In 1946, the New Statesman published this article on health minister Aneurin Bevan’s statement that the purchase and sale of private medical practices ought to be stopped. Such a practice is “an anomaly and a scandal”, wrote the unsigned writer, “because [for doctors] it makes the possession of capital rather than skill the master-key to medical success”. But some members of the medical profession disagreed with Bevan’s ideas; a set of seven principles put together by the “Negotiating Committee”, would, the writer said, be a “gratuitous challenge to Mr Bevan” – though it would unlikely be endorsed by younger, more progressive doctors. Beyond the problem of the sale of practices lay a core crisis of the NHS that Bevan had uncovered: “The average general practitioner today is a harassed man,” on call 24 hours a day and “economically dependent on fees determined by the mere number of his patients”. Bevan had many more decisions to make with regards to the establishment of the NHS.
Mr Aneurin Bevan stated recently that it would be incompatible with the provision of an efficient National Health Service that the future exchange of medical practices and the creation of new practices within that Service should be left entirely unregulated. In less parliamentary language this meant that the purchase and sale of practices is to be stopped. With this intention few people (it might have been thought), even in the ranks of the medical profession, would be inclined to quarrel. Traffic in practices drawing most of their income from public funds under a National Health scheme would be on all counts indefensible. But, apart from that consideration, the sale of practices is in any case an anomaly and a scandal. It is an anomaly because it has no basis in legal property right; any doctor may “squat” where he pleases, instead of buying a practice – if he can afford to wait, and prefers to expend his capital in waiting instead of buying a clientele ready-made. It is a scandal because it makes the possession of capital rather than skill the master-key to medical success.
Naturally, if practices are to cease to have a sale value, there must be compensation; and Mr Bevan has given an assurance that this will be provided in proper measure. Even with this assurance, however, his announcement has evoked a counter-attack from some elements in the medical profession. The Negotiating Committee, which represents an impressive list of professional bodies and claims to speak on behalf of all medical men and women in this country, has promulgated a “Bill of Rights”. It makes its co-operation with the government in the establishment of a National Health Service dependent on the government’s acceptance of seven principles:
- In the public interest, the medical profession must not have imposed on it any form of service which lends itself, directly or indirectly, to the profession as a whole becoming full-time salaried servants of the State or the Local Authorities.
- The profession should remain free to exercise the art and science of medicine according to its traditions, standards and knowledge, the individual doctor retaining full responsibility for the care of the patient, and freedom of judgment, action, speech, and publication, without interference, in his professional work.
- The citizen should be free to change his or her family doctor, to select the hospital at which he or she should be treated, and to decide whether to have recourse to public medical service or to obtain private medical attention.
- Doctors should be free to choose the form and place of work they desire without governmental or other direction.
- Every registered medical practitioner should be entitled as of right to participate in public medical service.
- Hospital services should be planned over “natural” hospital areas, centred on the universities.
- Doctors should be adequately represented on all administrative bodies associated with the proposed National Health Services.
To certain of these comprehensive principles no serious exception need be taken. We appreciate fully, for example, the anxiety of doctors that research and specialisation should not be cramped by the subordination of the most highly skilled practitioners to an administrative machine which might not be free from the defects of bureaucracy. But, taken as a whole, the Negotiating Committee’s conditions are a gratuitous challenge to Mr Bevan; and, in our judgment, they will not be endorsed by the younger, more progressively minded doctors themselves. They will not desire, in their private interests, to oppose the Minister in the making Public Medical Service attractive from the standpoint of salaries and conditions; nor would they wish the public to forgo Health Centres equipped with the finest modern equipment. They know that Mr Bevan must ensure that the facilities publicly provided represent medical care of a scope and character which millions have so far been denied.
For, behind the fine principles of the “Bill of Rights,” there lies the fact that we have at present, as a nation, a most inefficient medical service. The true “family doctor” was the salt of the earth – friend and confidant, and never-failing help in time of need. But he was never available to the bulk of the community. While we know of superb examples of personal service and first-rate clinics in working-class districts, the average general practitioner today is a harassed man, with too big a panel, with surgery hours often a perfunctory ritual, and with little leisure to keep abreast of modern developments or modern methods. Living on the intellectual capital he acquired years ago as a student or intern, he is on call 24 hours a day and is economically dependent on fees determined by the mere number of his patients. Even before the war, there were 19 million insured patients. Under a comprehensive Health Service that number will be more than doubled, so that, on the old basis, the “G.P.” would act as family doctor to 3,000 patients. Unless, that is, he imported assistants; in that case his patients, having selected him by that illusory process of “free choice” which the Negotiating Committee champions, would have to put up willy-nilly with the auxiliary and, to all intents and purposes, anonymous attention of his “curates”.
The chief cause of this is the existing mal-distribution of doctors. A few lush, fee-paying, well-to-do districts are notoriously over-doctored. Areas grossly under-doctored, with resulting over-swollen practices, are those in which the population is poor and thinly scattered or in which (as in the case of congested industrial centres) fee-paying patients are overwhelmingly outnumbered by the insured. A better distribution of doctors over the country is urgently needed; and, in addition, the total numbers of trained medical personnel require to be greatly augmented. Every class of society should be drawn upon for recruits to the medical profession; and since the need for capital at the end of a long and expensive training has been a big factor in inhibiting the poor boy or girl from becoming a doctor, a prerequisite of an adequate National Health Service is that medicine should be a career open to all who have skill. This consideration alone would be sufficient to justify Mr Bevan in putting an end to commercial traffic in practices.
In view of the attitude of the Negotiating Committee it is difficult to estimate how long it will be before the Minister of Health will be in a position to place before Parliament his completed scheme. Apart from stopping the sale of practices, he has to face a number of difficult problems. Since some redistribution of medical personnel is essential, he will have to decide – short of the (improbable) imposition of pure “direction” – what sort of inducement he can offer to attract doctors into the under-doctored areas.
In the meanwhile, however, a situation is arising in which the Minister might do well to take interim remedial steps. While most areas are short of doctors, and in the event of a bad epidemic of influenza the shortage might have serious results, more and more doctors are being released by the Services into temporary unemployment. They are, in fact, in a quandary. Shall they buy a practice, gambling on getting back its price from the State in compensation? Or shall they wait for Mr Bevan’s New Deal?
One method of avoiding the present waste of medical man-power would be, we suggest, for Mr Bevan to extend the Emergency Medical Service, and create a Medical Reserve – a pool of doctors to be held against the day of the salaried service. On demobilisation, doctors might be invited to join this Reserve in a civilian status, but with emoluments equivalent to those of their last rank in the Services. In return, they would have to accept an obligation to take temporary posts as assistants to overworked general practitioners or appointments in hospitals. Opportunities might also be given them to take refresher courses to equip them for their duties in a salaried State service later on. An improvised scheme of this nature might be opposed by the watchful Negotiating Committee as the thin end of a wedge driven into professional “freedom”; but it would be of real public advantage under present circumstances, and it would be most acceptable to many young doctors who now find themselves faced with an awkward dilemma.
Read more from the NS archive here, and sign up to the weekly “From the archive” newsletter here. A selection of pieces spanning the New Statesman’s history has recently been published as “Statesmanship” (Weidenfeld & Nicolson).
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