The medical profession’s attitude to other health workers contains a number of contradictory strands.

First of all, health workers are a resource. Consultants are likely to speak of ‘my physiotherapist’ or ‘my ward sister’. The work of other health workers is essential to the provision of the service for which the doctors see themselves as responsible. They see themselves as doing the work and everybody else as supporting them. A porter, a nurse, a medical secretary or a physiotherapist is therefore part of a doctor’s empire, just like an EGG machine or a body-scanner. The doctors therefore feel protective of the existence of the job, as a piece of their property, and may even feel protective of the individual, on a paternalistic basis, especially where an external attack is involved. They will also campaign for more nurses, more physios, more medical secretaries, so long as they feel that this is a reasonably high priority for the development of their own service.

Those staff who do not belong to any particular clinical empire, such as catering or laundry staff, will be in a much weaker position, since the doctors will not see them as falling under imperial protection. Doctors will, indeed, ignore them, until the service they offer becomes inadequate, and then doctors will blame them. Security in the NHS derives from being able to say, ‘Civis Sir Roderick sum’.

If health workers are primarily considered as a resource, the idea of them as a threat comes a very close second. There are objective conflicts of interest between doctors and other health workers, especially in the distribution of power, and doctors perceive this very clearly. In the laager mentality in which the whole world is a threat to the medical profession, the legitimate claims of other health workers become menacing border threats.

Only after health workers have been considered as a resource/threat will they be considered as colleagues or even as people.

Objective Differences of Interest

Doctors and health workers have some quite important interests in common, in particular their common interest in the defence of the NHS, and their common opposition to policies of public-sector wage restraint. It is noticeable that over the last decade, in which NHS cuts and public-sector income policies have become more prominent, doctors and other health workers have moved closer together. These common interests, however, are still probably outweighed by conflicts.

Even the question of remuneration is not straightforward. Although doctors and health workers share an interest in undermining public-sector wage restraint, doctors can probably do so more effectively on their own. Pay settlements for doctors are not a major factor in NHS budgets but pay settlements for nurses and for ancillary workers are. Since doctors are, on the whole, sympathetically considered by the establishment, the problem for the BMA has therefore been to find mechanisms which allow doctors to be paid well without setting precedents for other workers. The BMA has succeeded in doing this reasonably well, and has probably done better than it would have done if it had hitched its star to a united battle over levels of pay in the NHS.

The main mechanism which the BMA has used has been the argument that, whatever may be negotiated elsewhere, the award of the Doctors’ and Dentists’ Review Body must be implemented. It has therefore been able to rely on the traditional British habit of accepting the judgement of the referee. Although Review Body reports have sometimes been phased, and this has become almost the norm lately, they have always been implemented eventually, and only once, in 1970, was it necessary for the medical profession to take industrial action to achieve this. Medical pay negotiations have been a process of finding a formula which makes it look as if the doctors haven’t obtained any more than anybody else when, in fact, they have. Phasing achieves this by limiting the additional money paid out in the current year whilst allowing doctors to enter the next pay round with the higher baseline. Freezing part of an award has the same effect. In the first year the government can correctly point out that doctors have received no more than anybody else. The Review Body however will continue to base future recommendations on its previous award, rather than what was implemented, and when the award is finally implemented in full it will be possible to claim that it does not set a precedent for other workers since doctors are only receiving what they ought to have had earlier.

Doctors’ pay rates have therefore moved forward steadily in line with those in other sectors of the economy, and although there have been occasional hiccups caused by delays of a few months in the implementation of increases, Review Body recommendations have always been implemented even­tually. Such delays as there have been have not influenced the starting point of the following year’s pay round. This experience contrasts sharply with that of other health workers whose pay has lagged progressively behind that of other sectors for periods of several years, culminating in large catch-up awards.

It is in the interests of doctors to retain this advantage, since prospects seem bleak of persuading government to treat all its workers fairly and not use them as battering rams of pay policies.

