Medicine and Labour Chapter 6 Priorities, Medical Minorities and Power in the NHS

A Rational View of Priorities

The purpose of a health-care system is to prevent illness where possible, to cure those who suffer from illnesses which it has failed to prevent, to rehabilitate those who are disabled by diseases which cannot be cured and to care for those whose disabilities cannot be removed by rehabilitation. At the foundation of the National Health Service the most obvious defect in the British health-care system was the appalling state of the hospital service. The wartime Emergency Medical Service had acquired hospitals which were good in a few centres of excellence, but beyond that were of a very low standard. There were only fourteen properly functioning pathology laboratories in the country.

It is for this reason that the greatest reorganisation in 1948 was to the hospitals. General practice was continued on the Lloyd George model, but extended to the whole population and rationalised. Public health was unaffected. The hospitals, however, were nationalised and extensively reorganised. Over the first thirty years of the NHS tremendous improvements were made in the hospital service. Every health district now has a hospital offering a high standard of acute medical care.

The quality of medicine in the teaching hospitals is the equal of any of the best hospitals in the world, but many other countries could make the same claim just as truthfully. A health-care system must be judged by the standard of medicine offered away from the centres of excellence, and it is here that only a few countries can claim the success that the NHS has achieved. Now that a high quality of acute medical care is available, attention turns to the areas in which theNHS does less well. These are the priority areas of geriatrics, mental illness and mental handicap, the rehabilitative services such as physiotherapy, occupational therapy and speech therapy, and the newer areas of prevention, such as health education and public-health policy.

The reason that these are priority areas is not that they are more important than the provision of acute medical care. They are priority areas because improvement is needed most in the areas that one currently does least well. If we had excellent rehabilitative and caring services, but people were dying untreated from serious illness because of lack of drugs, operation facilities, physicians and surgeons, the priority for the NHS would be the improvement of acute medical care.

Some Other Views of Priorities

Another concept of priorities exists, and is that which has been used by Margaret Thatcher’s government. This accepts that there are priority services. However it links the concept to a static rather than a dynamic view of the NHS, so that the issue becomes not ‘Where do we most need to develop the NHS?’ but ‘Where are the most important areas to spend our limited resources?’

On this perception the priority areas must be financed by cuts in the non-priority areas, which overlooks the fact that the non-priority areas are past priorities and the only reason they are no longer priorities is because the resources have been allocated in the past to develop them. This notion of priorities is like building a house by knocking down each wall after you have built it to obtain the bricks for the next wall.

The concept of priorities for development, set out at the opening of this chapter, is essentially an application of the Law of Marginal Utility, which predicts that the value obtained from each successive increment of expenditure on a particular good is less than the value obtained from the previous equal increment.

The greatest compliment that can be paid to an institution is that it so successfully tackled the problem to which it directed its energies that future generations no longer saw the problem as a priority.

Let us suppose that, at a given time, we have met 40 per cent of the need in, say, cardiology and orthopaedics, and 60 per cent of the need in geriatric care. The priority is clearly to improve cardiology and orthopaedics. Ten years later 75 per cent of the need for cardiology and orthopaedics might be met, and 65 per cent of the need in geriatrics. The priority is now to improve geriatrics. However the Law of Marginal Utility is often disregarded. There is a tendency to compare average cost with average benefit rather than to compare marginal cost with marginal benefit. An example is the way that workers often pursue wage increases, rather than improve­ments in working conditions or leisure, long after their income has passed the point at which money ceases to be the main limiting factor in their well-being. If asked to justify this position, they will point to the importance of money by demonstrating all the things which they would not have if they were poor, rather than by considering the value of the extra things which they could have with some extra money, which may be of relatively limited value as a contribution to their well-being.

Similarly the importance of industry to the economy is emphasised by the self-evident truth that we would all be worse off without washing machines, televisions and trains, instead of addressing the question of whether more dish-washers and video games are more important to well-being than more leisure or better health services.

