martin rossdale

8/17/2019 Martin Rossdale

1/23

Martin Rossdale

More than any other creation of the post-war Labour Government the National

Health Service has been regarded with veneration and satisfaction by those on

the left. And indeed, confronted with the vicious medical anarchy which pre-

vails in the United States, no generous person can fail to regard with some grati-

tude the effort to provide adequate medical care for the whole British popula-

tion, to raise the ethics of medical practice above those of the market place.

Nonetheless such veneration and satisfaction has blinded those on the left to the

immense faults of the NHS, considered in a socialist perspective. An earlierarticle, in New Left Review 34, attempted a definition of health on socialist

principles; in the article which follows a number of crucial factors have been

selected which dramatically illustrate the failure of the NHS to care properly for

those for whom it was set up, and how this failure has affected the doctors around

whom, and despite whom, the NHS was erected.

Socialist Health Service?

3


2/23

Doctor and Patient

Both doctor and patient showed no awareness, had been given no indication, of how the new Health Service might embody an entirely fresh approach to ill-health.

The doctor/patient relationship has been the subject of innumerable

edulcorations on the radio and television. Time and again we are shownthe doctor as an altruistic, humane healer, above the vulgar influence of cash and business interest; and the patient, ready to co-operate withhim for his own good. Why such falsification? The doctor/patientrelationship is pitted with conflict; the lie merely repeated to dullour suspicions.

What generates this conflict? The kind of medicine which the doctorspractise and the nature of sickness itself. The new diagnostic andtherapeutic techniques, extraordinarily potent by comparison with their

predecessors, entail much greater risks to the patient. To use themsafely the practice of medicine requires ever greater precision and order.Rules have to be imposed and applied: to enforce them hierarchy anddiscipline are needed. But doctors are trained as decision takers, theireducation teaches them adulation of professional independence, of fullmedical responsibility for the patient, of continuity of care. The formwhich the scientific revolution in medicine has imposed on the actualstructure of the practice of medicine has engendered conflicts betweenthe doctor and medicine itself, conflicts which the doctor cannot actout because of his professed ethic and his attitude to medicine and the

patient. The strains burst forth in jets of anger and frustration, in auto-cracy, abruptness, the imposition of the doctor’s will on his patient, ashis right.

In practice it is unusual for anyone to claim that there is privilege;though in one sense it is obvious: the doctor is well, the patient sick.This confers a wide range of advantages, in particular mobility and free-dom. In addition, the sick man has had imposed upon him a dependentrole, he has asked the doctor in, he has asked his advice, he is willingto take it; this is the contract he has entered. Then there are the de-mands of society. Society does not want people to be sick. This is thereason for the institution of medicine. The doctor has to protectsociety from excessive sickness; a sickly society is inefficient and maydie out altogether, as the early settlers of Greenland did. At the sametime society is continually on the watch for fake sickness. Peopleappreciate that the environment can produce sickness in them, but thatthey, in their turn, can protect themselves from their environment,their society, by the production of sickness. The reality of such sick-ness is disputed, though conceded by the common idiom. We say we

are sick of work, of this district, etc. For such cases society needsdoctors as policemen, to protect itself against the skrimshanker, themalingerer, the lead swinger. And the doctor resents this role for throughit he is brought into conflict with his professed loyalty to the patient. Thisis why doctors resent certification. If a doctor refuses to concede theright of his patient to take time off work by signing the certificate, heexposes his role as health policeman, his loyalty to the other side, an

4


3/23

allegiance which he may prefer for social or class reasons beyond hisstated one.

Resentment and Fear

Because there are social pressures to be normal, most people do notwant to admit that they are sick; this is not merely because sickness ispenalized by a diminution of income and the curtailment of freedom.There are social pressures which force a person who falls sick ‘to actsick’; to go to bed, to take medical advice, in fact to undergo the arche-types of illness—the harrowing process of restriction, fear, and sub-mission to unwelcome procedures. If you are sick ‘you owe it to others’,‘you owe it to yourself’, ‘you ought’, even (in the case of certain con-tagious diseases) ‘you must’ go to bed, see a doctor. Most sick peopledon’t want to, they resist, and so when at last they do get to see theirdoctors, their mood is one of resentment, as well as of fear.

The resentment which patients feel towards their doctors is partly theconsequence, too, of the conditions which are imposed upon the patientby the system through which medicine is practised. The doctors andnurses have to play a part too—we shall come to that later—but thescript has been written for the patient and the doctor/director is notlikely to allow much freedom in the patient’s interpretation. In essencethe patient is helpless, he has admitted it by calling on the doctor and socontracting to accept his advice; he needs the doctor’s help and for it heis ready to co-operate with the doctor for his own good. The extent to

which a sick person signs away his rights and responsibilities as acitizen is hardly recognized. In hospital no patient expects to choosewhere he should sleep or in what company. He will take the food he isoffered. He will not question the treatment meted out to him, sub-mitting himself to the most unpleasant—and frequently medically use-less—procedures in order to ‘get better again’. His contact with theoutside world is restricted—he can see his friends and relatives onlyduring visiting hours, which are short and at compulsory times. If he islucky and mobile he may have access to a telephone, but he may not.The radio or television in the ward is likely to be tuned to one programme;if he is fortunate enough to have earphones his listening is optional, if there is a loudspeaker it is not. The point about these restrictions is thatthey are generally just accepted as part of the set-up, the way they dothese things, part of the system. (The most poignant example of suchdumb acceptance is the way relatives meekly hang about sister’s officeat visiting time in hospital to learn what is the matter with X and whatmay be expected. Then they pass on the edited scraps to the patient.)Consider the doctors’ resentment of patients who will not abide by ‘theirside of the bargain’. The difficult patient, strangely enough, is not the

patient whose serious illness poses most problems to the doctor (he isan ‘interesting case’ and is so frightened and so weak that he cannotresist the discipline imposed on him). It is the patient who is nearlybetter, or the patient who refuses to realize how ill he is, who makesthe most trouble for the medical staff. Again, there is the patient whodoes not appreciate the importance of medical etiquette, the patientwho goes to his medical practitioner merely for help in getting an

5


4/23

appointment with another consultant; or the dissatisfied patient whochanges from one doctor to another.

It is natural for the sick man to be apprehensive. Every sickness is avoyage into the unknown. The only people who have the maps are thedoctors: they drew them. Their knowledge of them is part of theirpower. (This partly explains the resentment by doctors of patients

who read up the details of their condition in medical textbooks.) Thesick man is under physical strain—the actual disability of his illness—but he is also under a mental, an emotional strain. Even when it is not thepatient’s fault that he is unwell and cannot work he does not receivefull compensation for the loss he incurs as the result of his sickness, so asubstantial part of the strain on him is worry about his dependents, aboutthe rent, and about his financial commitments. Then too he is worriedabout himself, about future experiences of pain, treatment, even death.According to conventional wisdom, part of the burden of the patient isoff-loaded on to his medical attendants; the worry, too, is eased by thefaith the patient has in his doctor, as if every patient were able to believethat his doctor was the best for him and his illness. The reality isstarker. By and large patients have to take the doctors they get, and theyhave to put up with the treatment they get, in whatever hospital andin whatever company they happen to find themselves.

