Abstract
When the NHS began, my father was already practising in a coal-mining community in Northumberland with all the privations, sickness and dangers that involved for miners and their families. In those days a doctor’s medical knowledge and skill was assumed. His reputation rested primarily on the relationship he built up with individual patients and families, and the conscientiousness with which he served them. This relationship was regularly tested at times of critical illness and was the subject of almost constant informal review through the inter-family and local gossip normal in a close community. As I learnt later when I joined him in practice, my father’s patients regarded him as a true professional – knowledgeable within his limits, having a liking and respect for patients combined with an engaging bedside manner, always willing to speak up for them and get outside help when necessary, and having a strong sense of personal responsibility for his clinical decisions and ethical behaviour. The result of such service was a trusting relationship with the vast majority of his patients that endured for years, lingering with them after his retirement and death. Today we would call this patient-centred professionalism.
Many doctors like him approached the new NHS with a mixture of anticipation and apprehension. They looked forward to being able to do more for the many people who couldn’t afford proper medical treatment. Yet they worried about whether the state would somehow interfere in their relationship with their patients. Theodore Fox, in his 1951 Croonian lectures, 1 put these hopes and anxieties into context in an excellent analysis of contemporary thinking on professionalism and the new relationship emerging between doctors and the state.
Three developments have had a lasting effect on medical professionalism in the NHS.
When the NHS began, confidence in specialist medicine was high. Medical science heralded dazzling advances in diagnosis and treatment. The Royal Colleges, which controlled specialty professional standards, used a language of professionalism that emphasized clinical excellence and original contributions to knowledge. Relationships with patients were assumed to be on doctor’s terms and so did not figure in medical education. The big question was what the colleges could do to persuade all their members to maintain a high order of professionalism. Their leaders knew that continuing public trust depended on the professional reputation of individual consultants and members of each specialty collectively. Reliance on personal self-discipline, enforced by traditional custom and conscience, 1 would not be sufficient. So, led by Charles Moran, Churchill’s doctor, they devised merit awards. One third of consultants would receive extra pay from the NHS for professional distinction. The remainder who did not would remain eligible and so would have a continuing incentive to achieve. For Moran, who kept notes about consultants in a little black book, professional distinction centred on a reputation for clinical acumen, with breadth of interest and an ability to communicate as desirable extras. 2 In the event the system, which continues in modified form to this day, was critical to maintaining unquestioning public trust in British specialist medicine until very recently.
By contrast, the situation in general practice was desperate. Two famous studies 3 4 showed general practitioners at one end of a broad spectrum who were excellent – highly professional – and many at the other end who were dreadful, lacking any sense of professional responsibility. It seemed that general practice was unfit for purpose in the new NHS. Conscientious family doctors were appalled. In 1952 they formed the College of General Practitioners, to set standards where none existed. 5 Subsequently the College, with the NHS, used the new vocational training as the test-bed for bringing new ideas about professionalism to general practice. 6 Examples include a focus on the dynamics of the doctor-patient relationship, teamwork, practice management, explicit standard setting, performance monitoring through medical audit, the professionalization of teaching, the involvement of the public in professional work, and collective responsibility for standards through a form of recertification and practice accreditation using Fellowship by Assessment and the renewal of teaching practice contracts. These developments together transformed the practice and morale of doctors who adopted the new ways of thinking. However, a significant rump declined to comply. There was no mechanism comparable to the specialist awards system to motivate them and no effective way of dealing with persistent poor practice.
This brings us to ‘the patients’ revolt’. 6 In the last 20 years the expectations of doctors and the public have diverged, as the public became less tolerant than the profession of poor practice. People now know that in modern healthcare the standard of professionalism of doctors is critical to achieving a good outcome and ensuring a safe and satisfactory process of care. Although remarkably forgiving – they understood that modern medicine is still an inexact science that involves judgement and is therefore prone to error – they nevertheless wanted the profession and the government to protect them better. The tipping point for change was the tragedy in paediatric cardiac surgery at Bristol. The driving force was public anger at trust betrayed. 7 The response is the ‘new professionalism’ embodied in the GMC’s Good Medical Practice 8 and the RCP’s statement on medical professionalism. 9 Good Medical Practice brings the public, the NHS and the profession together again on the attributes of a good doctor, and on ways of being as sure as possible that all registered doctors are good doctors through modern professional regulation, education, clinical governance and risk management. 10
The future of medical professionalism in Britain is still largely in the profession’s own hands. If doctors are prepared to make the new professionalism work for the public then the public will reciprocate with their trust and will willingly support them. In an era of heavy state paternalism in our public services, in which trust in politicians is at an all time low, people more than ever want to be able to trust their doctors. Fox offered wise words to guide us. ‘The outcome’, he said, ‘will rest less on what we claim than on what we are’. Exactly so.
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