This way of thinking operates in respect of health services also. The rational question is whether improvement of a failing service of care for the elderly or mentally ill will yield more benefit than a comparable investment in improving an already good acute medical service. The emotional question is whether acute medicine is more or less important than caring services, so that we see the choice as if we were choosing not to have penicillin or anaesthetics.

This tendency is reinforced by two powerful forces for inertia. One is that the process of solving the problems of the past has shaped attitudes, and people are very lazy about revising their attitudes in the light of changed circumstances. The second is that institutions have grown up to solve the problems of the past and are now vested interests for continuing to attach priority to those problems. Par­adoxically, the more successful we are at solving a problem the greater will be the status of the institutions which were set up to solve it and the greater our ingrained pride in the achievement. Therefore the less likely we are to recognise that the problem is no longer a priority.

Priorities and the Labour Movement

Nye Bevan may have said that priorities are the language of socialism, but the labour movement has never accepted that argument. The trade union movement operates on the basis that each person’s pay claim is independent and quite without any effect on the well-being of other trade unionists. The Labour Party operates on the basis of the party programme which contains every change the party wishes to see in every aspect of the nation’s life. Both wings of the movement are slaves to the composite motion in which everything is added together to produce a long resolution that contains everything that anybody wants.

The movement is therefore unhappy with the idea of health priorities. It can accept that we need better geriatric care, better psychiatric care, more health education, better community services. But it finds it difficult to come to terms with the fact that these are higher priorities than some developments in acute care. The problem is aggravated by the use of the Tory version of priorities as the justification for cuts. Moreover the obviously fraudulent use of this argument in some situations discredits the argument even in areas where it has validity, for example where a hospital closure really is part of a development that will improve health care.

This emotional difficulty in accepting the concept of priorities co-exists with an idea that priorities are somehow a progressive concept. This inconsistency is resolved by making scapegoats of the London teaching hospitals. There it is possibly to summon up an image of a sink of iniquity controlled by class enemies, draining resources away from the priority specialties and the poorer areas to sustain a cossetted privilege. For the sin of practising their specialty excellently, if rather expensively, London teaching hospital consultants come to be equated with the very fat man who waters the workers’ beer.

This approach ignores the fact that people are actually treated in the London teaching hospitals and they do not in fact absorb the whole of the NHS’s resources. If the cost per case in the London teaching hospitals could be brought down to the level operating in district general hospitals, between £100m and £150 million would be released for redistribution elsewhere in the NHS. (This estimate is based on extrapolation from the costs of certain hospitals, and is presented as an estimate of order of magnitude, rather than a precise estimate. It is expressed in 1984 prices.) This target is, in fact, unattainable since there are good reasons for the higher costs of these hospitals, such as the ‘London weighting’ element in the pay of those employed in the capital and other additional expenses involved in any London-based operation, together with the fact that they serve as referral centres for more difficult cases. A socialist health service still requires centres of excellence from which best practice can be disseminated. A socialist health service still needs to invest resources in new treatments, which will be expensive in their early research days but much cheaper later when they reach the stage of being widely available. Whether the centres of excellence should be so concentrated in London, and whether we should invest quite so much in excellence and experiment, are questions that can be debated, but certainly we cannot release the whole of the money that is theoretically available by turning the London teaching hospitals into district general hospitals. Even if we could, it would be insufficient to avoid the choices that have to be made elsewhere. Like Trident, or the money that could be obtained by expropriating the rich, the resources of the London teaching hospitals are spent a thousand times over in the rhetoric of the movement.

Priorities and the Medical Status System

The medical profession’s self-image is shaped by its ideology, which in turn is historically derived and embodies the priorities of the past. The role of doctors is seen as being a limited one. It is to assess and diagnose acutely ill patients, and prescribe the correct treatment, which, if all goes well, will lead to the patients recovering quickly and thanking the wonderful doctor who saved their lives. This is an important part of medicine and always will be.

