A New Kind of Doctor 10 A New Social Alliance

This book has sought to develop six features of medical professionalism, alternative to those of the Osier paradigm:

1. Where Osier sought association with medical science, while   forced  to  retain  the  customs  of secrecy  and mutual  deception    of    pre-scientific   hope   because (through   the   placebo   effect)  they   were   still  more generally effective than science, we must accept the full implications of experimental science in daily practice, for both groups and individuals, practising an open style of medicine which admits to ourselves, our colleagues, and our patients what we don’t yet know and what we haven’t yet done.
2. Where Osier saw original science as a rare and superior activity developed only within laboratories, and clinical innovation as confined to a few hundred beds in teach­ing hospitals, applied uncritically by GPs as best they could in the entirely different conditions outside, we must learn to apply scientific principles imaginatively to the health care of millions of people as they actually live and work.
3. Where Osier handled disease as an entity qualitatively distinct   from  health,   we  must  learn  to deal  with measurable, continuously distributed variables in which disease    (requiring   active   remedial   intervention)   is difficult  or  even  impossible  to separate from health (requiring active conservation).
4. Where Osier’s doctors, though usually unable to intervene usefully to change the course of illness, were masters of their pseudo-industry as unquestioned as bishops and cardinals, we must accept that effective medical care, and even more the effective conservation of health, requires an enormous range of skills other than those of doctors, including skills of other medical, nursing and health professionals who have been systematically subordinated to and exploited by us and our predecessors, and that our own skills will survive only if they can be shown to be useful.
5. Where Osier could treat patients as passive consumers of care which doctors devised and nurses implemented, but patients unquestioningly endured,   we   must   accept patients as colleagues in a jointly designed and performed production, in which they will nearly always have to do most of the work.
6. Where Osier sought his peer models and patrons among aristocratic gentlemen and the gentrified robber-barons of the first megacorporations, we must look to a more dependable alliance with the ordinary people we serve.

These six features have a single common theme, which Osier implicitly accepted but never articulated, because society in the first decade of the 20th Century appeared to be permanent, and professionalism seemed likely to share that permanence if it remained uncritical. All medical acts are social acts within a changing, people-made story, all medical services are social services with a history, and a social and historical view of human biology is at the centre of effective medical science.

The whole of medicine ultimately serves practical human ends; to be consistent with science, it must serve whole populations according to their needs rather than be merely available to individual demanders or purchasers of care, whether as a state-subsidized or freely marketed commodity. This means that the practice of medicine, and the professionalism derived from it, are related to the distribution of wealth and power in society, to its history and culture, and to the priorities that result from these, and medicine is thus inescapably a political subject.

It also means that medical practice has itself an effect on society. This effect may be particularly important today, when medical care pursues its objectives in a fundamentally different way from other forms of production, to some extent at least contradicting an otherwise commercial society. Doctors will not be able to influence or understand what is happening to their profession or to medical science, nor will they be able to make their own potential contribution to a more civil, less dangerous and damaging society, unless they recognize that they have political choices; that an important part of future history is in their hands, and theirs alone, giving them a civilizing power they must not abdicate in a world now too dangerous for neutrality.

In real politics (choices about what kind of world we want to live in, not about where individual politicians try to get themselves) medical care is moving from the periphery to the centre. We have already entered an era when unless democracy becomes truly participative we may lose what we have gained, achieved not passively through evolution of some natural law of spontaneous social ascent, but always through active work and open criticism. Doctors and laity who have hitherto ignored new developments in medical practice and relied on assumptions based on the Osier paradigm, developed from the now almost exhausted alliance between well-dressed but illusory care and infant medical science, have to face a new set of choices.

Can Doctors Become a Progressive Rather Than a Conservative Social Force?

According to polls cited in the medical press, 47% of British doctors voted Conservative in the 1987 election, a mere 7% for Labour. I have been unable to find data for the medical vote for earlier elections, but figures for all higher professions including medicine showed 15% for Labour in 1945, falling to 10% in 1950 and 6% in 1951 (Burnham,  J.,  The  middle class vote, London:  Faber &  Faber, 1954.). This suggests that collapse of medical opposition to the NHS in 1948 and consolidation of general professional support for it by the 1960s  (Mechanic, D., Faich, R., ‘Doctors in revolt’. In Weinberg, I. (ed.), English society, New York: Atherton Press, 1968.) were not translated into medical votes for Labour. The real effect of the popularity of ‘socialized medicine’ was on the Conservative Party, which first dropped its opposition to the NHS, and then claimed credit for its invention, eventually agreeing a virtually bipartisan policy with the Labour Party, except for ritual disputes about prescription charges.