The BMA has, therefore, been hostile to extension of the Review Body System to other health workers. Despite this, the system has been extended to other professional workers, including nurses, and Review Body awards will now cover a significant part of the NHS pay bill, instead of a part that is of merely symbolic interest. The effect of this remains to be seen. If it removes the advantage doctors have hitherto possessed, it may bring their interests closer to those of other health workers. The 1984 awards were implemented in full, except for that of the doctors, but this was inevitable in the first year of the system. The 1985 awards for nurses and paramedical workers were phased. The government has tried, with some success, to prevent the Review Body awards being used as a precedent for those staff not included in the system, and undoubtedly seeks to drive a wedge between professional and non-professional staff. However it seems unlikely that it can continue to do this for ever, especially since some professional staff (such as speech therapists and medical laboratory scientific officers, MLSOs) are also outside the system, and since ever-widening differentials would be unacceptable and would provide staff outside the system with a ready indicator of the extent of their exploitation. Quite apart from this consideration the Review Body awards, specially that for nurses, will be a significant part of the NHS pay bill even in their own right, something which the Doctors’ and Dentists’ Review Body alone never was.

Even if differences of interest over pay were to shrink or disappear there would still remain differences of interest over power.

Doctors remain the most powerful single group in the NHS power structure and any suggestion that they should give up any part of that power is vigorously resisted. This particularly applies to suggestions that other health workers should have any autonomy in controlling their own work (a privilege that doctors seek to deny others as vehemently as they claim it for themselves) or to any suggestion that there should be any system of industrial democracy matching the system of medical consultative machinery which exerts so powerful an effect on health service decision making.

Just as the Victorian middle class used to regard their servants as invisible, so doctors treat ancillary workers or student nurses in the same way. As a result of these attitudes a deep resentment of doctors builds up amongst other health workers. Doctors, as a collective group, are hated with an intensity which matches that felt by industrial workers towards their managers.

The intensity of this feeling is clearest in its obverse, the intense loyalty shown by health service workers towards doctors who treat them as human beings. At a hospital where, during the winter of discontent, doctors’ personal telephone calls were blocked by the switchboard as part of a work to rule, two psychiatrists who had expressed support for the pay claim were exempted by name from the sanction. A number of left-wing doctors have related how, on coming to the end of their junior hospital appointments, they were embarrassed by the effusiveness of the farewells from other staff and at the fact that they were sometimes bought leaving presents when this was not customary. A Medical Registrar who was a member of the MPU relates how he was once talking to other doctors and a ward sister about the difficulties of getting co-operation from the staff of the path lab. When the other doctors complained of the bloody-mindedness of the MLSOs he expressed surprise saying that he had never had any difficulties. The ward sister commented, ‘Well, of course, you wouldn’t have.’

The Intimate Reality

Doctors usually have separate dining rooms from other health workers or, at least, separate tables or a screened-off area. Pressures to remove these facilities have built up over recent years as part of efficiency measures and have been resisted and deeply resented by the medical profession.

This is only a symbol of the exclusive attitudes taken by doctors who rarely acknowledge the presence of other health workers. Professionally, doctors assume the right of decision-making without consultation. For example physi­otherapists have often complained of doctors discharging patients who are receiving physiotherapy without even informing the physiotherapist.

The Paramedical Professions

Within this phrase I embrace three different groups of professions. These are the remedial professions, the scientific professions and the behavioural professions (dieticians, clinical psychologists, health education officers and others). These are the areas within the NHS where there is a substantial body of professional work undertaken by people who are not doctors, dentists or nurses.

It will be noted that all three of these groups operate in the low-status areas of health provision – rehabilitation, non-clinical diagnostic support services, mental health and prevention. The high-status areas of provision are the preserve of doctors and supplementary professions will not be allowed to develop. One may contrast the position of the professions supplementary to medicine with that of ambulance drivers.

