POLITICS
The Well Woman and the Well Doctor
FERDINAND MOUNT
Hitherto the National Health Service has remained splendidly aloof from all this. Doctors have been taught, rather like AA patrolmen, to provide a first-rate break- down and tow-you-home service. Regular servicing of the vehicle and maintenance hints are not their concern. You are not expected to bother your doctor unless you are ill. If you are very ill he may advise you not to drink or smoke or to lose some weight, but on the whole the GP of the old school regards prevention as rather sissy and, in any case, bad for business.
It is fascinating, therefore, to observe the health craze creeping up on the Nation- al Health Service to join the scrap already in progress between at least three identifi- able contestants — the doctors defending their domain, the nurses attempting to enlarge theirs and the Government attempting to do something with the NHS, but still not quite sure what.
The health crazies first popped up on the political scene, as you might expect, as a wing of the big feminist push. Both the Labour and Liberal party conferences last year passed resolutions calling for 'Well Woman' clinics to be set up across the country. Conservative women are still ex- pected to be well.
'Well Woman' has a pleasantly folkloric ring; was there once a Well Woman of Hampstead whose herbs and simples charmed the warts of generations of Jays and Gaitskells? However, the movement has come a long way thence. Bupa, which is not exactly a left-wing front organisa- tion, maintains a Well Woman clinic at £75 a throw, as an offshoot of its health screenings (£185 for men and £210 for women). In the health screenings, the doctor gives you a thorough once-over, in addition to the x-rays and tests of blood, urine, blood pressure and so on. But the subversive thing about the Well Woman clinic is that it may be carried on by nurses alone, nurses being normally let loose unsupervised only on babies. And if Well Woman, then why not Well Man?
Norman Fowler, in his Green Paper on Primary Health Care published last week, muses rather vaguely on 'new schemes under which more than one service is provided under the same roof, such as health care "shops" '. This seems to me like Toryese for 'Well Person clinics'. Elsewhere in the Green Paper, Mr Fowler — or perhaps his professional minder, Dr Donald Acheson, the DHSS's Chief Medical Officer — squashes the nurses' pretensions to start treating patients on their own: 'The term "nurse practitioner" which originated in North America has over time had a variety of meanings and could be misleading' — which, being trans- lated, means 'empty those bedpans, Sister, and don't answer back.'
This put-down was provoked by Mr Fowler's own Community Nursing Review team. Their report, also out last week, is something of an embarrassment since it backs the nurses' ambitions to prescribe minor things like dressings and ointments, to deal with chronic visitors to the surgery, to make initial assessments of patients and to treat certain minor acute illnesses. All this is flagrant heresy. Only the doctor with his magic powers of divination is supposed to be able to spot whether a routine- sounding cough is the symptom of lung cancer. All the same, Mr Fowler must have cast a wistful eye at the nurses' ambitions.
For however you think of them — as 'nurse practitioners' or as 'paramedics', or even as 'barefoot doctors' — nurses come cheaper than GPs. And GPs come expen- sive, not least because they can make tidy little profits out of the present system — for example, out of shopping around for the cheapest locums. Mr Fowler plans to impose a retiring age for GPs and to stop the scandal by which GPs can retire as principals one day, collect the lump-sum benefit, and start work again the next day as salaried assistants. He is also confecting a 'Good practice allowance', just as Sir Keith Joseph is trying to work out ways of rewarding and encouraging effective teachers. Can such bureaucratic schemes ever properly mimic the market? Patients and doctors alike would, I think, accept that standards in general practice have risen over the past 20 years. But this has come about because of two thumping disputes and quasi-strikes, in the mid-60s and mid-70s, both times under a Labour government which surrendered totally and, I think, rightly and conceded what Mr Fowler's Green Paper coyly calls 'a restructuring of the remuneration sYs" tern' — i.e. lots and lots of money. As a result, a worldly-wise GP can now clear up to £40,000 a year from the NHS alone ", no more in real terms than his father did before the war, but at least he has re- covered from the income-erosion which many other professions have suffered. This is one problem that has been, quite effectively but very extravagantly, dealt with by throwing money at it, which should come as no surprise to Conservatives who believe so devoutly in the market sysrelll for the private sector. The fashionable remedy for this extravagance is the 'health maintenance organisation', competitive contractors providing an all-in GP and hospital service for a flat annual fee which may be paid by the State or bY individuals or their employers. And where do you imagine these HMOs would be likely to find the best value? I suspect it would often be at clinics where nurses were allowed to do a lot of the work new reserved for doctors. Now that there is a surplus of privat.e hospital beds in many parts of Britain, it Is natural to look to private general practice for the next boom. Should the Govern' ment offer extra encouragement, for exam: ple, by extending to the self-emploYed thf tax relief already available to e11ip1oyees7 Yet it is possible that the principal hope of the future may be not so much in dramatic shift in the boundaries betwee," private practice and the NHS as in self-h' (or rather self-heal) and a breaking dnvv,,e of unnecessary restrictive practices in medical profession — both sound Tharen., erite themes. If we are to copy the Mom_ icans, can we avoid making some canoe) tion between their obsession with diet 0.",e exercise and check-ups and the remarkable decline in coronary disease in the us? P°,, part of the way at least, the route ro, better and more economical health serviec may follow the same track as the de- ll Wo- man mystifying of medicine. The We the may turn out to be a threat to the Well may
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