In traditional terms, doctors have generally been too rich and secure to be attracted to any kind of socialist belief. Ever since World War II British doctors have enjoyed higher incomes and greater job security than any other profession, including ministers and members of parliament. In Western Europe in 1982, average annual net earnings for GPs from insurance-based or NHS-type systems before tax ranged from £40,000 in Denmark to £14,000 in Italy and the Irish Republic, with the UK ranking sixth out of 10 nations at £29,000. (Reynolds, B., ‘Where to find the good life in the EEC and still be a GP’, Medeconomics 1982; 3:52-3.)This does not take into account substantial additional earnings in many of these countries from private practice (negligible in UK general practice) or NHS index-linked pensions which are envied by doctors abroad. Using an older set of figures, Klein ( Klein, R., ‘International perspectives on the NHS’, British Medical Journal 1977; iv:1492.) estimated the ratios of all doctors’ incomes to average per capita income for all occupations as follows:

• German Federal Republic 8.5:1
• France 7.0:1
• USA 6.7:1
• Sweden 4.6:1
• UK 4.5:1

Doctors are drawn overwhelmingly from privileged back­grounds. This trend has increased over the past 20 years, and is still increasing now. Even in the 1960s, 40% of British medical students came from professional families (3% of the population). Though only 29% of school leavers with three or more A-level passes are privately educated, they get 57% of medical school places (‘Report of the Royal Commission on Medical Education’, (Todd Report), London: HMSO, 1968), (Donnan, S.P.B., ‘British medical undergraduates in 1975: a student survey in 1975 compared with 1966’, Medical Education 1976; 10:341-7.)

British doctors may on average be less affluent than their European, US or White Commonwealth colleagues, but they have a narrower range of income (fewer are either millionaires or poor), better pensions, and total job security once they achieve an ultimate career post as a consultant or GP. Compared with other people in Britain who work for a living they are rich; not promising material for traditional socialist parties. This question has been interestingly discussed recently by Steve Watkins, with a particularly useful analysis of medical professional organizations in relation to the political Left, though not a lot about GPs (Watkins, S., Medicine and Labour: the politics of a profession, London: Lawrence & Wishart, 1987.)

Proletarianization of Doctors?

Nevertheless, in the  USA, where medical millionaires are said to be commonplace, a serious case has been made for what McKinlay and  Arches call the proletarianization of physicians, in a paper which deserves careful reading (McKinlay, J.B., Arches, J., ‘Towards the proletarianization of physicians’, International Journal of Health Services 1985; 15:161-93.),together with important modifying comment by Chernomas (Chernomas, R., ‘An economic basis for the proletarianization of physicians’, International Journal of Health Services 1986; 16:669-74.). They present a rigorously argued case that in the USA, citadel of medical autonomy, there is a trend, uneven and incomplete but growing rapidly, for previously self-employed independent medical entrepreneurs to be first drawn, then driven into large groups under commercial management, of which the archetype is the Health Maintenance Organisa­tion (HMO). These are directed at the most profitable sections of the public rather than the poor, bureaucratized enterprises controlled by investors rather than  doctors, aimed at maximizing commodity-production of care and corporate profit, rather than either improved health for patients or greater job-satisfaction or personal income for doctors. The means of medical production are becoming too costly and too complex for doctors to own and control on their own, a process much accelerated by medical competition, which inflates the technical and minimizes the communicative components of care. Like other skilled technicians in modern society, doctors are therefore forced to become workers dependent on the sale of their labour-power to employers rich enough to own and control the means of producing a commodity which becomes more profitable as it becomes more (often unnecessarily) technically sophisticated.

In Marxist terms, objective social class position depends not on income or prestige, but on the social relations of production. According to this analysis, the open or latent conflict of interest lies not between rich and poor, but between those who live by owning the machinery of production, and those who live by working it for the owners. On this view, doctors who live by offering their skills for hire by others who own the machinery without which those skills cannot be expressed, rather than by doing their own work with their own tools, are workers employed for some­one else’s profit, however fiercely they may cling to their traditional status as independent professionals. In this sense, the proletarianization of US doctors is now proceeding with some speed, and could become an important factor in their future socialization and political stance, though to most people this requires imagination bordering on fantasy.

This applies much less to British doctors, at least to GPs. The assimilation of the medical profession to the needs of the State occurred earlier and more completely in Britain than in any other fully developed country, in particular contrast with the USA, where it was delayed by exceptional­ly powerful professional resistance. Assimilation to the needs of the State protected the British medical profession from the market, and thus paradoxically defended medical autonomy both from internal competition and from external commercial pressures. In the USA, successful professional resistance to assimilation to the needs of the State left medical entrepreneurs more vulnerable to commercialization on a larger scale, ideologically as well as economically, and the market was also potentially more profitable and easily exploited; Americans not only had more money, but were also culturally accustomed to part with it for medical care, a habit British patients have now almost lost. It is difficult to be indignant about the commercialism of medical mega-corporations if you have already accepted that physicians are essentially businessmen. The British medical ideology has preserved stronger elements of social duty, which may now to an important extent resist commercial pressures. More importantly, perhaps, it has left British GPs in charge of their own work. For both good and ill, they have been able to suit themselves, and as the New Conservative State makes its first tentative moves to return GPs to the market place, they will resist.

Assimilation of doctors to the needs of capitalist production has in all countries begun later than for other trades and professions. This has generally been attributed to uniquely fierce resistance by the medical profession; but all occupational groups, starting with the peasant forced from his strip of land to make way for the squire’s sheep, have always resisted loss of control of their means of production as long as they could, so this alone is not an adequate explanation. A more important factor has been the illusory nature of most medical care until about 1935, and much of it since. While so much medical activity depended on personal transactions between doctors and patients both of whose main functions were to maintain hope and maximize the placebo effect, doctors depended very little on their machinery, all of which could be carried in a little black bag and used in their front parlours, but very much on their personalities, which they alone could control. Now that medical care depends on costly buildings, machinery and supporting staffs which have to be shared with many other health workers, medical personality has become just one of many  instruments available to investors in search of new fields for profit, and except in personal psychiatry, no longer    provides    sufficient   machinery for  effective  or convincing production of medical care.