But there are other important medical tasks. It is a role of doctors to allow the dying to die free of pain and with dignity. It is a role of doctors to ensure that the incurably ill are cared for sensitively and sympathetically in a way which maximises the quality of life. It is a role of doctors to rehabilitate those who are disabled by illness and to enable them to find the highest degree of function compatible with their disability. It is a role of doctors to oversee the technical public-health systems that prevent illness. It is a role of doctors to mobilise politically for a healthier structure of social and economic activity and to educate people to healthier lifestyles. All of these roles would be acknowledged by the medical profession, but only as afterthoughts.

Doctors are taught to diagnose, treat and cure. Since that is what they are taught to do, it follows that it is what they want to do when they qualify. Therefore the greatest competition is for entry to those specialties which most closely approximate to this image: medicine, surgery, obstetrics and paediatrics. The least competition is for those specialties which have a different model of care, such as geriatrics, psychiatry or community medicine.

Although the doctors who choose these unpopular specialties as their first choice of career are as able as those who choose the popular specialties, they do not have to prove the fact by success in a highly competitive career structure, and they are accompanied into the specialty by others who have failed at, or decided not to attempt, their first choice. Overall, therefore, the specialty contains a lower standard of ability. This reinforces the status of the competitive specialties. The doctors who are consultants in the prestige specialties are therefore seen as the cream of the profession. They expect, and receive, more attention when demanding resources. This adds to the unattractiveness of the ‘Cinderella’ specialties.

Medical-school curriculum time is one ‘resource’ of which the prestige specialties claim a disproportionate share. Medical students must be taught medicine, surgery and obstetrics to a sufficient standard to enable them to practice as house officers. This is the legal requirement imposed by the General Medical Council. Everything else is extra, and consists of a few weeks squeezed into a crowded curriculum.

Merit awards (a system of salary supplements paid to consultants judged to be distinguished) are also dispro­portionately distributed, being paid to 52.1 per cent of cardiothoracic surgeons, 61.3 per cent of neuro surgeons and 55.1 per cent of cardiologists, but only 24.5 per cent of geriatricians and 25.3 per cent of consultants in mental handicap. These add to the greater rewards of the prestige specialties and reinforce the self-image which created the prestige in the first place. They also find it easier to attract high-calibre junior staff.

This network of factors produces a vicious circle.

LESS PRIVATE PRACTICE means LESS REMUNERATION which means LESS COMPETITION FOR ENTRY which means that THE SPECIALTY DOES NOT CONFORM TO THE PROFESSION’S SELF-IMAGE which means LESS COMPETITION FOR ENTRY which means FEWER JUNIOR STAFF which means that fewer doctors are exposed to the specialty which means that it DOES NOT CONFORM TO THE PROFESSION’S SELF-IMAGE, which means LESS TEACHING TIME which leads to LESS COMPETITION FOR ENTRY (since less emphasis is placed on the subject in medical education and therefore it does not conform to the profession’s self-image) which means a LOWER AVERAGE STAND­ARD. This means less teaching time, which means less conformity with self image. The lower standard and the lower conformity to self image means FEWER MERIT AWARDS, which means LESS REMUNERATION which means less competition for entry which means worse working conditions, which leads to less competition for entry. The lower conformity to self-image and the lower perceived standards means lower status when resources are being dished out, which means LESS COMMAND OF RESOURCES which means FEWER JUNIOR STAFF, WORSE WORKING CONDITIONS AND LESS TEACHING TIME, which means less competition for entry.

And so on round and round the vicious circle.

The medical profession has a high degree of autonomy in respect of the distribution of many important NHS resources (such as budgets for medical equipment), and a considerable say in the distribution of those resources which it does not autonomously control.

If these resources are distributed according to the medical profession’s own status model they will be directed primarily to the acute specialties. The system has been cynically described as ‘turning hospitals into adventure playgrounds for doctors’.