The patient is especially vulnerable to the demands of the doctor,moreover, just because he is so helpless, ready to clutch at any straw.Because his emotions are involved, he more unquestioningly accepts

what he is told. He may be more ready to accept the most flimsy ex-planations for his failure to get better than the bad news that he hascancer. (Some patients will superstitiously resort to proprietarymedicines, to panaceas and nostrums: the sick man is peculiarly at themercy of rogues.)

Doctors’ Attitudes to Disease

The difference between the attitude to sickness of the patient and of thedoctor is pronounced. Sickness, disease and death are the doctor’s

stock in trade. From the very earliest days of his medical education themedical student is on intimate terms with death. The cadaver is his in-troduction to the preclinical course, the autopsy specimen to hisclinical. In such ways the sensibility of the medical student, at thisstage in its formation no different from that of any other man, with itsstrong but suppressed fear of disease and death, is assaulted. Somestudents drop out. Those who remain are bound together: such harshand traumatic experiences are part of the initiation of the medical man.Later, in the wards of his teaching hospital the student encounters

disease removed from its environment and studies it without its con-text. Here the student is encouraged to follow the fortunes of a givenpatient, the vehicle of this or that disease, mastering the details of hiscondition and following its course to a successful cure, to palliation orto death. Again and again he will do this until he has learnt the follyand dangers of attaching himself too closely to any patient. (The lessonis enshrined in the aphorism ‘you can’t die with every patient’.)

6


5/23

All the same the doctor would be less than human if he were able tomaintain complete objectivity before his patients’ suffering. His train-ing then fastens on him another buckler—technical competence. This,of course, is the most important part of his contract with the patient,and the technical competence of the doctor is both his protection andhis most important tool. The understanding between them is clear onthis count too, that the doctor should place the interests of his patient

above all other considerations; that he should have an entirely objectiveestimation of the patient’s needs and that what he does for the patientshould be based upon these considerations as they impinge upon hisknowledge and technical ability. The doctor’s confidence arises fromhis technical ability and is eroded just because that ability can never beadequate. In the first place technical competence per se gives the doctoronly a limited social assurance in his regular confrontation with all sortsand conditions of men. His experience has probably been confined to asmall and well treated group, any other experience he may have had isvicarious, not actual. His advice, therefore, is couched in terms of hisown priorities, the importance he allocates to health in life, the securitywhich his work has assured him. He has had little experience of hardmanual labour in rough conditions, little experience of poor housing,poor food. In the second place there are very many diseases which thedoctor cannot cure, where the best he can propose is palliation andwhere, nevertheless, although he will not have claimed that he can curehis patient no matter what, a cure is expected of him. He is liable to beset back on his heels by the realization that his technical competence,his knowledge, is a real disadvantage.

Again, in every medical situation technical competence is challengedby the maverick element in the biological organism—toxic reactions todrugs, the atypical presentation of disease, ‘miracle cures’, and, equallymiraculous, the fulminating advance of disease. (The ascription of cures alone to the kindly intervention of the deity is a vivid example of the superstitious tolerance of people to the chance successes of doctors.)Prediction is also expected of him, the ability to forecast the course andoutcome of disease. But even a long experience of disease may be con-founded by the ‘wild’ human and spiritual response to stress. Everyone

knows the story of the man ‘given’ three months to live who outliveshis doctor. Can technical ability provide the formula with which toexplain to bereaved relatives the statistical inevitability of the one in nfatalities to this or that drug?

Hardly Credible ‘Rights’

Some ‘rights’ of medical attendants would be hardly credible in anyother context. The power to do strange or unpleasant things to thepatient, the power to demand confidences, to make assumptions, are

dressed up as functional necessities.

An important example of the power of doctor over patient is the case of the use of the placebo, that is, a medicine which is given to benefit orplease a patient, not by its pharmacological actions, but by psychologicalmeans. To the doctor who has been trained to accept as paramount theorganic causation of disease, the use of such a drug is a confession of

7


6/23

failure. ‘Those who have qualms of conscience about prescribingpharmacologically useless medicines tend to use semi-placebos, such asvitamins, in the vague hope that these may do some good. This is wrong,for thereby the prescriber deceives himself as well as the patient. If deception there must be, let it be wholehearted, unflinching andefficient. A placebo medicine should be red, yellow or brown; forblue and green are colours popularly associated with poisons or external

applications. The taste should be bitter but not unpleasant. Capsulesshould be coloured and tablets either very small (on the multum in

parvo principle) or impressively large; they should not look like every-day tablets such as aspirins.’1

Whence the humbug? It follows inevitably from a vision of medicinewhich can only recognize the organic disease. If the cause is not organic,the symptoms must be dealt with by trickery, by magic. If the doctorsattach most importance to the organic disease, it is natural that theirbias should infect the patient. The patient produces organic symptoms—

real enough to him—to attract the medical moth. If a patient whosetrouble is fundamentally environmental discovers that however he dis-plays it, the doctor’s first response is to look for an organic lesion, hewill do two things: he will start to think of his ownproblems in organicterms; and he will produce further organic symptoms when he findsthat the treatment of the original ones has not alleviated his problems.So it is even the doctor’s privilege to dictate what form the patient’ssickness should take.

If it is true, as we have suggested, that the doctor/patient relationship

contains suppressed antagonisms, then we should expect to find, builtinto the institutions through which the relationship is conducted,devices to absorb, take up and mask such antagonisms. This is so. In ahospital, for example, either the unpleasantries which the patient has tosuffer are performed upon him by subordinates or auxiliaries who arenot responsible for the decision, so that the doctor in charge is cushion-ed; or the patient is physically unaware—anaesthetized—of what thedoctors are doing to him, their assault on his body in surgery. Doctorsrealize what they are doing, what they feel they have to do to patients,but they know as men, not doctors, how their patients will feel aboutwhat has to be done. In much surgery it is necessary to pass a tubedown the patient’s nose into the stomach to enable the contents to beremoved. The passage of such a tube is unpleasant and while it staysdown (for a few days) it irritates and annoys the patient. Some surgeonshave the nurse pass the tube (the assault) but remove it themselves.There are techniques of anaesthesia, too, which make it possible foroperations to be carried out without the patient losing consciousness.But even when these techniques are used it is quite normal to administera light anaesthetic nevertheless: the patient does not want to follow too

closely what is being done to him, and the doctor is content that heshould not.