Paul Starr (Starr, P., The social transformation of medicine, New York: Basic Books, 1982.) points out that US doctors have, by their obstinate hostility to employment of any kind by the State and their insistence on independent entrepreneurial status, rendered themselves uniquely vulnerable to the process of proletarianization, though he does not use this confusing but logically precise term. Unassimilated to State service, they are wide open to take-over by megacorporations. The aim of capitalist production is to maximize profit through sale of commodities in the best markets; if medical care is the commodity, improvements in health are only a byproduct of such sales, will not minimize overall costs (because any commodity justifies itself by its sale, whether or not it is effective) and will aim at those in greatest need only to the extent that the State underwrites the cost. Now that medical care is potentially effective and real, rather than a relatively cheap but ineffective gesture of compassion, the State is only too willing to abdicate responsibility and hand over to the market. Under an administration eager to demolish even such partial elements of State service as the American Medical Association has allowed to exist, doctors are being driven into a situation in which they will cease to control the purpose or quality of their work, which ultimately threatens the independence both of the profession and of medical science (Relman, A.S., ‘The new medical-industrial complex’, New England Journal of Medicine 1980; 303:963-70.), (Ginzberg, E., ‘The destabilisation of health care’, New England Journal of Medicine 1986; 315:757-61.)

The process has been described by Freeman  (Freeman,   S.A.,   ‘Megacorporate   health   care:   a  choice   for   the future’, New England Journal of Medicine 1985; 312:579-82) in the New England Journal of Medicine in 1985. He sees the weakening grip of gentlemanly medical professionalism naively and uncritically, but has been forced to question assumptions hitherto unchallenged within the medical Establishment:

With health care costs for the United States approaching 11% of the gross national product, the current reformation of health care policy is being molded by a quest to relate the costs of production to the prices of services and then to reduce the production costs. The apparent shift in health care policy is one that moves us from a scientific to an industrial orientation. In the past the financing for health care at all levels was designed to support the development and application of scientific principles and knowledge. Physicians viewed their patients from the perspective of scientists and humanists, whose task it was to diagnose in detail the problems of patients and to treat them with the best that medical skill and technology have to offer. The issue of quality eclipsed that of quantity. After all, the physicians who designed the health care system were trained as scientists, not economists or business people.

However, business people are becoming the most important influence in the redesign of the health care system. . . This new party on the scene is pressing for a thorough redesign of the delivery system. Its orientation is to become actively involved in the business of health care—that is, to relate the price of the product to the cost of production, as in the industrial model.

The US industrial model of general practice is the Health Maintenance Organisation, the HMO, and this is the model which attracts both the New Conservative politicians, and a few of the more ambitious medical politicians who advised the government as the Green and White Papers on primary care were prepared. HMOs have been well described by Linda Marks in her excellent King’s Fund discussion paper on primary care (Marks, L., Primary health care on the agenda? A discussion docu­ment. Primary Health Care Group, King’s Fund Centre for Health Services Development, London, 1987.):

In Health Maintenance Organisations, a rapidly expanding sector of US health care, professionals act within a clear management frame­work and management control is exercised over a whole range of care. Procedures are codified; standards are set in relation to criteria for hospital admission, management of inpatients (length of stay, drug regimens, investigations) and the use of ambulance services; and protocols are devised for the management of common disorders such as hypertension. Styles of communication (with patients and other colleagues) may be monitored. A relatively high proportion of patients will be seen by ‘allied personnel’.

HMOs  in  the  USA have  developed  rapidly among the affluent middle class, and something very like them could be encouraged in the UK as the top level of a two-tiered service in   the   highly   competitive,   consumerist   society   actively pursued   by   the   New   Conservatives,   and   more   or   less acquiesced  in  by  the  dominant  elements in  the Labour, Liberal and Social-Democratic Parties. Though cheaper than the previous US model, demand-led fee-for-service care by independent medical entrepreneurs paid for through private health insurance, HMOs are still far too costly for low earners or the indigent. The norms used for clinical protocols tend to be legalistic rather than realistic, reflecting the aggressive tradition in US medicine which has always overstated the value of medical interventions and thereby raised the legal penalties of failure; a good example is the almost universal US practice of medication for high blood pressure from a threshold   of  diastolic   90   mmHg,   compared  with about 100 mmHg in Britain, although controlled trials probably justify this only from about 110 mmHg, certainly not more than 100 mmHg ( Hart,   J.T.,   Hypertension:   community   control   of  high   blood pressure, 2nd ed., London: Churchill Livingstone, 1987.).  From the doctors’ point of view, how­ever, the main consequence of HMOs is that they lost control over their work. The doctors lose the possibility of becoming creative craftsmen, and their patients lose the possibility of becoming  colleagues.   Patients  and   doctors are  at  last compelled to leave the informal, pre-industrial world where imagination, though rare enough, was still possible, to enter a new world of medical conveyor belts organized by a board of management geared not to improved health, but the generation of profit. This world will certainly be scientistic, but as a substrate for the development of medical science as understood in this book, it is likely to be a far more hostile environment than its alternative, neighbourhood care with local control, with needs measured by health burdens rather than available incomes, and outputs measured in health out­comes rather than medical procedures.

