BRITISH MEDICAL ASSOCIATION ANNUAL REPRESENTATIVE MEETING
INTERNATIONAL CONVENTION CENTRE, BIRMINGHAM
8:00 PM, WEDNESDAY 6 JULY 1994
My lords, ladies and gentlemen, I would like to say how honoured I feel to be elected as your President, and what a privilege it will be to serve the Association in this capacity. It is many years since a general practitioner was given this honour and never before has it been granted to a doctor from an Academic Department of general practice. I hope I will prove to be worthy of this high office.
I have enormously enjoyed forty two years in medicine and have particularly enjoyed my clinical work in general practice, for the last 26 years in the same practice in Lambeth. I have been fortunate in combining this with the stimulus of academic life in general practice spiced by research and teaching. Through my links with St Thomas's and later UMDS, as both sub-dean and chairman of the education committee, I have established many very happy relationships with specialist colleagues. I hope I can bring to the Presidency my experience linking specialist and generalist in clinical care, teaching and research. With this in mind and in the face of serious threats at this time to unity in our profession, I want to address my talk tonight to the issue of professionalism in medicine.
I entered general practice in the 1950s in a country town. In those days general practitioners were really independent contractors. They were regarded as professionals and this carried with it an ideology, responsibility to patients and loyalty to the standards of the profession incorporating well established ethical principles. Unfortunately, it was not possible at the time to practice medicine according to these high ideals, partly because both general practitioners and their patients were unclear about their roles in the new National Health Service, and partly because their terms and conditions of service were a major disincentive to developing high quality care.
Many general practitioners emigrated, but others through a commitment to simple research in the fifties and sixties began to clarify their role, encourage realistic expectations in their patients and develop appropriate training for general practice. Through the work of this Association and the enormous commitment and unity of members it was possible to re-negotiate their terms of service and obtain an historic Charter for general practice in 1966.
From that time on the discipline developed rapidly, not just in terms of the services provided but more importantly in understanding the knowledge and skills required to undertake the work. Central to this was a new concept of diagnosis as applied to new problems presenting at the level of primary, care and the evaluation of need in providing continuing care in chronic disease and disability. It soon became clear from research in general practice that the biomedical diagnostic model, frequently appropriate in secondary care and taught in medical schools, was not satisfactory for many of the problems encountered in primary care. Diagnosis in general practice has a much broader base, integrating clinical knowledge and skills with an understanding of human behaviour and community epidemiology, and is particularly dependent on well developed communication skills and an ongoing relationship between patient and doctor.
By the 1970s the role of the general practitioner had been well defined and it became easier to clarify the role of the specialist. The hierarchical relationship between specialist and general practitioner characteristic of the early years of the National Health Service was replaced by a relationship based on mutual respect of each other's roles and the main beneficiary was the patient.
The quality of care delivered at this time was largely dependent on the ideals and professionalism of the doctors and their commitment to continuing education. It would be naive however to suggest that high standards were maintained across the board and undoubtedly there were examples of lack of commitment and poor practice in both hospitals and general practice. It is important for the profession to accept some responsibility for the situation. Medical protectionism, weak management particularly in family practitioner committees and a failure of the profession to assert its moral principles, allowed colleagues to provide unacceptable levels of care. It was almost inevitable that in due course the Government would intervene. Nevertheless the care provided in the National Health Service in the 1980s was the envy of the world. In this context it is incomprehensible to me why the Government, in the late 1980s decided to embrace a system of medical care based on the American model from which the Americans have been striving to escape for four decades.
