There have been three main themes to this book.

The first is that the medical profession is not a monolithic force, as the left assumes, but that it consists of a variety of conflicting interest groups. Some of those interest groups have reason for supporting reforms which the labour movement may wish to see but which the profession at present opposes. The concept of unity of the profession is so strong that it would be difficult to divide those groups from the rest of the profession, since they will tend to pursue their interests within the machinery of the profession rather than seeking outside aid. However the machinery of the profession is itself sensitive to the articulated demands of minorities within it, to which it must respond if unity is to be preserved. A sensitive synchronisation of internal and external pressures could achieve changes that neither alone could achieve.

The second is that the medical profession is not a reactionary political force, as the left assumes, nor is it moving leftwards, as is sometimes assumed when it supports progressive positions. Rather it conducts its politics against a background of historically-derived norms of thought, some of which, such as the small trader mentality, the sense of identification with the establishment and the acceptance of the status quo implicit in depoliticisation, are reactionary, but others of which, such as the commitment to health, the commitment to independence of judgement and the sense of struggle against a hostile world tend towards progressive attitudes.

The third is that the profession is depoliticised and it is not, as the left may assume, in the interests of the left to disturb that depoliticisation. Rather the depoliticisation is the very thing which makes it valuable for the left to gain the support of the profession on health or civil-liberties issues, or the legit­imation of the profession on scientific issues, such as the medical consequences of nuclear war. This measured, cautious and depoliticised support is more valuable than a thousand BMA banners at the demo of the month.

The Labour Party has traditionally overestimated both the power and malevolence of the medical profession, whilst at the same time being insensitive to its attitudes and values. This is a recipe for disaster. The left within medicine has tended, in its organisational behaviour, to see itself as an embattled minority struggling against the same powerful malevolent force as the rest of the labour movement. It has sometimes seemed that the slogan is ‘I hate doctors too’. If it thinks that this is loyalty to the labour movement then it is wrong, for it owes the movement realistic advice and effective organisation, not a mirroring of its prejudices. Moreover in their very rejection of the profession, they reveal their membership of it. It is the height of elitism to place yourself above the elite to which you belong on the grounds that it is too elitist for you. The left-wing doctors’ image of ourselves as a group of committed doctors, true to the cause of the health of people, struggling against a hostile profession, is a strange mirror image of the profession’s image of itself as a group of committed doctors, true to the service of patients, struggling against a hostile world. We do not reject the profession’s mythology, we reproduce it. In doing so, we handicap ourselves, partly by rendering ourselves incapable of reacting to the situation as it really is and partly by alienating those who could otherwise be our allies.

The Challenge for the Left in Medicine

It ought to be possible to create a progressive medical organisation embracing as much as 20 per cent of the profession. This is a considerably larger proportion than the MPU has ever claimed to represent.

It is important for the left to create such an organisation, firstly to offer effective medical support to progressive organisations outside medicine and secondly to create an interest group within the profession to which the machinery of the profession will have to respond.

In saying that such an organisation could account for 20 per cent of the profession’s membership, I have in mind the fact that 8 per cent of doctors voted Labour even in 1983, that many who voted SDP or Liberal are also progressive in medical terms, that MCANW tapped a vein of several thousand doctors, and that groups who have interests opposed to the medical establishment, such as consultants in Cinderella specialties, family-planning doctors, black doc­tors, women, community physicians, juniors concerned with working conditions more than pay, inner-city GPs and others constitute more than half the profession. (It must of course be recognised that the politics of adding together special interest groups has serious limits, and that in any case the medical establishment is adept at conceding to special interest groups enough to keep them happy without changing the balance of the professional power structure.)

The failure of the MPU has been that it has attracted the politically committed activist, but has failed to attract ordinary members. If it is to be more than this it must become an organisation that progressive doctors join as naturally as all doctors join the BMA and overseas doctors join the ODA. It must attract the ordinary, depoliticised doctor whose professional practice is caring and humane, who supports the NHS and the public-health movement and who acknowledges the rights of patients and of other health workers.