Starving the NHS to Feed the Private Sector

Because British doctors accepted employment by the State, the immediate threat most of them face is not that they become cogs in a capitalist machine, but that they have somehow to meet rising public expectations with resources which are already declining in relation to traditional needs (because of an ageing population), apart from the new requirements of advancing medical science. They are employed in a deteriorating public service grudgingly funded by a government committed to reducing public spending by every available means.

Those who cannot tolerate this must either act to change it, which means looking for entirely new social allies, or move to the private sector. Private practice will increasingly provide employment for some specialists, but their privileges will not include exercise of the highest medical skills, since these must by definition be available equally to all who need them. If they are not, their skills will ultimately be distorted and damaged, whether doctors realize this or not, just as any tool is changed by the material on which it is used. They will follow the same path as their US colleagues; the private sector will, however tricked out with gadgetry, not be independent practice but just another branch of a multinational megacorporate business.

If present staffing levels of the NHS are not raised, roughly half the students now entering UK medical schools will never have a career post in the public service (Editorial,   ‘Medical   student   numbers   and   medical   manpower’, Lancet 1987; i:723-4.) . Britain has only 13.6 practising doctors per 10,000 population, compared with 19.2 in the German Federal Republic, 17.1 in Sweden, 16.7 in the USA, 16.4 in Canada, and 15.2 in Australia; but the UK government aims to reduce the number of UK doctors in the NHS to 11.9 per 10,000 (DHSS consultative document. ‘Hospital medical staffing: achieving a balance’, London: HMSO, 1986.), (Nussey, S.S., Pilkington, T.R.E., Saunders, K.B., ‘Where will this month’s medical school intake go?’, Lancet 1986; ii:977.), a staff cut of 16% over the next 10 years. Over this period our medical schools will be educating 70% more doctors. As a Lancet editorial concluded,

How can Government justify the training of 70% more medical students than can find career posts in the NHS while accepting that the projected NHS staffing establishment is about half that to be expected in a developed country? It is difficult to escape one of two conclusions: either the Government has no knowledge of or control over what is happening; or half the students are intended for a vastly expanded private sector.

True medical unemployment for British graduates is as yet nothing like the problem in Spain, Italy and Portugal, for example, where entry to medical schools has been unrelated to planned requirements for medical manpower, because the aim has for the past 150 years been to provide careers for entrepreneur doctors rather than to staff a public service. However, two generations of British doctors have come to assume that the Welfare State will guarantee employment for any doctor willing to do useful work; this guarantee has now disappeared. Demotion of the NHS to universally under­funded mediocrity, with our reputation as an innovating world medical power reduced to fleecing rich Arabs in Harley Street, could quickly destroy the loyalty of most doctors to the Conservative Party, and force them to look in new directions for their social allies. For example, consultants in Reading paid for whole-page advertisements in local news­papers to tell the public about the breakdown of NHS hospital services. Actions of this kind, unthinkable even five years ago, are becoming commonplace.

Doctors and the Future of Science

The same argument applies to a wide range of other skilled occupations  which though nominally   professional   and independent, now consist almost entirely of salaried workers without real control of the nature, purpose, or outcome of their work. To be a physicist, chemist, geologist, metallurgist, agronomist, biologist or graduate engineer today means to be employed either in private industry, or at some level of education or government service. The best incomes are always in private industry, work elsewhere is done either for job-satisfaction or because nothing else is available. Until the advent of applied nuclear physics, science was generally an academic activity with usually remote applications to pro­duction and the needs of the State, and its independence from the market and military and industrial secrecy was generally respected. Since the war, academic independence in the sciences has retreated to a point where half of all British scientific research is on weapons development, compared with 33% in France and 10% in the German Federal Republic. State   funding  of universities  has  become   conditional  on readiness to put scientific skills at the service of the State and of private industry. University departments have been forced increasingly to depend on direct commercial investment in their research in return for new knowledge which becomes the property of the investor, rather than the common know­ledge of mankind. If present Government policies continue, by  1990 there will have been a 30% cut in Government support   for  universities  in  real terms  since  1980;  these figures come from a presidential address to the BMA in 1986 by Sir Christopher Booth, director of the M.R.C. Clinical Research Centre, revealingly entitled ‘Better a commitment to health/find research than to missiles’ (Booth, C., ‘Better a commitment to health and research than to missiles’, British Medical Journal 1986; 293:23-6.)

In the USA, megacorporate industry has not only penetrated the universities, but seduced leading scientists from pursuit of knowledge for the world to pursuit of another million dollars for themselves. Molecular biologists now found their own companies and become millionaires, their discoveries just one more commodity in the market (Kenney,   M.,   Biotechnology:   the   university-industrial  complex, New Haven: Yale University Press, 1986.)

