Institute for the Study of Civil Society
David Gladstone (Editor)
William G. Pickering
The conviction of the GP, Harold Shipman, for murdering several of
his patients was taken as evidence that something was fundamentally
wrong with medical regulation, and both the Government and the
General Medical Council (GMC) have conceded that reform is
necessary. However, the real problem is self-regulation itself, which
allows the organised medical profession to exploit monopoly power.
Indeed, for nearly a hundred years the GMC has functioned, not only
as the guardian of medical ethics, but also as the enforcer of a tradeunion
rule book. The root of the problem lies in changes made at the
beginning of the twentieth century.
Towards the end of the nineteenth century doctors were keen to
distinguish their profession from ‘trade’. A profession, doctors claimed,
enforced higher standards than the minimalist ‘honesty is the best
policy’ pragmatism of the market. But did it? In truth there have been
two traditions within the medical profession. One saw medicine as a
vocation, and insisted on a code of ethics which prohibited doctors from
putting their interests above those of their patients. The other
regarded medicine as a ‘guild’ passing on the ‘mystery’ of medicine
from generation to generation and showing solidarity against outsiders.
The GMC continues to reflect both these traditions.
The origins of the General Medical Council lie in the Medical Act of
1858 which empowered it to erase a doctor from the medical register
if he was found guilty of ‘infamous conduct in any professional respect’.
Some doctors took the view that it constituted ‘infamous conduct’ to
fail to co-operate with professional restrictive practices intended to
limit competition and raise fees.
Several members of the GMC argued that it would be ultra vires for
it to protect the ‘pecuniary interests’ of doctors. However, the GMC
came under strong pressure from medical militants and a resolution
passed in July 1899 by the County of Durham Medical Union reveals
their ‘guild’ mentality:
That when the Qualified Practitioners of any district make a combined effort to
raise the standard of their fees, and thereby the status of the profession, it should
be deemed infamous conduct in a professional respect for any Registered
Practitioner to attempt to frustrate their efforts by opposing them at cheaper
rates of payment, and canvassing for patients.
In 1902 the GMC succumbed to these pressures and outlawed
advertising, the chief means of attracting new patients. The case in
question concerned a doctor who had issued handbills in a poor district
of Birmingham. Initially he had announced that he would provide a
free service for the poor, but he was so inundated by the response that
he found it necessary to issue a second circular advertising a small
charge of 3d, much lower than the going rate. The Medical Defence
Union led the case against him and told the GMC that the circulars
had been issued with one intention only: to take patients from other
‘medical men’. The GMC had resisted such pressures for many years,
but in 1902 it caved in and banned advertising.
That the GMC was being openly used to further the pecuniary
interests of doctors at the expense of patients was well understood at
the time. There was much press interest, including accusations that
the GMC had become an instrument of ‘trade-unionism’. Competition
was no longer something which might lead to social ostracism by the
medial fraternity, it could now cost you your job, and the BMA was not
slow to point this out to ‘blacklegs’.
The philosophy behind the GMC is to protect consumers by issuing
a licence only to doctors who have undergone a standardised programme
of education. Before the GMC was founded in 1858 there were
21 licensing bodies, and to some commentators this seemed like chaos.
However, we can now see more clearly that there was merit in
competition between organisations upholding different standards. The
reality of a single standard has not been that bad doctors have been
eliminated, but quite the opposite. Bad doctors, and in extreme cases
even criminals, have been shielded from normal accountability.
Without the official seal of approval of the GMC, doctors would have
to rely on their reputation, technical competence, character and
personal qualities to attract patients. But so long as they are on the
medical register, and so long as the medical register is controlled by
fellow doctors who can be counted on to be lenient in virtually all
circumstances, they are safe from serious scrutiny.
As in so many spheres, concentrated monopoly power is the underlying
problem, and the safest remedy would be to abolish the GMC.
Without the GMC we could expect a variety of agencies to emerge
giving their own seal of approval to doctors and hospitals. The royal
colleges would undoubtedly play a part, perhaps consumer organisations
might get involved, or maybe health insurers would provide a
seal of approval, just as car insurers maintain an approved list of
vehicle repairers. Such diversity would be more likely to foster the
tradition of medicine as a vocation which has been diminished, but by
no means destroyed, by the corrosive influence of officially-sanctioned
Each in their own way, the contributors to this book struggle with the
same problem and each offers a different solution. But while there is,
as yet, no agreement about the best strategy for reform, there is now
a wide consensus that the regulation of the medical profession cannot
be left as it is.
But far more is at stake than is implied by the contest between
champions of self-regulation and advocates of consumer control. A free
society depends for its vitality on the existence of organisations which
are independent of the political process, so that when political parties
submit their manifestos for appraisal by public opinion, there is a truly
independent body of opinion capable of standing in judgement, and not
merely a mass of individuals who have been manipulated by the
technicians of ‘news management’. Historically the professions have
been prominent among the organisations which have provided the
strong voices capable of serving as bulwarks against the undue
concentration of political power. The authority of the medical profession
rested partly on science but also on public respect for the tradition
of medicine as a vocation. Today, the challenge is to discover how best
to rebuild this spirit. The issue touches not only upon the machinery
of regulation, but also the extent to which clinical judgement has been
eroded as doctors have become more like Treasury gatekeepers and
less the champions of the patient. An independent profession, inspired
by service, and determined to put patients first, should not be content
to submit to central direction. For far too long many NHS doctors have
been willing to remain silent while they withheld or delayed clinically
necessary treatments on financial grounds. GPs, in particular, have
become progressively more like salaried government employees than
independent professionals and, although it will strike many as
counter-intuitive, abolishing the GMC is among the measures
necessary to reinvigorate the tradition of medicine as a vocation.
David G. Green
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