failed to work but it has actually made it much more difficult to pursue a harassment policy within the constraints set by a free society.

Let us suppose that the Labour Party were to set to one side the philosophical issue which underlies policies of harassment, not by admitting any change in the philosophy, but by acknowledging political constraints which prevent its effective implementation.

How Does Private Practice Damage the NHS?

What would be the consequences of an alternative approach of seeking to protect the NHS from damage by private practice, rather than to oppose private practice on its own demerits? One of the first consequences of such a shift of rhetoric would undoubtedly be increased public support, and another would be the removal of much ground from the feet of opponents. The total amount of private practice is very small as a percentage of expenditure on health care, but this statistic conceals the fact that its effect is concentrated on one very small area of the total health-care system, namely non-emergency surgery.

The National Health Service offers an emergency medical service which is, at its best, the equal of the best of other countries and, at its worst, better than the worst in most other countries. We have succeeded relatively cheaply in providing a good emergency medical service to the whole of our population, irrespective of means, and that is a major achievement of which we should be proud.

Private practice has little or nothing to offer in this sector, because it can do no better. The areas where the NHS is failing are in the areas of chronic sickness – psychiatry, geriatrics, rehabilitation, terminal care. Private practice has nothing to offer in this sector, either, for it can make no profit. It is insurance against the unlikely and short lasting contingency of acute sickness that offers scope for the insurance company, not provision for caring for the chronically sick, perhaps for years.(The growth of private nursing homes in the early 1980s may seem inconsistent with this statement.  But this growth was fuelled by the availability of DHSS money to pay the fees. It should therefore be seen as a form of privatised and subcontracted state-funded health care, rather than as part of the private sector per se.)

Private practice offers a better service than the NHS only in the sector of non emergency surgery, where it offers three advantages: a chance to jump the queue in a sector where there are waiting lists; a better quality of accommodation and ancillary services to a group of patients who are not very ill and are therefore particularly likely to concern themselves with ancillary services as much as with actual medical and nursing care; the chance to fix the date of admission in advance, which is valued by many business and professional people.

In concentrating our venom on the first of these three attractions the left has failed to recognise that the other two are legitimate, and could be offered by the NHS, even legitimately charged for by the NHS under an extension of the concept of the ‘amenity bed’. It would be necessary to take care that the purchase of better amenities did not become the purchase of other privileges, and that the fixing of admission dates in advance did not become a covert way of jumping the queue, but safeguards could be devised. What damage does queue jumping actually do to the NHS? Is it true, as the left claims, that it pre-empts resources and diminishes the service to the rest of the population, or is it true, as the right claims, that it draws additional resources into health care, relieving the burden on the NHS and therefore benefiting the rest of the queue by making it shorter?

Three distinct arguments are available to support the left’s position. One is the argument that health-care resources are stolen by the private sector. It is undoubtedly true that NHS resources are used by the private sector at less than the market price, sometimes at no price at all as consultants smuggle tests or X-rays through as NHS work. This should be controlled, but it is not a problem which strikes at the root of the viability of either sector of the health care system. It is also true that the private sector does not bear its share of the training costs of the health care system, and the NHS certainly should be permitted to impose a training levy on the private sector. However this is, again, not an issue that affects the viability of the sector.

The second argument is that the willingness of the public to pay taxes to support the NHS is diminished by the availability of the private sector. Society will allocate so much in the way of resources for health care, and if it is not collected by the Inland Revenue and spent on the NHS it will be collected by BUPA and spent on the private sector. Support for this argument can be found in the fact that the private sector has grown most spectacularly in a period in which health-service growth has been restrained below the level which opinion polls suggest the taxpayer would have been willing to bear.

The third argument is the strongest and also the least widely used. It is that private practice is sustained only by the distortion of NHS services by those doctors who have a vested financial interest in the failure of the NHS to compete effectively with their private practice.

