PROFESSIONAL AUTONOMY IN PUBLIC MEDICAL SERVICE

JULIAN TUDOR HART

Hon. Fellow, Welsh Institute for Health & Social Care

University of Glamorgan, Pontypridd.

Based on the fourth Robin Pinsent lecture in Birmingham March 11 1999.

Published as Hart JT. A new kind of doctor: professional autonomy in a public service. British Journal of General Practice 1999;49:854-7.

Dictionaries define autonomy as self-regulation of a person or group. Loosely, we understand it as freedom, a precondition for which, said Pascal, is recognition of necessity.  Unless we recognise inescapable constraints, we can only talk about freedom, not use it. Envied by English romantics for their primitive autonomy, Bedouin Arabs were not free to do or think anything outside the desert world in which they lived.

General practice faces its sternest but most appropriate test when trying to deliver effective care to whole populations in the bottom third of our economy.  Limited by received assumptions, UK general practice is beginning to resemble this Bedouin metaphor.  GPs in our post-industrial deserts are at risk of social isolation and clinical obsolescence.

THE NHS EXPANDED PROFESSIONAL AUTONOMY BY DETHRONING TRADE

Independent contractor status is the supposed foundation stone for our College ideology.[1]  This ignores an earlier transition.  I knew Robin Pinsent well enough to be sure that in 1948 he, like Will Pickles, Ekke Kuenssberg and most other founders of our College, differed from 85% of their GP colleagues by actively supporting the NHS in the turbulent six months preceding implementation of the Act. Robin’s priority was patients’ needs, not professional power or income, and he understood the difference.  So much so, that he refused ever to collect BMA-approved fees for private certificates, and publicly derided colleagues who continued to tap this demeaning source of petty income.

According to English pre-NHS wisdom, private practice set standards for public service, because public service would never be sufficiently resourced.  The NHS, offering free care for the previously fee-paying middle class, would therefore decapitate general practice.[2]  In fact the NHS released a wave of reforming energy at all levels, including birth of our College.  It dethroned private practice from moral authority, and swung substantial investment into secondary care for the first time since Edward VII.  Instead of looking back to mythical good old days, the College looked mainly to NHS urban group practice to provide wider and deeper social foundations for innovation, right up to the divisive contract of 1990.

After the NHS virtually eliminated trade in primary care, GPs could work for all people according to their needs, rather than some people according to what they could afford.  Their anticipated loss of autonomy never occurred, because they measured this not as freedom to do whatever they wanted, but as power to think and act effectively for patients.

WE STAND ON THE BRINK OF SALARIED SERVICE

Until very recently, independent contractor status conscripted every doctor who wanted to work autonomously in primary care to small business.  Small businessmen prefer profitable sites, with optimal balance between earnings and workload.  This formula guaranteed that areas of highest mortality, morbidity and GP workload always had least choice of staff.[3] 

Countries which traditionally exported doctors, first Scotland and Ireland, later southern Asia, staffed medical sweatshops which local graduates could avoid.  Many of these, notably the South Wales valleys, have depended for the past 30 years on GPs trained in Asia for 50-80% of their staff.  Used first as dead-end junior surgical staff, they were then tossed into the GP dustbin, to survive as best they could.[4]  We now face the consequences of unprincipled opportunism.  The hard-working sons and daughters of these Asian GPs now compete successfully for consultant posts, they want something better than corner shops.  The deep end of general practice is therefore in staffing crisis.[5]

Deregulating legislation rushed through by the Conservative government in its last months has allowed roughly 15% of advertised posts in general practice to be salaried by 1998.  Most of these contracts are held by Community Trusts, a few by Health Authorities.  There is no national contract, though the BMA wants one.[6]  A few of these posts are being used imaginatively, but most seem to be planned as transient props for the past rather than foundations for a different future.  This ignores opportunities for new advances as profound as the NHS in 1948, both for us and for our patients, a new stage in the same long transition from private trade to public service.  Independent contractor status is a tenuously surviving legacy of private practice.  With salaried service, GPs might finally escape from business, to enter social biology.

DEPERSONALISED TREADMILLS?

Piecemeal salarisation of general practice will probably continue, with little professional opposition so long as it avoids areas where trade is most profitable. Governments and civil servants prefer a tidy salaried command structure.  They would have moved in this direction long ago, had they not faced implacable professional hostility, and saved vast sums of public money by GPs’ willingness to accept responsibility for virtually all investment in primary care until 1967, and most until 1990.