In 1990 a new contract was imposed on general practitioners which was concerned more with accountability for services provided than with the doctor's traditional role of responding to patients' problems. Many of the services prescribed concerned with screening and health education had never been shown by research to improve health. A new massive bureaucracy made up of individuals who appeared to be ignorant of the findings from research in general practice developed. At the same time specialist services became organised into Trusts and determined by contracts with health authorities and fund holding general practitioners. In the hospitals, policy was strongly influenced by managers and profitability became a major motive for the services provided. Audit, a concept, derived from commerce and concerned with costs and benefits was introduced. Information for management, became of paramount importance, irrespective of its validity in reflecting the quality of care delivered. Finally Patients' Charters were introduced demanding services irrespective of the resources available and launched as if they were a new breakthrough in the doctor patient relationship.
It is becoming apparent that the control of health care provided in the 1990s, is concerned more with accountability than with professional standards. In my own experience in undergraduate education it has been depressing to find students contributing to seminars in general practice discussing the financial implications of care rather than as five years ago discussing the fascination of dealing with patients' problems in primary care. There is ample evidence that some general practitioners took advantage of the Government’s misguided establishment of special payments for health education for which there was little scientific evidence of benefit to patients' health but considerable financial reward. There is evidence that some specialists are constrained to develop a two tier system of care to protect their Trust hospitals from financial embarrassment.
I am not alone in my anxiety about the way in which market place medicine can threaten our professional behaviour. Thirty five years ago, in his Presidential address to this Association, Professor Thompson said, "The relationship between doctors and patients is deeper than that entertained by the solution of scientific and measurable problems. It is in truth a personal relationship in which intuition, sympathy and compassion play a considerable part". This is as true today, and I would warn politicians and patients that if they ignore the importance of this professional relationship in their charters, audits and protocols they will inevitably damage the high quality of medical care which has been built up over the last 50 years. Compassion may be replaced by financial incentives.
Elliott Freidson, a sociologist in America who at one time took the American medical profession to task for its lack of self discipline, now comments, "The flexible discretionary judgement that is necessary to adapt services to individual patients' needs, may be crushed between the forces of government regulation on the one side and the market forces of competition on the other".
Predictably my esteemed predecessor in this office, Sir Douglas Black, has summarised the current situation succinctly, "The absurd belief that management efficiency is more relevant to health care than the skills of dedicated doctors, nurses and other health workers, has dictated the substitution of contracts for mutual trust and co-operation; the creation of an artificial split between purchasers and providers neglecting their paramount common interest; and the development of costly information systems whose focus is on administrative and financial matters, not on clinical process, and still less on outcomes for patients".
I believe all these statements demonstrate the deep misunderstanding by both politicians and some patients of the importance of professionalism in the maintenance of standards in medicine. To expand this thesis I will refer to the work of Robin Downie, professor of moral philosophy in Glasgow. He describes six characteristics of a profession which I have summarised for this address.
If I could pick just a few words from this definition of a professional they would be concerned with the special relationship between professional and client based on beneficence, integrity and justice; the independence of the professional from state and commerce; and the fact that the professional must adhere to a moral code of ethics controlled by a professional association.
With patients' charters, contracts, accountability to a market centred management and a weakening of professional integrity, there is a risk that our standing as a profession is challenged. It is no consolation to know that we are not alone in this. The present Government clearly distrusts professionalism as a way of maintaining standards, with perhaps some justification on past performance. It would be happy to destroy public trust in the professions and this does not just apply to medicine, but to education, the police and the law.
If this is so then it is important that we put our own house in order and re-establish our professional ethos. I am personally totally committed to the importance of professionalism in medicine. I cannot conceive how good general practice can be based on a system dominated by accountability, except professional accountability to our patients. How for instance do you measure the outcome of terminal care, which is inevitably death? How do you measure the ability of the doctor to listen to patients, interpret what they are saying and identify their problems? How do you evaluate a doctor-patient relationship threatened by a charter which is essentially consumerist and adversarial? How can public health physicians retain their integrity when they are expected to be both arbiters of need and of economic constraints? How can specialists survive in a situation where throughput is the main performance indicator, and they are threatened with performance related pay?
