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Doctor in Practise

Regulating Doctors

Institute for the Study of Civil Society

London

David Gladstone (Editor)

James Johnson

William G. Pickering

Brian Salter

Meg Stacey

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

monopoly.

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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