Greed is a powerful but dangerous fuel for social machinery. Popular experience of the NHS soon taught us that a care system with an internal economy of gift relationships could cost less and operate with greater social justice and efficiency than care systems based on selling medical care as a commodity. By the 1960s a socialised NHS had become an apparently irreversible part of popular British culture, a consensus that had to be shared even by Conservative politicians if they wanted to get elected.
When Bevan laid the foundations of the NHS, he had more respect for doctors than they had for him. Once liberated from pursuit of fees, he trusted them to temper clinical optimism with scientific scepticism, to become less credulous than the general public about the effectiveness of medical and surgical interventions, and more cautious about the human costs of care, both in terms of professional workload, and risks of harmful side-effects and clinical accidents. This attitude seems to have prepared him for what can now be seen as a historic compromise with medical autonomy. Despite overall elected political control from the Ministry of Health, aimed mainly at geographical redistribution of resources, the pace and direction of NHS development was left almost entirely in the hands of senior consultant physicians and surgeons. The most important quality apparently sought in members appointed (not elected) to NHS Regional Authorities and Hospital Boards seemed to be ability to get on with senior doctors.
Doctors, nurses, and the many paramedical professions around them, were traditionally “non-political” pillars of established authority. Their conservatism made it easy to assimilate the socialised NHS into British consensus politics, although the American Medical Association continued to denounce it as communism, a not unreasonable description of a system in which wealth was distributed according to need, and nobody knew the price of anything.
Karl Marx’s principle of the “highest form of socialism”, “from all according to their ability, to all according to their need” , was realised in practice in the NHS, but modified in one vital respect; doctors were the sole judges of both ability and need. Other than their own, whose interests would this self-regulating profession represent? Initially, the rich and powerful could count on instinctive loyalty from the top doctors who had always dominated medical culture not only in their own sectional interest, but in the more general interests of a stable social hierarchy guaranteeing them high status. But in the longer run, none of these assumptions was secure, because medicine is science-led is now wholly dependent on the continued existence of a State-funded service, and is now developing the same relationships as in other forms of production; the age of the self- employed doctor is over. As the professional hierarchy shifted from aristocracy to meritocracy, the power and influence of doctors came more and more to depend on their work rather than their wealth and connections, and their continued support for the ruling few came to depend on continued provision of public service in their interest.
CONVERGENCE OF MEDICAL SCIENCE WITH MEDICAL PRACTICE
It is generally agreed by historians that not until the early years of the 20th century did all medical and surgical interventions put together even begin to save more lives than they destroyed. Substantial net saving of life began only about 1935, with introduction of sulphonamide antibiotics. At the time of the Lloyd George Act, treatment consisted of a great deal of heavy nursing, millions of gallons of often toxic but almost entirely ineffective medicines, and desperate ventures into abdominal and obstetric surgery when there seemed to be no alternative. At the birth of the NHS in 1948, effective medical treatment was just reaching take-off speed, with penicillin introduced generally in 1944, and the first antibiotics effective against tuberculosis in 1950. Surgery was changing from a last resort to a routine assumption, but only for conditions where life seemed impossible or intolerable without it. As always, nursing care was real and effective, but relatively unchanging and predictable in cost. Medical care, on the other hand, was rapidly shifting from dominant illusion sustained by scraps of reality, to dominant reality contaminated by residual illusion. A political decision to guarantee universal free care today would be a lot bolder than it seemed in 1948.
Like other sciences, medical science began with description, followed by experiment, and only much later by intervention with more or less predictable results. Except for a handful serving the top of society, doctors had little social authority or status until the late 19th century, when the evident future promise of medical science began to make it more credible than religion. Modern medical culture, and the social characteristics of medical professionalism, date from that time, when medical science promised much, but actually delivered almost nothing in terms of personal care for disease. It had real achievements, but these lay almost entirely in the field of public health, not personal clinical care. Medical wealth, and therefore power, was concentrated in personal clinical care for top people, not public health for the nation. The terms of medical professionalism were therefore the terms of medical trade, made credible by association with medical science, but certainly not based on it.
In its relations with other health workers and with patients, medical trade (and therefore medical professionalism) depended on maximising the power and authority of doctors, and minimising those of everyone else. Technical interventions had almost no positive effect on outcomes of illness before about 1910, began to be appreciable around 1935, and became dominant from the 1950s onward, but they were not the sole content of care. Even by 1991, David Eddy, professor of health policy and management at Duke University North Carolina, estimated that only about 15% of clinical interventions were fully supported by good scientific evidence; we are still much closer to the beginning than we like to think. Apart from nursing, the real and apparent effects on illness of reassurance, hope, and faith in one’s doctor, what is now called the placebo effect, was originally the main content of all treatments. It remains important enough today to be taken into account in all scientific studies (a fact which in no way invalidates science, but simply confirms that what goes on in our brains does, not surprisingly, affect the function of subordinate organs ). Doctors, patients, and all other paramedical health workers recognised this, and all of them (not just doctors) conspired to preserve and if possible magnify this effect, through a culture of secrecy, well-intended lying, and contrived optimism, all contradicting every principle of science.
Technological advance precedes cultural advance. The autonomous medical profession whose work was socialised by the NHS in 1948 still clung to this antiscientific culture, but their credibility, to themselves and to society, already depended on the most rigorous application of critical scientific method, in a state of free international intellectual competition which soon eliminated the self-deceiving customs of the past, at least at an academic level. As more and more of clinical medicine became real, there was less and less need for pretence. The new doctors understood biochemistry and elementary statistics, and welcomed their new opportunities to practice regardless of patients’ means. They began to understand that without skilled paramedical teams they were powerless, and that most of the really big problems in medical care were insoluble without intelligent participation by patients both in diagnosis and treatment.