In any sensibly-run health service, ambulance drivers, or at least a group of them designated to staff the emergency ambulances, would be highly qualified paramedical workers trained to administer emergency treatment. In fact any such training and development of the ambulance service has been obstructed by the idea that it would trespass on the domain of medicine. In Brighton ambulance drivers have been trained to resuscitate heart attack victims, and have been allowed to use defibrillators and a selected list of drugs to do so. Elsewhere this solution has been rejected in favour of special mobile coronary units which take doctors and nurses out to the patient. The latter system does not work – it arrives too late and attends low-risk patients. The Brighton system does work. It has not, however, been repeated.

In the low-status areas medicine may tolerate the growth of parallel professions. But in the glamorous areas everybody else must be kept in their place. My father died of a heart attack in an ambulance on his way to hospital. I do not know whether he would have lived had the ambulance been equipped with a defibrillator and a stock of emergency drugs, and staffed by people trained to use them, as it would have been in Brighton. But there is no doubt that people have died who would have lived if the Brighton experience had been repeated, and they have died on the twin altars of the medical profession defending its territory and the DHSS perpetuating the unskilled, and therefore low paid, status of ambulance drivers.

A further example of the deliberate deskilling of paramedical workers in the field of acute hospital care was the long resistance to the upgrading of operating theatre technicians from ancillary grades to professional and technical grades. The battle was eventually won, but only after a long, hard struggle.

In the low-status areas, however, supplementary professions have been allowed to grow up. The remedial professions are the mainstay of the rehabilitation services. They include physio­therapy, occupational therapy, remedial gymnasts, and art/music/drama therapy. Despite having far more expertise in rehabilitation than doctors, they operate under the directions of doctors, which causes considerable resentment.

The   scientific   professions   include   medical   laboratory scientific officers, radiographers, physiological measurement technicians (PMTs), biochemists, physicists and pharmacists. These professions are also engaged in struggles to assert their professional autonomy from doctors. Pharmacists wish to expand their role so as to give advice to patients about the use of drugs, which encroaches on the traditional role of the doctor. MLSOs, radiographers, and PMTs wish to control their own departments, a struggle which has been resisted by doctors who insist that they should be controlled by consultants or by scientists of consultant equivalent. Biochemists and physicists can attain status equivalent to consultants through their Top Grade posts, but there are very few of these and their creation is regarded as a second best to having a real consultant. Top Grade biochemists, for example, are usually only appointed by districts which don’t think they could attract a doctor to a post of consultant chemical pathologist.

Health-education officers, members of a new profession that is still paid on administrative and clerical scales rather than professional and technical scales, complain of being expected to play second fiddle to community physicians, to whom they are accountable. Clinical psychologists, another profession with Top Grade posts, i.e. consultant equivalent, have probably obtained more autonomy than any of the other paramedical professions, mainly because they are involved in areas like psychotherapy, mental handicap, psychogeriatrics, counselling, crisis intervention and preventive mental-health work which are of low status even amongst psychiatrists. It is probably true, however, that psychiatrists see clinical psychologists as their assistants and the autonomy they have built up reflects a lack of interest rather than a respect of territorial boundaries.

This is also true of the relative independence achieved by dietitians, who have achieved autonomy but not status (they are not on the golden PTA-A scales with their consultant-equivalent Top Grade posts).

The struggle by paramedical professions for independence from doctors manifests itself in a myriad of different issues.

The most prominent has probably been the battle for control of pathology laboratories. For many years the different professions in pathology laboratories, the doctors, biochemists and MLSOs, have co-existed in a state of harmony, with each directing their attention to their particular sphere of activity. The role of MLSOs has been to produce the technical output of the laboratory, in the sense of ensuring that the tests undertaken produce the most accurate possible result, whilst the role of doctors has been to ensure that that output is clinically relevant, so that it would be the doctors who would liaise with clinicians about the clinical relevance of particular abnormal results and who would decide what range of service should be provided. Neither would be the head of the laboratory – whilst some decisions, such as whether to introduce a new test, would be medical, others, such as what equipment to buy, would be technical. The role of biochemists was less clear, although in practice they tended to straddle the two components with a bias towards the medical side of the divide, since biochemists were often employed as substitutes for doctors in view of the poor recruitment to pathology. This arrangement worked satisfactorily so long as management was undervalued in the health service and so long as MLSOs were so clearly inferior in status to doctors that nobody doubted who really ran the laboratory.