Scientists are becoming, as Brecht’s Galileo predicted, ‘a race of intelligent dwarfs who can be hired for anything’ (Brecht, B., The life of Galileo, London: Eyre Methuen, 1963.)

Forward to the Jungle?

British doctors, in hospital and in general practice, are now in a bewildered and uneasy state. The only thing they can be sure about is that nothing is for sure. Future society is beginning to look very unpleasant, even to people who make a great deal of money out of things as they are, and might make even more in a more entrepreneurial service. Granted total professional dominance, despite their initial hostility to the NHS, doctors found it and its parent society pleasant places to live and work. Now that dominance and apparent autonomy are coming to an end, they are at last beginning to be made accountable, not to the patients they serve, but to a State chiefly concerned to evade responsibilities formerly taken for granted, or to corporations whose shareholders must be satisfied if they are not to be eaten by more ruthless competitors. Accountability is not in terms of lives saved or improved, but of cash saved or profits made.

More doctors today than at any time in the past are becoming open to political alternatives, though as yet they have hardly been offered one. They are looking for a way out, and are beginning to realize that it can’t be backwards; private general practice on the old model is no longer feasible for more than at most 5% of the population. The only credible choices are between accountability for cash to an increasingly centralized and authoritarian State presently governing in the interests of megacorporate multinational companies, together with some more elegant care for a privileged minority on the HMO model, or accountability for performance to local populations within the devolved, peripheralized State authority advocated in this book; but whereas accountability to centralized authority is already well advanced for the hospital services, is beginning for general practice, and will come by default if we do nothing, accountability to local populations and a peripheralized State machine can be won only through active mass education and united action by all grades of health workers, and these have scarcely begun.

Is the Welfare State Reversible?

In 1986 Professor Therborn of Nijmegen  (Therborn,  G.,  Roebroek, J.,  ‘The irreversible Welfare State:  its recent maturation, its encounter with the economic crisis, and its future prospects’, International Journal of Health Services 1986; 16:319-38.) marshalled evidence that so long as democracy prevailed, the welfare state was an irreversible institution in all advanced capitalist countries. Even the USA and Japan devoted over half their public expenditures to welfare purposes by 1981. Since he wrote, however, his own country, the Netherlands, has entered a crisis of welfarism centred particularly on the health service. Dutch health services have developed in ways which are indefensibly wasteful and extravagant; referrals by GPs to specialists are so high (more than twice as high as in the UK), initiated so casually and on what UK GPs would regard as such trivial indications,²³ that half the population is now being referred for some kind of specialist care each year. Even more perhaps than in the UK, if and when doctors become accountable for the effectiveness and efficiency of their work, they will find wide areas that are incompatible with social conscience. Inevitably, full advantage will be taken of this to attack the principle of a free and universal public service. Major faults in health services, education, and social services of all kinds, denied by trade unions and professional organizations too weighed down by defensive armour to be capable of imaginative counter-attack, leave huge gaps in the ideological defences of the Welfare State.

Therborn seems to leave out of account the possibility that the Welfare State may not be wound up, but privatized. Though the USA spends about four times as much per head on medical care as the UK, it is spent through a fragmented, fully entrepreneurial, fee-paid service which to British eyes appears to be a non-system. Unless we can develop a new social alliance to extend medical professionalism in new ways, if the NHS can be run profitably and more cheaply by entrepreneurs, only increasingly bankrupt and un­convincing traditions will delay passive privatization by apparently inevitable processes of decay in public and growth in private services. More than sentimental outrage will be necessary to preserve the Welfare State in the health sector. Though journalists can use them to make better copy, health services are not more important to a civilized society than either education or full employment. If these other features of society can be sacrificed to greed, so can our health services, though the softening-up process may be more difficult. Nations which can seriously contemplate privatiza­tion of prisons will consider anything, if it seems to make sense in cash terms.

Neither the Welfare State as a whole, nor the NHS in particular, can be defended just as they stand. The stamp of elitist authority imposed on them by social history as a precondition for their birth is now more than ever a liability, which must be overcome if the medical profession is to secure more dependable sponsorship from a broader social base. Above all, we have to overcome the profound divisions between health workers which have inevitably developed in an industry in which all but the doctors have always been expected to survive on subsistence wages, and in which even job security is now a thing of the past.

The Doctor-bashing Tradition

Each time the medical profession opposed legislative reforms of health services which made them accessible to more people in need, it forfeited more of the political respect and confidence of the public. People are not sorry for the poor doctors, any more than they are sorry for the poor farmers; in practical politics, there are no poor doctors or poor farmers, and no protests by the BMA or the National Farmers’ Union will change that popular impression.

The NHS, above all in its hospitals but on a smaller scale in each general practice team, is an upstairs-downstairs world of grotesquely unequal wealth and power, riven with traditions of snobbery and servility, in which health workers at all levels fight one another for whatever shreds of status they can get after the top doctors have helped themselves (Hull, F.M., Westerman, R.F., ‘Referral to medical outpatients department at teaching hospitals in Birmingham and Amsterdam’, British Medical Journal 1986; 293:311-14.). Doctors have, with few exceptions, stood aside from the struggles of other health workers for subsistence wages and elementary job security. Coal miners, not doctors, took effective action in 1982 to support the nurses in their battles for a living wage.

