Martin Rossdale

Socialist Health Service?

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 prevails in the United States, no generous person can fail to regard with some gratitude the effort to provide adequate medical care for the whole British population, 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 earlier
article, 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.
3

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 illhealth.
The doctor/patient relationship has been the subject of innumerable
edulcorations on the radio and television. Time and again we are shown
the doctor as an altruistic, humane healer, above the vulgar influence of
cash and business interest; and the patient, ready to co-operate with
him for his own good. Why such falsification? The doctor/patient
relationship is pitted with conflict; the lie merely repeated to dull
our suspicions.
What generates this conflict? The kind of medicine which the doctors
practise and the nature of sickness itself. The new diagnostic and
therapeutic techniques, extraordinarily potent by comparison with their
predecessors, entail much greater risks to the patient. To use them
safely the practice of medicine requires ever greater precision and order.
Rules have to be imposed and applied: to enforce them hierarchy and
discipline are needed. But doctors are trained as decision takers, their
education teaches them adulation of professional independence, of full
medical responsibility for the patient, of continuity of care. The form
which the scientific revolution in medicine has imposed on the actual
structure of the practice of medicine has engendered conflicts between
the doctor and medicine itself, conflicts which the doctor cannot act
out because of his professed ethic and his attitude to medicine and the
patient. The strains burst forth in jets of anger and frustration, in autocracy, abruptness, the imposition of the doctors will on his patient, as
his 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 freedom. In addition, the sick man has had imposed upon him a dependent
role, he has asked the doctor in, he has asked his advice, he is willing
to take it; this is the contract he has entered. Then there are the demands of society. Society does not want people to be sick. This is the
reason for the institution of medicine. The doctor has to protect
society from excessive sickness; a sickly society is inefficient and may
die out altogether, as the early settlers of Greenland did. At the same
time society is continually on the watch for fake sickness. People
appreciate that the environment can produce sickness in them, but that
they, in their turn, can protect themselves from their environment,
their society, by the production of sickness. The reality of such sickness is disputed, though conceded by the common idiom. We say we
are sick of work, of this district, etc. For such cases society needs
doctors as policemen, to protect itself against the skrimshanker, the
malingerer, the lead swinger. And the doctor resents this role for through
it he is brought into conflict with his professed loyalty to the patient. This
is why doctors resent certification. If a doctor refuses to concede the
right of his patient to take time off work by signing the certificate, he
exposes his role as health policeman, his loyalty to the other side, an
4

allegiance which he may prefer for social or class reasons beyond his
stated one.
Resentment and Fear

Because there are social pressures to be normal, most people do not

want to admit that they are sick; this is not merely because sickness is
penalized by a diminution of income and the curtailment of freedom.
There are social pressures which force a person who falls sick to act
sick; to go to bed, to take medical advice, in fact to undergo the archetypes of illnessthe harrowing process of restriction, fear, and submission 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 contagious diseases) you must go to bed, see a doctor. Most sick people
dont want to, they resist, and so when at last they do get to see their
doctors, their mood is one of resentment, as well as of fear.
The resentment which patients feel towards their doctors is partly the
consequence, too, of the conditions which are imposed upon the patient
by the system through which medicine is practised. The doctors and
nurses have to play a part toowe shall come to that laterbut the
script has been written for the patient and the doctor/director is not
likely to allow much freedom in the patients interpretation. In essence
the patient is helpless, he has admitted it by calling on the doctor and so
contracting to accept his advice; he needs the doctors help and for it he
is 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 a
citizen is hardly recognized. In hospital no patient expects to choose
where he should sleep or in what company. He will take the food he is
offered. He will not question the treatment meted out to him, submitting himself to the most unpleasantand frequently medically uselessprocedures in order to get better again. His contact with the
outside world is restrictedhe can see his friends and relatives only
during visiting hours, which are short and at compulsory times. If he is
lucky 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 that
they are generally just accepted as part of the set-up, the way they do
these things, part of the system. (The most poignant example of such
dumb acceptance is the way relatives meekly hang about sisters office
at visiting time in hospital to learn what is the matter with X and what
may be expected. Then they pass on the edited scraps to the patient.)
Consider the doctors resentment of patients who will not abide by their
side of the bargain. The difficult patient, strangely enough, is not the
patient whose serious illness poses most problems to the doctor (he is
an interesting case and is so frightened and so weak that he cannot
resist the discipline imposed on him). It is the patient who is nearly
better, or the patient who refuses to realize how ill he is, who makes
the most trouble for the medical staff. Again, there is the patient who
does not appreciate the importance of medical etiquette, the patient
who goes to his medical practitioner merely for help in getting an
5

appointment with another consultant; or the dissatisfied patient who

changes from one doctor to another.
It is natural for the sick man to be apprehensive. Every sickness is a
voyage into the unknown. The only people who have the maps are the
doctors: they drew them. Their knowledge of them is part of their
power. (This partly explains the resentment by doctors of patients
who read up the details of their condition in medical textbooks.) The
sick man is under physical strainthe actual disability of his illness
but he is also under a mental, an emotional strain. Even when it is not the
patients fault that he is unwell and cannot work he does not receive
full compensation for the loss he incurs as the result of his sickness, so a
substantial part of the strain on him is worry about his dependents, about
the rent, and about his financial commitments. Then too he is worried
about himself, about future experiences of pain, treatment, even death.
According to conventional wisdom, part of the burden of the patient is
off-loaded on to his medical attendants; the worry, too, is eased by the
faith the patient has in his doctor, as if every patient were able to believe
that his doctor was the best for him and his illness. The reality is
starker. By and large patients have to take the doctors they get, and they
have to put up with the treatment they get, in whatever hospital and
in 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 explanations for his failure to get better than the bad news that he has
cancer. (Some patients will superstitiously resort to proprietary
medicines, to panaceas and nostrums: the sick man is peculiarly at the
mercy of rogues.)
Doctors Attitudes to Disease

