DOCTORS AT MANCHESTER
The Shadow Over the BMA
By ANNIS GILLIE*
FOR the doctors gathered in Manchester this week for the British Medical Association annual meeting, three and a half days will be spent in discussing policy and more domestic Association activities, with an agenda of nearly 450 items. Some of the representatives of the geographical constituencies will then return to their practices, hospitals or offices and an ever- changing flow of others from all over the English- speaking world will spend four more days at the scientific meeting. This contrast in outlook and experience, subject-matter and way of discussion maintains the liveliness of our largest medical conference.
The overlap of a day containing both groups helps to leaven the lump of concern and dis- content among the first and their continuing presence can toughen discussions with the down- to-earth scepticism of the medico politicians then turned scientists.
Inevitably, the pattern of resolutions and amendments to the Annual Report of the Coun- cil is blurred by the knowledge that the Bruce Fraser working party on the future conditions of work in general practice has been sitting every week since Easter and has a big jab to do. Even the first instalment of its report (which is to be serialised) must be some way off yet. The Asso- ciation's memorandum of evidence on the general practitioner's amount of payment is now in the hands of the Review Body on Doctors' and Dentists' Remuneration. The storm that pre- ceded agreement on its content and presentation still rumbles on. Other motions relate to the problems of financing professional expenses and premises, matters that are being negotiated direct with the Ministry of Health at present.
There are 70,000 members of this Association, 45,000 of them in this country and almost half of these general practitioners. Most of them have the individuality of outlook, rivalry in loyalties and personal methods of working that seem inseparable from, and are even the expres- sion of, the responsibility for human beings' health and survival. The lull now in being over the remuneration of one section and the repercus- sions of this issue on the others is a welcome relief, and leaves time for the discussion of other pressing matters. Agreement on any serious issue of professional interest in its widest sense is hard to achieve. The leaders of the doctors are constantly faced with the risk of dimming the outlines of jealously kept principles of profes- sional work and standing when facing the problems that exist today. Necessarily the obli- gations involved by the independence of a family doctor, which has been secured by his peculiar contractual relationship to the National Health Service, meet increasing criticism in debate, as the advantages of this contract are gradually lost sight of. The rigid controls said to be inevitably associated with the possible alternatives are as yet scarcely appreciated. Many motions have their starting-points in these conflicting valua- tions. They are expressions of disturbed feeling, perhaps, more than issues of policy.
There is evidence, too, that there is concern in some quarters that the Association's exceed- ingly democratic constitution (last major revision *Chairman of the Central Health Services Coun- cil committee which reported on The Field Work of the Family Doctor' last October. 1902) is rather too close to that of a Greek city-state for the convenience and speed of nego- tiations, when a whole profession is involved in a national service. Yet to change it with any serious loss of the confidence of each member could be a disaster for more than the doctors.
Behind many of the motions is a darkening shadow. The size of the population is increasing faster than the number of doctors. The scope of modern medicine and the demands of men and women with rising standards of living and know- ledge are rising too. Family doctors are the first to feel the impact of new, partially formed de- mands. These demands are not only coloured by popular television programmes on medical and surgical techniques, but are stimulated by a proper desire for the full well-being that a healthy life can offer.
Instead of an increase in the numbers of general practitioners at least parallel to the population growth, there is actually a slowing of recruitment to this section of the profession, and the latest available figures show an overall fall. Ironically, this coincides with wide recognition that family doctors (and the profession as a whole) can gain from greater opportunities for them to work part-time in the hospital service. Many resolutions are based on this grave anxiety, and others refer directly to the consequences. Some, for example, deplore the waste of a doctor's time and the misuse of his judgment when industry requires his patient to produce a private medical certificate justifying brief ab- sence from work for an ailment where a patient's word is the only evidence. Fresh evidence is pro- vided by motions on the family doctor's statutory obligation 'to render to his patient all proper and necessary treatment' in contrast to the coun- selling, the preventive advice, or just the listen- ing ear, which have become so much a part of what he is expected now to offer.
A revival of interest in the establishment of health centres, where space, service and ease of meeting with colleagues and associated profes- sions are available, is another development. And always there is the theme that every doctor can do better work if the number of claims on his time are reasonable. The value of hospital beds in which to treat his own patients who lack nursing and domestic care in their own homes, but who also do not need the elaborate and ex- pensive diagnostic and therapeutic measures in
larger hospitals, is restated. A group of patients with transient illnesses can be visited in a much shorter span of time in a small hospital than when ill in their own scattered homes.
It is in part this problem of time, added to the value of preventive and supporting medical work, that lies behind the immensely interesting programme of the four-day scientific meeting. The old pattern of papers, demonstrations and discussions based on anatomical systems has vanished. There are now no section titles like 'Diseases of the Central Nervous System' or 'Advances in Cardiology.' Gone, too, is the wider grouping of subject-matter such as Tropical Medicine or the so recent innovation of a General Practice section. Instead, the overall day titles, 'Precursors of Disease' or Presympto- matic Detection and Control,' show medical work in the life setting of men and women, and not confined to body tissues. The study of disease now includes the conception of active living. After a further day on 'Continuing Care in Chronic Disease,' showing ways of securing the adjustment of men and women whose lives are hampered by their bodies, there follows The Next Ten Years' and a significantly final morn- ing on 'What are the Teachers Thinking?'—sig- nificantly, because from start to finish it takes at least ten years to produce a doctor, on the threshold of professional maturity.
Within these day titles are panel discussions, symposia and plenary sessions. Heads of univer- sity departments, pathologists, general practi- tioners, medical officers of health, directors of research units, administrators, and even a journa- list, are all contributors of papers. For example, on the day headed 'Continuing Care of Chronic Disease,' subtitles include 'Handicap in Middle Age,' Keeping Up-to-date with Medical S'Cience,' 'Care of the Elderly' and The Interdependence of Hospitals, General Practice and Community Care.' The range of themes of scientific know- ledge and experience that can be interwoven in this one day of the meeting is enormous, but related to life as it can be lived rather more than to disease which must be endured. To keep to ways and means in this section is a discussion on 'The Cost of Drugs,' tuned to their real value, not only to their price. It may be felt that surgery and radiology are elbowed out of such a programme design. They have their place, of course, in the overall picture, and a sym- posium called 'Cancer,' under 'Precursors of Disease,' gives opportunity of a specially con- structive kind; 'Glaucoma' in 'Chronic Disease' and a wide variety of subjects under 'Advanced Disease' all provide opportunities. Nor is the function of computers overlooked. The risk of a spot pattern that can result from emphasis on specialisation has been largely avoided.
Neither a conference nor a scientific meeting can shape a brave new world, but they serve to show the way that thinking and action are work- ing together. The scientific exhibition, the trade shows of publications, pharmaceuticals and in- struments, the hospital visits and the informal meetings provide a background of existing work. Discussions, when free and lively, can reveal half-formed ideas of the planners and researchers to be shaped and burnished by exchange of views with clinical teachers and workers in social and domiciliary medicine. Doctors who keep the spark of inquiry alight in their work can ex- change experience of early symptoms with those who see disease in its late stages. This Man- chester meeting promises, on paper, to provide catalysts to so much that is latent in medical thought and achievement. There should be a harvest of new thinking.
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