From a standpoint of elitist pragmatic politics it could, of course, be argued that inactive members are not important unless the organisation is short of money, and that there is nothing wrong with an activist organisation of a few thousand members. However there is something seriously wrong with such an organisation and with the politics which such an organisation represents. Such an organisation will always hear the voice of the political world more clearly than the voice of the profession. It-fvill therefore fail to act as an interpreter between the profession and the labour movement, because it will not understand the profession sufficiently to interpret it to the movement, nor will it know how to put its ideas across to a group that speaks a different language. This is the failure of the left in medicine for the last 70 years, and if it is not to go on failing in the same way, it must identify its constituency within medicine, listen to that constituency and appeal to it.

Our main failures have been that we have appealed to material interests (in traditional trade union style), rather than to idealism, and to a political identity rather than a professional one. We have also assumed that the BMA is the enemy, rather than the forum of debate, and that the profession’s love/hate relationship with it represents the quarrels of impending divorce rather than the quarrels of happy marriage.

The group of doctors to whom we must appeal are not badly off, nor do they see themselves as such, and, whilst they may well join an organisation for its trade-union service, they will not choose it because of that. What they will seek is a professional identity. In a depoliticised profession, an appeal to a political identity will attract only the abnormal, but an appeal to a professional identity (caring, humane, patient-oriented, team-oriented, concerned with prevention, rehabilitation, and care as well as cure), may attract people who will not then dispute the political correlates of that professional identity. Loyalty to the profession and its unity, embodied in the BMA, is not inconsistent with an identity of this kind, and just as it is natural for overseas doctors to join both the BMA and ODA, so it could become natural for progressive doctors to join both the BMA and the MPU. That is not to say that the MPU should ever insist that its members join the BMA (any more than any other medical organisation does) simply that it should not assume that they will not, or that the two loyalties are incompatible, or that the two organisations are rivals, or that its machismo is threatened if it sees the BMA as one of the forums within which it must organise. The MPU must maintain professional as well as political activities. That doesn’t mean that it must match the professional meetings organised by the BMA and centred on purely clinical problems. It does mean that it must organise meetings on subjects like community care, discussing professional problems and setting them in their political context.

If the MPU proceeds down this path with some humility it might well attract a number of doctors beyond the political sub-culture to which it currently appeals. If it does, it must realise that any educational process that then takes place must be a mutual one.

Can a Labour Health Minister Win?

It is not normally considered good negotiating practice to present your opponent with a set of unacceptable demands whilst at the same time having in your mind the certainty that you cannot win and that if you fail to persuade him or her you will have to surrender.

Dialogues between Labour health ministers and the medical profession in the past have tended to run as follows:

LABOUR:    I demand that you do exactly as I say.

DOCTORS: No.

LABOUR: Do you not realise that I have behind me the full force of public opinion, the constitutional mandate of a General Election victory, the legal authority of Parliament, and all the instruments of state power?

DOCTORS: Yes.

LABOUR: Then I require you to do exactly as I say by all the powers vested in me as a Minister of the Crown and the elected representative of the people.

DOCTORS: No, we won’t.

LABOUR: Oh, all right then. Hope you don’t mind my mentioning it. Just had to have a try, you know. If you’d just draft up a suitably bland press statement, I’d be delighted to sign it. Can’t go round antagonising doctors can we?

This script starts to go wrong with the first line. Proposals put to the profession have started from the proposition that the profession is the enemy rather than from the proposition that there may be common ground. The profession must therefore be bludgeoned or bribed. I fail to see the deep uncrossable chasm that separates the interests of a party committed to development and expansion of the NHS from the interests of the most influential health profession.

Once the lack of any fundamental conflict is recognised, the task can begin of tackling the specific areas of disagreement, many of which are important. In tackling these, the Labour Party must keep two things in mind. It must bear in mind the historical derivation of some of the profession’s emotional attitudes. If the problem of private practice, for example, were only an economic one, it would require only money to solve it. But since it is an emotional and historical one, doctors will no more appreciate the buying out of their right to private practice than GCHQ, employees appreciated the buying out of their right to trade union membership. Before economic issues can be tackled, the emotional issue of the right to independent medical practice must be tackled. But when that emotional issue is correctly specified, it becomes clear that the alliance between doctors and commercial interests is an alliance of convenience, and further thought reveals that it is an alliance that embodies ethical tensions of independence just as great as the conflict between the profession and state health services.