The difference between the attitude to sickness of the patient and of the
doctor is pronounced. Sickness, disease and death are the doctors
stock in trade. From the very earliest days of his medical education the
medical student is on intimate terms with death. The cadaver is his introduction to the preclinical course, the autopsy specimen to his
clinical. In such ways the sensibility of the medical student, at this
stage in its formation no different from that of any other man, with its
strong but suppressed fear of disease and death, is assaulted. Some
students drop out. Those who remain are bound together: such harsh
and 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 context. Here the student is encouraged to follow the fortunes of a given
patient, the vehicle of this or that disease, mastering the details of his
condition and following its course to a successful cure, to palliation or
to death. Again and again he will do this until he has learnt the folly
and dangers of attaching himself too closely to any patient. (The lesson
is enshrined in the aphorism you cant die with every patient.)
6

All the same the doctor would be less than human if he were able to
maintain complete objectivity before his patients suffering. His training then fastens on him another bucklertechnical 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 and
his most important tool. The understanding between them is clear on
this count too, that the doctor should place the interests of his patient
above all other considerations; that he should have an entirely objective
estimation of the patients needs and that what he does for the patient
should be based upon these considerations as they impinge upon his
knowledge and technical ability. The doctors confidence arises from
his technical ability and is eroded just because that ability can never be
adequate. In the first place technical competence per se gives the doctor
only a limited social assurance in his regular confrontation with all sorts
and conditions of men. His experience has probably been confined to a
small and well treated group, any other experience he may have had is
vicarious, not actual. His advice, therefore, is couched in terms of his
own priorities, the importance he allocates to health in life, the security
which his work has assured him. He has had little experience of hard
manual labour in rough conditions, little experience of poor housing,
poor food. In the second place there are very many diseases which the
doctor cannot cure, where the best he can propose is palliation and
where, nevertheless, although he will not have claimed that he can cure
his patient no matter what, a cure is expected of him. He is liable to be
set 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 challenged
by the maverick element in the biological organismtoxic reactions to
drugs, the atypical presentation of disease, miracle cures, and, equally
miraculous, 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 and
outcome of disease. But even a long experience of disease may be confounded by the wild human and spiritual response to stress. Everyone
knows the story of the man given three months to live who outlives
his doctor. Can technical ability provide the formula with which to
explain to bereaved relatives the statistical inevitability of the one in n
fatalities to this or that drug?
Hardly Credible Rights

Some rights of medical attendants would be hardly credible in any

other context. The power to do strange or unpleasant things to the
patient, 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 or
please a patient, not by its pharmacological actions, but by psychological
means. To the doctor who has been trained to accept as paramount the
organic causation of disease, the use of such a drug is a confession of
7

failure. Those who have qualms of conscience about prescribing

pharmacologically useless medicines tend to use semi-placebos, such as
vitamins, 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 and
efficient. A placebo medicine should be red, yellow or brown; for
blue and green are colours popularly associated with poisons or external
applications. The taste should be bitter but not unpleasant. Capsules
should be coloured and tablets either very small (on the multum in
parvo principle) or impressively large; they should not look like everyday tablets such as aspirins.1
Whence the humbug? It follows inevitably from a vision of medicine
which can only recognize the organic disease. If the cause is not organic,
the symptoms must be dealt with by trickery, by magic. If the doctors
attach most importance to the organic disease, it is natural that their
bias should infect the patient. The patient produces organic symptoms
real enough to himto attract the medical moth. If a patient whose
trouble is fundamentally environmental discovers that however he displays it, the doctors first response is to look for an organic lesion, he
will do two things: he will start to think of his ownproblems in organic
terms; and he will produce further organic symptoms when he finds
that the treatment of the original ones has not alleviated his problems.
So it is even the doctors privilege to dictate what form the patients
sickness should take.
If it is true, as we have suggested, that the doctor/patient relationship
contains suppressed antagonisms, then we should expect to find, built
into the institutions through which the relationship is conducted,
devices to absorb, take up and mask such antagonisms. This is so. In a
hospital, for example, either the unpleasantries which the patient has to
suffer are performed upon him by subordinates or auxiliaries who are
not responsible for the decision, so that the doctor in charge is cushioned; or the patient is physically unawareanaesthetizedof what the
doctors are doing to him, their assault on his body in surgery. Doctors
realize 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 about
what has to be done. In much surgery it is necessary to pass a tube
down the patients nose into the stomach to enable the contents to be
removed. The passage of such a tube is unpleasant and while it stays
down (for a few days) it irritates and annoys the patient. Some surgeons
have the nurse pass the tube (the assault) but remove it themselves.
There are techniques of anaesthesia, too, which make it possible for
operations to be carried out without the patient losing consciousness.
But even when these techniques are used it is quite normal to administer
a light anaesthetic nevertheless: the patient does not want to follow too
closely what is being done to him, and the doctor is content that he
should not.
Hierarchical Barriers

The administrative structure of the hospital reveals a similar buffer

1

Lancet ii, 321,1954, Editorial, The Humble Humbug.

