GENERALISTS & SPECIALISTS IN THE 21^ST CENTURY

Paul Noone lecture to NHS Consultants’ Association, Friends’ House, Euston Road, London Saturday 6 October 2007

It’s a great honour to be asked to give this year’s Paul Noone lecture, commemorating your first chairman, who packed into his 49 years as much effective work for the NHS as a socialised service, as I have managed to do in 80.  Above all, he created a lasting organisation for propagation of ideas, which I have never managed to do. 

I want to suggest ways in which those ideas need to change, now that the NHS is squeezed not only by its old enemy, private practice as a cottage industry, but by transnational corporations in league with government, betrayed by the party that gave it birth.  Effective opposition depends on a new relationship between generalists, specialists, and the people they serve.

THE NHS HAS THREE DIMENSIONS, NOT TWO

The relation between generalists and specialists depends fundamentally on the relation of both these professional groups to the populations they serve: three dimensions, not two.  Less obviously, it depends on whether these populations are seen by both professional groups as consumers pursuing their wants in a competitive economy, or as responsible citizens participating in the co-operative gift economy created by the NHS in 1948. 

As a socialised economy the NHS was no more than an embryo.  That was what Nye Bevan intended, what his and our enemies feared, and what subsequent generations of what virtually all patients and most health professionals soon learned to love. 

Freed from medical trade in care as a commodity, the 1948 NHS allowed both patients and professionals to develop a new relationship as co-producers of health gain, without the mutual mistrust inherent in any commercial relationship.  Between 1952, when the College of General Practitioners was founded, and 1974, when public health was at last nominally accepted by clinicians in stable cohabitation, an ideology of primary care was built around NHS practice.  This provided a base for developing community generalists independently from hospital specialists, with a postgraduate training programme far in advance of the traditional Royal Colleges.  In line with their preferred role as independently contracted entrepreneurs, GPs developed an ideology for personal consultation, which implicitly accepted the value of evidence from patients about the socially and clinically complex problems found in the real world, not yet organised into the packages required for referral to specialists.[1]  The RCGP largely failed to combine this with responsibility for the collective health of their communities, until this was thrust upon them by the first new GP contract, imposed by Kenneth Clarke in 1989.[2]   Some people still try to develop this combination,[3] but the College today seems an unlikely vehicle.

Obviously this third dimension of the NHS – the people we serve - has always existed, but so far it has never been generally recognised as a positive force, a power to be mobilised to assist efficient and effective production of health gain.  The productive power of patients provides the only force that can break through the limits set by otherwise finite resources.  In any free public service accessible to everyone and grudgingly funded from taxation in a capitalist economy, workload shouldered by healthcare professionals will preclude practice as taught in the ideal conditions of teaching hospitals.  The only possible solution to this is to mobilise the creative power of patients themselves, and the power of communities to value, conserve and develop their own health through greater public knowledge, understanding, and confidence in themselves.  Policies for development of the NHS should be judged by the extent to which they either support growth of this force by encouraging people to participate in care as healthily skeptical responsible citizens, or repress and confuse it by encouraging consumerism, promotion of wants, and credulous consumption of novel commodities.

THE CLUTCH FUNCTION OF COMMUNITY GENERALISTS

A mutually agreed division between hospital-based specialists and community-based generalists began earlier in the UK than in any other country.[4] Bevan’s NHS completed this process, by replacing specialoid GPs with a new workforce of real specialists in all hospitals.[5]  

For most of the 20^th century, this seemed to almost all informed observers outside primary care,[6] and to most of those inside, to be a catastrophic division between serious clinicians abreast of scientific advance, to be found only in hospitals, and community-based GPs dealing with trivial, self-limiting, or untreatable ailments, whose main function was to guide serious illness accurately to hospital specialists.[7]

For specialists to specialise, someone has to select those patients likely to benefit from specialist care, according both to consumer wants, and to professional judgement of needs – because in any system of personal care, wants always modify professional perceptions of need, most of all at primary care level.[8] [9]  In 1948 GPs lost all easy exits to specialoid roles.  They became captive to primary care, forever condemned to listen to everybody’s problems in their virtually raw state, rarely seeing the middle and end stage diseases about which they had been taught and from which they drew dignity and a sense of their own worth, and when they saw them, bound to refer them to somebody else, a real doctor.    For the first two decades of the NHS, no UK medical school tried seriously to educate medical students for a primary care role, nor recognised that community generalists needed knowledge and skills other than those possessed by hospital specialists. 

From 1948 to 1966. primary care had no territory of its own, neither knowledge nor skills peculiar to itself, nor scope for effective research.  It seemed to need only enough funding to keep GPs contented to perform their only provenly useful function – to provide a clutch at the interface between costly hospitals and cheap general practice,[10] so that real doctors in hospitals, doing real work based on real research, might be protected from the full force of unselected patient demand.  Hospital specialists then had at least some chance of working in the ways they had learned as students, whereas community generalists had no option but to work at whatever speed their local population dictated.  GPs were the wheels as well as the clutch.  In a care system freely accessible to the whole population, this demand-led speed inevitably exceeded the rate necessary to work as all doctors had been taught.  The difference between ideal and reality was more obvious in industrial and post-industrial areas than in affluent areas, but it dominated both.     