Private Practice as a Conflict of Interest

At its most blatant, this distortion is represented by activities which in any other area of human endeavour would be described as corrupt and would attract long prison sentences. For example:

  1. A consultant sees a patient privately for a consultation. The patient confesses that he cannot afford a full course of private treatment. The consultant agrees to treat him in hospital as an NHS patient, if he will pay for the initial consultation and the subsequent follow up appointments. The expensive in-patient care is thus provided by the NHS and the patient can afford the private out-patient care. The patient is then admitted ahead of the waiting list on the grounds of alleged urgency.
  2. A GP refers a patient to an eye surgeon who tells her that she must wait two years for her operation. The GP protests that the operation is urgent since the patient is nearly blind.
    The surgeon replies, ‘It doesn’t matter, she is coming in ‘ The GP protests that this will cost the patient her entire life savings, and the surgeon, somewhat abashed, then acknowledges that the case is urgent and admits her immediately as an NHS patient.
  3. Whilst a consultant is away at an international conference in Hawaii his Registrar clears the waiting list. The consultant, on his return, is very angry at the likely effect on his private
  4. A District Health Authority proposes to appoint a new consultant surgeon to reduce waiting lists, but the appointment is blocked by the Division of Surgery which
    objects to the competition for the private practice.

These are real not hypothetical examples.

Such corrupt behaviour exists amongst a small, but not insignificant, body of surgeons and the medical profession, although it does not approve of it, does nothing whatsoever to stop it.

However it is not in such blatant corruption that the real problem lies; the real problem is more subtle. The NHS employs a consultant surgeon. It employs him on a high salary, not as a craftsman or technician to do a specific number of operations, but as a senior member of its staff to develop a service. It accords him power and responsibility, it expects commitment. But the consultant sees this appoint­ment as only part, albeit the major part, of his practice. He knows that it is on the private part of his practice that he depends for the jam to add to the already very filling bread and butter provided by the NHS. He knows moreover that that private part of his practice will grow best if the NHS part of his practice fails to meet the needs.

If he is a man of unusually high integrity and unlimited dedication to the health of the community this does not influence him in any way. It is a matter of which the medical profession can be proud that a sizeable minority of surgeons do behave with this degree of integrity – certainly far more than demonstrate blatant corruption.

But surgeons are human beings, and it would be wrong to base our health care system upon any other proposition. The majority, whilst drawing the line at blatant corruption, do not attain the heights of iron integrity. Instead of seeing the waiting list as a defect in their service which they must fight by all possible methods to eliminate, they come to think of it as an inevitable defect of the NHS. Instead of adding a few extra patients to their lists, they start to restrict their service to the NHS to the sessions (and length of sessions) that they are nominally paid for, and to put their extra effort into their private practice. Instead of seeing their professional contributions, the standard by which their lives will be judged, in terms of the overall improvements they can make in the surgical service, they start to see it in terms of the perfection of the care they can offer to that minority of their patients who can afford to pay for as much of their time as they care to offer. A consultant who is developing a service has a vision of the future. The geriatrician dreams of the day when the long-stay ward will be empty and the community centres will be vibrant with old people enjoying their lives. I wonder how many surgeons have a dream of a hospital service with no surgical waiting lists and with facilities so excellent that none would dream of using any private alternative.

This is not to say that our hypothetical surgeon does anything dishonest, treats his NHS patients with anything but a high standard of professional treatment, does anything consciously to sabotage the NHS service or gives the NHS substantially less commitment in terms of time than it has paid for. Indeed if he did, his professional standing and hence his private practice would suffer. But what the NHS has paid for, and does not get, is commitment in terms of drive, initiative and identification. Those intangibles are the property of the private sector, and it is for lack of those intangibles that the NHS languishes.

I do not wish to blame surgeons for the inevitable consequences of the present system of organisation. I simply say that the system should be changed, and that those who hold senior powerful positions within the NHS should have no vested interest in its failure.

I know of no company which would allow its most senior managers to work also for its competitors. I do not believe that it would be regarded as a valid assertion of individual liberty if a Divisional Manager of British Rail were to claim the right to run a bus service in his spare time, however marketable his skills in transport-system management may be.