system. Of course the doctors have not deliberately organized the

hospital in order to avoid painful emotional involvement with their
patients, but the hierarchical forms which have been selected permit
this. In hospital, under the consultant doctor who is in charge of any
patient, there is a registrar and under him a houseman. The patient
lives 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. The
ancillary services are arranged in a similar way. If the patient had an
immediate personal relationship with the doctor responsible for him, it
might be impossible for the doctor to insist on the unpleasant procedures which his training taught him to think necessary for the patients good. To evade such situations deputies are used extensively. The
doctor with whom the patient has most opportunity to make personal
contact, the houseman, makes few decisions about the treatment of the
patient. He has to present his chief with a daily digest of his patients
condition. Most of the decisions are made by the registrar and the most
difficult ones (those which cause doctor as well as patient most distress),
are made by the consultant, but contact between the consultant and the
patient is minimal. The consultant has to assess the information he
receives from his subordinates about the patient and to collate it with
his own findings. That is why we so often hear patients complain that
consultants are distant and inaccessible. But we do not hear the same
complaints from the other doctors because unlike patients they do not
expect a personal interest to be taken in them. General practice provides 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 the
doctor feels that the claims of the patient on his privacy, on his sleep
and on his recreation amount to an assault. At times like these the doctor
resents the discovery that he is at the patients beck and call.
Such conflicts in the doctor/patient relationship are not openly expressed although they are common knowledge. (They are ritualized and
cherished in the gross rituals of Ealing medical comedy, a pabulum of
inexhaustible attractions to the public. Medical humour, from the postcard antics of lecherous housemen to the ludic rituals of hospital staffs
at times of festivity, when doctors are dressed up as women and submit
to the overtures they are commonly imagined to inflict on nurses, or
when plates of turkey are left in front of patients on intravenous diets,
offer the most melancholy critique of the relationships under discussion.) They are as integral a part of the NHS as the modernized workhouses which have provided its hospitals. Both seem resistant to
legislative demolition. But unlike the run-down hospitals the reason for
these conflicts are structural. They will remain so long as health is considered a commodity and the patient a vehicle which brings disease to
the doctor. A better relationship depends on the bilateral understanding
of common problems, a more open, total, relationship between them.
The Doctors
Who are the doctors? What are their prejudices, their training, their beliefs? It is
they who determine the personality of the Health Service. Of especial interest and
9

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. These
institutions are the teaching hospitals.
The teaching hospitals of England and Wales were allowed to maintain their own boards of governors and to be administered separately
because it was argued that this would give them greater freedom to set
higher medical, scientific and research standards whose effects would be
spread throughout the regional hospitals. Almont Lindsey in his
Socialised Medicine remarked: The revolution in administration, which
drastically altered the basic pattern of so many hospitals, was milder in
its effects on the teaching hospitals. Having occupied a somewhat
privileged 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 the
university and by the hospital medical staff. They are not restricted to a
maximum of 25 per cent doctors on a board. Unlike regional boards
too, they have no management committee, they are their own executive and select their own staff. The members of the boards are volunteersthe cause of a heavy class bias as the tradition of public service is
largely confined to those with the leisure, money and social confidence
to indulge in it. The privileges of the position of the teaching hospitals
were a greater administrative independence, the maintenance of their
own boards of governors directly answerable to the Minister; more
money per patient;2 the retention by the boards of governors of endowments (the endowments of other voluntary hospitals had passed to the
Minister), the right to receive further endowments, and the right to
use these as the testator had directed and as they saw fit.
They enjoyed other privileges which were more indirectly related to
their status as teaching hospitals. Situated in large cities, they were less
liable 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 nursing
schools 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 196061 show that there was a large
difference in the cost of caring for a patient in a hospital administered by a Hospital
Management Committee and in a hospital administered by a Board of Governors.

Acute
Cases

Net in-patient
cost per week

Net in-patient
cost per case

27.16s.11d.

53.12s.3d.

Mainly
Acute

23.19s.6d.

63.18s.9d.

Acute
Cases

36.12s.1d.

74.4s.od.

Mainly
Acute
10

32.4s.1d.

83.11s.4d.

Type of hospital

HMC

Hospital

BOG

Hospital

nurses.The case fatality for a number of conditions, notably ischaemic

heart disease, peptic ulcer, appendicitis, hernia of the abdominal cavity
with obstruction, conditions of the gall bladder, hyperplasia of the
prostate and skull fractures and head injuries, is significantly lower in
teaching than in non-teaching hospitals.3 With the exception of the
London Hospital every teaching hospital in London is within three
miles 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 teaching
hospitals lie in medical and political history. The prestige of the voluntary
hospitals was reflected partly from their aristocratic sponsors, partly
from the status of scientific medicine, the loyalty of the medical men
who had been trained in them, and the dignity they acquired by their
employment of notable members of the medical Royal Colleges. But
Bevan used the old divisions between the local authority hospitals and
the teaching hospitals to prevent the former from organizing any
opposition to the acceptance of his plans. By offering the top doctors
who worked in the teaching hospitals preferential conditions of work,
part-time sessions to allow them to continue their private work, the
secret disposal of public money to be paid them as Merit Awards to be
decided by their cronies, and the right to administer their own hospitals, Bevan seduced the doctors who worked in the aristocratic
teaching hospitals into acceptance of the National Health Service. In
the name of academic freedom it is argued that teaching hospitals must
remain outside the regional hospital board pattern. In London where
there are 30 different hospital authorities, 26 of these are teaching
hospital authorities12 undergraduate and 14 postgraduate. These
teaching hospital authorities are highly selective in the type of patient
they admit. In the case of the postgraduate teaching hospitals they all,
except one, serve specialities and are not available to admit general
medical cases. The undergraduate teaching hospitals too, do not serve
the general medical needthey are not forced to accept cases sent to
them by the Emergency Bed Service, the central clearing house for
patients in the areaand the patients they select for admission are
chosen according to their value as teaching material. Of the 23,412
beds in the London hospital area in 1960, 12,251 were under the control
of teaching hospitals. Thus in the capital itself, the effect of Bevans
concessions to the teaching hospitals has been to drive a coach and
horses 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 the
NHS is also due to their role as selectors and educators of doctors.
Medical students are selected by medical schools, either by the Dean
alone or by a committee of members of the staff. There are many more
applicants 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

