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