There is I believe a very real risk that some members of our profession will be lured into market place medicine. There will be lucrative rewards for those who respond to the demands of management and redundancy notices for others. This is the inevitable outcome of a commercial enterprise. This is what it is all about and it is potentially very divisive in our profession.
I believe that this Association must strongly assert its professional standards. It must critically examine simplistic methods of measuring the quality of medical care, glib protocols for care of specific diseases, and methods of monitoring the delivery of care which may be motivated more by economic arguments than scientifically based measures of outcome. Epidemiological data are likely to be used to determine management protocols and it must be remembered that these data are based on community studies and may not be relevant to this individual who is my patient with whom I have a special relationship. In saying this, I would stress the importance of our relationship with patients. Most patients do respect their. doctors. They are our best allies and not always fairly represented in decision making. I mentioned at the start of this address the lack of congruence between doctors' and patients' expectations in the early days of the National Health Service. This was resolved largely at the micro level in the doctors' consulting room. This incongruence has recurred partly through the commercialisation of the health service and partly as a result of establishing unrealistic patient charters. In the National Health Service doctors have contracts with their patients. These contracts must be sensible and concerned with providing the best care that resources will allow, not on mechanistic process measures which ignore the resources available. It must also be accepted that the provision of care inevitably includes emergencies, and the patient with a myocardial infarct, a haematemesis, or a ruptured ectopic pregnancy, rightly expects immediate care, even if the doctor has to leave other patients in the waiting room to provide it. Patients usually seem to understand this better than administrators. It therefore behoves us to establish strong relationships with patients both through the daily contacts between doctors and their patients and between the Association, and community health councils and other patient participation groups, many of whom are as concerned as we are about what is happening to their health service.
In reasserting professional standards, the profession is inevitably faced with the problem of reaccreditation. There is no doubt that a sound method of reaccreditation based on professional performance is infinitely preferable to the constraint of bureaucratic accountability determined by non-medical managers of health authorities or trusts. It would however be unwise to rush into reaccreditation until the profession is convinced that the methods are valid and measure the knowledge and skills appropriate to different practitioners in different specialities and in different settings.
As a general practitioner I would like to conclude my address with particular concern for the current state of recruitment to general practice. It is a fact that the applications for trainee vacancies have fallen dramatically in the last few years. It has been suggested that it is the stress in general practice which is deterring would be recruits. With increasing partnership size, better off-duty rotas, primary care teams of nurses and health visitors, better premises and practice managers, it is difficult to believe that physical and mental stress is greater today than at any time during my professional lifetime. It seems more likely that a perceived loss of job satisfaction and respect clearly manifest at medical meetings, in the journals and in conversation with doctors is to blame. Harassed by bureaucracy, accountability, patients' charters, increasing demand for care, increasing litigation and no consistent strategy, general practice has ceased to be fun..
As established practitioners we have a responsibility to undergraduates and to new entrants to our profession, to teach them properly and inculcate in them high ideals. It is very easy for us to convey our disillusionment and despair to students when we should be inspiring them with the ideals for which they must fight.
Dinosaurs of general practice like myself may look back through rose tinted spectacles, but at least we can say we enjoyed our work, it was fun, and when we retired, many of our patients said they were sorry to see us go. We must put the fun back into medicine, because it is an enormously satisfying profession. The time has come to stand up for our ideals and moral principles, for properly organised education and self audit as the touchstones of professionalism and good medical care, and abandon market place medicine administered by enormously inflated and often ill-informed management bodies. Is it possible that reaccreditation by Peer Review can be bartered for accountability to lay administrators; that patients' charters can be negotiated between patients and doctors and not imposed by Government edict; that priorities in care can be determined by research rather than political expediency; and that doctors can be given the space and time to develop their discipline uncluttered by unremitting change.
Can the B.M.A- and that means not just the Officers, but all its Members, as in 1965, lead us out of the mire of market place medicine to the high ground of professional medical care. That is the end to which I will address myself during my period of office as your President.