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Consultants and changing health care.

CONSULTANTS, for long at the apex of the British health care system, are increasingly finding their privileged position under scrutiny and challenge. This is clearly an issue of importance to the small elite professional group concerned. But it could potentially be the harbinger of more radical reform affecting the nature of medical education and training as well as the way in which health care is delivered. As such its importance may reach far beyond the immediate interests of the consultants themselves.

Consultant dominance of health care processes is an important aspect of the professionalisation of medicine which has taken place in Britain over the past century. As such any discussion of the consultants' future must be set within the medico-political framework of the past. Two historical periods are especially significant.

The first is the growing differentiation within the medical profession that occurred during the nineteenth century. While consultant specialists increased their medical prestige and associated social influence, for many GPs the situation was very different, especially, when as the result of the expansion of medical teaching, the profession became too over stocked for comfort.[1] In such a situation the GP was |a vulnerable individual in a highly competitive buyer's market'.[2] Meanwhile as physicians and surgeons worked together in the hospitals and co-operated in the medical schools |the differences between them came to be of somewhat less importance than their common interests as hospital consultants'.[3] It was this group who |mutually gained in prestige as teaching and research expanded in the new medical schools and hospitals became the centre of medical excellence'.[4] As a result of these developments, the hospital consultants |began to see themselves and to be seen as a superior elite over against other qualified practitioners':[5] a situation that was reinforced both by numbers and referral patterns.

Even as recently as the outbreak of the Second World War there were only some 3,000 consultants compared with more than 20,000 GPs.[6] But, even more importantly, as the result of a deal between the BMA and the Royal Colleges, |specialists would not see any private patients except at the request of a customer's GP'.[7] This gave the GP the security of sending their more puzzling patients to a consultant colleague for a second opinion. But it also meant that consultants |instead of having to attract their own patients ... were able to sit back and await the arrival of those referred by their former pupils or by local doctors who knew of their fame'.[8]

Processes such as these, reinforced by the pattern of medical training and education, created a distinct hierarchy within the medical profession. It was this division within the medical establishment that Aneurin Bevan, as Minister of Health, was to exploit so skilfully in the creation of the National Health Service. It is this period of the 1940s, therefore, which forms the second period of historical significance in considering the evolution of consultant dominance.

The story of GPs' resistance to working in the new NHS is well known. That they did become part of the service on the day appointed for its inauguration -- 5 July 1948 -- owed much to the compromises and concessions which Bevan negotiated with the consultants. Whereas at the introduction of the National Health insurance scheme:

in 1912 Lloyd George had aimed to by-pass the elite to get at the humble

working doctor; Bevan used the elite to capture the GP. In effect he bought off

(|stuffed their mouths with gold' were his words) the consultants and used them

as a counter weight to break down the resistance of the BMA.[9]

Not only because of their political usefulness but also because they were the elite corps whose willing participation was regarded by Bevan as fundamental to the image of the NHS as a first class service |they were offered many fresh inducements without being expected to sacrifice too many of their privileges'.[10] These included part time contracts for consultants who were also to have their own pay beds in hospitals for private patients. Not only were consultants guaranteed high earnings from the public service, they were also able to maintain private practice and the virtual monopoly of distinction awards that accompanied it. The NHS may have offered a new deal in health care to the British people, but its creation represented a significant accommodation between the interests of civil society and the power especially of a small elite sector of the medical profession.

In the 1940s it seemed that consultants had achieved a powerful political attestation for their position at the apex of the health care system. That situation was itself reinforced by important innovations in medical technology in successive decades which ave hospital medicine a pre-eminent position -- not least financially -- within the NHS. How is it then that the consultants' future looks much less secure in the early 1990s? There are a number of factors which help to explain it.

The first is the increased emphasis on managerial accountability and responsibility introduced into the NHS during the 1980s. This process is perhaps best exemplified by the introduction -- following the 1983 Griffiths Report -- of general managers into the Health Service, charged with responsibility for the efficient use of resources. But there are other indicators of the same process: the |limited list' of drugs for NHS prescriptions, the introduction of a wide variety of measures such as performance indicators and quality adjusted life years (QALYs) and the emphasis on information technology in the 1989 NHS White Paper which, again, provides the. opportunity |to extend managerial control over professional behaviour with the object of securing better value for money'.[11] All these procedures and processes reflect the interest of a government concerned with reducing the level of public expenditure and a view of doctors typecast in the role of careless users of resources'.[12] Not |progressively, therefore, clinicians in hospital practice have increasingly surprisingly, therefore, clinicians in hospital practice have increasingly been brought by management into resource-use decision making processes either as members of committees concerned with resource allocation or as budget holders directly accountable to a unit general manager.