Opponents of salaried service rightly claim that by itself, it does nothing to improve quality of care, but entails high risks of bureaucratic stagnation, depersonalisation, and loss of continuity, very evident in many countries.  However, opponents have virtually ignored successful salaried services in several countries comparable with our own, nor do they consider mounting evidence that independent contractor status has generally failed to maintain continuity, as it has shifted from single-handed to group practice,[7][8] though personal continuity was supposed to be its main justification.

Salaried service as a treadmill for doctors and a clinical slum for patients is all too familiar, wherever public service has to develop as a barebones alternative to affluent private practice.  Without mass pressure first to restore and then to promote priority for redistributive, tax-based public services, that is its natural outcome in any market society. 

The positive potentialities of salaried service depend on active struggle, in alliance with our patients.  Advance could then be initiated by health professionals, not against or in spite of them.  For this, at least a critical mass of innovative GPs  (whom I would estimate as roughly one third to one half) need to be won to this strategy.

Only about 20% of GPs seem to rule out salaries on principle,[9]  but with few exceptions, GPs who have created excellent group practices and vocational training schemes, and are now trying to make the rhetoric of a primary-care-led NHS into reality through Primary Care Groups, reject all immediate proposals for salaried service.  They see nothing feasible with salaries which they couldn’t achieve themselves, without giving up their personal ownership of the heart of NHS primary care.

Such progressive partnerships are as exceptional now as they always were.  Though about one-third may be seriously trying, far fewer show evidence of succeeding.  Independent contractor status has no mechanism for extending to all practices the good work of an exemplary few which organise regular meetings where work of the whole team can be critically discussed by the whole team, and where clinical or population policies (other than pursuit of centrally rewarded targets) are agreed.

Personal ownership of large chunks of the NHS has become intolerable for many staff who are excluded from this power.  It ensures that doctors remain the rate-limiting factor on creativity for everyone else.

CRISIS IS A PRECONDITION FOR REFORM

If salaried props work to the present job definition of GPs the downward slide in morale will continue, with less continuing care, more crisis intervention, more emergency admissions, more self-referrals to accident and emergency departments, and higher costs for irrational prescribing.  Experience shows that salaried service can begin only where independent contractor status has already failed, where new staff can no longer be recruited in the old way, and independent contractor status is no longer a viable option.

Salaried staff need to work in new ways, no longer assuming that GPs are responsible in the first instance for the entire range of work which hospital specialists can’t  do better, or deem too trivial. Who does what needs to be based on evidence from analysis of the actual work of primary care and the skills needed to perform it, not on traditional professional hierarchies.

This new work will take time. GP workload has risen throughout this decade.[10] Where can new time come from? If GPs employ others to do it, why should they pocket the difference between their own hourly earnings, and those of other staff?  Who will be responsible for training and quality control?  Will they abandon other tasks not yet specifically rewarded, though no less important? Home visiting rates fell by 27% between 1981 and 1991, while the number of pensioners rose by 7%.[11] Did this include visits for terminal care?  Stick pushing and carrot pulling of independent contractors cannot ensure comprehensive, effective, and efficient service. 

The tasks of both hospital and primary care long ago became too complex to be owned or controlled by one group of professionals, answerable only to their own uncritical peers, subordinating other health workers to their authority.[12]  Consultants formally conceded this in 1948, because they understood their work required public investment in hospitals, though they retained huge informal power.  GPs did not understand that primary care stood in equal need of investment.  They wanted to be left alone, so they were left alone.  Since then, as state investment has increased, so has management control. For government, the great advantage of independent contractor status was that in the name of autonomy, GPs voluntarily accepted a pecuniary interest in mean and unimaginative provision of care, and inflated expectations for what one man could accomplish.  This has been steadily eroded by increasing state investment in primary care, direct or indirect, as governments slowly began to understand that you can’t build effective or efficient hospital care without a foundation of effective and efficient primary care.  For industrial and post-industrial areas at least, independent contractor status is losing its grip both on both government and professionals.

OR CHARIOTS OF FIRE?

Salaried service is both inevitable, and a necessary but not sufficient precondition for serious advance in quality of care.  There’s going to be a battle, between social forces using salaried service principally to rationalise further retreat from the original aims of the NHS to provide free comprehensive care for the entire population funded from taxation, and forces using it to reassert 1948 principles in a new situation.