of applying at several medical hospitals at the same time. At the

London Medical College in 1954 there were some 3,000 applicants of
whom 600 were given interviews and of whom only 100 gained a
place.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 the
arbiters 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-recruitment
into the medical profession is appreciated. In 1957, 50.6 per cent of all
medical students in British medical schools had fathers who were
doctors. (Doctors take between 5 and 7 years to train. Medical recruits of
1957 are junior doctors now). In the London teaching hospitals the
figure was 73.2 per cent. Of the total numbers of parents of medical
students whose occupations could be classified in 1957, manual workers
made up only 16.1 per cent; and in the London teaching hospitals the
figure was lower: 13.8 per cent. These figures for medical and dental
students are the lowest of the entire student body of Great Britain; in
technological subjects the percentage is more than double. The education of medical students before their arrival at medical school is shown
in the charts below which compare the primary education of male and
female medical students in London and the rest of Britain with the
national 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
Local
Authority
Private
or Prep.
Both
Types
Not
answered

39.5

26.6

50.9

44.0

65.8

60.7

41.6

57.6

32.2

38.8

22.0

26.6

16.7

15.8

15.2

15.1

10.8

12.3

2.2

1.7

2.1

1.4

0.4

table5

The next
compares the secondary education of British male
students. Male students at London teaching hospitals are compared
with male medical students over the rest of the country and with male
students in all other faculties.
Headmasters Conference
and Independent Schools
Direct Grant Schools
Grammar Schools maintained by
the Local Education Authority
Non-HMC Independent
Schools

London Medical
Schools

Other Medical
Schools

All University
Faculties

43.1
9.0

32.5
13.4

21.3
12.6

42.3

48.6

60.2

4.7

4.3

5.0

It is also interesting to note that even in 1964, in a survey carried out in

a London teaching hospital by the students themselves, 67 per cent of
them had had a Public School education, 28 per cent had been educated
at a Grammar School, 4 per cent had been educated privately and 1 per
cent had had a technical education.
4
Almont Lindsey. Soc. Med. p.175 and Kelsall R.K., Applications for Admission to
University state that there are more applicants per place to medical schools that for any
other University place.
5
Kelsall, Application for Admission to University, 1957.

12

It would be unwise to extrapolate too far from these bizarre figures, but
it cannot be denied that the medical profession, judged by its recruitment lies stranded on the beaches of tradition.
In their publications at least, medical educators make clear what they
look for in candidates for medical training. Dr Henry Miller of the
Medical School of Kings College, Newcastle spaciously declared that
the only qualities required in a medical student were high intelligence,
good character, pleasant personality, robust physical and mental
health, indomitable spirit, boundless physical energy, a sense of humour,
and keen ambition disciplined by a lively social conscience. He must
also be happy. Of course, such qualities would also fit the applicant to
take up the post of Prime Minister, Archbishop of Canterbury, or
Secretary of the Medical Research Council. Unfortunately they are not
conspicuous among those seeking to sit at the feet of the medical
teachers in the University of Newcastle upon Tyne. On a more
realistic level, said Dr Miller, it would perhaps be reasonable to examine the qualities of really good doctors. In this connexion he would
refer to the kind of doctor anyone would like to look after them if they
were ill. . . What were the qualities manifested by such a man? The
first was that he was not always by any means intellectually brilliant. I
think he is always intelligent, and usually very intelligent, but often in
a rather pragmatic way. It seems to me that clinical medicine has little
use for the neurasthenic type of individual . . . I know there have been
great neurasthenics . . . but I do not think any of these had the qualities
required in a responsible clinician . . . Finally I would say that there is
another quality which is required and which is in many ways the most
important. I refer to common sense . . . we all know brilliant academics
to whom nobody ever entrusts their health. They may be positive
geniuses but they lack . . .
The tone is familiar, recalling the accreted wisdom of a hundred publichouse arguments; the facetious positing of the unattainable ideal, the
appeal to sound common sense, the preference for the empirical man
rather 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 the
medicine it teaches in terms other than its own. In them the needs of
clinical medicine have been promoted over the requirements of the
whole Health Service. The irony of Bevans device to ensure the participation of the most prestigious doctors and hospitals has been to give
them the power to distort the NHS according to their will.
The Medical Curriculum

Just as important as the actual selection of medical students is their

formationthe medical curriculum and their extra-curricular activities.
As the doctors in teaching hospitals see it, the future of medicine here is
dependent on a homogeneously conscientious, well-disciplined and
meticulous 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