Hierarchical Barriers

The administrative structure of the hospital reveals a similar buffer

1 Lancet ii, 321,1954, Editorial, ‘The Humble Humbug’.

8


7/23

system. Of course the doctors have not deliberately organized thehospital in order to avoid painful emotional involvement with theirpatients, but the hierarchical forms which have been selected permitthis. In hospital, under the consultant doctor who is in charge of anypatient, there is a registrar and under him a houseman. The patientlives in a ward which is the responsibility of a sister under whom,arranged in an appropriate peck order, are staff nurses and other nurses

in various stages of their training, seniority and responsibility. Theancillary services are arranged in a similar way. If the patient had animmediate personal relationship with the doctor responsible for him, itmight be impossible for the doctor to insist on the unpleasant pro-cedures which his training taught him to think necessary for the pat-ient’s good. To evade such situations deputies are used extensively. Thedoctor with whom the patient has most opportunity to make personalcontact, the houseman, makes few decisions about the treatment of thepatient. He has to present his chief with a daily digest of his patient’scondition. Most of the decisions are made by the registrar and the mostdifficult ones (those which cause doctor as well as patient most distress),are made by the consultant, but contact between the consultant and thepatient is minimal. The consultant has to assess the information hereceives from his subordinates about the patient and to collate it withhis own findings. That is why we so often hear patients complain thatconsultants are distant and inaccessible. But we do not hear the samecomplaints from the other doctors because unlike patients they do notexpect a personal interest to be taken in them. General practice pro-vides another example. The professed ethic of the family doctor is that

he is available whenever his patient is in need, but there are times,especially at night, at the weekend and during social occasions when thedoctor feels that the claims of the patient on his privacy, on his sleepand on his recreation amount to an assault. At times like these the doctorresents the discovery that he is at the patients’ beck and call.

Such conflicts in the doctor/patient relationship are not openly ex-pressed although they are common knowledge. (They are ritualized andcherished in the gross rituals of Ealing medical comedy, a pabulum of inexhaustible attractions to the public. Medical humour, from the post-

card antics of lecherous housemen to the ludic rituals of hospital staffsat times of festivity, when doctors are dressed up as women and submitto the overtures they are commonly imagined to inflict on nurses, orwhen plates of turkey are left in front of patients on intravenous diets,offer the most melancholy critique of the relationships under discus-sion.) They are as integral a part of the NHS as the modernized work-houses which have provided its hospitals. Both seem resistant tolegislative demolition. But unlike the run-down hospitals the reason forthese conflicts are structural. They will remain so long as health is con-sidered a commodity and the patient a vehicle which brings disease to

the doctor. A better relationship depends on the bilateral understandingof common problems, a more open, total, relationship between them.

The Doctors

Who are the doctors? What are their prejudices, their training, their beliefs? It isthey who determine the personality of the Health Service. Of especial interest and

9


8/23

of vital importance therefore is the character of the institutions which doctors of the past and present have created to train the doctors of the future. Theseinstitutions are the teaching hospitals.

The teaching hospitals of England and Wales were allowed to main-tain their own boards of governors and to be administered separatelybecause it was argued that this would give them greater freedom to set

higher medical, scientific and research standards whose effects would bespread throughout the regional hospitals. Almont Lindsey in his

Socialised Medicine remarked: ‘The revolution in administration, whichdrastically altered the basic pattern of so many hospitals, was milder inits effects on the teaching hospitals. Having occupied a somewhatprivileged position before the establishment of the Health Service,they were permitted to continue as aristocrats of the hospital world.’By comparison with regional boards there is a far higher proportion of doctors on Boards of Governors, the result of appointments by theuniversity and by the hospital medical staff. They are not restricted to amaximum of 25 per cent doctors on a board. Unlike regional boardstoo, they have no management committee, they are their own execu-tive and select their own staff. The members of the boards are volun-teers—the cause of a heavy class bias as the tradition of public service islargely confined to those with the leisure, money and social confidenceto indulge in it. The privileges of the position of the teaching hospitalswere a greater administrative independence, the maintenance of theirown boards of governors directly answerable to the Minister; moremoney per patient;2 the retention by the boards of governors of endow-

ments (the endowments of other voluntary hospitals had passed to theMinister), the right to receive further endowments, and the right touse these as the testator had directed and as they saw fit.

They enjoyed other privileges which were more indirectly related totheir status as teaching hospitals. Situated in large cities, they were lessliable to the shortages of ancillary staff which reduced the efficiency of remoter hospitals. They employed approximately double the number of doctors and nurses per patient. Their prestige enabled their nursingschools either to work an effectual colour bar in the selection of their

nurses or to work a severely limited quota in their intake of immigrant

2 The National Health Service Accounts for 1960–61 show that there was a largedifference in the cost of caring for a patient in a hospital administered by a HospitalManagement Committee and in a hospital administered by a Board of Governors.

Net in-patient Net in-patient Type of hospital cost per week cost per case

AcuteCases £27.16s.11d. £53.12s.3d.

HMC Hospital

MainlyAcute £23.19s.6d. £63.18s.9d.

AcuteCases £36.12s.1d. £74.4s.od.

BOG HospitalMainlyAcute £32.4s.1d. £83.11s.4d.

10


9/23

nurses.The case fatality for a number of conditions, notably ischaemicheart disease, peptic ulcer, appendicitis, hernia of the abdominal cavitywith obstruction, conditions of the gall bladder, hyperplasia of theprostate and skull fractures and head injuries, is significantly lower inteaching than in non-teaching hospitals.3 With the exception of theLondon Hospital every teaching hospital in London is within threemiles of Harley Street. A consulting appointment to a London teaching

hospital is the foundation of a flourishing private practice, and most of the teaching hospitals have large private wings attached to them.

The causes of the anomalously privileged position of the teachinghospitals lie in medical and political history. The prestige of the voluntaryhospitals was reflected partly from their aristocratic sponsors, partlyfrom the status of scientific medicine, the loyalty of the medical menwho had been trained in them, and the dignity they acquired by theiremployment of notable members of the medical Royal Colleges. ButBevan used the old divisions between the local authority hospitals andthe teaching hospitals to prevent the former from organizing anyopposition to the acceptance of his plans. By offering the top doctorswho worked in the teaching hospitals preferential conditions of work,part-time sessions to allow them to continue their private work, thesecret disposal of public money to be paid them as ‘Merit Awards’ to bedecided by their cronies, and the right to administer their own hos-pitals, Bevan seduced the doctors who worked in the aristocraticteaching hospitals into acceptance of the National Health Service. Inthe name of academic freedom it is argued that teaching hospitals must

remain outside the regional hospital board pattern. In London wherethere are 30 different hospital authorities, 26 of these are teachinghospital authorities—12 undergraduate and 14 postgraduate. Theseteaching hospital authorities are highly selective in the type of patientthey admit. In the case of the postgraduate teaching hospitals they all,except one, serve specialities and are not available to admit generalmedical cases. The undergraduate teaching hospitals too, do not servethe general medical need—they are not forced to accept cases sent tothem by the Emergency Bed Service, the central clearing house forpatients in the area—and the patients they select for admission are

chosen according to their value as ‘teaching material’. Of the 23,412beds in the London hospital area in 1960, 12,251 were under the controlof teaching hospitals. Thus in the capital itself, the effect of Bevan’sconcessions to the teaching hospitals has been to drive a coach andhorses through the principle of regionality and of the availability of hospital beds according to the needs of the patient.

