Personal View: A brave new paradigm?
Authors: Michael Williams
Journal: BMJ (2004)

Today we stand on the threshold of a new medical paradigm. The post-1948 consensus has broken down, and medicine in the United Kingdom embarks on a journey into the unknown.

Aneurin Bevan famously complained that in order to bring the effectively private sector consultants on board the new NHS in 1948 he had “to stuff their mouths with gold.” Training as I did in the 1970s I met many consultants who fondly remembered this era and for whom practising in a large teaching hospital was a salaried hobby, with the right to see and treat private patients as and when they chose. As one of my bosses said, “I am a consultant. I am not here to do anything; I am here to be consulted.” Not for him the tyranny of job plans and planned activities—just the certainty that he was valued for his expertise.

Not all was well in the medical world then. As juniors we really did work one in twos and three in fives. One contract I had was for 128 hours a week, leaving just 40 hours free for everything else: social life, shopping, arranging the next job, and, oh yes, sleeping. Mind you, we covered fewer patients, the inpatients were generally less sick, and the very sick, very elderly patients were given tender loving care in a side room instead of heroic medicine and surgery and a long stay bed in the high dependency unit.

There were compensations. Doctors, however junior, had the respect of society. Hospitals had doctors' car parks. There was a doctors' dining room; and in many a doctors' mess there was a cleaner or housekeeper to cook a breakfast and mother young doctors who had been working continuously for 48 or 72 hours every weekend. All that has gone.

We learnt by apprenticeship, we knew our patients, and we had pride in our firm. Even when we got annoyed at not seeing “the boss” for weeks on end, at least we knew that one day we too would be consultants with our own junior staff, our own right to private practice where and when we chose, and, above all, the unflagging respect of society. That's all gone too.​too.




Figure 1





Pride in the firm: but are today's doctors in danger of losing power and society's respect?

Credit: WELLCOME LIBRARY, LONDON




Today most of us are just about to sign a time sensitive contract. This would have been an anathema to our forebears, proud as they were of their commitment to continuity of care. Where once we worked for local hospitals with their own idiosyncratic logos and quaint traditions, now the ubiquitous, uniform blue and white banner of the NHS covers all.

Some would argue that medicine retains its power through medical management, in the person of clinical and medical directors. I would argue, however, that medical managers are marginalised in the lower tiers of the organisation, while real power emanates from politicians and the Department of Health directly to chief executives of the trusts and health authorities.

This year's fashion is for shorter training of doctors to increase their numbers. From a human resources point of view this must weaken the position of doctors, as the bargaining power of any individual decreases. A shorter training period will decrease the expertise of the people trained, and as a consequence they will lose expert power and society's respect. It is not a coincidence that the margins between medicine and the paramedics are being blurred by the transfer of duties formerly undertaken only by doctors.

The other fashion of the day is for plurality of provision—shorthand for the first steps to privatisation. What then is the new medical paradigm? Perhaps the future of British doctors is no more than as interchangeable medico-surgical units working out a portfolio career for a series of American and South African multinationals. Surely we can do better than this?