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 undesirable
irregularities 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 the
brash medical student into the socially accepted ideal of the doctor. The
tone of many textbooks of medicine is profoundly conformist or even
reactionarythus one surgical text book describes anal and penile warts
as being found especially amongst the criminal classes. In a textbook of
psychiatry the paranoid personality is claimed to be found amongst the
active, self-righteous and dogmatic people who stand up for their
rights, to real or supposed infringement of which they react with vigour,
the founders of sects, movements of all kinds, who are dominated by
an 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 under
assessment against the time when he will apply for his first appointment at his own teaching hospital.
The corollary of this is the suppression or inhibition by the teaching
staff of activities or criticisms which they find undesirable. Thus, in the
St. Marys Hospital Gazette again, two pages were left empty where a
report on clinical teaching should have been printed. The Dean would
not allow it to be published for the normal circulation of the paper. At
the Middlesex Hospital an entire issue of the journal was impounded
because it included among statements on birth control by representatives of the Church of England, the Church of Rome, and Judaism: an
article by a representative of the Family Planning Association in which
pre-marital intercourse was mentioned neutrally. It was suggested that
this might adversely affect the recruiting of nurses. On another occasion
the student editor of a hospital magazine was warned by the Dean after
he had published an article on the DDR which was not condemnatory.
Another factor which produces conformity and discipline within the
hospitals is the excessively hierarchical structure, so that the people
who 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 uniforms of nurses at different stages of their training and grosser differences between them and fully trained nurses. There may even be as many
as 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 the
varying amounts of time devoted to each.
The medical curriculum has two parts. Preclinical education, during
14

which the student is taught the elements of physics, chemistry and

biology, followed by anatomy and physiology; and a clinical training
on the wards of a teaching hospital as well as in its outpatients and
other departments. Medical education as a process of teaching the
student to reason, to search the world with fresh eyes and draw conclusions from his observation, ceases when the student has taken the
2nd 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 patient
in relation to his surroundings. With the start of clinical work the
student 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 questions 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 the
time of the student, hawking its own view of medicine, anxious to
reproduce itself. And because the teaching in these hospitals is done
by the practitioners in that particular branch of medicine, because
the establishment of consulting and teaching posts has fossilized previous priorities in medicine, the most venerable subjects are taught
most, and the newest subjects are taught least. Thus the student spends
six months each on medicine and surgery, shares two months between
proctology, 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 particular
but circumscribed field, they are unable to integrate their own speciality with what other specialists have taught, and not usually interested
in trying. To the student of medicine his patient is less than the sum of his
parts, 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 in
teaching hospitals on the nature of health itself, on the purpose of the
practice of medicine, on what are, and what ought to be, the growing
points 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 are
dying or defunct. Certainly the juggernaut of curative medicine will
roll on, impelled by the efforts of the biological sciences, and we may
reasonably expect medicine to apply the new knowledge to the problems of disease. But if, in those places where medicine is actually
taught, there is no curiosity, no investigation, into what doctors ought
to be doing, or trying to do, of the place of medicine in society, then
medicine can never be more than a fig leaf over the more embarrassing
parts of the society in which it is practised.
15

Medical students have a narrow interest in medicine because of an

overly specialized training. They know little of society and its mechanisms, of the place of medicine within the social sciences, of the interrelationship of the productive processes (of housing, of work, of travel
and communications). They are blinkered by their education; any
interest 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. Even
attempts to hold a meeting about Nuclear Disarmament have been
blocked. On the other hand the religious societies of numerous cults
proliferate, and these, together with extra-curricular activities of the
most neutral kind provide the worthless fodder which leaves medical
students with cultural beri-beri. A typical medical school notice board
displays:
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 about

their activities. Leisure activities comprised drinking, reading, going
out with girls and going to the cinema and theatre, all about equally
popular. Only 34 per cent of the total were members of University
Societies, of which religious societies accounted for about half and
musical societies were next in popularity. 75 per cent of the men
indulged in sport and 42 per cent of the women took an active interest
in rugby, golf, cricket, tennis, swimming and squash. Card playing was
the most popular non-athletic sport. Only 7 per cent took an active
part in politics, 40 per cent were Conservative in their sympathies, 20
per cent Labour, and 13 per cent Liberal. 41 per cent were anti-apartheid. 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 (37
per cent) and in this category reasons given for non-attendance were
mainly directed at the church itself. 10 per cent were Jewish of which
only 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 a
part of our question, Who are the doctors? For the general public there
are two images of doctors from which it can generalize. The one is its
general practitioners, the other the doctors as they present themselves
through their official bodies. It is not insignificant consequently that in
the press and the news, the doctors are making more public pronouncements 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 are
generally accepted to represent the doctors (or many of them) and the
16

quality and character of these statements should not be ignored as an

indication of the social character of the medical body. Thus they have
spoken in favour of checking the health of immigrants before their
admission and they have implied that the increased availability of means
of contraception is related to an increase in the diagnosis of certain
venereal diseases. But it is the statements about pay and status which
weigh 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 are
members of insurance schemes which make private medical care available to
them.
In June 1964, the Nuffield Nursing Homes Trust was operating 10
homes 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 private
treatment being menaced by a pincer movement of increasing demand
and diminishing supply. In 1961 pay beds comprised 1.1 per cent of all
NHS beds, a slight fall from 1949 when pay beds comprised 1.3 per cent
of all beds. Lees and Cooper6 commented. At first sight the fall in the
number of pay beds seems odd in view of the rapid rise in the number insured privately. A partial answer to the paradox is that 194961 falls
into two distinct periods. During 194953 the number of pay beds and
private patients fell sharply. Since then the number of beds has fallen
very 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 a
whole. In short, an abrupt fall in demand for pay beds during 194953
was succeeded by a sustained increase that shows every sign of continuing.
The government has not yet revealed its plans for pay and amenity
beds in the current hospital building programme. One view is that the
number of pay beds may well increase sharply and is based on the fact
that many regional boards have asked the leading provident associations
for the number of members living in their areas.7 On May 5th, 1958,
Walker Smith, then Minister of Health said, I am always prepared to
consider proposals both for private and amenity beds where this is
possible and where, in the view of the Regional Hospital Board, there
is a demand.
As counterpoint, the Annual Report of the Minister of Health 1961
stated that the number of beds unused for lack of staff exceeded 10,000,
slightly less than double the number of pay beds administered by the
NHS.
Hospital Pay Beds
Private practice occurs both in the general medical services and in the
6 BMJ

July 8th, 1963 p. 1531.