So perhaps there can be a solution based on suppression of the commercial sector, but acceptance of an independent sector, so long as the interests of the NHS can be protected.

A Labour health minister has potential allies within the profession in the form of those groups whose interests are better served by a redirection of resources than by acceptance of the status quo in terms of the medical status system.

There are, however, difficulties in mobilising these groups. Doctors in these groups tend to retreat into a state of professional dedication and, when they do protest their fate, it is usually within the machinery of the profession rather than outside it. There is a danger that they will react negatively to an attempt to divide the profession rather than positively to an attempt to favour them.

I doubt if interest groups within the profession can ever be used overtly to divide it. The role they can play is to create pressures within the profession that make it impossible for the leadership to ignore them when the opportunity to further their interests arises.

This is yet a further reason for the MPU to develop from its present role of a narrowly based, activist organisation, more outside the profession than in, to a role of a broadly based progressive doctors’ movement playing its full part in medico-political trading. Only when that development has taken place can the profession’s leadership be pinched between internal and external pressures, and the external pressures be interpreted to the profession in terms of their professional correlates rather than in alien political terms.

There is, for example, no point in seeking the support of the profession for the idea of bringing health and social services together within a single democratically elected authority, by arguing the case in terms of the distribution of power. Such a case would be better made out by pointing out the advantages of unified caring services.

Likewise, there is no point in appealing for a shift of resources and professional practice towards community care in the alien language of priorities, efficiency and cost effectiveness. The appeal must be on the importance of caring and rehabilitation as professional goals. The medical profession is adept at adjusting its ideology. It was paternalist when that was fashionable, scientific when that was fashionable and could become caring if that came into fashion. It might even rather enjoy it.

Will Doctors March with the Left?

BMA involvement in campaigns may be at three levels. It may be an overt involvement in which the BMA shares a platform with other campaigning forces. It may be a patronage form of involvement in which the BMA makes statements of support for a campaign. It may be a scientific legitimation in which the BMA endorses scientific statements but leaves the cam­paigners to make appropriate use of them and to draw political conclusions.

The BMA’s opposition to the closure of the Elizabeth Garrett Anderson hospital, its opposition to the Police and Criminal Evidence Bill and its campaigns on seat belts and smoking are examples of overt involvement in campaigns which the left would also support. Its statements of opposition to government restraints in health expenditure is an example of the ‘patronage’ form of involvement since the BMA did not actually get involved in the health campaigns, whilst the nuclear war issue is an example of scientific legitimation since the BMA did not make any political statement but merely provided the ammunition. The reason that each of these issues attracted the level of involvement that it did is explicable in terms of the conflicts between the profession’s commitment to health, which is a potentially political commitment, and its depoliticisation as a profession.

Smoking and seat belts are ‘safe’ health issues since they do not lie at the teeth of party-political conflict, or the organisation of society (or, at any rate, can be perceived as not doing). Individual closure campaigns can be seen as ‘safe’, because, although it is true that public expenditure restraint would fail if every single cut were successfully resisted, it is also true that no single cut is, by itself, essential to the public expenditure restraint programme. Hence each cut can be challenged on its merits without overtly challenging government policy.

Challenges to public expenditure policies in general are health issues, and therefore legitimate, but also political issues and therefore illegitimate. Hence the more cautious approach. Nuclear war and other political public health issues are less clearly health issues. Their legitimacy is therefore even more in doubt. When they are ‘safe’, as with smoking and seat belts, this will not matter. But when they strike at the roots of party-political conflict or social organisation, they will be approached with even more circumspection than issues related to health care. Hence the reason for the BMA stopping at scientific legitimation in its attitude to nuclear war.

The Police and Criminal Evidence Bill seems at first sight to fall in the wrong classification. It was surely neither a safe issue nor a health issue. However, the classification applies only to issues which do not directly and immediately affect the interests of doctors. The profession will of course defend its interests including its professional ethics. Its attitudes to civil liberties is coloured by its own conflicts with the police over confidentiality.

