544
Industrial action by doctors The extent and intensity of the industrial action taken by consultant and junior hospital staff in the past week represent a sad tribute to the polarisation of attitudes achieved by the Labour government since it took office in 1974. Any reasonable administration would have foreseen the discontent that the economic hardships the oil crisis and its aftermath would create. Cancelled rebuilding plans, abandoned research projects, reductions in staff numbers, and even rationing of essential material resources may have been inevitable in such circumstances, but so, too, was the resulting frustration among doctors, nurses, and all other NHS employees. Even so, most of them have been willing to look for ways of seeing the Service through its difficulties, and working parties have been taking the opportunity to re-examine entrenched beliefs and look at topics such as the reallocation of resources and the assessment of medical priorities. Yet against this background Mrs Castle and her close political advisers have made no effort to be conciliatory: instead, they have seemed anxious to exacerbate differences of opinion within the NHS by their pursuit of a quite unnecessary conflict with consultants about their private practice-by any objective assessment a matter of minor importance for the NHS, but a principle which the medical profession sees as a grave threat to its independence. Slowly and reluctantly doctors who a few years ago would never have considered that any quarrel with the Government justified action against their patients have changed their attitudes. In part their militancy has been fuelled by the seeming indifference of the Department of Health to the well-argued, reasoned requests by the professions for help with the deteriorating state of the NHS; but the Department's attention and interest have been given to doctrinaire issues such as the harassment of agency nurses. Hence the Hospital Junior Staff Committee conducted its negotiations about the new contract in an atmosphere of scepticism which extended to the reassurances given when the Department asked for postponement of introduction of the new pay scales until October. When they were caught by the Government's pay policy the junior doctors naturally felt cheated and deceived. Next, as if to pour fuel on the flames of discontent, Mrs Castle chose to issue a consultative document that most hospital staff saw as a threatening ultimatum-and her blank refusal in fact to consult the profession about it was the final action that set the Secretary of State and doctors on their collision course. By last week the BMA Council had no real choice: it had to back the decisions in favour of militant action taken by the junior and senior hospital committees, which had themselves been pressured by the anger of their constituents, many of whom were determined to act whatever the decision taken centrally. But this restriction of their work by hospital doctors (though in line with that taken in recent years by doctors in other Western countries) nevertheless represents a regrettable decline in professional self-esteem which could permanently damage relations between doctors and the public. The refusal (p 601) by the royal colleges to back their members and fellows in restricting their labour emphasises the dilemma in which many doctors now find themselves. Despite their profound disenchantment with recent events, they cannot easily overturn lifelong attitudes based on the principle that a doctor's primary duty is to his patient. There are very real practical difficulties for the doctor of conscience who tries to apply the doctrine of "emergencies only." A patient can be assured that his condition
BRITISH MEDICAL JOURNAL
6 DECEMBER 1975
is not urgent only after diagnosis, not before; necessarily that means that in each case the decision must be an individual one based on examination by a doctor and not on interrogation by a receptionist. If doctors are to maintain public trust and respect there must be an unequivocal undertaking by hospital staff to recognise the general practitioner's right to decide whether or not his patient's condition requires urgent treatment. The unpalatable truth-stressed by several speakers at the Council meeting-is that the more effective action of this kind is made, and hence the stricter the interpretation of "emergency," the greater the risk becomes that patients (and doctors' professional consciences) will suffer. But is there an alternative? What can a profession do when faced with an obstinate opponent who refuses to modify political dogma to take account of realities and seems to ignore the very real merits of compromise? No easy solution will now be found to the current disputes, for the Government has deliberately dragged them into the centre of the political arena; Mrs Castle's statement earlier this week showed no evidence of any change in attitudes. Doctors have been put into a position as representatives of the professional middle classes in an era of the politics of envy. The calculations which set the limit of £12 million for the complicated extra duty payments to junior staff are acknowledged to be approximations based on data which are open to various interpretations. There is still room for compromise, but the Government seems less concerned with justice than its belief in the political need to be tough with young doctors. In a similar way, the attack on private practice is an essentially political action which is little more than a pawn in the complex chess game being fought out within the Labour party and the trade union movement, in which the Health Service unions COHSE and particularly NUPE are among the heavyweights. Again, the justice of the profession's case has received little attention, though by an odd quirk of timing only last week the White Paper on devolution' listed private practice among the health matters that would be delegated to the new assemblies in Scotland and Wales, surely making even more convincing the case for postponement of any legislation. Only Government obduracy now stands in the way of the solution proposed by the BMA-reference of the issue to the Royal Commission on the NHS. What seems not to be understood by the Government is the gulf of confidence that has now opened up between it and the mass of doctors throughout the country. Parliament has a constitutional right to legislate how it wants for the NHS; but the medical profession has an equally important freedom-the freedom to refuse to accept the new terms of service, especially when imposed unilaterally. While Government attitudes remain intransigent, the BMA will need to press on with preparation and publicity of its plans for an alternative agency system for the employment of hospital doctors-for mass resignation may be the only course that is both ethical and honourable. Such a drastic course of action may still be avoided. For most doctors the Health Service is central to their lives; those who have given it 30 years of effort will not stand by and watch their achievement dissipated to satisfy a politician's ego. The undeniable fact is that in less than two years the Department of Health under Mrs Castle's direction has brought the NHS closer to destruction than at any previous time in its history. The best hope for the future lies in her replacement by a minister less concerned with political dogma and more committed to the true interests of medicine and the Health Service.
1Our
Changing Democracy. Devolution to Scotland and Wales. London, HMSO, 1975.