Selection and Recruitment

Aside from the critical consequences of the teaching hospitals’ academic

and material superiority to regional hospitals, their importance in theNHS is also due to their role as selectors and educators of doctors.Medical students are selected by medical schools, either by the Deanalone or by a committee of members of the staff. There are many moreapplicants than vacancies, although the figure is inflated by the practice

3 Lee, JAH et al . Lancet , 1957, ii, 785; 1960, i, 170 and Medical Care, 1963, i,71.

11


10/23

of applying at several medical hospitals at the same time. At theLondon Medical College in 1954 there were some 3,000 applicants of whom 600 were given interviews and of whom only 100 gained aplace.4 It is hard, therefore to credit the claim that there is a shortage of applicants of adequate quality, especially since the doctors alone are thearbiters of the qualities, aside from the straightforwardly academic ones,which are required for a recruit to their profession. The claim is even

harder to credit when the exceptionally large degree of self-recruitmentinto the medical profession is appreciated. In 1957, 50.6 per cent of allmedical students in British medical schools had fathers who weredoctors. (Doctors take between 5 and 7 years to train. Medical recruits of 1957 are junior doctors now). In the London teaching hospitals thefigure was 73.2 per cent. Of the total numbers of parents of medicalstudents whose occupations could be classified in 1957, manual workersmade up only 16.1 per cent; and in the London teaching hospitals thefigure was lower: 13.8 per cent. These figures for medical and dentalstudents are the lowest of the entire student body of Great Britain; intechnological subjects the percentage is more than double. The educa-tion of medical students before their arrival at medical school is shownin the charts below which compare the primary education of male andfemale medical students in London and the rest of Britain with thenational averages for all university students. The figures are percentages.

London Medical Students Nat . Av. for Med . Studs. Nat . Av. Univ. Male Female Male Female Male Female

LocalAuthority 39.5 26.6 50.9 44.0 65.8 60.7Private

or Prep. 41.6 57.6 32.2 38.8 22.0 26.6BothTypes 16.7 15.8 15.2 15.1 10.8 12.3Notanswered 2.2 0 1.7 2.1 1.4 0.4

The next table5 compares the secondary education of British malestudents. Male students at London teaching hospitals are comparedwith male medical students over the rest of the country and with malestudents in all other faculties.

London Medical Other Medical All University

Schools Schools FacultiesHeadmasters’ Conferenceand Independent Schools 43.1 32.5 21.3Direct Grant Schools 9.0 13.4 12.6Grammar Schools maintained bythe Local Education Authority 42.3 48.6 60.2Non-HMC IndependentSchools 4.7 4.3 5.0

It is also interesting to note that even in 1964, in a survey carried out ina London teaching hospital by the students themselves, 67 per cent of

them had had a Public School education, 28 per cent had been educatedat a Grammar School, 4 per cent had been educated privately and 1 percent had had a technical education.

4 Almont Lindsey. Soc. Med. p.175 and Kelsall R.K., Applications for Admission toUniversity state that there are more applicants per place to medical schools that for anyother University place.5 Kelsall, Application for Admission to University, 1957.

12


11/23

It would be unwise to extrapolate too far from these bizarre figures, butit cannot be denied that the medical profession, judged by its recruit-ment lies stranded on the beaches of tradition.

In their publications at least, medical educators make clear what theylook for in candidates for medical training. Dr Henry Miller of theMedical School of King’s College, Newcastle spaciously declared that

the only qualities required in a medical student were high intelligence,good character, pleasant personality, robust physical and mentalhealth, indomitable spirit, boundless physical energy, a sense of humour,and keen ambition disciplined by a lively social conscience. He mustalso be happy. ‘Of course, such qualities would also fit the applicant totake up the post of Prime Minister, Archbishop of Canterbury, orSecretary of the Medical Research Council. Unfortunately they are notconspicuous among those seeking to sit at the feet of the medicalteachers in the University of Newcastle upon Tyne.’ ‘On a morerealistic level’, said Dr Miller, ‘it would perhaps be reasonable to ex-amine the qualities of really good doctors. In this connexion he wouldrefer to the kind of doctor anyone would like to look after them if theywere ill. . .’ What were the qualities manifested by such a man? Thefirst was that he was not always by any means intellectually brilliant. ‘Ithink he is always intelligent, and usually very intelligent, but often ina rather pragmatic way. It seems to me that clinical medicine has littleuse for the neurasthenic type of individual . . . I know there have beengreat neurasthenics . . . but I do not think any of these had the qualitiesrequired in a responsible clinician . . . Finally I would say that there is

another quality which is required and which is in many ways the mostimportant. I refer to common sense . . . we all know brilliant academicsto whom nobody ever entrusts their health. They may be positivegeniuses but they lack . . .’

The tone is familiar, recalling the accreted wisdom of a hundred public-house arguments; the facetious positing of the unattainable ideal, theappeal to sound common sense, the preference for the empirical manrather than the brilliant one, and more seriously disturbing than any of these, the conception of the ideal medical man in terms of the clinician,

the organic medicine man.

The greatest failure of the teaching hospital is its failure to see themedicine it teaches in terms other than its own. In them the needs of clinical medicine have been promoted over the requirements of thewhole Health Service. The irony of Bevan’s device to ensure the parti-cipation of the most prestigious doctors and hospitals has been to givethem the power to distort the NHS according to their will.

The Medical Curriculum

Just as important as the actual selection of medical students is theirformation—the medical curriculum and their extra-curricular activities.As the doctors in teaching hospitals see it, the future of medicine here isdependent on a homogeneously conscientious, well-disciplined andmeticulous working force of junior doctors, the men they are training.In a sense they are right. Because of the risks entailed it is preferable to

13


12/23

ensure that recruits to medicine are sound, painstaking and meticulous,rather than brilliant and intuitive. (Brilliant doctors are necessary too.)Like other students medical students are curious, lively and energetic;the problem of the teacher of medicine is to curb or remove undesirableirregularities without producing a smooth planed surface.

It is here that the curriculum, not only its content but those aspects of it

which are stressed, plays an important part in the transformation of thebrash medical student into the socially accepted ideal of the doctor. Thetone of many textbooks of medicine is profoundly conformist or evenreactionary—thus one surgical text book describes anal and penile wartsas being found especially amongst the criminal classes. In a textbook of psychiatry the paranoid personality is claimed to be found amongst ‘theactive, self-righteous and dogmatic people who stand up for theirrights, to real or supposed infringement of which they react with vigour,the founders of sects, movements of all kinds, who are dominated byan over-valued idea, best described perhaps as a “bee in the bonnet”.’A stress on conformity, however, is not only apparent in the textbooks.The medical student is constantly aware that his behaviour is underassessment against the time when he will apply for his first appoint-ment at his own teaching hospital.