Between 1948, when the socialised NHS began, and 1989, when the first serious steps were taken to drag it back to the market, the British medical profession began a qualitative change, from systematic mystification and lying (mostly in the cause of hope and optimism) to systematic audit of the truth, from using science to being scientists. This change is very far from complete, but its direction is not in doubt. It may be delayed, but will not be changed by current attempts to corrupt medical science by commercialising the NHS. We can be sure of this, because even in the United States, with a health care system already corrupted by decades of commercialism and universities demoralised by visions of immensely profitable “intellectual property”, the logic of medical science is creating internal criticism which must ultimately burst through the constraints of the market. More than any other group, doctors know not only what medical science makes possible, but also how little of this is effectively applied to the people as a whole. A body of intelligent men and women has been created whose work is vital to any society, and who know what can and should be done. Permanently to prevent them doing it for all because a few families must have three cars, a yacht and a swimming pool, is not possible.
WHAT ABOUT THE WORKERS?
Doctors have been pushed a long way into understanding their own situation in society, but most are still far from understanding the pressures on other health workers, without whom modern medical practice is impossible.
Despite the behaviour of the BMA leaders, Bevan kept all his promises to the doctors, respecting not only their professional autonomy, but also defending the high incomes guaranteed to consultants by the notorious Distinction Awards system. He backed Lord Moran against attempts by Hugh Gaitskell, then Chancellor of the Exchequer, to reduce them. Neither Bevan nor any of his successors, Labour or Conservative, showed similar respect for other health workers. Having inherited a grossly underpaid nursing, domestic and ancillary workforce in 1948, the NHS faced a 22% rise in its wages bill in its first year, after conceding a 30% wage rise for nurses. From then on, Bevan put his full weight behind government demands for restraint and self-sacrifice for all other health workers.
Perhaps this was political realism, inevitable if the NHS was to be born at all; but if loyalty to doctors secured its birth, taking all other health workers for granted almost led to its death. The right of workers in public service to wages comparable with workers in commodity production was never willingly conceded by any government, Labour or Conservative. Year after year, nurses and other paramedical staff refused to take industrial action for wages comparable to those in commodity services and manufacturing, and saw themselves slip down the social ladder in consequence. The inevitable result of holding down wages for the lowest paid workers in essential public services was eventual confrontation . In the 1978-79 “winter of discontent”, the last Labour government used such waning energy as it had to keep hospital porters, domestic staff, dustmen and gravediggers where they had always been, at the bottom of society. Fifteen years of uninterrupted Conservative rule has followed. To find a way out of a deep hole, we need to think about how we fell in.
Medical autonomy took the rest of the medical team for granted. Roughly 10% of the workforce took all the decisions for everyone else. In other fields, socialists have painfully discovered that participative democracy is a not an option, but a necessity. Command socialism can build the primitive outlines of an industrial economy, but to get beyond that, people must be free to think and work for themselves in their own way, using their own brains. An economy fuelled by fear is even worse than one fuelled by greed, and the new social fuels we need for socialism can’t be developed in a barracks. Next time round, to go forward at all we must go together. The phrase “care team” must acquire real meaning, but working experience is doing just this. Unity across the whole spectrum of medical, paramedical, nursing and domestic staff will be difficult to achieve, but if we look thoughtfully at how effective health care must now be delivered through diverse but integrated care teams, a material rather than romantic basis for unity can be understood; in 1948 it was unthinkable.
WHAT ABOUT THE PATIENTS?
The autonomous medical profession could ignore any active role for patients even more easily than for other health workers. Doctors traditionally recognised two kinds of patient. Paying patients, like other customers, were always right and therefore had to be humoured. Non-paying, public service patients, were supposed to earn their right to care by having serious or at least interesting diseases, and to be grateful for getting any care at all; beggars can’t be choosers.
The advent of the NHS, giving everyone a right to medical care whenever it was needed, paid for by everyone by taxes throughout their working lives, potentially created an entirely new situation. From 1948 onwards, the service belonged to the people, and so did its most skilled workers, since the substantial costs of training both doctors and nurses was borne almost entirely by the NHS and paid for by taxes, not tuition fees. But it took a long time for most patients to see it this way, and even longer for doctors. Until well into the 1980s, NHS patients were (by international standards) notoriously uncritical, so that (for example) even today, malpractice insurance cover for doctors can be about nine times less in the UK than in the USA. You complain about faulty goods you have bought, you don’t complain about gifts.
An important reason the new radical Conservatives have, so far, got away with imposing market competition on the NHS, is that they recognised that patients were no longer prepared to be taken for granted by a State-funded charity, which seemed to advance only at a speed and in directions convenient and interesting for doctors, not patients. Forty years is a long time to go on feeling grateful for gifts you have already paid for with taxes. People are not all fools. They know very well that the charm of shop-assistants is superficial, motivated more by bonus payments for sales than by personal concern for the customer, but they prefer being valued only as consumers, to not being valued at all.
The nationalised health industry followed the same authoritarian pattern as other nationalised industries, conceived by socialists perhaps, but certainly not implemented by them. Like all the others, the nationalised health service was run not as a new kind of industry by the people, for the people, and of the people, but as the old kind of industrial dictatorship, without even the illusory democracy of consumer choice. Unlike other nationalised industries, however, the NHS despots were distributed non- hierarchically throughout its operative units, as clinically autonomous doctors, at a folksy level of despotism not entirely inaccessible to individual consumers. And so, when the rest of State capitalism crashed, the NHS did not. It had within itself the basis for future change, not back to the market, but up, out, and beyond anything the market could ever imagine.