Industrial action by doctors The extent and intensity of the industrial action taken by consultant and junior hospital staff in the past week represent a sad tribute to the polarisation of attitudes achieved by the Labour government since it took office in 1974. Any reasonable administration would have foreseen the discontent that the economic hardships the oil crisis and its aftermath would create. Cancelled rebuilding plans, abandoned research projects, reductions in staff numbers, and even rationing of essential material resources may have been inevitable in such circumstances, but so, too, was the resulting frustration among doctors, nurses, and all other NHS employees. Even so, most of them have been willing to look for ways of seeing the Service through its difficulties, and working parties have been taking the opportunity to re-examine entrenched beliefs and look at topics such as the reallocation of resources and the assessment of medical priorities. Yet against this background Mrs Castle and her close political advisers have made no effort to be conciliatory: instead, they have seemed anxious to exacerbate differences of opinion within the NHS by their pursuit of a quite unnecessary conflict with consultants about their private practice-by any objective assessment a matter of minor importance for the NHS, but a principle which the medical profession sees as a grave threat to its independence. Slowly and reluctantly doctors who a few years ago would never have considered that any quarrel with the Government justified action against their patients have changed their attitudes. In part their militancy has been fuelled by the seeming indifference of the Department of Health to the well-argued, reasoned requests by the professions for help with the deteriorating state of the NHS; but the Department's attention and interest have been given to doctrinaire issues such as the harassment of agency nurses. Hence the Hospital Junior Staff Committee conducted its negotiations about the new contract in an atmosphere of scepticism which extended to the reassurances given when the Department asked for postponement of introduction of the new pay scales until October. When they were caught by the Government's pay policy the junior doctors naturally felt cheated and deceived. Next, as if to pour fuel on the flames of discontent, Mrs Castle chose to issue a consultative document that most hospital staff saw as a threatening ultimatum-and her blank refusal in fact to consult the profession about it was the final action that set the Secretary of State and doctors on their collision course. By last week the BMA Council had no real choice: it had to back the decisions in favour of militant action taken by the junior and senior hospital committees, which had themselves been pressured by the anger of their constituents, many of whom were determined to act whatever the decision taken centrally. But this restriction of their work by hospital doctors (though in line with that taken in recent years by doctors in other Western countries) nevertheless represents a regrettable decline in professional self-esteem which could permanently damage relations between doctors and the public. The refusal (p 601) by the royal colleges to back their members and fellows in restricting their labour emphasises the dilemma in which many doctors now find themselves. Despite their profound disenchantment with recent events, they cannot easily overturn lifelong attitudes based on the principle that a doctor's primary duty is to his patient. There are very real practical difficulties for the doctor of conscience who tries to apply the doctrine of "emergencies only." A patient can be assured that his condition
BRITISH MEDICAL JOURNAL
6 DECEMBER 1975
is not urgent only after diagnosis, not before; necessarily that means that in each case the decision must be an individual one based on examination by a doctor and not on interrogation by a receptionist. If doctors are to maintain public trust and respect there must be an unequivocal undertaking by hospital staff to recognise the general practitioner's right to decide whether or not his patient's condition requires urgent treatment. The unpalatable truth-stressed by several speakers at the Council meeting-is that the more effective action of this kind is made, and hence the stricter the interpretation of "emergency," the greater the risk becomes that patients (and doctors' professional consciences) will suffer. But is there an alternative? What can a profession do when faced with an obstinate opponent who refuses to modify political dogma to take account of realities and seems to ignore the very real merits of compromise? No easy solution will now be found to the current disputes, for the Government has deliberately dragged them into the centre of the political arena; Mrs Castle's statement earlier this week showed no evidence of any change in attitudes. Doctors have been put into a position as representatives of the professional middle classes in an era of the politics of envy. The calculations which set the limit of £12 million for the complicated extra duty payments to junior staff are acknowledged to be approximations based on data which are open to various interpretations. There is still room for compromise, but the Government seems less concerned with justice than its belief in the political need to be tough with young doctors. In a similar way, the attack on private practice is an essentially political action which is little more than a pawn in the complex chess game being fought out within the Labour party and the trade union movement, in which the Health Service unions COHSE and particularly NUPE are among the heavyweights. Again, the justice of the profession's case has received little attention, though by an odd quirk of timing only last week the White Paper on devolution' listed private practice among the health matters that would be delegated to the new assemblies in Scotland and Wales, surely making even more convincing the case for postponement of any legislation. Only Government obduracy now stands in the way of the solution proposed by the BMA-reference of the issue to the Royal Commission on the NHS. What seems not to be understood by the Government is the gulf of confidence that has now opened up between it and the mass of doctors throughout the country. Parliament has a constitutional right to legislate how it wants for the NHS; but the medical profession has an equally important freedom-the freedom to refuse to accept the new terms of service, especially when imposed unilaterally. While Government attitudes remain intransigent, the BMA will need to press on with preparation and publicity of its plans for an alternative agency system for the employment of hospital doctors-for mass resignation may be the only course that is both ethical and honourable. Such a drastic course of action may still be avoided. For most doctors the Health Service is central to their lives; those who have given it 30 years of effort will not stand by and watch their achievement dissipated to satisfy a politician's ego. The undeniable fact is that in less than two years the Department of Health under Mrs Castle's direction has brought the NHS closer to destruction than at any previous time in its history. The best hope for the future lies in her replacement by a minister less concerned with political dogma and more committed to the true interests of medicine and the Health Service.
1Our
Changing Democracy. Devolution to Scotland and Wales. London, HMSO, 1975.