Our situation is new in three ways. First, the apex of advanced economies is shifting from production of material commodities to production of knowledge.  Appropriation of wealth increasingly depends on legal and cultural submission to the concept of private intellectual property.  This will be as fiercely contested as was the concept of private property in land, which even in Europe took well over 1000 years.  Resistance to unregulated markets in intellectual property could enlist a much wider social majority than was ever available for socialisation of the means of material production.

Second, both the public and health professionals are beginning to see flaws in consumerism, and the significance of developing patients as co-producers of health gain as a social product, rather than consumers of care as a personal acquisition.[13]

Third, on a basis of regionally organised primary care, information technology creates the possibility that cumulative records of the process of care could provide a database for mass participation in research.  Based on what we have learned, largely through College initiatives, about the nature of continuing care as a life story, these records could quantitatively reflect real lives, and thus have wider uses than the episodic fragments available from hospital care.   Using such cumulative records, the experimental nature of all consultations could be used to produce new knowledge.  The NHS is the biggest single employer in Europe, a major producer of wealth, though not in commodity form.  Associated with research-based biotechnology, it could become a very much bigger employer and wealth-producer.[14] Though some of this new wealth would have initially to be traded for profit, it seems unlikely that such primitive social arrangements could be permanent: but that’s another story.

So far, patrician leaders of our profession have, predictably, chosen to submit to established power, pleading for a special relationship as their reward for justifying to the mass of the people why rich Britain today cannot afford the same social generosity as impoverished Britain in 1948.[15]   But GPs are not patricians.  Autonomy concerns power.  The power we need is power to apply the whole of medical science effectively to the real problems of all the people.  Locked in the past, we can’t be effective, and autonomy becomes illusory.  To have autonomy in a necessarily more regulated future, we must fight for it, as advocates for our patients as well as for our right to retain clinical judgement, with this public as our allies.  Not only we, but all skilled workers, have a right and duty to control not the aims of our work, which must be agreed by society as a whole, but the ways those aims are achieved.  We need to work with our patients in our own way, because that way will certainly be most socially efficient.  Whether established power then regards us as enemies depends on whose interests they choose to serve.

REFERENCES

1 Gray DJP. General practitioners and the independent contractor status. J Roy Coll Gen Practit 1977;27:750-6.

2  Geiringer E. Murder at the crossroads: or the decapitation of general practice. Lancet 1959;i:1039-45.

3 Hart JT. The Inverse Care Law. Lancet 1971;i:405-12.

4 Esmail A, Everington S. Racial discrimination against doctors from ethnic minorities. BMJ 1993;306:691-2.

5 Taylor DH, Esmail A. Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire? BMJ 1999;318:306-10.

6 Chisholm J. Challenges for GPs in a primary care-led NHS. RCGP Members' Reference Book 1998/9, pp.354-5.

7 Gray DJP. The key to personal care. J Roy Coll Gen Practit 1979;29:666-78.

8 Freeman GK, Richards SC. How much personal care in four group practices? BMJ 1990;301:1028-30.

9 A survey by Medeconomics (March 1998) showed only 20% of a sample of 500 GPs would prefer independent contractor to salaried status regardless of terms.  12% would accept salaries at less than ,60 000 a year, 27% would accept ,60-70 000, and 40% would hold out for over ,70 000.

10 Pedersen PL, Leese B. What will a primary care led NHS mean for GP workload?  The problem of the lack of an evidence base. BMJ 1997;314:1337-41.

11 .Aylin P, Majeed F A, Cook DG. Home visiting by general practitioners in England & Wales. BMJ 1996;313:207-10.

12 Hart JT. To whom are we answerable? Lancet 1983;ii:1132-3.

13 Hart JT. Two paths for medical practice. Lancet 1992;340:772-5.

14 Hart JT. Going for Gold: a new approach to primary medical care in the South Wales Valleys.  Third revision. Welsh Institute for Health & Social Care, University of Glamorgan, 1999.  Copies available from WIHSC, Glyntaff Campus, University of Glamorgan, Pontypridd CF37 1DL, price £5.00.

15 Shock M. Medicine at the centre of the nation's affairs: doctors and their institutions are failing to adapt to the modern world. BMJ 1994;309:1730-3.