It is therefore difficult for other health workers to see doctors as even potential allies, and easy for anyone without any more positive policy to sound militant by raising a flag against medical oppression. Progressive doctors are mostly too ashamed of this record of collective arrogance and indifference to argue, and try to distance themselves from their colleagues in the hope that they may be accepted as honourable exceptions.

Of course, many doctors are rich enough to be little capitalists and landlords, and many GPs are still very bad employers, taking full advantage of the job-satisfaction which still ties some receptionists to work for around £1 an hour without a written contract, and more or less un­limited overtime without pay. However, to dismiss the whole profession on these grounds as potential allies would be as ridiculous as if porters or ward cleaners were to dismiss nurses on the grounds that they also tend often to be arrogant or condescending in their attitudes to less glamorous and even more badly paid and insecure occupations in the health service; no doubt these are attitudes some nurses pick up from doctors, because doctors dominate the culture of hospitals and the health service, so that one way or another medical attitudes are mirrored from top to bottom of all their many divided and divisive hierarchies.

In the great demonstrations of the London unions around the time of the dock strike of 1886 and the socialist revival, the top hats and white kid gloves of the printing compositors were in the front ranks; the ‘gentlemen comps’. They were probably better off than most London GPs in those days; but unlike doctors trapped in the social assumptions of the Osier paradigm, they identified their own interests with those of other working men, and the need for unity was understood both by these elegant aristocrats of labour, and by dockers trying to escape from an animal existence through a guaranteed sixpence an hour. No doubt much might have been said (and was said, privately) about the smug respect­ability of the gentlemen comps, but it would not have been helpful to a cause more serious than these sectional differ­ences. Doctors certainly deserve criticism, but they also deserve some credit for producing more evidence about their own failings than any other occupational group I can think of. The unity of health workers is difficult, but it can and must be achieved because without it all of us will lose the NHS as a comprehensive service available to all according to need, although it has generally been a rotten employer and its attitude to staff relations has been feudal. Where we are going to is more important than where we have come from.

Enlightened protagonists of primary care get tired of opposing the obstinate vanity of medical professions in nearly all countries, which insist both on occupying the middle of the road to health, and on moving along it at a pace determined not by public needs and scientific advance, but by the personal preferences of their weakest colleagues, and all of this at prohibitive prices. Understandably, plans for primary care, from the World Health Organization to the Cumberlege Report, tend to bypass the doctors as an irrelevance to health. Though doctors are only a subset of all health workers, they are a necessary subset, just as health workers are not the only people who determine the state of the public health, but are nevertheless vital to its maintenance. No movement for better health is really likely to succeed without them, nor will the medical profession itself usefully survive if it does not learn to accept a less arrogant role.

From Where We Are, With the People We Have

If the medical profession wishes to survive as a large body of workers privileged to apply medical science to all who need it, it must learn to accept new social allies; and if those new allies are to have any hope of attaining power in government, they must learn to accept the doctors, in both cases not as they are, but as they can become. Despite the immense cultural difficulties in doing so, the British working class has got to redefine itself to include people who have lived, thought, and felt differently .from industrial workers, who are for the most part ignorant of social relationships within heavy industry and manufacturing, but who are now coming into collision with a section of the ruling class which has deserted a large part of its traditional social base, as well as its more thoughtful peers. People have to be allowed and encouraged to change.

Ideal people, who think and behave in all respects as we hope people will one day behave in some future better society, at present scarcely exist. If they are to be found anywhere, they are in coal-mining communities like the one I have lived and worked in for the last 26 years. Even in such communities, these people of the future are rare; serious plans must be based on the real people we have, produced by the society we have. It’s a damaging society, that’s why we want its structure to change; so why be surprised that it produces damaged people like ourselves, capable of heroism but also of weakness and self-seeking?

We have to make a start from where we are with the people we have. The NHS contains elements of a future more equitable, stable, happier society on which we can build. In the minds of the people it remains a successful demonstration of the superiority of service for need over commodity production for profit. Imaginatively extended, at primary care level it could be an important new vehicle for development of the social machinery of participative democracy, and of the new attitudes to measured evidence needed for a society in which every cook not only really does learn to rule the State, but also learns to make up her mind about road safety, the hazards of nuclear power, or what to do and what not to do about her high blood pressure or her period pains, on the basis of evidence. If we want to survive, we must enter a new age of Popular Science, not awestruck by incomprehensible technology, but with the immediate scepticism and ultimate faith of real science.

The Social Function of Medical Science

The Osier paradigm secured a credible and profitable associa­tion with science at a time when effective medical science scarcely existed. Both Osier himself and his successors who led the profession were aware of this gap between the hopes of patients and the reality which doctors could deliver, and strove always to reduce it. At the leading edge of practice particularly, this has been the most potent force in medical professionalism. That is to say, in any open conflict between the needs of medical science and other less worthy pro­fessional ambitions, science has had to come first, because public faith in the profession has depended on the assumption that no other outcome is possible; which is why such conflicts have generally been concealed not only from the public but from professional consciousness.

