Feature

Disempowering the doctors

The power and status of consultants is threatened by developments within the profession itself, as well as by the government’s changes to the NHS. David Gladstone offers a historical perspective

New issues in health care tend to make the headlines: whether it be the performance of budget-holding GPs or trusts or, in the aftermath of the Tomlinson Report, the future pattern of health services in London.

So it is all too easy to forget the historical continuities in the supply of health care. Three examples illustrate the point. The system has long been more concerned with curing illness than promoting health. Escalating health care costs pose significant financing problems in both the public and the private sector. Health care structures have traditionally been dominated by the hospital sector and by consultants.

My concern is with this professional aspect of medical practice, the historical origin of consultant power, the ways in which that power is exercised and the dimension of challenge and change.

The 1858 Medical Act unified a highly disparate set of practitioners into an autonomous self-governing ethical profession. The General Medical Council, created by the Act, was charged with overseeing medical education and maintaining a register of those legally qualified to practice medicine. The significance of the register ‘lay in those it excluded. For all ranks of regular practitioners now appeared as “insiders” lined up against all “outsiders”... who are automatically constituted by exclusion into the “fringe”.’¹

Over the same period towards the end of the 19th century, there was a growing diversity within the medical profession. As a result of the expansion of medical teaching, the GP became ‘a vulnerable individual in a highly competitive buyer’s market’. Meanwhile, as physicians and surgeons worked together in the hospitals and co-operated in medical schools ‘the differences between them came to be of somewhat less importance than their common interest as hospital consultants’.

It was this group ‘who mutually gained in prestige as teaching and research expanded in the new medical schools, and hospitals became centres of medical excellence.’²

In the political arena that prestige was at its zenith at the time of the creation of the NHS. Facing extensive resistance from GPs, Aneurin Bevan, as Labour Minister of Health, ‘bought off (“stuffed their mouths with gold” were his words) the consultants and used them as a counter weight to breakdown the resistance of the BMA’.³ In return for their support ‘they were offered many fresh inducements without being expected to sacrifice too many of their traditional privileges’.⁴ Not only were they guaranteed high earnings from the public sector, they were also able to maintain private practice and the virtual monopoly of distinction awards that accompanied it.

By the mid 20th century, consultant specialists had thus added to their significant prestige within the medical profession considerable importance in the nationalised health care system.

Consultant specialists exercise their power in a variety of ways and through a number of institutions, including the General Medical Council and Royal Colleges. I have discussed this more fully in Opening up the Medical Monopoly. But a number of monopoly features, arising from the historical situation described here, warrant attention.

First, the operation of a patronage system in the appointment of consultants. Isobel Allen’s research indicated the role of personal recommendation in medical promotion and preferment. It tended to confirm the view that some influential medical personnel have the power to advance or restrict the progress of doctors in the up-coming generation.⁵ Because the number of junior doctors far exceeds the number of consultant posts, the importance of personal recommendation has become increasingly apparent. But its consequence, according to Allen, is a tendency towards conservatism and a situation where academic, intellectual or clinical excellence is not enough for a career at the top.

The second example comes from the self regulating nature of medicine. Charged with regulating the profession in the public interest, the GMC has shown itself sensitive to criticism. But its methods of dealing with patients’ complaints has been the subject of a television documentary based on the powerful criticism both of its decisions and procedures voiced by one of its few lay members. Ten years ago Christopher Pollitt noted that, despite the nationalisation of health care, the medical profession ‘retained extensive independence and used it to further the cause of “scientific” hospital based specialist medicine and successfully to defend the mysteries of clinical freedom’.⁶

How much has changed? Consumer choice and quality of service are the third example. While the GMC has supported the wide availability of factual information about GP services, it has been much more circumspect in its approach to information about specialists. Arguing against the direct advertisement of specialist services, a report produced by a GMC committee concluded that its long-term effect would be ‘to dismantle the present arrangements for medical care which are based on the referral system’.

Meanwhile, a recent research study of referral procedures concluded that British patients wait longer to see a specialist than in any other European country, even though British GPs refer relatively fewer patients.⁷

For each of these issues, it is necessary to ask: in whose interests do they operate?

Power is not exercised in a vacuum; and the climate within which medical professional power is exercised is changing. The internal market, managerial accountability, medical audit, new technology to make possible short stay or day case treatment for many categories of patient, along with the indicative drugs budget, quality assurance and the Patient’s Charter, are just some examples of recent changes.

Another, of potentially enormous significance, is the Calman Report on medical education and training published earlier this year.⁸ If its proposals for shorter, better supervised and more structured training programmes are implemented - and there are financial costs in doing so - the consequence will be an increase in the number of specialists. That may reduce the length of waiting lists in the NHS, while in the private sector, where fees were initially set at a premium to attract consultants when skills were scarce, a reduction in the fee levels to private insurers could be expected. That is the significance of the Monopolies and Mergers Commission review into BMA guidance on recommended fee rates for surgical procedures, whose report is due this autumn.

It is a paradox that the impetus to change medical education and training came neither from the medical profession nor government but from legal challenges and the concerns of the European Commission that the British government had unlawfully discriminated against foreign-born doctors since 1977 by not recognising qualifications accepted everywhere else in the EC.

The chair of the Junior Doctors Committee of the BMA hailed the Calman Report as representing one of the most important changes in the medical profession since the inception of the NHS. But, however desirable it may be to be freed from the inheritance of the medieval guild system, the strength of opposition to Calman’s recommendations should not be under-estimated.

In the light of Machiavelli’s dictum that ‘the innovator makes enemies of all those who prospered under the old order’ it is well to have been reminded by the Chief Medical Officer that ‘the purpose of medical education is not simply about providing jobs for doctors but improving services to the patient’. That may be an appropriate yardstick against which to assess the medical profession’s response to Calman.