The cornerstone, therefore, of protecting the NHS from damage by the private sector must be the introduction of new contractual arrangements which prevent consultants who work in the NHS from working also in the private sector. (Certain forms of private practice, such as medico-legal work, which require the expertise of a doctor but do not amount to the provision of health care, would need to be exempted from this prohibition.)

The effect of such a prohibition would be virtually to abolish private practice outside the field of surgery, and to limit private practice in surgery to a few centres. Had this been done in 1975 there would have been no private practice outside London. That can no longer be confidently predicted to be the effect, but certainly the amount of private practice after such a change would be less, and its potential for growth less. Those consultants who would leave the NHS after such a change would be drawn from highly competitive specialties where they could be replaced overnight by promotion of adequately experienced and under-utilised Senior Registrars, who could in turn by replaced by promotion of adequately experienced and under-utilised Registrars.

Why do Consultants Support Private Practice?

The introduction of such a change would be dependent on finding ways to ensure that it was not the subject of a prolonged, and widely supported, campaign of resistance by the medical profession. To consider how that may be avoided it is necessary to understand both the economic and emotional significance of private practice to the medical profession.

The economic significance of private practice to the medical profession is much less than is commonly thought. A small number of consultants earn very large sums of money from their private practice, but they would simply leave the NHS anyway if the two were separated, and would not be particularly missed.

In 1971-72, according to figures presented in the 1974 Review Body report, the average consultant earned about 15 per cent of his income from private practice. This figure has not been calculated since, and is out of date, and conceals the difference between consultants in specialties such as geriatrics where private practice opportunities are very limited, and the larger earnings of consultants in specialties such as surgery. Even so a significant salary increase in return for the giving up of the right to private practice would easily buy out the right to private practice. If the Labour Party is still prepared to stuff consultants’ mouths with gold, I would have thought that an addition of £10,000 p.a. to the consultant’s salary would lead to the profession’s leadership being trampled in the rush, provided that attention was also paid to certain emotional aspects of the significance of private practice. This would cost £120 million per annum. This is a large sum, about 1 per cent of NHS expenditure, or about one-third of one year’s NHS growth at Labour Party projected spending levels. But if we don’t think private practice causes enough damage to spend one-third of a year’s NHS growth on getting rid of it then we ought to stop moaning about it.

The traditions of private practice are rooted in the days of the voluntary hospitals, when consultants who worked predominantly in private practice offered their services free of charge to the voluntary sector. It was through this work for the charitable hospitals that the doctor became known to the general practitioners who were to refer patients to him in the remunerative part of his practice.

The proposal by Nye Bevan at the time of the establishment of the NHS that these consultants should become full-time salaried employees of the NHS marked a very substantial change from that pattern of practice. It represented a threat to autonomy and a threat to income, and was resisted accordingly. Attitudes which may have been appropriate in the circumstances of the charitable hospital became inappropriate as consultants came to derive the bulk of their income from the hospital and the hospital, for its part, came to rely on them as its senior managers and to expect a full-time commitment. It is this transition which has produced, imperceptibly, the impossible situation of a full-time senior employee with a vested financial interest in the failure of the service he controls. No sane person would set up such a system, but its evolution is easily understandable.

Since 1948 considerable changes have taken place in the significance of full-time salaried NHS employment to the consultant body. To most doctors their NHS employment is now the predominant feature of their professional life and is no longer strange and unusual. So why should not the economic interest in private practice be bought out?

During the period that private practice was becoming irrelevant to the majority of consultants the profession’s attitudes to it were going through the usual stages in the death of an outdated and institutional sacred cow. The old arguments were being replaced by new rationalisations. The particular argument which gained the most strength was the idea that the government should not be allowed to become a monopoly employer.

By 1975 the profession’s attachment to private practice was historical. It was quite acceptable to say things like ‘I think consultants should be paid enough not to have to bother with private practice’ or ‘I think the NHS should be good enough not to need private practice.’ The attachment to private practice amongst those consultants (about half) who did not actually do any was very tenuous, and the attachment amongst those who had private practices was probably not particularly hostile to the idea of being bought out, if the price was right. Amongst the profession’s leadership the attachment to private practice was greater, since the leadership have a greater emotional attachment to the mythology of the profession and take longer to catch up with changing moods.