Medical science is now advancing at exponential speed, a fact which will be rammed home by the arrival during the next few years of practical techniques resulting from funda­mental discoveries in molecular biology. These will for the most part not be effectively or economically applicable to symptomatic   illness   within   episodic consultations; to be used efficiently, they will require personal continuity, team care within the community, close in every way to how and where people live and work, with patients fully able to share in decisions about their lives, which even more than now will depend on intelligent assessment of conflicting probabilities rather than dogmatic positive assertions. There is no way that these new functions can be accommodated within the old Osier paradigm; either we shall develop a new kind of primary doctor able to incorporate the best of the old within a new, wider, more imaginative but also more planned, measured, and quantified mode of care, or GPs will lose social efficiency by splitting into two groups, one responding to  demands within the old paradigm but in large profit-oriented organizations over which they will have no control, the other seeking for needs without doctors, in organizations for primary care which would have to re-invent the wheel, and turn other health workers into the new kind of doctor we really need.

Medical science has potentially   acquired   a new and important social function at a new social level. Traditionally, of all highly educated men and women, family doctors have been closest to real communities of ordinary people, repre­senting scholarship and learning to a scientifically more or less   uneducated   public. Much of this may have   been sentimental hokum, but not all of it. The science and scholar­ship this represented originally tended to contain both negative and positive elements. Negatively, the doctor merged scientific with social authority in a generally authoritarian, intimidating, and dogmatic approach, dressed in a waistcoat and smelling of carbolic. Far from reflecting the power of Medical Science, this authority was designed to conceal its weakness, to bridge the gap between hopes and realities and to reinforce the placebo effect. The positive elements, on the other hand, were the connection with innovative science (the doctor who kept up with professional literature, and occasionally used a scientific imagination to apply it to local circumstances),   naturalist   curiosity,   and occasional frank admissions of ignorance, which meant a lot when they came from an educated man because they implied the constructive doubt central to scientific thought. When Sir James Mackenzie, the greatest general practitioner Britain ever produced, took up his unhappy appointment as a consultant at the London Hospital Medical College, his contemporaries heard a new and characteristic phrase: ‘I do not know. . . I wonder, I do not know. . .’

This combination of continuous critical revision, objective measurement, evaluation of evidence and constructive doubt, linked with rocklike faith in the urgency and reality of social progress, defines a truly scientific approach to the world. If this approach could be brought to community level, if it were in everyday use by primary care teams and the populations they serve, we might gain some more solid ground on which to halt the retreat and begin again to build a better society of participative democracy.

 Mass Experience of Quantified Doubt

We already have the necessary beginnings of this. Ever since thalidomide, all of us, doctors and patients alike, have known that all medication which can do good can also in some circumstances, not always predictable, do harm. For example, more than 30 years after it was clearly proved, more doctors and more patients are beginning to understand that blood pressure is a continuously distributed, graded risk, so that any division between normal and abnormal must represent a practically rather than biologically determined decision, namely the point beyond which medical intervention is more likely to help than to harm the patient, based on the best evidence we have from controlled trials. Gradually it is becoming understood that many other important reversible indicators of future ill health can, like high blood pressure, no longer be effectively handled with the crude yes-no system of disease labelling we have learned in the Osier paradigm; airways obstruction, obesity, alcohol and nicotine damage, non-insulin-dependent diabetes, and a steadily growing list of other kinds of chronic damage are becoming wholly or partly amenable to quantified measurement with appropriately quantified treatment, balancing probable gains against possible risks.

This kind of medical care will demand doctors who read original work in scientific journals, with sufficient inde­pendent judgement and confidence to apply them in the always unique conditions of their own locality, and to think beyond the generally primitive, episodic level of medical thought transmitted in teaching hospitals. It will require nurses who not only insist on having a protocol to work to, but also recognize that protocols should be based on evidence, and that as new evidence becomes available, protocols must change; nurses must therefore also read and ultimately contribute to original scientific literature, and think and act for themselves; and therefore the professional distinctions between doctors and nurses must diminish and their training should overlap. And it will require patients who can begin to cope with the limited but threatening uncertainties of real medical care and the science of organized doubt, rather than the bland reassurance of medical pretence and its scientistic technical certainties.

There has already been more change in this direction than most people realize. In the early 1970s the Medical Research Council needed to recruit 18,000 patients to a trial of the effectiveness of drugs in preventing stroke, heart attacks and other complications of moderately raised blood pressure. The only way to get so many subjects was through GPs. Recruiting 176 practices to the trial, 600,000 people were screened and 18,000 followed in the trial, demonstrating for the first time anywhere in the world that data of high quality could be collected on a large scale, whether from searching records, from interviews, from blood samples, from electrocardiographic tracings, or other clinical or laboratory procedures, from ordinary group practices with a research nurse attached. This General Practice Research Framework has now expanded to 300 group practices covering about 3 million people, and is now undertaking a variety of multicentre research studies   which   would   be impossible with smaller populations, or without the access and continuity made possible by association with general practice. Obviously work on this scale must have an effect on the attitudes to consultation and consequent tasks of both health workers and the populations they serve.