The corollary of this is the suppression or inhibition by the teachingstaff of activities or criticisms which they find undesirable. Thus, in theSt. Mary’s Hospital Gazette again, two pages were left empty where areport on clinical teaching should have been printed. The Dean would

not allow it to be published for the normal circulation of the paper. Atthe Middlesex Hospital an entire issue of the journal was impoundedbecause it included among statements on birth control by representa-tives of the Church of England, the Church of Rome, and Judaism: anarticle by a representative of the Family Planning Association in whichpre-marital intercourse was mentioned neutrally. It was suggested thatthis might adversely affect the recruiting of nurses. On another occasionthe student editor of a hospital magazine was warned by the Dean afterhe had published an article on the DDR which was not condemnatory.

Another factor which produces conformity and discipline within thehospitals is the excessively hierarchical structure, so that the peoplewho work and study in the hospital are divided into grades and levels,each separate from the other.

In most hospitals, for example, there are subtle differences in the uni-forms of nurses at different stages of their training and grosser differ-ences between them and fully trained nurses. There may even be as manyas three different kinds of white coat to distinguish various classes of

doctor.

Yet another important quality of the curriculum arises from the choice of which aspects of medicine are and are not included, and from thevarying amounts of time devoted to each.

The medical curriculum has two parts. Preclinical education, during

14


13/23

which the student is taught the elements of physics, chemistry andbiology, followed by anatomy and physiology; and a clinical trainingon the wards of a teaching hospital as well as in its outpatients andother departments. Medical education as a process of teaching thestudent to reason, to search the world with fresh eyes and draw con-clusions from his observation, ceases when the student has taken the2nd MB at the end of his preclinical education. In the wards great store

is set by clinical observation but none by the observation of the patientin relation to his surroundings. With the start of clinical work thestudent becomes increasingly preoccupied with the acquisition of skills and the learning of techniques, too numerous to list here, all of which have been evolved with the object of answering specific ques-tions about the functioning of this or that mechanism of the patient.

The Concept of Specialism

The concept of specialism is deeply bedded in the teaching hospitals.Like every other speciality, psychiatry for example is competing for thetime of the student, hawking its own view of medicine, anxious toreproduce itself. And because the teaching in these hospitals is doneby the practitioners in that particular branch of medicine, becausethe establishment of consulting and teaching posts has fossilized pre-vious priorities in medicine, the most venerable subjects are taughtmost, and the newest subjects are taught least. Thus the student spendssix months each on medicine and surgery, shares two months betweenproctology, psychiatry, ears, noses and throats, and has only two

lectures on the structure of the NHS and on the Public Health Services.

Because the teachers in hospitals are specialists, excelling in a particularbut circumscribed field, they are unable to integrate their own speci-ality with what other specialists have taught, and not usually interestedin trying. To the student of medicine his patient is less than the sum of hisparts, each of them the province of another specialist. The apogee of the medicine he is taught is the ‘grand round’ of a professor of medicine,with a medical registrar, a houseman, a ward sister, a physiotherapist, a

psychiatric registrar, a priest, an almoner and six students in attendance.

It is not surprising, therefore, to learn that there is little discussion inteaching hospitals on the nature of health itself, on the purpose of thepractice of medicine, on what are, and what ought to be, the growingpoints of medicine. Such discussion as there is, is unintellectual,empirical. The criterion is what can be done, not what ought to be done.That is why the teaching hospitals and the medicine they enshrine aredying or defunct. Certainly the juggernaut of curative medicine willroll on, impelled by the efforts of the biological sciences, and we mayreasonably expect medicine to apply the new knowledge to the prob-lems of disease. But if, in those places where medicine is actuallytaught, there is no curiosity, no investigation, into what doctors oughtto be doing, or trying to do, of the place of medicine in society, thenmedicine can never be more than a fig leaf over the more embarrassingparts of the society in which it is practised.

15


14/23

Medical students have a narrow interest in medicine because of anoverly specialized training. They know little of society and its mechan-isms, of the place of medicine within the social sciences, of the inter-relationship of the productive processes (of housing, of work, of traveland communications). They are blinkered by their education; anyinterest they might have had has been repressed by reactionary teachers.Among the teaching hospitals in London, there is only one in which

there is a political association. In many hospitals they are forbidden. Evenattempts to hold a meeting about Nuclear Disarmament have beenblocked. On the other hand the religious societies of numerous cultsproliferate, and these, together with extra-curricular activities of themost neutral kind provide the worthless fodder which leaves medicalstudents with cultural beri-beri. A typical medical school notice boarddisplays:

HOSPITAL CATHOLIC UNION

Charlotte Bingham, author of the best seller Coronet among the Weeds

answers questions put by the Rev. Jos. Christie, SJ. Is Chastity out of date?

HOSPITAL OPERATIC SOCIETY

Wanted males. Tenors and bases to sing in The Pirates of Penzance.

CHRISTIAN UNION

Dr A will address the Union on: ‘The Christian Approach to Vacations ( sic )’.

Numerous advertisements for ‘Hops’.

In 1964 the students of Manchester Medical School were polled abouttheir activities. Leisure activities comprised drinking, reading, goingout with girls and going to the cinema and theatre, all about equallypopular. Only 34 per cent of the total were members of UniversitySocieties, of which religious societies accounted for about half andmusical societies were next in popularity. 75 per cent of the menindulged in sport and 42 per cent of the women took an active interestin rugby, golf, cricket, tennis, swimming and squash. Card playing wasthe most popular non-athletic sport. Only 7 per cent took an activepart in politics, 40 per cent were Conservative in their sympathies, 20per cent Labour, and 13 per cent Liberal. 41 per cent were anti-apar-

theid. 64 per cent held some religious belief. 90 per cent of the Catho–lics (15 per cent) were regular attenders, 64 per cent of C of E (37per cent) and in this category reasons given for non-attendance weremainly directed at the church itself. 10 per cent were Jewish of whichonly 30 per cent were attenders, owing apparently to the difficulty of working and going to synagogue on Saturday.

Nonetheless, a look at their selection and education can only answer apart of our question, Who are the doctors? For the general public thereare two images of doctors from which it can generalize. The one is its

general practitioners, the other the doctors as they present themselvesthrough their official bodies. It is not insignificant consequently that inthe press and the news, the doctors are making more public pronounce-ments about their pay and their status in society than they are about,say, modern public health hazards or the changing pattern of disease.Of course there are public statements by associations which aregenerally accepted to represent the doctors (or many of them) and the

16


15/23

quality and character of these statements should not be ignored as anindication of the social character of the medical body. Thus they havespoken in favour of checking the health of immigrants before theiradmission and they have implied that the increased availability of meansof contraception is related to an increase in the diagnosis of certainvenereal diseases. But it is the statements about pay and status whichweigh the most heavily. To understand them we must first look at the

realities of private practice and the NHS payment system.