Times, January 12th, 1963.

7 Financial

17

hospital service. It is difficult to estimate the extent of private general

practice. Doctors are by nature anarchists8 so that there are few means
of checking the amount of private work they do or admit to doing. It is
easier, however, to get some impression of the extent of private practice in the hospital service since it is only done by those consultants who
are in the part-time service of the NHS. In 1959 nearly two thirds of all
work 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-time
consultant cannot work more than nine for the NHS. Despite this, in
1956, the income of part-time consultants exceeded that of whole time
consultants by an average of 20 per cent, while in a few specialities such
as neuro-surgery, plastic surgery, thoracic and orthopaedic surgery the
average was more than 30 per cent.9 It might be thought that these kind
of reasons alone would be enough for the doctors to favour the retention of part-time service in the NHS, but if we are to believe the evidence
of the witnesses before the Committee of Enquiry into the Cost of the
National Health Service, there were other sound reasons as well.
Provision must be made for part-time consultants in the hospital service so long as private practice and pay beds continue. These srvice of
many eminent consultants could only be obtained through a part-time
contract. One of the beneficial results of the NHS has been the spread of
the consultant services to the remoter areas of the country. This improvement has been due, in some degree, to the provision of consultant services on a part-time as well as on a whole-time basis. Private
practice (including not only the treatment of private patients but also
private work on behalf of the Courts, Insurance Companies, etc) gives
the consultant a wider outlook in his work and prevents his becoming
too remote from the world outside the hospital.10
The rationale of private practice for the patient is clearly stated in the
Brochure of the Hospital Service Plan, a comparatively small provident
association:
The increase in popularity during recent years of private medical
treatment is well known among business and professional men and
women, and in fact, people in all walks of life . . . There are many
reasons for this growing interest. Private patients are able to chose the
specialists they wish to treat them, which besides being more medically
satisfactory assists the creation of the doctor patient relationship that is
psychologically so beneficial, and see him by appointment at times which
avoid coinciding with business commitments. Time and money are
saved 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
8 Kenneth
9 Royal

Robinson. Speech to the Institute of Hospital Administrators May 1956.

Commission on Doctors and Dentists Remuneration. Cmnd. 939, pages 62

and 63.
cit. Cmnd. 9663 para 401.

10 Op.

18

private room and one can more easily continue to lead a more normal
life.
Sickness is, of course, a very personal matter and different people
react in different ways. Some are naturally gregarious and enjoy being
with others with whom they can discuss their illnessesand 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 when
they want to sleep, or being disturbed at night by extraneous noises and
possibly themselves disturbing other patients. Others find these things
distracting and prefer the independence of a room of their own which
also may possibly help them to feel as if they were at home.
While everyone is entitled to hospital treatment under the NHS, it is not
always possible nor is is reasonable to expect that it can be arranged so
as to fit in with the patients wishes.
Reasonable in tone, this explanation reveals some of the most pernicious aspects of private practice. It is not made entirely plain why those
who are not gregarious and who dislike being woken at six oclock
should either have to pay to escape these unpleasant features of hospital
life or submit to them. In effect private medical insurance schemes are
particularly beneficial for certain privileged classes in the community,
typically, important business personnel. Because their companies can
claim tax rebate on the money spent, the community as a whole pays
indirectly for private medical service for these people. Furthermore,
where the facilities of the Health Service are already inadequate, the
public pays part of the cost of a private medical service which has
priority over the ordinary one.
Luxury Service

I shall make only a few simple points about private practice. In the
first place, it is wrong that medical facilities should be expended on the
provision of a luxury service for a few when there is evidently so great
a 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 consumers are preventing their own high standards from becoming widespread throughout the National Health Service. As I have made clear
elsewhere, the NHS badly needs the valuable opinion formed of doctors,
consulted by these consumers, at the personal, the administrative and
the Ministerial level. Finally, it is unjust that doctors who owe their
training to education on grants at medical schools here, and their
experience and eminence to work which they have done in the NHS at
everybodys expense, should apply this valuable knowledge only to a
highly select number of patients. A solution would not be impossible.
Employees of the NHS, like any other public employee, should not be
allowed to subcontract their precious skills to the highest bidder.
Doctors should be either whole-time employees of the Health Service
or 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 be
their affair and we should not expect the public to subsidize them. And
of course there should be no pay beds in NHS hospitals either.
19