This clutch function was impressively cost-effective.  Even in 1990, when the worldwide Neoliberal offensive was already in full swing, Alain Einthoven, its foremost advocate, freely admitted that the NHS provided healthcare to the same general standard as the US nonsystem, to all of the people and at less than half the per capita cost.[11] All health economists and policy experts then agreed that the main reason for this was the gatekeeper function of GPs, which in turn depended on separation of primary from specialist care.  The referral function applied in 5% of consultations provided the clutch, the elementary caring function applied in the other 95% provided the wheels, and the whole vehicle was oiled by mutual trust created and maintained by continuity. 

The gatekeeper role did not, as forecast, inhibit development of community generalists.  There was good evidence from comparisons of European care systems that primary care was wider in scope and more sensitive to the full range of presented problems where GPs had a gatekeeper role.[12]  Compared with almost all other countries, the old NHS therefore succeeded in using its hospitals and their specialist workforce rationally, and sustained professional philosophies of thrift and scepticism compared with care systems with direct access to specialists.  By and large, NHS patients trusted their GPs to make decisions in patients’ interests, because they knew decisions were taken in wholly non-commercial transactions.  Waiting and seeing remained an option.  Nobody made any money out of it, but millions of pounds were saved for the NHS.

THE GATEKEEPER ROLE BETRAYED

Having discovered this wonderful asset, why have all UK governments since 1979 sought to replace the gatekeeper role by a healthcare market driven by consumer wants, with numerous competing paths for access, making the gatekeeper role ever harder to sustain?  The answer is twofold, with gatekeeping apparently assaulted from two totally opposed directions.  This appearance underlies much of the confusion and despair now prevailing among the huge majority of people still loyal to the NHS idea, but standing voiceless and powerless as it falls apart.  

From the right comes the obvious assault of a huge pile of capital, mainly in USA, searching since the 1980s for larger and more profitable fields for investment as it ran out of profitable patients in USA.  Since the Seattle meeting of the World Trade Organisation this has swept through every government committed to global capitalist development, all of which have opened their public services to free trade in care.  The extent of this capitulation has varied according to the strength of organised resistance.  The so-called reform of the NHS has been used as an effective driving force for this offensive, whose first target was the healthcare intelligentsia accustomed to seeing our NHS as a beacon of social progress, rather than a pirate flag for restored competition and profit.  A free market in care as a commodity depends on consumer choice between competing providers.  It necessarily fragments care into packaged and standardised saleable units.  It necessarily destroys planned divisions of labour based on informed judgement of population needs, leaving all such divisions to be determined by pressures of consumer wants.  And to promote competition, it creates multiple points of access for consumers, so that the gatekeeper function gives way to shopping around.  

From the left, on the other hand, comes a much less obvious assault.  It aims at a different target, but so closely linked that it’s hard to hit one without damage to the other.  Most GPs would like to work closer to specialists, but without losing their gatekeeper function, which protects patients from overinvestigation and overtreatment, as well as saving the NHS from bankruptcy.   

Ever since community generalists lost direct access to hospital resources, they’ve tried to get in again, not only to recover trade, a battle already lost long ago, but to recover dignity and peer respect as participants in clinical innovation.  Medical science is a single frame, including all areas for both prevention and care.  Hospitals and their associated research laboratories need not be the only sites for research and innovation, but they have dominated both professional and public imaginations so long that it generally seems that way.   Now that all community generalists have had appropriate undergraduate and postgraduate teaching, and have confidence in their own role working within communities, most would welcome much closer association with specialists. 

This is not the aim either of government or NHS administrators, who are mainly concerned to reduce the cost of out-patient care. This may be achieved to some extent by demanding more from GPs.  In the pre-“reform” NHS, GPs were literally contracted to do whatever GPs usually did.  That was the definition of their work.  Since new GP contract imposed in 1989, every government has added more and more items to a list of priority clinical tasks, which now define what GPs must do to get paid.  These have never included continuing care of sick or dying patients in their own homes, so these and similar unspecified tasks are pushed further back in the queue of competing priorities.

Even so, demanding more clinical work from GPs and paying for it by piece rates has not been enough to replace hospital out-patient departments for referrals.  It probably has been enough to replace them for monitoring common chronic illness or high risk for illness, because GPs are now encouraged to organise call and recall clinics, and to delegate specific monitoring tasks to practice nurses with a little additional training, or now to Health Care Assistants with almost no training at all.[13], other than ability to read and follow disease management guidelines devised centrally, by our most respected specialists, assisted by a few of our most respected generalists, from the best research evidence available.  And at the other end, the entry to care, triage nurses are replacing GPs for first encounter. 

Bit by bit, community generalist doctors are sliding away from all those roles that connected the NHS with the real world of raw, unsorted complaint.  For many GPs that will be a relief.  For anyone interested in developing community generalists as imaginative resident human biologists, with continuing responsibility the health of defined populations, it’s a cause for extreme concern.