Private Practice

There are approximately one and a half million people in this country who aremembers of insurance schemes which make private medical care available tothem.

In June 1964, the Nuffield Nursing Homes Trust was operating 10homes with 303 beds in all and planned to open five more homes, each

of about 30 beds, by the end of 1966 to counter the danger of privatetreatment being ‘menaced by a pincer movement of increasing demandand diminishing supply’. In 1961 pay beds comprised 1.1 per cent of allNHS beds, a slight fall from 1949 when pay beds comprised 1.3 per centof all beds. Lees and Cooper6 commented. ‘At first sight the fall in thenumber of pay beds seems odd in view of the rapid rise in the number in-sured privately. A partial answer to the paradox is that 1949–61 fallsinto two distinct periods. During 1949–53 the number of pay beds andprivate patients fell sharply. Since then the number of beds has fallenvery little and even rose in 1961 while the number of patients has risen

by 18 per cent and has been in line with the increase in NHS patients as awhole. In short, an abrupt fall in demand for pay beds during 1949–53was succeeded by a sustained increase that shows every sign of con-tinuing.’

‘The government has not yet revealed its plans for pay and amenitybeds in the current hospital building programme. One view is that thenumber of pay beds may well increase sharply and is based on the factthat many regional boards have asked the leading provident associationsfor the number of members living in their areas.’7 On May 5th, 1958,Walker Smith, then Minister of Health said, ‘I am always prepared toconsider proposals both for private and amenity beds where this ispossible and where, in the view of the Regional Hospital Board, thereis a demand.’

As counterpoint, the Annual Report of the Minister of Health 1961stated that the number of beds unused for lack of staff exceeded 10,000,slightly less than double the number of pay beds administered by theNHS.

Hospital Pay Beds

Private practice occurs both in the general medical services and in the

17

6 BMJ July 8th, 1963 p. 1531.7 Financial Times, January 12th, 1963.


16/23

8 Kenneth Robinson. Speech to the Institute of Hospital Administrators May 1956.9 Royal Commission on Doctors’ and Dentists’ Remuneration. Cmnd. 939, pages 62and 63.10 Op. cit . Cmnd. 9663 para 401.

hospital service. It is difficult to estimate the extent of private generalpractice. ‘Doctors are by nature anarchists’8 so that there are few meansof checking the amount of private work they do or admit to doing. It iseasier, however, to get some impression of the extent of private prac-tice in the hospital service since it is only done by those consultants whoare in the part-time service of the NHS. In 1959 nearly two thirds of allwork done by consultants in hospitals was done on a part-time basis. A

whole-time consultant in the NHS works 11 sessions a week, a part-timeconsultant cannot work more than nine for the NHS. Despite this, in1956, the income of part-time consultants exceeded that of whole timeconsultants by an average of 20 per cent, while in a few specialities suchas neuro-surgery, plastic surgery, thoracic and orthopaedic surgery theaverage was more than 30 per cent.9 It might be thought that these kindof reasons alone would be enough for the doctors to favour the reten-tion of part-time service in the NHS, but if we are to believe the evidenceof the witnesses before the Committee of Enquiry into the Cost of theNational Health Service, there were other sound reasons as well.

‘Provision must be made for part-time consultants in the hospital ser-vice so long as private practice and pay beds continue. These srvice of many eminent consultants could only be obtained through a part-timecontract. One of the beneficial results of the NHS has been the spread of the consultant services to the remoter areas of the country. This im-provement has been due, in some degree, to the provision of consult-ant services on a part-time as well as on a whole-time basis. Privatepractice (including not only the treatment of private patients but also

private work on behalf of the Courts, Insurance Companies, etc) givesthe consultant a wider outlook in his work and prevents his becomingtoo remote from the world outside the hospital.’10

The rationale of private practice for the patient is clearly stated in theBrochure of the Hospital Service Plan, a comparatively small providentassociation:

‘The increase in popularity during recent years of private medicaltreatment is well known among business and professional men and

women, and in fact, people in all walks of life . . . There are manyreasons for this growing interest. Private patients are able to chose thespecialists they wish to treat them, which besides being more medicallysatisfactory assists the creation of the doctor patient relationship that ispsychologically so beneficial, and see him by appointment at times whichavoid coinciding with business commitments. Time and money aresaved through staff absences due to illness being reduced to a minimum.Communication with the patient is greatly facilitated through the use of the telephone in private rooms and visiting hours are more convenient.In fact a Company Executive could meet his colleagues in a private

room and the use of a dictating machine would present no difficulty.Undoubtedly, the feeling of being in hospital is minimized by having a

18


17/23

private room and one can more easily continue to lead a more normallife.

‘Sickness is, of course, a very personal matter and different peoplereact in different ways. Some are naturally gregarious and enjoy beingwith others with whom they can discuss their illnesses—and the food.They do not mind being woken up early, or whether the windows are

shut when they would like them open, whether the lights are on whenthey want to sleep, or being disturbed at night by extraneous noises andpossibly themselves disturbing other patients. Others find these thingsdistracting and prefer the independence of a room of their own whichalso may possibly help them to feel as if they were at home.

‘While everyone is entitled to hospital treatment under the NHS, it is notalways possible nor is is reasonable to expect that it can be arranged soas to fit in with the patients’ wishes.’

Reasonable in tone, this explanation reveals some of the most perni-cious aspects of private practice. It is not made entirely plain why thosewho are not gregarious and who dislike being woken at six o’clockshould either have to pay to escape these unpleasant features of hospitallife or submit to them. In effect private medical insurance schemes areparticularly beneficial for certain privileged classes in the community,typically, important business personnel. Because their companies canclaim tax rebate on the money spent, the community as a whole paysindirectly for private medical service for these people. Furthermore,where the facilities of the Health Service are already inadequate, thepublic pays part of the cost of a private medical service which haspriority over the ordinary one.

Luxury Service

I shall make only a few simple points about private practice. In thefirst place, it is wrong that medical facilities should be expended on theprovision of a luxury service for a few when there is evidently so greata need for them to be used for the common good. Secondly, it seems,to judge by the brochure at least, that a sophisticated group of con-sumers are preventing their own high standards from becoming wide-spread throughout the National Health Service. As I have made clearelsewhere, the NHS badly needs the valuable opinion formed of doctors,consulted by these consumers, at the personal, the administrative andthe Ministerial level. Finally, it is unjust that doctors who owe theirtraining to education on grants at medical schools here, and theirexperience and eminence to work which they have done in the NHS ateverybody’s expense, should apply this valuable knowledge only to ahighly select number of patients. A solution would not be impossible.

Employees of the NHS, like any other public employee, should not beallowed to subcontract their precious skills to the highest bidder.Doctors should be either whole-time employees of the Health Serviceor not. There can be no room for private practice under the mantle of the NHS: if doctors wish to work on their own account that must betheir affair and we should not expect the public to subsidize them. Andof course there should be no pay beds in NHS hospitals either.

