SOCIETY TODAY

Medicine

The game of the state

John Linldater

The chips are down. Thousands of family doctors are preparing to resign from the NHS en bloc. BUPA membership is growing rapidly, and private health schemes are being set up by do-it-yourself groups all over Britain. One fifth of the doctors who qualify from British medical schools emigrate each year to the United States of America or Canada and are replaced by doctors from underdeveloped countries. Hospital waiting lists grow longer, while more money is deflected to newer, bigger and better health board offices and highly paid administrative staff, leaving nothing in the kitty for paying hospital specialists for the overtime that they have been working.

The resignations are intended to strengthen the hand of the British Medical Association negotiators, but the chances are high that the Government will lead a trump with some form of wages control policy in April, and that doctors will once -again find themselves outmanoeuvred.

In addition, a predictable and substantial number of doctors do not propose to resign from the health service. These include many who have recently arrived from countries with a generally lower standard of living, and who already account for twenty-five per cent of the total number of registered medical practitioners in Britain. To these must be added any doctor who gives poor value for money. A doctor who averages four minutes for each consultation and who off-loads every least problem into the nearest hospital, then has the free time to accept larger lists of patients, thus increasing his personal income while reducing his overhead expenses. Such a doctor practices a contemptible pen-and-notepad medicine, and makes a mockery of his meticulous training: he has been corrupted by the system.

Finally the status quo will also be supported by doctors who hold one of the secret "merit" awards. These awards are the diabolical, unprecedented and outrageous brainchild of the late Aneurin Bevan who, when asked how he would prevent the leaders and elders of the medical profession from exposing publicly the inherent defects of the NHS, replied with characteristic, direct, eloquent inelegance: "I shall stuff their mouths with gold." And stuff them he did, under the counter, with unpublished awards of sums which can be as large as £10,000 per annum each, above the regular pay scale, given for a "merit" which has never yet been specified, and for which there is no advertised method of competing. These awards can be withdrawn by the selfsame abitrary magic that confers them, and it seems to follow that award holders usually toe the line and rarely rock the boat.

Merit awards were conceived to secure consultant compliance with the principle of a health service that was "free" at the time of use; which principle placed the general practitioner at the mercy of the feckless five per cent of timewasting patients and, eventually "free" came to be equated with "valueless". The converse, American system, which corrupts the doctor by giving him total power over his patient, is, of course, equally bad, if not worse, but there are numerous logical, realistic and balanced methods between these two extremes, of structuring a workable and economical health service: all depend upon divorcing health from politics.

The merit award scheme served the Government well. It was therefore inevitably exploited to secure compliance with other controversial government measures such as the immigration and registration of foreign doctors without examination.

To take another example, it is well and widely known that six per cent of NHS abortions are performed by caesarian section and that, in such abortions, the baby is born alive, often wriggling, sometimes whimpering but always with heart beating, and that it must, therefore, be killed subsequently by omission or neglect, or by some active means such as live cremation in an incineration chamber. The killing is done notwithstanding the provision of statutes expressly to give absolute protection to any child which, separated from its mother, shows a sign of life.

The fact that there has not been any national outcry specifically diverted against the self-evidently illegal practice of caesarian abortion suggests that a considerable number of senior obstetrician gynaecologists have already become committed to blind obedience to government edict, notwithstanding the unequivocal lessons of Nuremberg.

The medical profession, therefore, has chiefly itself to blame when, in the end, an operating theatre porter decides whether or not a surgeon may operate, and when a sixty-four year old patient recovering from nervous exhaustion is threatened with starvation because the unions suspect the he might be guilty of paying for his own treatment, It turned out, in fact, that he was a genuine NHS patient, so they fed him after all: but it was a nasty incident.

The medical profession might argue, in justification that, in a crazy, topsy-turvy society in which union squabbles prevent Parliament itself from enjoying hot meals, almost anything is to be expected and that unions such as NUPE are, anyway, merely acting as the militant arm of the left wing of government, pulling Barbara Castle's chestnuts out of the fire and implementing controversial policies which not even she could hope to steer successfully through a public debate. Resistance to the unions would thus, by Lavalesque reasoning, avail nothing. But many of the elders of the medical profession are highly award-conscious. They do not try very hard to resist.

This really is the crux of the problem. The doctor, in his traditional, respected role as a highly educated, independent, disinterested counsellor and friend, has an important stabilising role to play in society. Such a role is the antithesis of any part of the Kafkaesque plans of the social engineers of the welfare state, in which only committees are wise, in which the Party alone is respected, where nothing is independent of central power and where advice can only be given by a duly authorised counter clerk in an approved Citizens' Advice Bureau. There is no place, in such a scene, for the traditional, family doctor. His status is, accordingly, already being whittled away and eroded, The dispute between the medical profession and the Government may thus best be imterpreted as a stand for personal liberty. But the medical profession is not, alas, itself united. A quarter of its members have no concept of the integrated background of personal freedoms for which our forefathers so grimly and successfully fought.

The rank and file majority of the profession feel vaguely betrayed and cheated. The profession, as it was when they started it, even now scarcely exists. The rape of the Hippocratic oath by a well organised gang of abortion law reformists throws the rest of medical ethics into chaos. Family doctors, today, can only maintain a decent standard of living by doing less work and by doing it less conscientiously and, demoralised by their Alice-in-Wonderland system of payment for work not done, they often end up by cheating their patients of the best care that they could give, but for the fact that they are paid not to give it. Lack of ethical and professional cohesion accounts for widespread apathy, which is reflected not only in continuing medical emigration, but also in the falling membership of the British Medical Association.

Why, indeed, should a doctor subscribe to a professional organisation which itself rates his professional opinion as to a patient's insurability, longevity,

Spectator March 22, 1975 physical health and mental stability as worth not more than £6? An architect doing a similar job, surveying a house, quite rightly expects to earn about £100, as does a solicitor vetting and processing a bundle of deeds. By contrast, the junior hospital registrar working a hundred hour week earns less than a Glasgow dustman whose union has just rejected, with an oath, the Glasgow Corporation offer of E90 per week.

The fault lies chiefly in unbelievable mismanagement coupled with total loss of government aim. Unrealistic, megalomanic directives continually spur a monstrous, lavishly furnished bureaucracY into a sort of madness of Parkinsonian expansion to take on fresh, unnecessary and unlikely com-. mitments and recklessly spend public funds on fancy frills such as organising and supervising baby sitters on a national scale and nationalising the distribution of contraceptives, whilst leaving the sick untreated. The newly discovered pure Factor VIII for the treatment of haemophilia, for example, is not being made generally available through the NHS which is, nevertheless, spending ten times as much money on free French letters and nice, clean abortion chambers.

Hundreds of children who suffer from haemophilia will therefore grow up in pain, permanently deformed and crippled, who could have led normal, healthy lives if national health spending had been properly directed. Yet it was precisely for the purchase of such expensive therapy that the NHS was originally approved by Parliament. 3,000 haemophiliacs do go without the costly, modern treatment whilst there are plenty of funds for showing sex education films to schoolgirls and for equipping them, free, with the kit for their practical homework. Never has there been a more massive misappropriation of resources, or a more grotesque, Orwellian parody of health care. It is this, quite as much as low salaries, which is driving doctors out of Britain and out of the NHS.