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Author Archives: Julian Tudor Hart

The Welsh created the NHS, modelled on miners’ mutual aid schemes. They have so far strongly resisted attempts to return healthcare to market competition. Since devolution a new generation of socialists has been quietly running NHS Wales as a public service – not for private greed. And for this reason, the Welsh NHS is now under attack from a propaganda Blitzkrieg. The crescendo of political and media attacks on NHS Wales are light on evidence. So why do we hear hardly a squeak of dissent from the opposition front bench in Parliament, to defend their own Party in Welsh regional […]
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This book has sought to develop six features of medical professionalism, alternative to those of the Osier paradigm: 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. Where Osier saw original science […]
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No word has been more fashionable over the past twenty years than ‘community’; Community Care, Community Nurses, Community Physicians, Community Health Councils, even the poll-tax is beautified as the Community Charge. No ministerial speech is complete without some reference to it, and the urgency of returning tasks and responsibilities to it, previously supposed to have been undertaken by hospitals and welfare agencies. All this seems to assume that every­where real communities still exist, with the qualities and resources necessary for care. Do Communities Still Exist? Population data from national or regional statistics tell us very little about real communities. They […]
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Doctors are rarely accountable for the average quality of their work in terms of outcome. They have to answer for exceptional events, unexpected disasters lying outside the normal range of experience, but rarely for assessment of average process, and virtually never for average outcome. If disasters don’t occur, or don’t reach the ears of authority, quality of work is assumed to be satisfactory. Even if it is so obviously unsatisfactory as absolutely to demand enquiry, that enquiry will use process rather than outcome measures. For example, the expected mortality of a planned operation for repair of inguinal hernia in a […]
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Within the Osier paradigm, doctors have generally accepted accountability in two directions; to their professional colleagues collectively, and to their patients individually. In each case, accountability has been at two levels: a formal level of official complaint, disciplinary action or litigation; and an informal level of custom and expectations. Because in Osier’s time doctors had so little influence on the outcome of illness, accountability for outcome was not possible. Even the traditional Hippocratic rule ‘primum non nocere’ (above all, don’t harm) was not enforceable; desperate fear condoned desperate remedies; so doctors were encouraged to add substantial risks from treatment to […]
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Though most thoughtful and well-informed GPs now accept the need for more staff, equipment and postgraduate train­ing, they are uncertain about what new investment is needed, and even more so about how it should be made. The only answer fully consistent with autonomy in the Osier paradigm would be that GPs should invest their own money as entrepreneurs, selling their services as commodities in an open market. In Britain, though not in many other developed countries, this had lost majority professional support by the 1920s and after 1948 its few remaining adherents became isolated. So long as the State was […]
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When doctors began to measure their work, they measured what they saw and did, not what they didn’t see and there­fore couldn’t do. Cobblers don’t assess their work by count­ing barefoot children; like other entrepreneurs, doctors perceived their customers, not the population as a whole. In 1966, before immunization against rubella (German measles) was available and abortion was legal only if a mother’s life was in danger, I was consulted by a 42-year-old woman with an unplanned and unwanted sixth pregnancy. There were no reasonable grounds for abortion, though that is what I would have recommended, and what she would […]
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 The NHS revolutionized the distribution, staffing, equipment, planning and administration of hospitals by nationalizing them all, initiating a centrally planned programme of co­ordinated development. Three quarters of all hospitals in use in 1948 were built before 1914, half dated back to the 19th Century. One-third were former workhouses with a custodial rather than a caring tradition. Half the hospitals had fewer than 50 beds. In 1947 only 8% of all doctors were hospital-based specialists, limited to a few large cities; by 1960 consultants were available in every district general hospital, they comprised 20% of all doctors, and were in charge […]
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If positive answers to the defeatism of the Liberal Critique can only be found beyond the present limits of professional­ism, we must look at what those limits are. Traditionally, the main task of doctors has been to respond to the complaints of individual patients suffering from disease, or fear of disease. The profession has always contained a minority, Public Health Medical Officers, Medical Officers of Health, Community Physicians, who are supposed to conserve health in populations rather than restore it in sick individuals; but they are at the periphery, and have not been encouraged or sometimes even allowed to combine […]
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The late 1960s was a time of ideological confusion when the idea of social progress generally lost the association with science it had in the 1930s. The medical age of optimism began to seem an age of credulity. In 1971 Cochrane (Cochrane,  A.L., Effectiveness and efficiency,  London:  Nuffield Provincial Hospitals Trust, 1971.)  was the first of a series of authors presenting fundamental criticisms of the theory, practice and profession of contem­porary medicine in Britain and North America (Powles,  J.,   ‘On  the  limitations  of modern  medicine’, Science,Medicine and Man 1973; 1:1-30;  Fuchs, V.R., Who shall live?, New York: Basic Books, 1974;  Cochrane,   […]
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The National Health Service (NHS) Act was promised in the Labour landslide election of 1945, passed into law in 1946, and the service itself launched in 1948: a non-contributory comprehensive service making all forms of medical, dental and nursing care, in hospitals or in the community, available free to the whole population, paid entirely from central government funding. I qualified from St. George’s Hospital in London four years later, and will retire from full-time clinical practice in 1988; the NHS allowed me to do my own work and refer my patients to the full range of specialist services during an […]
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AUTHOR’S FOREWORD In 1977 the World Health Assembly of the United Nations agreed that: The main social target of governments and WHO in the coming decades should be the attainment by all the citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. This was further elaborated at the WHO Alma Ata conference in 1978, with a declaration endorsed by the British govern­ment, which spelled out that this ambitious target could never be achieved by medical action alone, centred on hospitals. It depended on adoption […]
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