Priorities and Professional Empires

Everything that has been said about the low status medical specialties applies a fortiori to the areas of medical work which have been hived off to the professions supplementary to medicine.

In the curative field doctors are undoubtedly the pre-eminent profession. In the rehabilitation field their role is shared with physiotherapists, occupational therapists, speech therapists, clinical psychologists, art music and drama therapists and other non-medical therapists. In the caring field the dominant role is probably played by nurses, whilst in prevention the role of community medicine faces a strong challenge from health-education officers.

These other professions have even less power and control over resources than the Cinderella specialties of medicine, and indeed medical supremacy over these professions is main­tained by the process in which it is largely through the doctors with whom they work that these professions are able to gain access to the resources which they need. In return for this patronage doctors claim a right of control. However the doctors who offer this patronage are themselves the lowest-status members of the profession.

The Reaction of Low Status Specialties to their own Low Status

There is a popular image of medicine. The overworked houseman idealistically enjoys long hours of hard work, willingly submitting to this process in the knowledge that it will only last for a year or two and that it is the passport to knowledge, competence and power. The earnest young registrar effortlessly saves life as he takes his postgraduate exams in his stride and inexorably rises up the career ladder, on the way discovering a few new cures through his research. The kindly old family doctor, his surgery adjacent to his large stone house, dispenses friendly advice as well as medical treatment. The brilliant consultant, powerful and individualistic, parks his Rolls Royce in a reserved parking space on his way to sort out the most difficult patients, pausing only to ring up the administrator and give him his orders for the day.

The image is white and male. It carries an aura of limitless control of resources.

The image has been dented a little by public dissatisfaction with the GP service, by the 1975 junior doctors’ dispute and by the knowledge that cuts have affected the previously undammed torrent of resources. But it is still the image of how medicine ought to be, and of how medicine in general is. Variations from the image are exceptions – scars upon the smooth face of reality, sometimes scandals to be put right.

The image is not just a public image. It is the profession’s self-image projected outwards and willingly accepted by those to whom it is projected.

Hardly anywhere is this image true. Nevertheless doctors who fail to match up to it must struggle against their failure.

The prestige-specialty consultant can only rationalise that failure by perceiving threatening forces that bleed away resources and unreasonably obstruct the medical profession’s legitimate exercise of power. So the paranoia of medicine is given a new twist and prestige-specialty consultants act up to the image by demanding resources and power.

For the Cinderella-specialty consultant, for the doctors in sub-consultant positions and for general practitioners the situation is more difficult. Acting up to the image will not work, for the medical status system licenses demigods and the licensed demigods will always be more successful than the unlicensed demigodlets.

There are therefore three possible strategies. One is to struggle for a personal advancement from the status of demigodlet to that of demigod. A second is to challenge the judgement of the status system that doctors of one particular type should be seen as demigodlets rather than demigods. A third is to deny the case for the whole status system.

The Professional Respect Strategy

The first strategy consists of gaining the confidence of the demigods so that in time they will regard this particular demigodlet as being really one of them. The demigodlet begins by stressing the way in which her particular specialty is really just like the prestige specialty. (Demigods contain a disproportionately low, and demigodlets a disproportionately high, number of women specialists (as, indeed, of black specialists). The pathologist begins to visit patients on the ward to sort out their electrolyte imbalances or investigate their funny blood films. The geriatrician stresses the great intellectual challenge of sorting out multiple pathology with the muted presentations of disease in the elderly. The public-health doctor pretends to be treating a patient, the community, and adopts a new name for the specialty (community medicine) which represents this concept but which nobody outside the specialty actually understands. They wax lyrical about the tremendous clinical challenge of their specialty. They demonstrate a considerable degree of professional dedication. They seek medico-political office and acquire a selection of roles – BMA Divisional Secretary, MEG representative on the Computer Sub­committee, Vice-Chairman of the Car Parks Planning Team-which nobody else wants and which are completely without power.