19


18/23

A further element of private medicine is its display of doctors’ medi-cine in an almost pure form. Medicine, that is to say, confined to thedoctor, the patient and his money. In most other kinds of medicaltransaction other elements play a part. The reactions of doctors to allintrusions of non-professional control into medicine are very similar.Further non-medical administration has only to be proposed for themedical ant-heap to be in an uproar, and the doctors thrown into the

utmost perturbation.

The crux lies in the problem of financing curative medical services.The doctor presents his bill at the very moment when the patient isleast able to pay it: the more serious the illness, the more necessarymedical attendance; the greater his disability, the worse his financialembarrassment. The idea, which was practised in the East, of paying adoctor to keep you fit (in effect preventive medicine) has never takenroot in the more backward West. The earliest of the doctors’ concerns,therefore, has been to devise means of getting round this problem,since their philosophy prevented them from seeing easier means,sociologically and medically, of overcoming it.

One solution was to treat only the wealthy: the doctors who wereonce retainers at the great courts are still to be found in spirit with theirexclusive private practices. Another answer is to charge those patientswho are sufficiently wealthy a disproportionately large sum formedical services, to pay for the treatment of those who are not. It is adelicate system, however, depending on the rich patients’ willingness

to be mulcted for the benefit of the poor, and on the doctors’ willing-ness to divert such profits to the treatment of the poor. Sooner or later,if the doctors are to treat poor patients and be paid fairly for theirtreatment, some kind of insurance scheme is essential. It is at thismoment that the most basic clashes between doctors and societyoccur. Who is to care for the sick poor, and secondarily, who is to payfor this care?

Quarrels are likely to arise, moreover, between doctors about whoshould undertake the unrewarding care of the poor. Before the in-

stitution of the NHS there was no provision to pay for adequate con-sultant services, and they flourished only in London where consul-tants were retained by the teaching hospitals and so had the opportunityto work up a flourishing private practice. In the provinces they wereparticularly sparse. In the North East in 1946, excluding Newcastle,there were only two doctors with an exclusively consulting practice inmedicine.11

Today consultant services have been established to cover the whole

country and the quarrel rather takes the form of competition to beappointed to hospitals whence a private practice can be launched.Another expression of the same problem is the enthusiasm of the BMAthat patients should have free choice of their doctor. Of course patientsshould. If the catch phrase is reversed though, it is a little plainer what

11 The Hospital Services of the North Eastern Area, HMSO 1946.

20


19/23

the doctors’ preoccupations are. There is no shortage of doctors, forexample, in districts such as Chelsea and Hampstead, whereas theMidlands and the North are again finding it harder to recruit generalpractitioners to work there.

Medical Care of the Poor

The question of who is to pay for the medical care of the poor is closelyrelated to the first question. The issue is between the community andsections of it. There were, and still are, doctors and sects whose re-ligious idealism was sufficient to encourage them to take responsibilityfor care of the poor; but society was not ready to do so until certain ideasand attitudes to disease had been either superseded or adopted. So longas disease, for example, was seen as punishment or a visitation, it musthave seemed futile or presumptuous for the community to interfere. Tosome extent the singling out of diseases which are usually contractedduring sexual intercourse and the undertone of condemnation of those

who have such ‘venereal’ diseases is a residue of this pernicious ideo-logy. Again, in the wider context, the refusal of most general practi-tioners either to give honest contraceptive advice or to fit contracep-tive devices for unmarried girls should be remembered. And while thescientific revolution of medicine was freeing society of its incorrectconceptions of disease, workmen whose experience taught them im-mediate connection between the environment and disease were startingto form clubs and friendly societies to help pay for medical care. Fromsuch societies, the more comprehensive idea of NHI grew. But from the

outset there was bickering between doctors and patients about whoshould control them, for with control went the power to adjust thedoctor’s fee. Already the dispute about the comparative merits of feeper item of service, capitation payment and a salaried service wasbeginning. What is the importance, to doctor and to patient, of thesealternative modes of payment?

The advantages of a fee per item system to the doctors are evident. Theimposition of a fee on the patient, the right to adjust it, the right tocharge the wealthy patient more heavily without losing anything by

treating the poor patient, all these features explain the demand for sucha system now among doctors in England. Its disadvantages to thepatient are equally plain. The doctor-patient relationship is set accord-ing to the amount of money the doctor reckons he can charge the patient.There is financial impediment to the free access of patient to doctor. Aclass system is built into a national health insurance scheme. Thedoctor alone, not the patient, is the arbiter of the value of his services.

The Capitation System

The capitation system of payment which is the NHS method of payingdoctors was inherited by that service from the NHI. The doctor is paidso much per patient, with various ‘loading’ devices to make one size of practice financially preferable to another and to compensate for work-ing away from large centres of population. It was popular with thedoctors initially because it seemed to reward those with the largestlists. In fact, there is a maximum list size, and as the ‘Pool’ system

21


20/23

reveals all too clearly there is little point in struggling to gain a fewmore patients if the real determinant of the GPS’ income is a previouslyagreed average. ‘As one doctor said, “The capitation method is allright so long as the capitation fee is big enough.” So I asked him whathe meant by big enough. The reply was, “Twice what it is now.” Ithought he had a point there.’12

The real disadvantages of the capitation system, are the abuses it per-mits. In 1958 the Medical World Newsletter gave the example of twopractices, both of which were managed by well-trained doctors. Onewas a group practice of three partners with ample nursing and clericalassistance, which was responsible for 7,000 patients. The other practice,which also had 7,000 patients, was run by two partners from their ownhomes with little assistance. The expense ratio to payment of the firstpractice was 49 per cent so that each partner earned £1,320. The otherpractice had an expense ratio of 23 per cent so that each partner earnt £3,00013

There are other abuses to which the capitation system is subject,especially partnerships which are financial fictions and partnerships inwhich the amount of money earned by each partner bears no relationto the amount of work each does. It is particularly difficult to obstructthe former just because it is in the interest of good general practice thatdoctors should be encouraged to work in partnerships rather than alone;and it is not possible to assess the number of partnerships which arefraudulent in this sense because it is, and should be, to some extent in

the doctors’ financial interests to work a partnership. About one quarterof all GPS work single handed, and about a half in partnerships of twoor three. Only about a sixth work in partnerships larger than threewhose size suggests a genuine group practice. As for partnerships inwhich the senior partner earns a disproportionately large amount of the total income, especially scandalous examples have been found of senior partners taking a half to two thirds of the income without everseeing a patient14 but again the extent of such sharp practice is unknown,and probably since there is at present a shortage of recruits to generalpractice, diminishing. It is doubtful whether the capitation system

could ever be made proof against such abuses without being so tram-melled with restrictions that it would present nothing but disadvantagesby comparison with a salaried service. Indeed, it is significant that nowthat the doctors seem to have reached the limit of their patience withthe system, it is to the fee-per-item-of-service method that they haveturned, seeing, no doubt, ‘freedom’ (by which they mean room formanoeuvre) in that system which they are now denied by capitation.