A further element of private medicine is its display of doctors medicine in an almost pure form. Medicine, that is to say, confined to the
doctor, the patient and his money. In most other kinds of medical
transaction other elements play a part. The reactions of doctors to all
intrusions of non-professional control into medicine are very similar.
Further non-medical administration has only to be proposed for the
medical 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 is
least able to pay it: the more serious the illness, the more necessary
medical attendance; the greater his disability, the worse his financial
embarrassment. The idea, which was practised in the East, of paying a
doctor to keep you fit (in effect preventive medicine) has never taken
root 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 were
once retainers at the great courts are still to be found in spirit with their
exclusive private practices. Another answer is to charge those patients
who are sufficiently wealthy a disproportionately large sum for
medical services, to pay for the treatment of those who are not. It is a
delicate system, however, depending on the rich patients willingness
to be mulcted for the benefit of the poor, and on the doctors willingness 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 their
treatment, some kind of insurance scheme is essential. It is at this
moment that the most basic clashes between doctors and society
occur. Who is to care for the sick poor, and secondarily, who is to pay
for this care?
Quarrels are likely to arise, moreover, between doctors about who
should undertake the unrewarding care of the poor. Before the institution of the NHS there was no provision to pay for adequate consultant services, and they flourished only in London where consultants were retained by the teaching hospitals and so had the opportunity
to work up a flourishing private practice. In the provinces they were
particularly sparse. In the North East in 1946, excluding Newcastle,
there were only two doctors with an exclusively consulting practice in
medicine.11
Today consultant services have been established to cover the whole
country and the quarrel rather takes the form of competition to be
appointed to hospitals whence a private practice can be launched.
Another expression of the same problem is the enthusiasm of the BMA
that patients should have free choice of their doctor. Of course patients
should. If the catch phrase is reversed though, it is a little plainer what
11 The

20

Hospital Services of the North Eastern Area, HMSO 1946.

the doctors preoccupations are. There is no shortage of doctors, for

example, in districts such as Chelsea and Hampstead, whereas the
Midlands and the North are again finding it harder to recruit general
practitioners to work there.
Medical Care of the Poor

The question of who is to pay for the medical care of the poor is closely
related to the first question. The issue is between the community and
sections of it. There were, and still are, doctors and sects whose religious idealism was sufficient to encourage them to take responsibility
for care of the poor; but society was not ready to do so until certain ideas
and attitudes to disease had been either superseded or adopted. So long
as disease, for example, was seen as punishment or a visitation, it must
have seemed futile or presumptuous for the community to interfere. To
some extent the singling out of diseases which are usually contracted
during sexual intercourse and the undertone of condemnation of those
who have such venereal diseases is a residue of this pernicious ideology. Again, in the wider context, the refusal of most general practitioners either to give honest contraceptive advice or to fit contraceptive devices for unmarried girls should be remembered. And while the
scientific revolution of medicine was freeing society of its incorrect
conceptions of disease, workmen whose experience taught them immediate connection between the environment and disease were starting
to form clubs and friendly societies to help pay for medical care. From
such societies, the more comprehensive idea of NHI grew. But from the
outset there was bickering between doctors and patients about who
should control them, for with control went the power to adjust the
doctors fee. Already the dispute about the comparative merits of fee
per item of service, capitation payment and a salaried service was
beginning. What is the importance, to doctor and to patient, of these
alternative modes of payment?
The advantages of a fee per item system to the doctors are evident. The
imposition of a fee on the patient, the right to adjust it, the right to
charge the wealthy patient more heavily without losing anything by
treating the poor patient, all these features explain the demand for such
a system now among doctors in England. Its disadvantages to the
patient are equally plain. The doctor-patient relationship is set according 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. A
class system is built into a national health insurance scheme. The
doctor 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 paying

doctors was inherited by that service from the NHI. The doctor is paid
so much per patient, with various loading devices to make one size of
practice financially preferable to another and to compensate for working away from large centres of population. It was popular with the
doctors initially because it seemed to reward those with the largest
lists. In fact, there is a maximum list size, and as the Pool system
21

reveals all too clearly there is little point in struggling to gain a few
more patients if the real determinant of the GPS income is a previously
agreed average. As one doctor said, The capitation method is all
right so long as the capitation fee is big enough. So I asked him what
he meant by big enough. The reply was, Twice what it is now. I
thought he had a point there.12
The real disadvantages of the capitation system, are the abuses it permits. In 1958 the Medical World Newsletter gave the example of two
practices, both of which were managed by well-trained doctors. One
was a group practice of three partners with ample nursing and clerical
assistance, which was responsible for 7,000 patients. The other practice,
which also had 7,000 patients, was run by two partners from their own
homes with little assistance. The expense ratio to payment of the first
practice was 49 per cent so that each partner earned 1,320. The other
practice 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 in
which the amount of money earned by each partner bears no relation
to the amount of work each does. It is particularly difficult to obstruct
the former just because it is in the interest of good general practice that
doctors should be encouraged to work in partnerships rather than alone;
and it is not possible to assess the number of partnerships which are
fraudulent in this sense because it is, and should be, to some extent in
the doctors financial interests to work a partnership. About one quarter
of all GPS work single handed, and about a half in partnerships of two
or three. Only about a sixth work in partnerships larger than three
whose size suggests a genuine group practice. As for partnerships in
which 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 ever
seeing a patient14 but again the extent of such sharp practice is unknown,
and probably since there is at present a shortage of recruits to general
practice, diminishing. It is doubtful whether the capitation system
could ever be made proof against such abuses without being so trammelled with restrictions that it would present nothing but disadvantages
by comparison with a salaried service. Indeed, it is significant that now
that the doctors seem to have reached the limit of their patience with
the system, it is to the fee-per-item-of-service method that they have
turned, seeing, no doubt, freedom (by which they mean room for
manoeuvre) in that system which they are now denied by capitation.
We are left with the salaried service whose advantages are precisely that
it avoids the failures of all other means of payment, in particular because the dialogue between doctor and patient is not accompanied by
the bass drone of financial considerations on either side. But the dispute
12

BMJ. 2, iii, 63.