Management accountability may represent one contemporary challenge to the consultants' status. Another comes from the articulate consumer. In recent times, it has been suggested, the consumer voice has taken a variety of different forms: a concern with ineffective or even. harmful drug supply (e.g. thalidomide), a positive commitment to greater Individual responsibility in matters of health (a recurrent theme of self help groups and an integral part of the rhetoric of government policy over the last ten years or more: the publication in July 1992 of The Nation's Health merely continues that trend), |a vigorous neo-liberal challenge to professional monopoly as inhibiting informed consumer choice[13] as well as the challenge from the dis-satisfied patient represented by the marked increase in the number of complaints about the quality of medical care.

The Patient's Charter, an idea much promoted by John Major, with its emphasis on quality of service merely continues that emerging trend with its provision of yardsticks and guarantees. This too may impact directly on clinical practice, as one vision of the future expresses it.

Clear thinking about what you are producing and monitoring of the results as

demanded under the Citizen's Charter presumes some concept of the |output'

of the organisation . . . Before long the Department of Health will find itself

managing a series of independent trusts and budget holders, all of whom have

selected measurable and achievable output strategies; and without any orders

being given down from the top the NHS will quietly have changed from trying

to do everything to doing only what it can measurably do best.(14)

The influential report on London health care produced earlier this year by the King's Fund Commission envisages a shift away from traditional style acute hospitals towards an enhanced role for primary care in matters of health promotion, care and treatment. As the Audit Commission's 1992 report indicated, developments in medical technology are already altering the nature of medical practice. |The rapid development of minimally invasive methods of diagnosis and treatment,. .. less toxic anasthesia (and) developments in pharmaceuticals' have all made possible a shift away from surgery into primary care and enhanced the possibilities for short-stay, day-case treatment.[15] In consequence, |in-patient hospital stays will be progressively reduced for many categories of patient, leaving longer stays in acute hospitals beds increasingly the sphere of cases presenting with complex multiple pathologies'.[16]

Where secondary (hospital) care is seen as a resource |explicitly organised to enhance the capacity and support the work of primary health care practitioners',[17] the implication is a not inconsiderable challenge to the traditional power relationships within the medical profession and to the century-old established referral pattern between general practitioners and hospital-based consultants. But medical changes of this sort are occurring at the same time as legal challenges to consultant status, a debate which sets the issue of medical manpower in a European context.

The 1975 European Community Medical Directive governing the mutual recognition of qualifications came into force in 1977 and was designed to ensure that fully qualified doctors, whether general practitioners or specialists, could practice anywhere in the European community. But |Perfidious Albion soon worked out ways in which continental specialists would be recognised but not accredited. In spite of the introduction of European certificates of specialist training, the NHS and private health insurers continued to rely on UK certificates of specialist accreditation awarded by the Royal Colleges'.[18]

Meanwhile, the details of those UK practitioners who hold the European certificate of specialist training are, under Standing Orders of the General Medical Council, held on cards which are kept private and confidential. These processes are now under challenge both in the European Commission (the case of Uccio Queroi della Rovere) and in the British legal system where Dr. Anthony Goldstein has recently been granted leave to seek to prove that Britain was in breach of European law in relation to the system of specialist accreditation. The Department of Health has instituted a review under the chairmanship of Dr. Kenneth Calman, the Chief Medical Officer, to advise health ministers on the action needed to harmonise UK regulations with EC law. But already, it has been suggested, that |the Royal Colleges and the General Medical Council should prepare themselves for reform. Their monopoly days are over'.[19]

Superimposed on all the challenges to consultant status which I have reviewed so far was the announcement in early September 1992 of an investigation to be carried out by the Monopolies and Mergers Commission (MMC) over possible |price fixing' in the fees charged for private medical treatment. Much in line with the American health insurance industry's concern with escalating treatment costs, the central feature of the first British investigation into the private medical sector is the guideline published by the BMA which sets recommended fee rates for medical and surgical procedures. While the BMA insists that they offer guidance and not recommendations, the Office of Fair Trading has pointed out that:

If these are adhered to by a significant proportion of consultant doctors, they

may effect the nature of competition and the level of fees in the market for

the supply of private medical services.[20]

The report of this investigation is due to be presented to the President of the Board of Trade within twelve months. Like the contemporaneous legal actions, the MMC investigation raises pertinent questions about the operation of restrictive practices within the medical profession. While they may |protect the prestige and income of consultants' one assessment has concluded, |they are good neither for the rest of the profession nor for the patients they serve'.[21]

It seems unlikely that the consultants' future will be as privileged and powerful as their past. Managerial reforms and changing medical procedures have already established that; and as I have shown other processes of change are also at work.

For the future, three issues seem to be especially important: the location of specialist care, the nature of the specialist task and the related matter of education and training.

My earlier discussion based on the King's Fund Report suggested a new balance between primary and secondary health care sectors. While not suggesting the abandonment of hospital medicine, its future role will be more circumscribed.