The Botched Settlement of 1975

In 1975, when the private practice issue came to the fore, the MPU advised the Labour government of the time that the way to deal with the problem was to offer a substantially increased differential to consultants who worked full-time for the NHS, and to offer that, if necessary, over the heads of the profession’s leaders.

That advice was ignored and attention focused instead not on the issue of full-time contracts but on the much less important issue of pay beds. As a result the profession perceived the issue as an attack on its economic interests, which was indeed a valid view.

The settlement ultimately reached with the profession was so totally bodged that the anti-private-practice cause was set back 20 years.

Pay beds were to go, gradually, but in the end this strengthened rather than weakened private practice. In return the differential between consultants who worked entirely for the NHS and consultants who worked also in private practice was reduced from 2/11 of salary to 1/11, and consultants could earn up to 10 per cent of their income from private practice without incurring this penalty (previously a consultant needed to forgo the right to private practice totally or give up 2/11 of salary). (Consultants who accept a full NHS workload are of two kinds, with the option lying entirely with the individual. ‘Whole-time’ consultants have a full NHS commitment and their private practice is restricted. Prior to 1975 they   were   totally   barred   from   private   practice,   except   in   limited medico-legal fields (the so-called Category II work). Since 1975 they have been allowed to have a private practice, so long as they do not earn more than 10 per cent of their income from it for more than two successive years. ‘Maximum part-time’ consultants have an identical NHS commitment to whole-time consultants but have no restrictions on their private practice prior to 1975 they were paid 9/11 of a whole time salary Now they’re paid 10/11) Not only had we actually moved backwards in terms of eradicating the mixture of private practice and NHS practice, but the profession’s attachment to private practice had increased in two important ways.

First, an attack on private practice had taken place which had been an attack on the profession’s economic interests and it had been repulsed. To an emotional attachment to an outdated concept had been added the new power of a shared victory over a shared external attack. Moreover the opponents of private practice had now been shown to be interested only in doing doctors down. Any future proposals they might make would be treated with an appropriate suspicion.

Second, the number of doctors who would have a direct financial interest in private practice was to increase as a result of the settlement. Until 1975 the consultant body had been characterised by a growing proportion of consultants who were full-time NHS consultants. Those doctors were natural allies of any proposal to increase the differential between full-time and private practitioners, or to increase the consultant salary in return for abandoning the right to private practice. After 1975 most of that group acquired small private practices under the 10 per cent rule.

The opportunities which were wantonly squandered in 1975 will not recur and there is no point crying over spilt milk. The lessons of this defeat, however, should be learned.

If a future Labour government is to seek the separation of private practice from the NHS by offering a new contract to doctors over the heads of their leaders, it will need to pay a much higher price than it would have got away with in 1975, and it will need to make concessions which acknowledge the changed emotional situation.

It will need to realise that it will be suspected of merely preparing the ground for abolishing private practice and becoming a monopoly employer, and it will need to realise that the 1975 battle rooted that particular rationalisation of private practice deeply in doctors’ subconscious, simply because it was the most prevalent rationalisation of an outdated attitude around at the time when the profession had to fight a battle over it. If, therefore, the Labour Party is to control private practice and at the same time deal with the medical profession’s reaction to that by rational economic bargaining, it will need to neutralise this emotional reaction by conceding what it knows but has never admitted – that it is impractical to ban the private sale of medical services.

If the full implications of this are accepted, then it will be necessary for the Labour Party to state quite clearly the extent to which it will feel itself entitled to harass and control private practice, and the extent to which it will feel obliged to tolerate it.