This strategy is a sell-out. It imposes the medical model, the system of practice developed for the acute specialties, upon specialties where other models are appropriate and seeks involvement in the machinery of the medical status system by accepting its hegemony. In time individuals will gain respect, a merit award and even positions of modest power within the system, but only at the expense of the objectives they ought to have fought for.

This strategy has been pursued most successfully by the geriatrician. Twenty years ago geriatrics was the ultimate dead-end of medicine. The geriatrician tended the rows of long-stay beds caring for patients who would never be discharged. Few resources were sought, even fewer obtained. No self-respecting doctor would enter the specialty, which many did not even see as a specialty, merely as a task for some drop-out to do.

Today geriatricians are accepted as only one step below their elder brothers – the physicians. Indeed the trend is towards reintegration of geriatrics into general medicine by creating consultant physicians with a special interest in geriatrics. Many geriatricians hold positions of power within the local profession. The rows of long-stay beds have been replaced by acute geriatric wards, rehabilitation wards, day hospitals and functional assessment facilities. The grind of the pointless ward round of the socially dead has been replaced by the intellectual challenge of sorting out the diagnosis in case of ‘immobility’, ‘deteriorating social function’, ‘acute cerebral failure’ or ‘recent onset incontinence’, and by case presentations, discharge conferences, home assessments and consultations with colleagues.

This is progress. For far too long it has been assumed that the ailments of the elderly are due to the ageing process and people have been lovingly cared for until they died of a treatable disease. The discovery of acute geriatrics has changed that.

Likewise the geriatricians’ interest in rehabilitation has enabled resources to be obtained for units that will improve the level of function in elderly people, sufficient to send them home to months or years of useful interesting life, when previously they would have faded quietly away in the long-stay ward. Geriatricians do not actually rehabilitate people. Physiotherapists, occupational therapists, speech therapists and social workers rehabilitate people. What geriatricians do is to refer patients, receive regular reports which they write into the case notes and finally authorise discharge. Nonetheless geriatricians, in the course of raising their own professional status and building their professional empires, have obtained resources for rehabilitation and that achievement cannot be denied.

However, in the process of giving credit to the geriatricians for their considerable achievements let us not overlook the things they haven’t achieved. The long-stay wards are as drab as they ever were. Instead of being not visited very often by low-status doctors whose job it is to look after them but who dislike the job and do it badly, they are not visited very often by high-status doctors whose job it is to do something else and who enjoy that something else so much that they resent the time spent on the pointless task of visiting the long-stay ward.

In fact a great deal can be done to improve the quality of life on long-stay wards, not by following a medical model but by treating a long-stay ward as a community of people who must be inspired and enabled to make their life enjoyable. Parties and outings can be organised, entertainers arranged to visit, residents brought into the decision making process of the ward. Geriatricians rarely do this.

In the community, too, the geriatrician has not realised the full potential. The geriatrician has not been the main campaigner for sheltered housing, for access to buildings, for special public-transport schemes for those who cannot use conventional public transport, for pre-retirement courses to assist the elderly in accommodating to the challenge of the period between retirement and the disability of old age, for over-sixties clubs, for meals on wheels, for night-sitting services, for granny-fostering schemes or granny-sitting schemes.

Some of these things, such as access to buildings, have come about because the vociferous campaigns of the young disabled have achieved changes which have benefited the much larger number of elderly disabled. Others have been initiated by social services sometimes under pressure from relatives, but hardly ever under pressure from doctors.

What the specialty of geriatrics has done is to take that part of the process of caring for the elderly which can fit into the medical model, direct their energies into that, and thereby win the confidence of the profession that they are, after all, just like other doctors. The result is a system of care for the elderly which is heavily biased towards a small section of the client group.

It may be argued in response to the above criticism that what the geriatricians have done is all that doctors could be expected to do. Surely it is for the doctor to apply medical skills to that part of the problem which is susceptible to those skills, and to leave others to do other things.