In the twenty-first century diagnosis, investigation, treatment and care which

require the use of expensive equipment and a range of highly skilled personnel

will take place in acute care hospitals and day care centres. The primary health

care team will need to draw on this kind of specialist help for people for whom

outcomes are better when treated by teams with specialist skills -- such as major

traumas or certain cancers or where treatments or investigations use expensive


What this suggests is that while there will be a certain similarity between present hospital populations and those in the future, they will not be identical. As a consequence the role of hospital medicine may well be more specific, with the consultant specialist as one of a team providing expertise and treatment. Educational programmes, therefore, inter alia must include training specifically directed towards inter-personal relations and the dynamics of multi-professionals working in partnership.

There also needs to be greater clarity about the nature of the specialist task. At present it is an amalgam of diverse elements: clinical, management, academic and training. To what degree might it be possible for individuals, by contractual agreement with Health Authorities or Trust employers, to be responsible for different aspects of this growing diversity, within a single specialist grade; perhaps at different stages in their personal career development? A rationalisation of this sort, with the accompanying changes in training programmes, could begin to address the increasing service, training, academic and managerial demands on hospital specialist manpower.

Underlying both the aspects so far discussed, is the related issue of education and training. As the Chief Medical Officer at the Department of Health has recently pointed out, |The continued high quality of the services provided to patients inside and outside the NHS depends largely upon our capacity to continue to educate and train doctors to the highest possible standards'.[23]

This issue has received particular attention in recent proposals advanced by the Junior Doctors Committee of the BMA and the Hospital Doctors Association. Arguing for the harmonisation of UK and EC specialist certification, they propose that it should be awarded to those who have successfully completed a specified duration of training involving a programme of education and clinical experience with clearly defined objectives, supervision and assessment. But equally important in their proposal, and currently receiving the support of several of the Royal Colleges, is the idea that the length of training should be reduced. A period of between six and eight years is envisaged compared to the average ten to fifteen years which it currently takes for a graduate in medicine to become a consultant. In relation to other European countries, it has been suggested that, the British training system for hospital doctors is |wasteful and corrupt because it allows so many to train so hard and so long in an effort to become one of the few. And while undergoing the longest training period in Europe, the UK's junior doctors are expected to provide a top grade service with little supervision'.[24] Such a reform of the training system designed to supply fully qualified specialists within a shorter time would clearly increase the number of specialists available. So too would the publication of the private list currently held by the GMC of those UK practitioners who are qualified by means of the European certificate of specialist training.

By whatever means their numbers are increased, any significant addition to the specialist cadre could have important implications for both the public and private sectors of health care. Private fees were initially set at a premium to attract consultants when skills were scarce. By the simple law of supply and demand it would be expected that any significant increase in the supply of specialists would reduce the price levels to private insurers, assuming that no impediment existed to free market conditions. Meanwhile, in the public sector, increasing numbers of specialists could speed referral between GP and the hospital sector and shorten the hospital waiting times for surgical procedures. The question which needs to be addressed is whether a system of medical manpower structured on |an eighteenth century guild model ... that rests on apprenticeship, patronage and promotion by preferment'[25] Should stand in the way of creating the conditions for change and offering better value for money in health care to both tax payers and patients alike?


[1.] Roy Porter (1987). Disease, Medicine and Society in England 1550-1860. p.53. [2.] ibid. p.54. [3.] Margaret Stacey (1988). The Sociology of Health and Heating. p.83. [4.] ibid. [5.] ibid. [6.] Donald Gould (1992). |Though many are called, few are chosen'. New Scientist, 25 April, p.47. [7.] ibid. [8.] ibid. [9.] Derek Fraser (1984). The Evolution of the British Welfare State. p.235. [10.] Charles Webster (1988). The Health Services since the War. Vol. 1, p.305. [11.] Mary Ann Elston (1991). |The Politics of Professional Power: Medicine in a Changing Health Service'. In Jonathon Gabe et al (eds.) The Sociology of the Health Services. p.58. [12.] C. Davies (1987). |Viewpoint: things to come; the NHS in the next decade'. Sociology of Health and Illness, volume 9. [13.] Elston (1991). Op cit. p.78. [14.] Eamonn Butler (1992). |Government and Opposition: Views on the Strategy for Healthcare in Britain over the next five years'. Keynote address to IHR Conference on |Competition and Profitability in the Healthcare Insurance Industry', 12-13 May. [15.] King's Fund Commission (1992). London Health Care 2010, p.72. [16.] ibid. [17.] ibid, p.76. [18.] Malcolm Dean (1992). |European Doctors at the Gate'. The Lancet, September 12, p.660. [19.] ibid, The Independent, 9 September. [20.] Cited, The Independent, 9 September. [21.] Editorial 9 1992). |The Doctor's Dilemma', The Times, 2 March. 22. King's Fund Commission op cit., p.79. [23.] Press statement (1992). Chief Medical Officer, Department of Health. 9 September, para. 11. [24.] Editorial (1992). |Time to exercise career secrecy'. Hospital Doctor, July. [25.] Malcolm Dean (1992). Op cit.
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Author:Gladstone, David
Publication:Contemporary Review
Date:Dec 1, 1992
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