From these guidelines it should be possible to see just how far the profession will be willing to go on any particular issue. The left should understand that patronage and scientific legitimation are themselves useful, and that patronage or legitimation from a depoliticised profession may be more useful than platform-sharing with a profession which lost that depoliticised status, especially if left-wing doctors are available to share platforms and draw the conclusions from which the profession as a whole shrinks.

The ways in which one seeks platform-sharing, patronage or legitimation are different, and framing a request for one in the same way as a request for another can lose the whole argument. Thus the left was seen to be defeated at Dundee on nuclear war because it made a bid for overt support when all that was available was legitimation. The failure of the bid for support overshadowed the success of obtaining a very large majority in favour of legitimation.

The following year, by toning down the resolution and bidding only for patronage (impossible the previous year because of the press coverage), MCANW was able to obtain patronage. The same lesson is true of the successes and failures of resolutions on unemployment and health which have succeeded when confined to legitimation, but have failed when they bid for higher levels of support.

The left in medicine owes it to the left generally to learn how to mobilise the support from medicine that is possible, instead of sinking valiantly with the Red Flag flying, an approach which might be exciting and fun, and may boost one’s ego no end, but doesn’t actually help the movement.

Will Doctors Make Common Cause with Patients?

An alliance between the medical profession and the patients’ movement could be a powerful force for reshaping and defending the National Health Service. At one level such an alliance could be easier to bring about than an alliance with the left, simply because doctors distrust politics but are committed to an ethic of service to patients. However at another level such an alliance would be harder to bring about because the patients’ movement challenges the power of doctors in a way that the left does not.

The left may challenge some of the formal managerial power of doctors and demand democratic control, but it does not challenge the intimate reality of the doctor/patient relationship. Indeed, in demanding more resources for health care, resisting economic assessment of the cost-benefit of health care, placing defence of the NHS above its reshaping, as well as being noticeably uncomfortable with questions of priorities, the left is the medical profession’s best ally in expanding its empire.

If the medical profession were convinced that an alliance with the patients’ movement offered real prospects of a political pay-off it might be prepared to renegotiate some of the issues which currently lead it into conflict. There is scope to make progress on issues like a mutually acceptable complaints procedure if that would facilitiate developments such as a common campaign for improvement of the NHS.

What stands in the way of such a development is that the patients’ movement actually has very little clout with which to deliver such a pay-off. Nor is it at all clear that the motivations which lead people to challenge the nature of their relationship with their doctors would survive a transformation of their organisation into a straightforward campaign for health care, however accommodating the medical profession was prepared to be to secure such a transformation.

Doctors must accommodate the patients’ movement to a certain extent lest it damage their reputation as disinterested servants of the public. If the movement gains power and support they may well establish liaison arrangements through which issues can be negotiated. It is unlikely that there will be scope for alliance, except perhaps where doctors can genuinely demonstrate that the reason for a poor doctor/ patient relationship is lack of resources.

Will Doctors Identify with Other Health Workers?

The attitude of doctors to other health workers has certainly changed over the last ten years. The 1972 industrial action attracted hostility from the profession at large and embarrassment on the part of the left. The 1983 industrial action attracted sympathy from the profession at large and active support from the left.

Over that time the BMA had passed through a process in which it had become overtly trade-union minded and it is now much more likely to describe NUPE, COHSE and ASTMS in terms which suggests that it accepts them as being in the same business. It speaks even more warmly of NALGO and IPCS.

Yet medical paranoia still sees other health workers, even professional workers, as part of the external hostile world. Doctors’ behaviour towards other health workers is still arrogant and dominating.

The struggle for professionalisation by the paramedical professions is a key battle. If doctors in the specialties which rely on team-work can be persuaded to see their own downgrading in the medical status system as analogous to the downgrading of their paramedical team colleagues, there may be scope for refocussing professional consciousness so as to embrace the paramedical professions rather than to exclude them. Such an approach was discussed in some detail in Chapter Twelve. The MPU, within ASTMS, is well placed to present such a campaign to the medical profession. The danger in the campaign is that it might merely refocus elitism rather than break it down, and might play into the hands of those who want to divide professional from non-professional workers.