Cited by Lindsey. Socialized Medicine, p. 132.
14
Lindsey, op cit. p. 166.
13

22

about modes of payment encapsulates the difficulties of attempting to

patch socialism over the holes in our society.
A Socialist Strategy for Health

This survey of the Health Service has not touched on vast areasits chronic
shortage of money and staff, its long waiting lists, its antiquated hospitals and its
squalorthe 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 for
facile pessimism: that its implementation is impossible before the
establishment of a socialist society. The socialist society will not rise
like Aphrodite, perfect from the waves; and a socialist strategy for
health can only take place within the framework of the struggle for a
socialist society. It should be formulated with two main points in mind.
First there is the part it plays in the overall socialist strategy by helping
both patient and doctor understand what health is or should be, by
encouraging constructive criticism of the inadequate service, by exposing valueless social reform. Second, there is the extent to which its
attempts at temporary improvement can alleviate the suffering, the
misery and the day-to-day hardships of life.
The socialist strategy for health must be a revolutionary one. As such it
cannot afford to ignore the strength of the opposition. Where does the
strength of conventional medicine lie? In the doctors and the institutions they have created to practise their kind of medicine, and in peoples
confidence in their competence and in the adequacy of their services. In
the end we shall have to assault both these positions. Until we can do
so we must erode them little by little. At first the attack on the doctors
can be directed against the topical and important deficiencies of general
practice: the crowding of people, sick people, into bleak, drab, cold
waiting rooms, queues for attention, cursory examination, no explanations, no sympathy, mechanical sympathy, medical obscurantism, rudeness. Against the hospitals we may use all the complaints of such enlightened bourgeois organizations as the Patients Association; and we
can also condemn them openly and directly as squalid legacies in ideology as well as form of the Poor Law. It is essential that the attack
should 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 from
their position as unique arbiters on all matters of health. Until now all
medical 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 the
information to discuss these matters intelligently. In fact, patients have
persistently shown a great curiosity about disease and the management
and sociology of the health services which has been fobbed off with
vulgarizations such as Dr Kildare and Emergency Ward 10. The curiosity
has been stunted by the doctors reluctance to discuss these matters with
them. Self-management must be brought into the health services, not
23

only because health is too important a subject to be left to the exclusive

arbitration of the doctors, but also, because only the patients can
humanize and democratize the practice of medicine. Another aim in the
manoeuvre against the doctors position as arbiters on all matters of
health must be the invasion and extension of the province of health by
those from otherfalsely separatefields of study. It is the turn
of sociologists, social psychologists, anthropologists, urbanists,
architects, all those in fact whose work in the humane sciences is the
study of the influence of environment, to claim their share of the title of
doctor or health worker. When such workers are recognized as practitioners 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 service
which is now provided by doctors; and we shall have inserted into the
health service workers who are far more susceptible to socialist ideas
than doctors are; they are more supple, more willing to experiment,
bolder, less hidebound. If we were to wait for the doctors alone to
initiate their own socialist revolution of medicine, we should still be
waiting the month after the millenium.
Characteristically the ideals of bourgeois society are as stoutly maintained in the citizenry as they are in formally reactionary institutions.
The strongest reactionary forces such a strategy will encounter will be
peoples conviction that doctors are automatically objective and capable in their best interests, that the medicine they practise is the best
available, 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 charlatan. This will be the most difficult position to capture; its conquest will
be the most valuable: for once people have been shown what the doctors do not do they can be shown what they ought to do.
To some extent shocking discoveries of inadequacies (for instance that
perinatal mortality is greater in home deliveries although these mothers
are selected because they are at smaller risk; the small number of doctors
who 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 to
remove hope, to create alarm, without offering the immediate possibility of anything better, is callous. A more useful tactic is the exposure
of the doctors own confusion of ethic, of the deterrent value of the
fee per item of service, the confusion in the doctors own attitudes to
general practice and the funnelling into general practice of those
doctors who have dropped out of the hospital service.
A Socialist Health Centre

But the most vivid way to demonstrate the inadequacies of the Health
Service is to compare it with what it could be. Socialist medical personnel, co-operating on an equal footing with health workers of all
kinds, could set up a pilot scheme in social and environmental medicine
in the form of a health centre. In this way the public would see the
fundamental difference between an attempt to practise medicine on
socialist principles and even the most altruistic medicine now prac24

tised in the NHS. It might even be possible for a socialist medical administrator of sufficient prestige to persuade a Minister of Health of
the advantages of such a scheme so that it could be carried out with
ministerial financial support. But even if the Ministry lacked the imagination to realize how the Health Service would benefit, a trade
union at least should be convinced of the use of such a scheme for its
members and their families. Such a plan demands a medical staff who
are socialists and therefore sensitive to the needs and possibilities of the
plan, who have learnt or are willing to learn to do without the undemocratic traditional doctor/patient relationship and try to cultivate
in its place a co-operative spirit, as much patients self-management as
doctors control. Of course, this requirement will present the greatest
difficulties. Patients have become so conditioned to their undemocratic
doctor/patient relationship that they will be as hard to wean from it as
the doctors.
What can this pilot health centre scheme give the community which
could not be given by a conscientious set of doctors working as a group
practice? The principles behind the work of the centre would be quite
different from those which underlie group general practice. Patients
will have opportunities for choice, treatment, and information at present
denied them. Further, questions of health and sickness would be
studied, not in their present fractured and dehumanized context, but in
an environment which would illuminate more truthfully the problems
of how people are distorted by their surroundings and how these
surroundings must be changed.

25