That would be true if the medical profession did not lay claim to the territory that it vacates. Let nurses run the long-stay wards and control the resources, let the remedial professions run the rehabilitation units and control the resources, and let local authorities develop the community facilities and have the resources to do so. Let us recognise that the medical services are only a part of the NHS and let large blocks of power be transferred to other groups to reflect their role. Let us recognise also that the NHS is only part of the caring industry and that resources ought to go into other parts of the system. Such pressures have, of course, arisen as a consequence of the medical profession’s abdication from so much of the health-improvement process and it may be that it is simpler to allow those processes to diminish the power of the medical profession than to change the medical profession so that it does the whole of its job. But the medical profession resists those pressures.

Either the medical profession is society’s main health adviser, in which case it must give attention to all aspects of the health-improvement process and not simply to that bit which it enjoys most, or it is the custodian of a set of acute curative skills which are one of the influences on health, but only part of the process, and not necessarily the most important part. In the former case it must stop imposing the medical model on everything it touches, and in the latter case it must share power with those groups who make other contributions to health which complement its own. It cannot have it both ways, unless, of course, society is stupid enough to let it.

The Medico-Political Strategy

The second strategy, of organising medico-politically for the adoption of a different collective judgement about a particular group of doctors has also been tried on many occasions. A group of doctors realises that they hold low status within the profession. They form an association and march on BMA House where they batter their heads against the unyielding walls baying for blood, which soon flows freely from their own wounds. Then they are invited inside. Over a glass of sherry the minority that controls the profession explains to them that minorities must bow to the needs of the profession as a whole. However their case has been heard. A special issue of BMA News Review will be written about their problems. A few cosmetic changes will take place. At the next ARM a few members of the group who have been pursuing the first strategy and have got as far as being BMA Divisional Secretary will be invited to the rostrum and hailed as heroes. By now the group will have been divided. Its more credulous leaders will have been co-opted into the establishment to learn the art of compromise. They will be expected to take the lead in attacking the remainder as ‘divisive, threatening the unity of the profession, unrealistic’.

The history of the Overseas Doctors’ Association can be seen in this light, and will be described in Chapter 11. The rise and fall of the JHDA, described in Chapter Four, can also be seen to have followed this pattern.

If these are the two most important examples, numerous others could be given. An upsurge of anger amongst associate specialists was defused by the creation of a special subcommittee of the CCHMS, although very little actually happened in consequence. The establishment of an associa­tion for deputising doctors protesting at their exploitation by the JBMA-approved deputising services in general practice, was met at first by resistance and then by absorbing the association as a BMA group and making cosmetic change to the composition of the relevant BMA committees. The creation of a BMA group was the only practical consequence of a campaign by Civil Service doctors. In all of these cases it can be seen that a statement of BMA concern coupled with some reform of BMA structure to create a place for the doctors concerned sufficed to put down discontent.

The third strategy, of challenging the whole status system, is the strategy consistently urged by the MPU on all these groups but never actually followed by any of them.

The group that has fought hardest and compromised least is probably the community-health doctors. These are a varied group of doctors working in the school medical service, child-health clinics, family-planning clinics and various other essentially preventive clinical activities.

This work used to be undertaken by doctors who were on the lower rungs of a career in public health, and who then proceeded to become Medical Officers of Health after serving their apprenticeship in these grades. This link was broken in 1974 with the creation of a proper career structure for community medicine, but in any case was quite inappropriate to the increasingly complex task of educational medicine, and the equally specialised field of family planning.

The community health doctors then began the fight for proper career structures and for posts of consultant status.

Their first opponents were community physicians. Com­munity physicians saw community-health doctors as part of their empire. Those community physicians who originated in public health remembered clinic work as something they had done at an earlier stage of their career and regarded claims for independence as impertinent. All community physicians were concerned at the decline in the number of staff directly accountable to them, and community-health doctors were the bulk of their present staff.