The Tolerable Limits to Private Practice

The Labour Party will need to assert its right to control private practice in any sector where it exceeds 10 per cent of total health care provision, or where it deprives the NHS of resources which it needs. It should affirm the constitutional principle set in 1948 that charitable health-care facilities are the property of the public and can be taken into state ownership without compensation.  To take into the NHS whichever of the BUPA hospitals, and other charitable hospitals, the NHS needs would be no different from the nationalisation of the voluntary hospitals in 1948, and such a measure should be taken as a quick way of regaining some of the ground lost by the NHS in the period in which the Tory government restrained NHS spending below the growth levels which a rationally organised economy would have chosen. The private sector could then judge for itself how far it wished in future to adopt charitable status. The Labour Party should affirm that the provision of facilities by the NHS for the private sector will be based on the question of what is best for the NHS (although the NHS probably should provide pathology-laboratory and X-ray facilities to avoid the private sector developing its own – we must not repeat the pay beds mistake). It should also affirm that there is no area which will be conceded to the private sector as its inalienable right, and should expand amenity bed facilities and facilities for booked admissions in direct competition with the private sector. It should also set out to reduce waiting lists by allocating additional resources to non-emergency surgery, and should advertise the strengths of the NHS and the weaknesses of the private sector.

Having asserted the legitimate extent of its expression of its hostility to private practice it should formally forswear any attempt to go beyond these legitimate areas.

But the medical profession’s emotional resistance to the concept of a monopoly employer will run deeper than merely guaranteeing the continued existence of a private sector. There will be a fear that the separation of private practice from the NHS would mean the end of independent practice, since the private practitioner would have no shop window in which to gain professional respect, and so the only form of private practice which could survive would be the commercial form which is provided by commercial companies employing their own doctors. Monopoly employer there might not be, but oligopoly there would be, if those commercial companies set their terms by Whitley Agreements and controlled the practice of their employees by the demands of profit.

The impracticality of the Golden Age of Independent Practice, or the fact that it meant hardship and poverty for some amidst riches for others and the reality that the profession as a whole is better off in state employment than it ever was in independent practice is a rational refutation of an emotional attitude, and therefore does not counter it effectively. Quite apart from the profession’s emotions there is also an advantage for the NHS in ensuring that in so far as a private sector exists it consists of independent practitioners rather than commercial companies. This can be achieved partly by offering the profession whatever controls on commercial medicine it wishes to see to protect independent medicine from it in the reduced private sector, and partly by allowing some limited contact between independent practice and the NHS. Although it would be impossible to permit the continuation of a situation where those who have a substantial role in the NHS can have a subsidiary and conflicting interest in the independent sector, there is no objection to the reverse, that those who work predominantly in the independent sector could have a limited place in the NHS as a shop window provided that the number of weekly sessions (one session = 3£ hours) was sufficiently limited to prevent abuse. The idea of an honorary consultant could be revived with those who leave NHS consultant appointments for the independent sector being entitled to offer between one and three sessions to the NHS. (If we were really true to tradition these sessions should be unpaid However there may be limits to the profession’s attachment to tradition Grey-Turner and Sutherland, op. cit., p. 164.)

In summary, just as the medical profession’s economic interest in private practice must be bought out, so its emotional interest in independent medical practice must be indulged by creating a small island of independent medical practice, protected from commercial competition, and in turn controlled in size so to protect the NHS. This island will become increasingly irrelevant until it ceases to be of such significance as to be practically offensive. The key issue on which no concession should be made is that those who hold important positions in the NHS, with power to influence its development, cannot be allowed to have interests which are dependent on the failure of the NHS.

Independent Contractor Status in General Practice Private practice is not an issue in general practice, since there is so little private general practice, but the emotional attachment of the profession to independent medical practice takes a different form – the concept of the independent contractor. Moreover, although the emotional power of private practice was naturally in decline until it was revived by the 1975 debacle, there is no evidence of any similar decline in the power of the independent contractor concept.

In the nineteenth century the practice grew up whereby general practitioners varied their fees to meet the capacity of their patients to pay. The poorer sections of society paid a fixed sum, in return for which they received whatever care they needed, whilst the rich continued to be charged for the services of the doctor as they used them. This arrangement was by no means universal and so friendly societies began to take on the role of intermediary, arranging medical care for their members. This created antagonism with the profession, which saw this model of care as a threat to its own interests. There were two problems. One was that the friendly society saw no reason to pay more for the health care of the rich than for that of the poor, and no reason to limit their own membership to the poor. At the same time they modelled the fees they were prepared to pay on the fees which doctors charged the poor, rather than the more lucrative rates which they charged the rich. The friendly society, moreover, was powerful: it had a great deal of business at its disposal, and the doctors who sought that business were disunited and in competition with each other.