We are left with the salaried service whose advantages are precisely thatit avoids the failures of all other means of payment, in particular be-cause the dialogue between doctor and patient is not accompanied bythe bass drone of financial considerations on either side. But the dispute

12 BMJ. 2, iii, 63.13 Cited by Lindsey. Socialized Medicine, p. 132.14 Lindsey, op cit . p. 166.

22


21/23

about modes of payment encapsulates the difficulties of attempting topatch socialism over the holes in our society.

A Socialist Strategy for Health

This survey of the Health Service has not touched on vast areas—its chronic shortage of money and staff , its long waiting lists, its antiquated hospitals and its

squalor —the usual excuses for its failure to satisfy the ideals of its founders,The effort has been to show is that these deficiencies are secondary, not primary,

symptons of its failure.

A maximalist interpretation of ‘health’ must not be the excuse forfacile pessimism: that its implementation is impossible before theestablishment of a socialist society. The socialist society will not riselike Aphrodite, perfect from the waves; and a socialist strategy forhealth can only take place within the framework of the struggle for asocialist society. It should be formulated with two main points in mind.

First there is the part it plays in the overall socialist strategy by helpingboth patient and doctor understand what health is or should be, byencouraging constructive criticism of the inadequate service, by ex-posing valueless social reform. Second, there is the extent to which itsattempts at temporary improvement can alleviate the suffering, themisery and the day-to-day hardships of life.

The socialist strategy for health must be a revolutionary one. As such itcannot afford to ignore the strength of the opposition. Where does thestrength of conventional medicine lie? In the doctors and the institu-

tions they have created to practise their kind of medicine, and in people’sconfidence in their competence and in the adequacy of their services. Inthe end we shall have to assault both these positions. Until we can doso we must erode them little by little. At first the attack on the doctorscan be directed against the topical and important deficiencies of generalpractice: the crowding of people, sick people, into bleak, drab, coldwaiting rooms, queues for attention, cursory examination, no explana-tions, no sympathy, mechanical sympathy, medical obscurantism, rude-ness. Against the hospitals we may use all the complaints of such en-

lightened bourgeois organizations as the Patients’ Association; and wecan also condemn them openly and directly as squalid legacies in ideo-logy as well as form of the Poor Law. It is essential that the attackshould be not only an attack but also an education in the real nature of the institutions and of their philosophy.

Even more important tactically will be the ousting of the doctors fromtheir position as unique arbiters on all matters of health. Until now allmedical planning has required the ‘expert’ opinion and acquiescence of doctors. The expert opinion and acquiescence of patients has not been

so eagerly canvassed. The doctors have argued that patients lack theinformation to discuss these matters intelligently. In fact, patients havepersistently shown a great curiosity about disease and the managementand sociology of the health services which has been fobbed off withvulgarizations such as Dr Kildare and Emergency Ward 10. The curiosityhas been stunted by the doctors’ reluctance to discuss these matters withthem. Self-management must be brought into the health services, not

23


22/23

only because health is too important a subject to be left to the exclusivearbitration of the doctors, but also, because only the patients canhumanize and democratize the practice of medicine. Another aim in themanoeuvre against the doctors’ position as arbiters on all matters of health must be the invasion and extension of the province of health bythose from other—falsely separate—fields of study. It is the turnof sociologists, social psychologists, anthropologists, urbanists,

architects, all those in fact whose work in the humane sciences is thestudy of the influence of environment, to claim their share of the title of doctor or health worker. When such workers are recognized as prac-titioners in the health services the achievement will have been twofold.We shall have extended the popular understanding of the meaning of ‘health’, exposing in the process the inadequacies of the narrow servicewhich is now provided by doctors; and we shall have inserted into thehealth service workers who are far more susceptible to socialist ideasthan doctors are; they are more supple, more willing to experiment,bolder, less hidebound. If we were to wait for the doctors alone toinitiate their own socialist revolution of medicine, we should still bewaiting the month after the millenium.

Characteristically the ideals of bourgeois society are as stoutly main-tained in the citizenry as they are in formally reactionary institutions.The strongest reactionary forces such a strategy will encounter will bepeople’s conviction that doctors are automatically objective and cap-able in their best interests, that the medicine they practise is the bestavailable, that to ask any more of them is impertinent and that anyone

who claims to do what they cannot or what they condemn is a charla-tan. This will be the most difficult position to capture; its conquest willbe the most valuable: for once people have been shown what the doc-tors do not do they can be shown what they ought to do.

To some extent shocking discoveries of inadequacies (for instance thatperinatal mortality is greater in home deliveries although these mothersare selected because they are at smaller risk; the small number of doctorswho take refresher courses; the incidence of disease caused by doctors)may force the public to realize that all is not well with its medical

services. But exploitation of such discoveries should be limited, for toremove hope, to create alarm, without offering the immediate pos-sibility of anything better, is callous. A more useful tactic is the exposureof the doctors’ own confusion of ethic, of the deterrent value of thefee per item of service, the confusion in the doctor’s own attitudes togeneral practice and the funnelling into general practice of thosedoctors who have ‘dropped out’ of the hospital service.

A Socialist Health Centre

But the most vivid way to demonstrate the inadequacies of the HealthService is to compare it with what it could be. Socialist medical per-sonnel, co-operating on an equal footing with health workers of allkinds, could set up a pilot scheme in social and environmental medicinein the form of a health centre. In this way the public would see thefundamental difference between an attempt to practise medicine onsocialist principles and even the most altruistic medicine now prac-

24


23/23

tised in the NHS. It might even be possible for a socialist medical ad-ministrator of sufficient prestige to persuade a Minister of Health of the advantages of such a scheme so that it could be carried out withministerial financial support. But even if the Ministry lacked the im-agination to realize how the Health Service would benefit, a tradeunion at least should be convinced of the use of such a scheme for itsmembers and their families. Such a plan demands a medical staff who

are socialists and therefore sensitive to the needs and possibilities of theplan, who have learnt or are willing to learn to do without the un-democratic traditional doctor/patient relationship and try to cultivatein its place a co-operative spirit, as much patients’ self-management asdoctors’ control. Of course, this requirement will present the greatestdifficulties. Patients have become so conditioned to their undemocraticdoctor/patient relationship that they will be as hard to wean from it asthe doctors.

What can this pilot health centre scheme give the community whichcould not be given by a conscientious set of doctors working as a grouppractice? The principles behind the work of the centre would be quitedifferent from those which underlie group general practice. Patientswill have opportunities for choice, treatment, and information at presentdenied them. Further, questions of health and sickness would bestudied, not in their present fractured and dehumanized context, but inan environment which would illuminate more truthfully the problemsof how people are distorted by their surroundings and how thesesurroundings must be changed.

martin rossdale

Documents