Two things combined to disturb the relationship. One was the success of ASTMS in raising the professional status of MLSOs, and the other was the growing emphasis on manage­ment which led health authorities to look for a line managerial head of the laboratory.

The BMA, supported by the Association of Clinical Biochemists, accepted that there should be a head of the laboratory and said it must be a doctor or a Top Grade biochemist. The purpose of the laboratory was its clinical output and this must be dominant, the technical output being merely a means to an end.

ASTMS, on behalf of MLSOs, also accepted that there should be a head of laboratory, but argued that it should be open to all professions. Whilst the clinical output was obviously the purpose of the laboratory, that was a philosophical rather than a practical point. Most of the decisions a head of laboratory would have to make would relate more to the technical questions than to clinical questions. Doctors should not be turning themselves into managers, but rather should be developing their own clinical involvement with patients, advising clinicians about the implications of particular abnormal findings.

The battle raged, and still rages, in pathology laboratories up and down the country, the most notorious example being in Fife where it led to an occupation of the laboratory by MLSOs which was forcibly brought to an end by police.

What ASTMS has done for MLSOs (and for some other professions) has been essentially the same as what the BMA has done for doctors over the last 150 years. The objective has been to assert a professional territory, to emphasise the significance of the professional qualification and the importance of the service, and as a result to claim autonomy, power and money.

When the BMA was undertaking this process it hid the economic motivations behind a smokescreen of genteel professionalism. ASTMS has done the reverse – hiding the elitism of its professionalisation behind a smokescreen of trade union fundamentalism.

The message is the same: ‘Our members are engaged in an important service, which requires a high degree of technical expertise so that they need autonomous control over a defined professional territory. It is moreover necessary to give them high pay so that the standards of the profession will be maintained by attracting the most able applicants.’

The same techniques have been used by clinical psychologists and by pharmacists, both of them represented by ASTMS, with greater success since there has been less medical opposition. Psychiatrists have been willing to leave certain professional areas to psychologists because of lack of interest, whilst clinical pharmacology is, surprisingly given its proximity to high-status areas, an undeveloped specialty. The graduate status of both professions may also have helped.

The Rehabilitation Services

The remedial professions have faced similar difficulties in asserting their autonomy, but have been much less forthright in defending their position. Although ASTMS represents speech therapists and art therapists it has only a minority position in the more powerful areas of physiotherapy and occupational therapy, whose dominant associations have preferred genteel professionalism to gloves-off territorial assertion.

Doctors are not interested in rehabilitation and it has proved impossible to appoint consultants in rehabilitation. Where consultants have been appointed in rheumatology and rehabilitation, or some other similar combination, the emphasis has usually been on the specialty with which the appointment is linked, so that a consultant in rheumatology and rehabilitation will be a consultant rheumatologist first and rehabilitationist a poor second. There are, of course, individual exceptions, and some enthusiasts have made considerable contributions to the field. However these exceptions do not disturb the general picture.

For that reason there has been nobody to challenge the remedial professions for managerial control of their own service, but there has been considerable resistance to any questions of clinical autonomy.

One model that is followed by geriatricians and some other rehabilitation-oriented consultants is to hold case conferences at which members of the rehabilitation professions concerned with particular patients will report on their progress. The consultant will then write these reports into the patient’s case notes, and instruct the physiotherapists, OTs etc to do what they have recommended he should tell them to do. This touching ritual emphasises medical dominance, but does have the benefit of educating doctors, who may even over time come to have some interest in the subject of rehabilitation, and also gives the remedial professions some input into medical decision%iaking. It’is therefore preferable to the alternative system, whereby consultants refer their patients to physio­therapy, occupational therapy or speech therapy and then ignore them, even to the point of discharging patients without consulting the therapists who are doing the bulk of the work. A patient lying in a bed receiving rehabilitative treatment but not actually posing diagnostic problems or requiring curative treatment is seen, on this model, as blocking a bed.