The chapter entitled ‘Contract Practice and the Associa­tion’ in Muirhead Little’s volume of the history of the BMA covering this period described some of the problems and gives a feel for the profession’s attitude. To quote from that chapter:

The strength of the position of the societies lay in the lack of union amongst medical men. As in the similar case of the Poor Law Medical officers, the societies relied, and too often justifiably, from their point of view, on finding one amongst the local practitioners whose poverty or whose anxiety to get into practice induced him to accept their niggardly terms. Not only were the rates of pay extremely low, but the societies obstinately refused to allow a wage limit to be fixed above which members should be ineligible for medical benefit. Cases occurred of members whose prosperity increased so that they became wealthy or at least too well off to be attended on the same terms as day labourers … In answer to an inquiry in the [British Medical] Journal [in 1900], the editor touched the sore spot when he alleged that the practitioners themselves are chiefly to blame; indeed it is within our knowledge that in several instances in which medical men have entered into a medical (signed) agreement not to take any new club for a less sum than 5s. per annum for each member, first one and then another have withdrawn therefrom, with the view to accept such appointment at 4s. and 3s.

In 1894 the BMA established a fund to support the practitioners of Cork who were in dispute with the clubs and benefit societies and had withdrawn their labour (the term used was ‘resigned their positions’, of course, not ‘strike’). Socialists may perhaps look with sympathy on these battles by a group of workers against exploitation. The whole context of the battle suggests that the profession was not yet the oppressor.

The principles which the profession evolved were that there should be an income limit for benefit, so that the rich did not exploit the doctors on the back of arrangements made to benefit the poor, and that the patient should have free choice of doctor, with the same contractual terms being available to all. When Lloyd George introduced the National Health Insurance Scheme the BMA saw it as simply a massive form of contract practice, and tried to apply the same principles. On the question of the income limit they lost, but on the question of free choice of doctor they won. Contract practice in the new National Health Insurance Scheme was to be on the basis that the profession had tried, sometimes successfully, more often unsuccessfully, to extract from the old friendly societies.

The battle was not over. Whatever was officially agreed many of the approved societies between the wars exerted some control over the doctors who worked for them. But when the Executive Councils replaced the approved societies upon the establishment of the NHS the same old principles applied. Moreover the greater uniformity of the new NHS finally stamped out the remnants of the oppressive friendly society. It is ironic that the profession should have won a century-old battle for a particular set of principles of contract at the very moment that they ceased to be relevant.

The profession had, over a period of about a century, developed a strong resistance to the idea of employment of general practitioners by an agency established to provide their services. This grew out of its experiences with friendly societies that such employment would be exploitative and destructive of the local market in medical services. Only with the establishment of the NHS was this local market finally abolished, so that contract practice covered the whole population at proper rates of pay, negotiated centrally.

The Myth Perpetuates

Century-old concepts do not readily disappear, nor were they helped by the first set of negotiations for general practitioners’ income, in which the government insisted on basing its assessment of GPs’ average income in the past on their income tax returns, leaving the profession with the acute embar­rassment of trying to find credible reasons for these being a misleading measure. Doctors were convinced that the new NHS was going to be just as exploitative as the old friendly societies. (In 1952 arbitration by Mr Justice Danckwerts awarded a pay increase of over 100 per cent, restoring income but not trust.)

