Column1 May 2001

Doctors on the defensive
'One thing is clear from the "Doctors' day of action" - GPs are angry. But that's the only thing that is clear.'

by Dr Michael Fitzpatrick

Instead of complaining about stress and making militant gestures, doctors should abandon self-indulgent posturing and think critically about the direction of medical practice.

On 1 May 2001, some general practitioners (GPs) around the country will take part in protests promoted by three free-sheet trade newspapers (which are financed by drug companies). Fearful of being outflanked, the British Medical Association has chosen the same week to ballot GPs on the proposal that doctors threaten to resign from the NHS unless the government meets its demands (within the next 12 months). The proximity of the general election has no doubt contributed to the unusual volatility of the world of medicine.

One thing is clear from the GP tabloids - doctors are angry. Unfortunately, that is the only thing that is clear. You only have to ask 'what are doctors angry about?', and the confusion sets in. Perhaps surprisingly, money is not a major concern: according to one recent survey, GPs' income increased by 14 percent in 2000 (1).

For GP, the paper that launched the current furore under the banner 'RESPECT: a campaign for GPs' back in March, the central issue seems to be the need to bolster doctors' morale in face of violent assaults by patients. Whether or not this is a major problem (and, as I have argued before, I believe that it isn't (2)), it is difficult to see what either government action or industrial action might do to alleviate it. In fact, Tony Blair personally endorsed the GP campaign in a letter to the paper (3).

Stress is another recurrent theme. Whether this is attributed to demanding patients or to the pressures of government reforms, doctors are complaining about increasing levels of anxiety and depression and are resorting to helplines and counselling services to prevent 'burnout'. Every week the GP press reports a new survey revealing unprecedented levels of stress and new measures to deal with it. At the end of April 2001, headlines focused on a study that showed a higher risk of suicide among women doctors than among the general female population (though the fact that the suicide rate among male doctors is less than half the suicide rate for the general male population was ignored).

And reports of doctors driven by stress into taking early retirement feature prominently. Portsmouth GP Lester Russell, who has had enough at 42, is offered as the medical equivalent of Phoenix the calf in a plea for public sympathy for the beleaguered medical profession. One problem with this policy of parading doctors as helpless victims of patients and politicians is that it will be immediately forfeited by the mildest display of militancy.

There can be no doubt that the burden of work on GPs has increased dramatically in recent years. Though this is partly due to rising consumer expectations, the key factor has been the growing scale of government intervention in health (which is itself a major factor in increasing public demand).

The government has encouraged a wider role for general practice both in the management of chronic diseases (diabetes, coronary heart disease, mental illness) and a greater involvement of doctors in dealing with a wide range of social problems. It is also driving GPs to meet performance targets, such as providing appointments within 24 or 48 hours. Furthermore, the government is pushing forward reforms in the way medical practice is regulated (including proposals for appraisal and revalidation).

The main defect of the current campaigns in general practice is that they lack a coherent critique of the government's reform programme. They may articulate GPs' anger and frustration at the amount of time and paper wasted through these policies, but they do not advance any alternative to them. Indeed, as ministers and civil servants never tire of pointing out to the leaders of the BMA, they endorsed the main themes of current government policy when they signed the NHS Plan in summer 2000.

BMA leaders now accuse the government of bad faith, but many of New Labour's health policies have been adopted from within the medical elite itself.

The BMA now faces an uncomfortable squeeze. On the one side is a government determined to show its modernising zeal against traditional professionals and public service bureaucracies - on the other stands the mass of GPs, reeling under a barrage of post-Harold Shipman media hostility and trying to deal with patients shifted out of hospital wards and clinics, as well as taking on much of the work of the disintegrating social services.

At this moment, the BMA has revived the tactic of mass resignation which it used to great effect in the negotiations over the Charter for a Family Doctor Service in 1965 and 1966. The contrast between this conflict and the current dispute is striking. In pushing through the Charter, the BMA not only won significant pay increases for GPs, it established the basis of modern general practice - improved premises, reimbursement for practice staff, vocational training, trends towards group practice and health centres, etc.

Today the BMA chases after the tabloids while fighting a rearguard action to uphold its right to negotiate for all GPs (the government wants to deal with the expanding body of salaried GPs directly). Unable to advance an alternative vision for general practice, it merely expresses the existential distress of today's doctors.

It is a disgrace that doctors have become so self-obsessed that their organisations have virtually ignored such significant developments as the abolition of the community health councils, the trends towards the privatisation of primary care (through the encouragement of private finance initiatives), the threat to confidentiality arising from the use of patient data, and the extension of coercive mental health legislation to cover people with a 'personality disorder'.

The combination of confessional anguish from the GP tabloids and sabre-rattling from the BMA is unlikely to make much impression on the government, even at a time of pre-election sensitivity. Indeed, there is a serious danger that the government will call the leaders' bluff and thus expose the current campaign's underlying incoherence and the lack of commitment to it among doctors.

Before we can take on the government, doctors need to develop a clear alternative to the current direction of primary healthcare policy. I would suggest the following elements:
  • reject the intrusive and moralising expansion of general practice into the spheres of lifestyle in general, and in particular into sexual health, teenage pregnancy, domestic violence, drug abuse, child protection, parenting and the policing of welfare benefits.


  • review the role of general practice in screening programmes of dubious value, notably cervical cytology and mammography (rather than extending these into even more dubious areas, such as prostate cancer).


  • refuse the currently proposed frameworks for appraisal and revalidation, which are excessively bureaucratic and authoritarian.


  • reject the proposed 24-hour/48-hour appointment performance targets which are absurd and irrelevant to good general practice.


  • demand the abandonment of NHS Direct and Walk-In health centres and refuse all cooperation with these wasteful political stunts.
The reorganisation of primary healthcare with a focus on the care and treatment of those who are ill, rather than the moralising of the well, would be beneficial to both doctors and patients and would improve relations between them.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

(1) Doctor, 5 April 2001

(2) See Second Opinion, by Dr Michael Fitzpatrick

(3) GP, 30 March 2001

Reprinted from : http://www.spiked-online.com/Articles/00000002D08F.htm


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