The rational solution would be that there should be a supply of rehabilitation beds, under the control of the remedial professions themselves, who should take clinical responsibility for patients who require rehabilitation rather than cure. If the problem in appointing consultants in rehabilitation is that doctors are neither educated in rehabilitation nor interested in it, it is far from self-evident that it is sensible to put the system under the control of doctors. Perhaps, instead of trying to find some way of attracting doctors to this field, we should develop a career structure which would allow members of the remedial professions to undergo further training which would enable them to become consultants in rehabilitation. Such an arrangement has been advocated by a working party set up by ASTMS, but would undoubtedly meet bitter opposition from the medical profession.

Other Battlegrounds

The difficulties experienced by the remedial professions have an unfortunate side-effect in their influence on the attitude of social workers. Social workers resist incorporation into primary-care teams, and resist amalgamation of health services and personal social services because they perceive that if they were to accept either of these developments they would come under medical control. The experience of other professions suggests that they are right. Important develop­ments are therefore obstructed.

In general practice the problems have a rather different form. By defending their independent-contractor status GPs have put themselves in a position where they cannot claim control of the other professionals attached to their practices. However by insisting on an anarchic system of patient lists instead of a predominantly geographical system (which could still accommodate patient choice in those exceptional cases where patients make a genuine choice) they force other professions either to leave the primary-care team or to adopt the same anarchic system, which they universally find less satisfactory than a geographical system.

Health-education officers are a new profession. Their work considerably overlaps the public-health work of community physicians, and health-education officers complain both of community physicians trespassing on their territory (a rather arrogant claim since it has been the territory of community medicine and public health, its predecessor, for over 100 years) and also of community physicians controlling them. This last complaint is made most strongly by health-education officers who want to get involved in radical public health advocacy in fields like food policy or anti-smoking campaigns, and complain of being prevented from doing so by community physicians who have slotted into a health service management role and perceive the proposed activity as politically unsafe. Given the history of public health this is a particularly ironical situation.

‘Rethinking Community Medicine’, produced by the Unit for the Study of Health Policy, advocated a multi-disciplinary approach to the field of work of community medicine, in which doctors, health-education officers, social scientists and others would take part as equals. The document has sunk without trace in terms of its influence on official thinking.

Health-education officers are not currently graded as professional staff, but are employed on administrative and clerical grades. Whilst this grading structure continues there are considerable problems in enhancing their status because of the problems of differentials with senior administrators. Health-education officers complain that their union, NALGO, sides with the administrators in this situation, which is not surprising since NALGO is the administrators’ union first and foremost. NALGO may also be reluctant to allow health-education officers to transfer to professional and technical grades in case it opened up scope for recruitment by ASTMS.

The Role of ASTMS

The position of ASCMS as the dominant force campaigning for upgrading of health professions dovetails neatly with the role of the MPU, a section of ASTMS, in campaigning for the interests of neglected groups in the medical profession. This dovetailing is historically accidental. The MPU was attracted to merge with ASTMS more by an affinity with the AScW as a radical scientists’ union than by any affinity with a process of professionalisation of the paramedical professions. None-theless the affinity is there. The paramedical professions are downgraded by the same status system that downgrades the Cinderella specialties and doctors in those specialties ought to be natural allies of the other professions involved in those areas, instead of being the front-line of the battle to preserve the very model which peripheralises the paramedical professions and the non-acute specialties alike.

The troops on the ground don’t necessarily see it that way. Although ASTMS has gained a dominant position in some health professions, there are others where the concept of genteel, long-suffering professionalism reigns supreme. Although the MPU sees itself as the union for the Cinderella specialties it has not been noticeably successful in recruiting outside the political subculture that has been its core since the 1940s.

It remains to be seen whether ASTMS will succeed in spreading its brand of aggressive professionalism into those professions which have hitherto rejected it, and whether the MPU will succeed in broadening its base.

There is also scope for debate about whether the process actually is a fundamentally progressive one. Were it to succeed it would transform the status system of the medical profession and strengthen considerably the position of rehabilitative, preventive and caring values. It would therefore be a progressive development. But it would not fundamentally break down the elitism of medicine. It would simply co-opt a range of other professions into that same elite.