Medicine has always been unique among sciences in that it has had to act without adequate data (another way in which it resembles politics); or at least appear to act, which in this context comes to the same thing, because doctors have had to believe in what they were doing. Medicine has never been able to observe nature undisturbed, or to contrive simple experiments with the freedom available to physicists, chemists, or non-human biologists, because it was dealing with distressed human material. In the past all this was a serious weakness, and made medicine the least scientific, least quantified of sciences, most heavily contaminated with a humbug particularly hard to eradicate, because the placebo effect, supported by a little token technology, was generally more useful and effective than serious attempts at scientific clinical medicine. The placebo effect imparts and sustains hope; hope, and even more, hopelessness, have physiological consequences; there is nothing inherently unscientific about the placebo effect, the fault lies in our attitude to it. Most of all, this was the case in general practice, the area of clinical medicine most remote from laboratory medical science and most exposed to patient pressure for something (anything) to be done. In general practice it was even more difficult than in hospitals to observe without acting, or to recognize good outcomes as results of the natural history of illness rather than medical intervention.

Though the culture of general practice remains less scientistic than the culture of specialist practice in hospitals, the real situation is now potentially reversed. Scientific work in hospitals is limited in a fundamental way by the self-selection of sick people whose health breakdown seems serious enough to justify the disruption of their lives involved in hospital referral or admission, and their separation from a still unknown total population. The position of a hospital-based doctor as a medical scientist resembles that of a botanist offered a dead branch fallen from a tree, and asked to determine its cause of death without any opportunity to examine the surviving stump; except that the botanist would at least be aware of this limitation, whereas the division of labour and diagnostic resources between doctors working in hospitals and in the community makes it difficult for specialists surrounded by scientistic machinery to perceive opportunities for scientific work outside, with less machinery, but with access to whole populations. The number of GPs who read and contribute to serious medical scientific literature has increased rapidly over the past 30 years, particularly during the last decade. Innovation in truly scientific, population-based practice is now beginning to occur on a large scale, though in a minority of practices and still limited by the structure and traditions of practice, and by dwindling DHSS leadership and material support since 1979. The key, of course, is organized contact with the whole population at risk; without this, GPs content to deal only with presented demand are no better than hospital specialists, and much worse   in   that   they  are   less   well organized, staffed and equipped, and more isolated from peer criticism.

The basic scientific development of various parts of medicine will continue to occur mainly in hospitals and laboratories, perhaps even more so in this new age of molecular biology. The validation and therefore the develop­ment of the practice of medicine as a whole, however, will be established for the first time in primary care. GPs and all the members of primary care teams will become, as many already are, peripheral scientists. They have not only their registered populations, the unique and essential human material for this, but also all the previously inconceivable data and information-handling power of microcomputers, photocopiers and telefax, which will give the smallest peripheral unit intellectual resources which thirty years ago would have required a national university library and an army of office workers.

Just as every GP was, in the Osier paradigm, an outpost of established social authority, every health centre could now become an outpost of popular science. But our opportunities are greater even than that; each such outpost of science is in intimate daily contact with all of the people. With such a basic social unit we have an already functioning growing point for popularized science and a new kind of participative democracy, in a mature, literate and industrialized society.

Primary Care Centres as Growing Points for Participative Democracy

Practices which accept responsibility for the health care of their registered populations, as well as for responding to demands for diagnosis and treatment of disease and other problems already recognizable by patients, should review their work and report their findings back to their populations. How this is done seems to me to be not very important. It could be a comprehensive annual report (hopefully not too overloaded with statistics) or it could just be evidence from a random sample of records about one particular problem such as unwanted pregnancies, uptake of cervical smears or prevention of maturity-onset diabetes by control of obesity; the point is that the information should be based on an audit of real, randomly-sampled material, with discussion of the problems of omission rather than meaningless boasts about how many patients have been seen, how many smears have been taken and so on, without relation to the numbers at risk. Unless we know what ought to have been done, we cannot evaluate what has been done. Writing of medical records in 1971, the material evidence on which all measures of the quality of medical care have to be based, Lawrence Weed (Weed, L.L., ‘Quality control and the medical record’, Archives of Internal Medicine 1971; 127:101.) wrote:

We should continually remind ourselves that not to think quantitatively about the needs of all of the people has qualitative implications for most of the people.

Public discussion of the problems revealed by such a report would help people to gain confidence in themselves, not only patients but the primary care team. In recognizing the reality of the problems facing both the team and the population it serves, and the initially huge gaps in performance on both sides which must be remedied, we can at last stop pretending we are all perfect and get down to effective work. Of course work of this kind would present difficulties, but they would be new difficulties of growth, openness and inexperience, rather than the old difficulties of defensive pomposity, secrecy, jealously guarded job demarcations and stagnation.

A future government that is serious about not just maintaining the NHS but imaginatively improving and extending it as one part of a more general commitment to a fundamentally different and more wholesome society, would give resources and legislative recognition to such developments. The exact forms of this recognition are not important now. What is important is that a number of working models should be available from which to choose, adapted to the specific problems and opportunities of a wide variety of neighbourhoods.

The forward march of Medicine is not halted, nor, for long, is the forward march of Labour; their paths must and will converge. De-industrialized Britain needs growth industries. In their widest sense, health care and education are potentially our biggest employers, and so they should be, in a truly civilized state. We need a larger, more imaginative, more generous society than the one we have now to make room for them, but it will also be a more sceptical society, forcing us to build with less haste, but more solidity.