Our present system of organising general practice is based on the model of practice which the BMA sought unsuccessfully to extract from the friendly societies at the turn of the century. Any doctor can set up in practice in a district, subject to controls which prevent the setting up of new practices in over-doctored areas, and subject to the requirement that the doctors must be vocationally trained in general practice, i.e. have spent three years in hospital and one year as a general-practice trainee (this is a relatively new requirement and previously anybody who had done one year’s pre-registration house job and acquired full registration could set up). In fact very few doctors do simply set up practice -most become partners in existing groups or apply for single-handed practices when they become vacant. The ‘setting up’ concept, however, demonstrates the entre-preneurial principles on which the system is based. When doctors are in practice they must attract patients, but are not allowed to advertise for them (this is the reason that doctors prefer to join existing practices since otherwise it may take some time to build up a large enough list to attract sufficient income to live comfortably).

For each patient who joins the doctor’s list the National Health Service pays the doctor a fee. Patients are completely free to choose their doctor, and doctors to accept or reject any patient, although there is a reluctance amongst doctors to poach each other’s patients, so the patient’s freedom is less total in practice than in principle, and the doctor’s freedom is also not absolute since the NHS has an allocation system for patients who can’t find a doctor to accept them.

The NHS does not employ doctors, it merely contracts with them to provide certain services to certain patients in return for certain payment. The NHS is therefore in the role of the friendly society providing the money with which its members will make their arrangements with the doctor of their choice. The system has a number of disadvantages. Because of the anarchic system of matching doctors to patients the doctors do not, on the whole, serve a clearly defined geographical area. This makes it difficult to relate to other health professions, such as district nurses or health visitors, who work most effectively on specific patches. If they retain their patch organisation they must abandon the advantages of being attached to GPs.

Because GPs control the service they provide it is difficult to fit them into a planned total service. Even if agreement is reached with their representatives that they will take on a particular role, or practise in a particular manner, individual GPs may go their own way.

Finally a system of remuneration has grown up, based on a mixture of flat-rate allowances, capitation fees, item-of-service fees and arrangements for partial reimbursement of some expenses, whose main characteristics appear to be that it is excessively complicated, and that it favours the GP who provides the least possible facilities for his patients.

I am unaware of any rational argument, either from the point of view of the NHS or from the point of view of the profession, for continuing a system of organising generalpractice for which the main argument seems to be that it would, had it been in operation at the turn of the century, have prevented some abuses, then current but now irrelevant, by friendly societies.

Living With the Myth?

Nonetheless the system has a very deep emotional appeal to GPs and there is no doubt that the Medical Practitioners’ Union suffers very heavily in terms of GP support by advocating a salaried service. The commitments of the Labour Party to the introduction of a salaried service is seen as a serious threat by the majority of GPs, one which they would probably be prepared to resist by industrial action.

It may be that we could tackle this problem better by accepting the history that produced it, and the emotions which that history produced. Perhaps the planning of general practice could be achieved by delegating some of the remuneration of GPs to local negotiation so that the contracts drawn up locally with independent contractors reflect local needs. Perhaps incentives could be given to move towards geographically-based practices. Perhaps the condition for shelving permanently the terrifying idea of salaried practice could be a willingness by the profession to face up to and deal with the problems which the present system causes.

For, whilst the profession has no rational reason for its attachment to the present system, it must be said that the labour movement also seems unclear as to why it wants to change it, or what benefits will accrue from a new system of remuneration, and having failed to define those benefits has therefore failed to ask whether they can be obtained in ways which are less threatening to the emotions and traditions of the profession. It is not surprising, when a salaried service is presented as an end in itself, that the profession should be suspicious. However absurd the basis of its traditions, it is surely entitled to be suspicious if it is asked to abandon them for reasons which are unclear but seem to have something to do with controlling doctors.

Doctors and Cuts

The reaction of the established machinery of the profession to cuts has been cautious. There has been no doubt that the BMA has been prepared to state its opposition to the effects of cuts on health care. Indeed Jonathan Neale, in Memoirs of a Callous Picket, attributes the increasing emphasis on mana-gerialism in the NHS to an attempt to reduce the influence of consultants in order to implement cuts. Neale is hardly an apologist for the medical establishment, and his book is a grass-roots view of the problems of hospital workers.