ASTMS seeks to counter this danger by adopting a stance of trade-union fundamentalism. It resists sharing the bargaining table with non-TUC affiliates, plays a leading role in forming joint trade union committees, adopts a militant stance on defence of the NHS and supports industrial action by health workers. Moreover it is not prepared to compromise on these principles, even if they detract from the recruitment of professions whose participation in the professionalisation process is essential to the ASTMS dream of uniting all the paramedical professions (and their supporters in medicine) within a single union.

This is characteristic of the general approach of ASTMS which has succeeded in persuading large sections of the middle class to follow left-wing leaders by delivering the goods in terms of defence of their interests. The activists, in ASTMS and in similar unions such as TASS or ACTT, have been left-wing professionals who have seen their membership of a TUC-affiliated union as evidence of working-class status.(At the time of writing a merger between ASTMS and TASS was under discussion and seemed likely.) By vigorously defending the interests of a group of people who would not share that perspective, they recruit them and educate them gently in the fundamentals of trade unionism. Those who join may not share the political perspective of the leadership, but that is not to say that the leadership is unpopular, or that there would be support for changing it, or that the membership has been deceived. On the contrary the members go into the bargain with their eyes open and in full knowledge of the package on offer, because they trust the leadership’s determination to defend their interests and they are prepared to tolerate its politics. They prefer a vigorous effective left-wing trade union to a wishy-washy one whose political approach is closer to their own.

The essential elitism of the ASTMS approach to professionalising the paramedical professions is therefore leavened firstly by the effects on the ideology of health care that would result from success, secondly by the concomitant trade-union fundamentalism which draws health profession­als into the community of health workers, and thirdly by the sense that any break in the dominance of medicine must be a move away from elitism, even if the break is only achieved by a lesser elite.

It is possible that even those leavening factors may prove powerful enough to destroy the whole attack. To those who argue that the MPU should have merged with COHSE rather than ASTMS, or that it should campaign for cuts in doctors’ pay, my response is that it is better to fight realistic battles than to lose magnificently in ideological purity.

Nurses

At first sight nurses are simply another paramedical profession (although that phrase is not traditionally used to include them) and similar considerations apply. There are, however, two differences. The first is the traditional sexist relationship conjured up by the phrase ‘doctors and nurses’ whereby it is assumed that each doctor (male) will find a pretty young thing amongst the nurses who will look after him, cook his meals, answer his telephone and understand enough medical jargon to be a sounding board for his problems.

The second is that nurses outnumber doctors by a ratio of more than two-and-a-half to one. The medical profession could withstand the breaking down of its boundary with the paramedical professions which are very diverse and which it outnumbers by more than two to one, but it could not survive a breakdown of its boundary with a single much larger profession.

For these two reasons the relationship between doctors and nurses is even less open to renegotiation than that between doctors and the paramedical professions.

Indeed some groups, such as midwives and health visitors, distance themselves from the rest of the nursing profession in an unconscious (or perhaps conscious) recognition that as a separate group they may be less threatening and may have a chance to become part of the action if medicine decides to co-opt paramedics but exclude nurses.

That does not mean that the nursing profession as a whole does not attempt to renegotiate the relationship with medicine. The same kind of battles are fought as in the paramedical professions.

As in the paramedical professions, there is the conflict between genteel and aggressive professionalism. There is a third element, effectively absent from the paramedical professions, which is a rejection of professionalism and a willingness to identify with the mass of health workers. In trade union terms genteel professionalism is represented by the old guard of the RCN, aggressive professionalism by the younger and more radical elements of the RCN and by COHSE, and anti-professionalism by NUPE.