However community-health doctors were the majority of the electorate of the Central Committee for Community Medicine, and shivers of apprehension spread through the committee when some of its members were defeated by community-health doctors in elections. The committee then began to give attention to the problems of this group of doctors, and to campaign for the creation of consultant posts in the community-health clinics (the title Principal Clinical Medical Officer was suggested for these posts, above the existing grades of Clinical Medical Officer and Senior Clinical Medical Officer). The academic body, the Faculty of Community Medicine, did not have the same pressures of a mixed electorate and remained unhelpful.

The next obstacle to be overcome was the opposition of general practitioners. GPs collectively have always opposed the existence of the community-health clinics, believing that the work can be done as part of primary care. Thus GPs have always opposed the existence of family-planning clinics, believing that the provision of contraception should be a matter for general practice. Many women wish to receive contraceptive advice from doctors who do not also have a relationship with other members of the family. Many women regard family planning as part of the process of controlling their own lives, not as a medicalised problem, and wish to receive it from doctors who understand that, not from doctors who are illness-oriented. Not all GPs offer family-planning advice, many of those who do so provide a poor service, and there are deficiencies in the GP service, such as the reluctance to use barrier methods. The family-planning clinics provide more than simple contraception – they also provide such services as psychosexual counselling. GPs ignore these arguments.

In the same way GPs believe that they should be responsible for the surveillance undertaken by the child-health clinics, the so-called ‘paediatric surveillance’. Paediatric surveillance depends upon an organisation which ensures that all children are called for their health examinations, and general practice is not equipped for recall systems of this kind. Many GPs are quite unaware of the objectives of routine surveillance and a booklet produced by the Royal College of General Practitioners on the subject has been criticised as inadequate and misleading. Even if surveillance of the pre-school child were feasible in general practice, the school-health service would still be needed since it would be quite impossible for each school to arrange routine health examinations by the large number of GPs who will have patients at the school, and, in any case, the requirements of educational medicine are highly specialised. A substantial number of GPs do not want to have anything to do with routine health examinations, feeling that they have enough to do treating illness. Despite these arguments the General Medical Services Committee firmly believes that the child-health clinics should be closed and the work transferred to general practice, not least because they believe they could negotiate a fee for it.

GPs have therefore used their voting power in the BMA to block any moves to develop a career structure for community health doctors. The only time that a breakthrough was made was when the MPU launched a recruiting campaign amongst community-health doctors. Within a month of that announcement being made, the GMSC withdrew its opposition to the creation of training programmes for clinical-medical officers. We see here the power of a threat to the unity of the profession, provided it is skilfully deployed.

The threat from general practice began to recede a little after these events, especially when it became clear that the government was not going to agree to item-of-service fees for paediatric surveillance. However the GMSC remained essentially hostile to community health clinics.

Another threat then began to emerge – a threat from consultants. At first the main problem with consultants was that they opposed creation of consultant-equivalent posts in community health because it amounted to dilution of the consultant grade. (They had similarly opposed, unsuccessfully, the creation of a consultant grade in community medicine in 1974, which explains why the consultant grade in that specialty is called ‘Specialist in Community Medicine’ rather than ‘consultant’.) The position changed when the specialty of paediatrics began to experience career-structure problems with an excess of Senior Registrars. Plans were drawn up to create consultant community paediatricians, drawn mainly from the ranks of doctors who had completed a paediatric training, and probably under­taking some hospital work as well. Pressure for this was orchestrated by the British Paediatric Association which was able to operate free of the constraints of maintaining professional unity – a demonstration of the value of a group of doctors having its own representative body, independent of the BMA. Although this looked as if it met the need for a consultant-led service, it would actually give that service an illness-oriented approach, and would leave existing community-health doctors still doing the bulk of the work, but with no career opportunities and under the control of consultants who had been inappropriately trained and whose interest probably lay elsewhere.

The battle continues. Community health doctors have now faced conflict with all three of the main sections of the profession, and are still fighting for the continued existence of their specialty and for its full recognition.