Can the medical profession begin to see itself as a group of health workers which, whilst it has interests at variance with those of other workers, has even more interests in common? Moreover, is this a true picture? Can doctors be persuaded that it is true?

Part of the problem is that it really isn’t true. Doctors have power and, whilst some doctors have less power than others, their interest is in gaining their share of that power not in dissipating it. So long as doctors have that power they will inevitably be part of management rather than part of the workforce.

The common interest that doctors do have with other health workers is in defence of the NHS, and whilst the NHS is under attack doctors and other health workers can be brought closer together. That probably accounts for the movements that have taken place over the last decade.

It can also be argued that doctors have a common interest with other health workers in levels of health service pay. However this is only true when the pay of doctors and other health workers are constrained by the same factors. Hence doctors have been closer to other health workers when their pay has been subject to the same constraints than when they have been treated differently. It may be that it will become increasingly difficult for doctors to be preferentially treated. But the medical profession is well aware that it is cheaper to settle with doctors than to treat all health workers fairly and that medicine will achieve better deals in isolation than it will in unity.

To some extent, because of their paranoia and their ideology of struggle, doctors see themselves as less powerful than they are and may underestimate the extent of their privilege. They may therefore be more amenable to seeing their interests as tied to those of other health workers than would actually be justified by reality.

On the other hand medical support for other health unions may be more easily motivated by paternalism on the part of those who recognise, and feel a responsibility for, their privilege.

Health unions would be well advised to discriminate between those issues in which doctors do have common interests with them, such as defence of the NHS, and other issues. They may also be well advised to discriminate between the more powerful and less powerful members of the profession and seek to pry them apart instead of pushing them together in the face of a common enemy. But, for all that, health unions will continue to remember that the interests of doctors and the interests of other health workers do differ, and that doctors won’t forget that.

For the Labour Party this poses problems. Does the party seek to secure progress for its health policy by negotiating it with the medical profession, based on a historical understand­ing of the emotions and interests of doctors, as I have advocated? Or does it take the view that such an approach would inevitably make concessions to the interests of doctors in areas of conflict with the interests of other health workers? Probably it should tackle this dilemma pragmatically, balancing the needs of workers, the needs of the service and the need to accommodate powerful forces.

For the left in medicine the dilemma is that a form of double-think is induced. Left-wing doctors identify with other health workers on political grounds, and there is nothing wrong with that. In seeking to enrol the rest of the profession they will emphasise the common interest of doctors with other health workers, but other doctors will not believe them because the argument isn’t true, nor is it actually the reason that left-wing doctors support other health workers. In arguing for support for other health workers left-wing doctors will actually be appealing to the paternalism of the profession. They cannot make an overt appeal to that paternalism, because they would find it unacceptable to do so, nor can they reveal their own real motives (even though everybody knows what they are) because they would be unacceptable.

Therefore the left in medicine will support health workers for one reason, will argue that the rest of the profession should support them for another quite different and invalid reason and will thereby hope to persuade the profession to support them for a third reason, different yet again, which the left is unwilling to appeal to directly.

Left-wing doctors will conceal this dilemma by conflating the concept of ‘other health workers’ with the concept of ‘other health professionals’ so that the shared interests of the MPU’s constituency within medicine and the ASTMS’s constituency in the other health professions becomes a supposed model for the shared interests of all health workers. In doing this they will be aided and abetted by the way in which white-collar unionism dilutes its elitism with large dashes of workerism and trade union fundamentalism.

For left-wing professionals the membership card of a trade union affiliated to the TUG is a certificate of membership of the working class. The problem is that to be effective they have to avoid inducing that perception in their apolitical potential recruits.

Conclusion

The relationship between the medical profession and progressive movements is not straightforward. It is a complex of points of common interest and points of conflict and can only be improved by negotiating the one against the other. That can only take place if the points of conflict and of potential alliance are correctly specified. Moreover the profession is not monolithic, although it may present a monolithic face, and it can be influenced by internal as well as external pressures, if its internal politics are correctly understood and progressive doctors competently play their part in negotiating the terms on which professional unity can be maintained.

This may seem a bland and obvious truism with which to conclude a book. But however obvious it may be, it is still a lesson that the left has not yet learned.

What do you think?

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