Aggressive professionalism takes different forms. The most effective has been the managerial form, whereby nurses have created a hierarchy of nursing administrators who have asserted autonomous control of nursing and who demand involvement in decision making. An alternative approach is the professionalised caring form, whereby nurses assert that caring is one of the functions of the NHS and that nursing is the profession that deals with that function so it should control  that area of activity. This view is dominant in nursing education. The third approach is the high-technology form whereby nurses seek to expand their roles so as to undertake work that was previously the domain of doctors. This approach is popular with junior doctors, who may in consequence be disturbed less at night, but not with consultants who don’t get disturbed at night but do have the ability to smell a rival force at least fifteen years away. Amongst nurses this approach is most common in intensive care units and Casualty, and to a lesser extent on all acute wards. Nurse educators see it as a dilution of the caring professionalism and nurse administrators see it as likely to produce conflicts with doctors at times and on issues that are not of the nurse administrators’ choosing. It is therefore an entirely grass-roots movement, strongly hindered from above.

The biggest obstacle to the nursing profession’s successful professional development is the medical profession which will stop it at all costs. The second biggest obstacle is the genteel professionalism of ward sisters who resent with equal intensity the hierarchy of nurse administrators, the new-fangled ideas of nurse educators, and the extra work involved in extending the role of nurses and won’t touch any of them. The third obstacle is that nurses are so underpaid and exploited, and also so numerous, that no competent Financial Secretary to the Treasury would permit any health minister to give them a glimmer of support for professionalisation, so it may well be that the anti-professionals have got it right after all and that nurses should join NUPE and resolve their exploitation in straightforward trade union ways before they can begin a process of aggressive professionalism.

Whatever process is followed the medical profession will watch it like a hawk, for it has no intention of surrendering power to nurses.

Ancillary Workers

Apart from ambulance drivers who are a nascent paramedical profession to be nipped in the bud before they get started, doctors do no; feel threatened by ancillary workers. On the whole they find them to be invisible, except when their unions demand a share of power, but even that is regarded more asludicrous than threatening, and is referred to as demon­strating how ridiculous the unions are rather than as saying anything at all about ancillary workers.

Doctors only really notice ancillary workers when they are on strike. The attitudes that doctors have taken to industrial action by ancillary workers have changed over the last decade.

In 1973 the attitude of doctors to the industrial action was unremittingly hostile and many doctors were willing to strike-break. Amongst left-wing doctors the attitude was one of embarrassment, with support being offered for the claim but a noticeable silence about the industrial action.

Between 1973 and the winter of discontent in 1978-79 a number of things happened. Junior doctors themselves took industrial action in 1975 which made it more difficult for doctors to take a holier-than-thou attitude. The pay policy against which the winter of discontent was fought had affected doctors as well as ancillary workers. NHS cuts had begun.

In 1978-79 the profession’s attitude had changed. Doctors at large now felt the kind of embarrassment that left-wing doctors had felt in 1973, supporting the claim, and often saying so, but not being willing to support the industrial action. Left-wing doctors had moved on to express cautious support for the action, although the support was still verbal rather than practical.

By 1982 the process had continued further. Whilst Labour had been reluctantly pushed into cuts by the IMF and the constraints of a small parliamentary majority, the Tories embarked on cuts as a deliberate act of policy. In the process the attitudes of doctors had also hardened in the direction of support for the ancillary workers. Left-wing doctors were now unequivocal. Doctors joined picket lines during their lunch breaks and MPU branches collected large sums of money. A few doctors took part in the strike, including some GPs who closed their surgeries on the days of action. The bulk of the profession, however, did not follow the left. Rather they had reached the position that the left had reached in 1978-79 of expressing support but not doing anything. Support was expressed by the Chairman of Council of the BMA and by the Hospital Junior Staffs Committee. A heated debate at the General Medical Services Committee was inconclusive. However all the craft committees rejected motions putforward by the MPU that doctors should reject the government’s pay offer and attach themselves to the TUC claim.

Between 1973 and 1982 the profession as a whole had moved from a position of hostility to a position of cautious support, and left-wing doctors from a position of embar­rassment to one of overt and unequivocal support. So complete had this shift been that there was no overlap between the two spectrums of opinions – even the BMA was more supportive of health workers in 1982 than even the MPU had been in 1973.