John Havard, Secretary of the BMA, is quite unequivocal in stating the BMA’s support for the National Health Service, and indeed contrasts this present attitude with the attitude ten years ago, when there was considerable hostility to the NHS in BMA House. This hostility is not concealed in Elston Grey-Turner’s official history of the BMA, where Grey-Turner, a former Secretary of the BMA, writes:

The National Health Service is 33 years old. Very briefly and superficially the NHS is popular with the public but not with the doctors. Medicine and politics do not mix well. In the first half of its existence it was the general practitioners who found the most difficulty in living with socialised medicine, and in the second half, the chief problems and discontents have arisen in the hospital service and among hospital doctors.

If Grey-Turner correctly identifies the feelings that were present in BMA House at the time of his secretaryship, (and it is likely that he does, for others recall the strength of similar sentiments), is Havard right in perceiving a change?

I think there has been a change. I recall that in 1977 MPU members felt very pleased when we persuaded the HJS Con­ference to pass a resolution of support for a National Health Service funded out of general taxation and free at the time of use, but now I don’t think we would see such a resolution as even worth putting up – it would be taken for granted.

So how far has the change gone?

It no longer surprises us when the Chairman of Council opens the ARM with a speech defending the NHS and calling for more resources (although it very much surprised us when the then chair Tony Grabham did that in 1981). It surprised us a little when John Havard referred specifically to ‘problems with the Conservative government’ in his speech to the 1984 ARM. It no longer surprises us when government statements on public expenditure receive a critical response from the BMA. It no longer surprises us when the BMA conducts surveys about the effects of cuts on patient care.

So there is no doubt of the official position.

But we do not see BMA banners on demonstrations. We do not hear of BMA support for particular campaigns against closures. We do not receive BMA messages of solidarity at work-ins. We do not see the BMA at meetings of NHS Unlimited or of local health care strategy groups.

The official position therefore is expressed in the corridors of power and in the messages of the lobby, rather than at the grass roots of political struggle.

This mixed reaction reflects the confusion which cuts in the NHS create in the ideology of medicine.

Do cuts, for example, favour the economic interest of doctors? The objective answer is obvious. The profession obtains the bulk of its income from the NHS and is better off under the NHS than it ever was in the days of independent medical practice. Cuts in the NHS threaten the jobs of doctors, and certainly threaten their conditions of work and the attractiveness and job satisfaction of their NHS practice, which constitutes all of the practice of the majority of doctors and the bulk of the practice of most of the rest. This objective interest accounts for the profession’s anti-cuts position, so why is that position so half-hearted and why do contrary strands appear?

Firstly, because the subjective attachment to the romantic vision of independent medical practice is strong enough to leave the feeling that perhaps the decline of the NHS may be the opening for independence. An absurd idea, probably recognised^ as such, but still powerful enough to hold the profession back from wholehearted support of the NHS.

Secondly because the politics of the situation seems to lead the profession away from the political party of the British establishment and towards the party of Bevan and Castle and salaried practice and opposition to pay beds. The medical profession has, in fact, outgrown the need to associate with the establishment to raise its social status, but it has not yet realised that. Grey-Turner described the profession as ‘the shock troops of the middle class’. That is the language of a rising craft not of a learned profession. The profession is suffused with the snobbery of the nouveau riche, and has yet to learn that it no longer needs to pretend. Faced with a parvenu government which offends the aristocracy and attacks the interests of culture, traditional institutions and the professions as much as it attacks the working class (and all in the name of Trade), the medical profession has to think twice before it realises that it isn’t Trade. And it would have to think much more than twice before it demeaned itself by an alliance with the working class.

Thirdly, because the situation poses conflicts for the depoliticised stance of the profession. On the one hand the commitment to health and to patient care beckons clearly to a determined stand against an attack on the health of people. But on the other hand this isn’t a marginal political issue like seat belts. It is the centre of the strategy of the government. Can the profession dare to take up such a political stance?

And so powerful doubts conflict with the demands of economic interest and of patient care. The profession’s own interests and its most powerful ideal point one way, and generations of political habits and assumptions point the other. The BMA reconciles these conflicts by opposing cuts, but from the sidelines not the centre of the melee.