David Joselin: The NHS has been a failure - and here's why

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The Independent Online

Yesterday's White Paper on Health sensibly suggests shifting some resources towards bringing services closer to the community. For example, it is estimated that an additional 1,000 GPs would be needed to work in health centres and supermarkets.

Yet at present, restrictive practices are distorting priorities. In a first-class National Health Service, there would be no waiting lists, consultants would be infinitely more available, and would be at the forefront of hospital emergencies. All this is commonplace abroad, but does not happen in Britain because the NHS is riddled with practices which restrict consultants to such a trivial proportion of the medical profession that the NHS can never be a first-class system.

Why restrict the number of consultants? Money of course - it is all about supply and demand. A scarcity of NHS consultants raises the demand for consultants in the private sector, and the private sector means serious money for NHS consultants. Thanks to the National Health Service Act of 1948, consultants not only have a monopoly of senior positions in the NHS, they have a monopoly in the private sector as well.

The Royal Colleges artificially restrict consultant posts to about 25 per cent of the medical profession. It is obvious that the NHS needs a huge increase in consultants, especially in surgery, and it could increase the proportion of consultants in the medical profession from 25 per cent to 40-50 per cent if it wanted to, as happens abroad.

In 1948 Aneurin Bevan, the first post-war Minister for Health, agreed that governments would not interfere with the entrenched labour practices of the Royal Colleges of Physicians and the Royal Colleges of Surgeons. This agreement remains a major cause of NHS waiting lists. Bevan chose to model his hospital system on the existing voluntary hospitals, but he did not understand the medical profession.

In 1948, the teaching hospitals had hierarchies of "junior" doctors. Consultants headed huge teams of senior registrars, registrars, senior house officers, housemen and medical students. The consultants spent most of their time in the private sector, while "their" junior doctors did the routine work.

The non-teaching hospitals had few junior doctors, but coveted them. When the consultants rejected Bevan's national health service in 1947, he had to convert them, famously, promising to "stuff their mouths with gold". Less famously, he promised teaching-style teams to every consultant who would join him.

"Junior" doctors now make up over 40 per cent of all the doctors in the NHS. Allowing 30 per cent for the general practitioners, little more than 25 per cent are left to be consultants. But as I saw when I worked in Canada, juniors need only make up 11 per cent of a medical profession, allowing more than 40 per cent to reach consultant status at a much earlier age. US figures tell a similar story. NHS consultants are heavily over-protected compared to their overseas equivalents. Productivity is ruinously low.

I watched as NHS-trained general practitioners admitted and treated patients in three Canadian district hospitals. They manned the hospital wards, the Accident and Emergency departments and the Special Wards expertly. They delivered their own patients in obstetric units safely and professionally. Most importantly, they assisted surgeons at operations and physicians at the bedside, enabling them to exercise a genuinely informed choice of consultants in referrals. GPs in hospitals provided a scamless service.

Do general practitioners have the time to do this in Britain? Of course they do, especially if they were to form a larger proportion of the profession. There are already over 30,000 of them in England and Wales. Each doctor sends to hospital wards an average of two or three patients a week in medicine, and one or two patients a week in surgery. For general practitioners to replace junior doctors would mean only a small amount of extra work for them, but it would enable UK specialist training to develop into one of the best on earth.

The NHS would have a substantial increase in the number of consultants after only six years of intensive training, as abroad, and the increased numbers would make consultants more available to patients. They could be at the forefront of hospital emergencies. Outpatient waiting lists would disappear, and surgical waiting times would be drastically shortened.

After 60 years of failure, it is time for a radical solution. General practitioners should be allowed to manage their own patients alongside consultants in district hospitals, as well as in the community.

djnewnhs@aol.com

The writer is a retired GP

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