It remains to be seen whether this shift is a permanent transformation of attitudes or simply a feature of particular political circumstances.

It seems unlikely that the shift of attitude can go any further. The bulk of the profession is committed to the idea that the NHS is an amalgam of personal empires run by doctors. Therefore doctors see themselves in a role akin to that of a shareholder/manager. They will therefore tend inevitably to place themselves on the management side.

On local disputes this will almost inevitably be the case. It is only in national disputes, where the issue can be presented as the NHS versus the government, that it will be possible to mobilise sympathy from the bulk of the profession for action taken by ancillary workers. The one exceptional situation in which a local dispute may take on those characteristics would be where doctors do not support the management decision, either because it was taken against their advice (a highly unlikely situation) or because it was imposed from above by government instructions and constraints (a real situation in certain cuts campaigns which have gained medical support). Doctors would only move closer still to ancillary workers if the power of the medical profession were considerably dim­inish^, but that seems highly unlikely.

This in turn places constraints on the extent to which left-wing doctors, who are already unequivocally committed to support of other health workers, can actually express that support in the isolated situations in which they find themselves. It seems unlikely that it will be possible for them to offer more than was offered in 1982, namely token supporting action coupled with financial contributions.

Administrators

The medical profession’s concept of the National Health Service is that it is simply a system for supplying doctors with the equipment to carry out their work. It is assumed that the hospital service will be controlled by consultants and that they will decide the allocation of resources by apportioning them democratically between the competing empires. The par­ticipants in this process of apportionment will be the consultants, not managers and not patients.

The centrepiece of this process is the concept of clinical freedom, which precludes any outside interference in a doctor’s decision about the treatment to be given to a patient.

This relationship confines managers in the NHS to an essentially peripheral role in decision-making in which they are only free to manage the support services, and even then only free to manage them in accordance with the expressed needs of the medical profession.

Over the last decade pressure has gradually increased to change this relationship. Resources have been short and have had to be directed to the priority areas. The medical profession’s priorities have been based on the profession’s own status system and ideology (implicitly and in practice, whatever the explicit statement) and this has conflicted with the priorities of government and of informed public opinion (although not necessarily of general public opinion). The question has therefore arisen as to whether doctors are the best people to allocate the scarce resources. Along with this general question has come the realisation that the clinical freedom of one doctor to prescribe expensively for one patient may deny another patient the opportunity to receive any treatment at all in a lower-status field such as geriatrics.

Concurrently with this concern about finance has been the increasing debate about medical treatment and its inad­equacies and a growing demand for accountability. A few scandals about expensively misused resources coupled with a few scandals about poor treatment and followed by a few scandals about corruption culminating in the prosecution of doctors were sufficient to add fire to these concerns.

The relationship between doctors and managers was transformed by the 1985 Griffiths reorganisation in which new general managers were appointed at regional, district and unit level to take the health service under proper control.

This reorganisation was bitterly criticised by the Labour Party, not least because the objective seemed to be to overcome the power of the professions to obstruct Tory policy. However the Labour Party will also need a proper management structure if it is to impose its will on the NHS. This will be true whether that will is to be imposed centrally through the existing structure of an NHS controlled by a Minister of the Crown, or locally, through democratically elected authorities. The Labour Party has never fully succeeded in implementing a health policy and if it had wished to do so it would have needed to carry out the very shift in power from professions to managers which has been implemented by the Conservative government in 1985. However much the Labour Party may now oppose a structure which permits the Tories to implement their policy, it is unlikely that the structure will be dismantled when a Labour government is in power, anxious to implement its own policy.

Whatever government is in power will in future wish to invest authority in those who manage the health service on its behalf, and they will be managers not doctors. How the profession will cope with this challenge to its traditional attitudes remains to be seen. Bitter conflict is to be anticipated. The profession’s position is summed up in the comment, ‘Doctors and nurses are the teeth of the service, and managers only exist to serve them.’ A contrary position was put by Professor Alwyn Smith, President of the Faculty of Community Medicine, ‘On the contrary, doctors and nurses should be controlled by managers, and the managers should represent the people.’

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