AUTOMATIC TRANSMISSION?

Piece-rate contracts with GPs as cottage entrepreneurs can’t replace specialists in hospital out-patient departments, but perhaps they might if specialists met them halfway at a new site for care, a polyclinic.  So thinks Lord Darzi, and an impressive list of specialist and a few generalist colleagues who have helped him prepare his plans for future NHS care in London.  Hospitals would shrink to their core functions for patients requiring invasive procedures, most of which would be done as day surgery.  Specialists would at last be reunited with their generalist colleagues, to the satisfaction of both.

This apparently seamless combination of staff seems to promise a new vehicle, its parts so rationally connected that it no longer needs a clutch to allow for different speeds between the engine of specialism, and the wheels of primary care.  If this great new programme can actually be implemented, with the huge building programme it would entail on costly London sites, we may be approaching an automatic transmission, and anyway the clutch provided by gatekeeping is now so full of holes that it seems to be on the way out.  NHS Direct, practice nurses and HCAs will now provide the wheels, and community generalists can at last climb up into some sort of specialism, at least some distance from the dirty, dangerous and distressing world of unsorted life.

Where will all this rationality come from?  From guidelines, allowing a much larger and less expensively educated workforce to participate in care, just as Henry Ford’s unskilled workers could, by concentrating on small specific tasks within a clear overall plan, replace skilled engineers, and still produce a better car, at a lower price, with a higher profit.

A prototype for this automated transmission already exists in Seattle, the Kaiser Permanente healthcare complex, which on paper at least, has claimed to provide much better care than the NHS, at a much lower price.[14] Whether this claim is true or even credible, when an international comparison of healthcare costs starts off by adjusting for international price differences, and a comparison of care ignores differences in coverage and case mix, [15] is irrelevant to my argument.  All NHS policy makers have chosen to believe it, and it is certainly true that Kaiser has brought specialists and generalists together, more rational use of medical skills has followed, and this process is much more cost-effective than other US corporate providers, for the working population it serves.   For government by any of our three main parties in serious contention, that will be enough to justify following the same pattern here.

The Darzi report promises something very like Kaiser, but on a much bigger scale, and somehow including all the poorest, sickest people with most socially and clinically complex chronic problems.  Unlike Kaiser, the NHS can’t transfer difficult patients by taxi to Skid Row, to manage their paraplegias and colostomies as best they may.[16] This sort of thing could discourage the corporate investment in the Darzi project which seems to be the only possible way to fund it.  Unless Gordon Brown is prepared to tear up his entire New Labour project as ruthlessly as he deleted Clause 4 of his Party’s constitution, there can be no state funding for Darzi, and any more PFI projects would certainly bankrupt every London Primary Care Trust. 

The plan is only conceivable on the assumption that capital investments come from a very large corporate provider with past experience of HMOs, almost certainly in USA.   This provider would be legally compelled to give higher priority to the interests of its shareholders than to London citizens, all its transactions would be subject to commercial secrecy, and none of its controllers would be elected.  Lord Darzi would not be the first highly intelligent technical expert, with impeccable intentions, to prove himself a fool in politics.  The NHS was created by politicians and only through political action can it be maintained and developed.  The only space outside politics is the market, which is where the NHS will go if doctors are stupid enough to fall for an apolitical service.  Darzi’s plan makes sense only as the spearhead of something much uglier.

THE FUTURE

I think the Darzi Report is significant only as an entry point for further disintegration of the NHS by corporate providers looking for new investments with high profits.  Of course, if the social responsibilities of the NHS don’t change, there will be no high profits.  This has already deterred many who planned to profit from breaking up the NHS, including the many insider dealers among clinicians and administrators corrupted by more than three decades of corrupt government.  But don’t count on this.  Each step in the process of creeping privatisation takes us further away from the public service ethic we have somehow to restore.

I think we need to restore confidence in many sound developments we already have in primary care, in care shared between generalists and specialists, in care shared between generalists, specialists, and patients themselves, and above all in medical science, which is still pulling things forward however strong the commercial and political tides are against it.  The invisible hand of science is as important to real progress in health care, as the invisible hand of the market has been to capitalist economy.

It may not be popular to say so, but I believe community generalists, whoever they may be in the future, have a more difficult, more effective, more demanding job than specialists.  This is because their real responsibility is to organise the entire interface between what needs to be done in the real world, and the skills and evidence-based knowledge required to do it, for lists of real people with names, addresses, and telephone numbers who can and do hold them personally to account.  The job is even more difficult because we have not as yet dared to put this forward as our job description; to know the full outline of human biology, including its important social subsets, and apply it to a set of real people with their consent and co-operation, in continuing relationships measured in decades if no longer in lifetimes.

If some medical generalists find this too difficult or uncomfortable, they will find a rung somewhere on Lord Moran’s old ladder,[17] which is still in fair shape.  But having seen the young people entering our medical schools today, I believe most will not.  From where we already are, with the people we already have, are we not a thousand times more powerful than the few professional voices raised in support of Bevan’s NHS in 1948?  All we need is political understanding.  Political will must follow.

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