Presidential address by Sir Alexander Macara
12th October 2005
Thank you, Stefan for being a superb President. You presided over us with
idiosyncratic charm and an irresistible urge to get people along to meetings.
You have made your mark on general practice and general civic affairs in the
City in a way which makes me proud to have been one of your teachers. We are all
greatly indebted to you for all you have done for us and particularly during the
last year. You will be a very hard act to follow.
It was suggested to me that I should respond to a challenge this evening, to
tell you something about public health. It I am to do that, and to try to make
it interesting, and to chime with your own experiences and insights into
medicine, especially in Bristol, I ought first to define public health. I have
to start with the obvious observation that the very term evokes many different
images. There is the historical image of the sanitary unit with the provision of
drains and sewers and general and environmental control which is, not to be
sneered at. Most of the world still doesn’t have these benefits, which is why
90% of all hospital beds in the world are occupied by victims of
gastrointestinal disease. Public health may, on the other hand, be more
pragmatically described in terms of what its practitioners do, which, as I shall
illustrate, is dictated by law and politics. I was persuaded, probably one of
the things I got right, to come to Bristol as Assistant Medical Officer and
School Medical Officer because of the foremost reputation of the Public Health
Department. Under Robert Wofinden, it really was the best in the land. In those
days public health departments were large, multi-disciplinary organisations,
headed by a Medical Officer of Health who had very great power and authority. In
the addition to the environmental control function, they provided front-line
services under Part III of the NHS Act 1946, with which of course you are all
familiar, including health visitors, district nurses, midwives and mental health
social workers and a wide range of so-called “permissive services” under a
clause sanctioning anything which could be described as “prevention, care and
after-care”, which covers just about everything. And that led to home helps, to
health education and other innovations. Whilst training as an assistant, which
included child health clinics, statutory medical inspections of schools,
immunisation and vaccination and for some colleagues, speech and hearing
clinics, port health and occupational health services for local authority
employees, recall the first time my fiancée Sylvia called in on me when I was in
a verucca clinic. I think she did rather wonder what sort of future she would
have a with a verucca doctor. But there it was. Opportunities were available and
were taken, with relief from the other work, for epidemiological research and
health education and for teaching medical and other health professional
students. It was the clinical work, of course, which presented hazards to this
innocent from northern regions. There was the disconcerting, maternal,
introduction of her daughters. “This one is normal and this one is evil.” There
was my first intention to refer a child with a wisp to the Speech and Hearing
Clinic because the child did have a lisp, until physical examination revealed a
stye. My local vocabulary expanded. It was by then obvious that such basically
clinical services, should be provided in primary care by general practitioners
and their expanding teams, now about to be dismantled by New Labour. The loss of
the local authority Public Health Departments in the 1974 reorganisation
rationalised the development of primary care but spelled the death of the Public
Health Department and the loss of the valuable link between the NHS and the
local government with its environmental, educational and social services. The
work of today’s Public Health physician and the growing number of non-medical
public health specialists, has changed with time but requires similar skills.
Directors of public health and primary care trusts coordinate the work of their
colleagues, who specialise in such fields as health promotion and protection,
applied epidemiology and involvement in commissioning the work of secondary care
services. It is interesting to compare these realities with theoretical
definitions of public health, which may be summarised as “the science and art of
the prevention of disease, the promotion of health and the provision of health
care in defined communities together with research and teaching in these
fields”. How then should its practitioners relate to the work of their clinical
colleagues in health care? John Ryle, the eminent Cambridge physician who
controversially moved to a Chair in so-called social medicine in Oxford before
the Second World War, had a graphic metaphor. He compared, what he described as
the microscopists in health care with the telescopists. The microscopist focused
upon a defined field in great depth while the telescopist ranged over the whole
landscape relating the parts to the whole. These were, he stressed, metaphors.
The microscopists were at risk of developing tunnel vision to the neglect of
everything outside of their field of vision and the telescopist of star-gazing
to the neglect of what was actually going on around them. This metaphor
obviously must not be taken too far because clinicians do employ the telescope
within their field of practice and telescopists, that is to say public health
practitioners welcome opportunities to maintain contact with individual patient
care. Likewise, I reject any suggestion that public health is uniquely or
exclusively concerned with primary prevention, which is everyone’s business, and
what are populations if not aggregations of individuals? Indeed, what is the
point of health care at all if it is not preventative, preventing disease from
occurring in the first place and when it occurs, preventing it from spreading in
the individual or to others, together with providing rehabilitation to prevent
break-down. Simply put, public health is primarily concerned with anything which
affects the health of people and medicine in general; with anything which
affects the health of patients. Now before I succumb to incipient dotage, I will
apply anecdotage to illustrate a career in public health and to show what
lessons can be learned and passed on, starting with the parochial Bristol scene,
proceeding to the international field and finally addressing the intermediate
national scene. A general point has to be made which applies everywhere and to
every level. All organisational activity is ultimately political. It is futile
to aspire to taking medicine out of politics, especially in a national health
care system, because it is governed by politics, which in turn are dictated by
economics and the availability, or lack of availability, of resources - of
finance, of people, of goods and services, of power and of trade. Hence the
relevance to health of energy supplies, whether from fossil fuels, notably the
polluting ones of coal and oil and nuclear power, and of agricultural subsidies,
like the common agricultural policy which has corrupted trade. The significance
of politics and economics to the public health is most evident in the
contrasting philosophies of politicians and health professionals. While everyone
rightly responds to immediate needs, the health care professionals take an
essentially long-term view, starting with history and continuing with prognosis,
whilst the politician is preoccupied with current issues and the immediate
future, seeking quick results, any fix to secure their retention of power.
Witness Chris Smith, the hapless Shadow Health Secretary, before the fateful
1997 election, who did not get appointed as Health Secretary in the new
administration, because he had gone to Barts where the consultants had given him
a rattling good lunch and he allowed himself to say he thought the hospital
should be preserved, which was not Labour policy. Anyhow, Chris asked for my
help: he said “Sandy “(they always use first names to give you strokes to get
what they want)”, give us five pledges to fulfil when we come into power”.
That’s the political or the politician’s approach. Witness also (I thought it
worth trying, but never mind) the baffled incredulity in Virginia Bottomley and
her shadow counterpart, Margaret Beckett, when I suggested to them separately
that they should get together to identify a consensus in health care for the
future. Conversely, every successive reorganisation of health care systems, with
their disruption to supply, is dictated by political expediency, currently to
promote ostensible decentralisation and plurality of provision to enhance the
mantra of patient choice, but within centrally set standards and benchmarks: a
sure recipe for local accountability, but effective continuing central control
whereby the Government distances itself from the outcome at the sharp end. Hence
the intention that blame be delegated locally whilst any credit is taken
centrally. The role of the media in all this is crucial, in forming, rather than
informing, public opinion. They have their own agenda – to maximise sales,
advertising revenue and influence. Hence their addiction to spin and their
shameless pandering to the basest instincts of their market: more of this, with
particular reference to Bristol, anon.
Now to the local scene, frankly autobiographical. The influence of vested
interests was soon to be demonstrated to me by two salutary events. The first
was a meeting of the Council’s Health and Education Sub-Committee in 1963 to
which we put the case for fluoridation of the public water supply, because that
was then within their power. The Health Department fielded an articulate dental
professor to display or to deploy the scientific arguments. So persuasive was he
that he was asked, “why, if the case was so strong, had action not been taken
sooner?” To which he replied, thinking he would clinch the argument “Might one
not ask the same question about the control of tobacco.” His reward was to be
dismissed with a curt and cold “Thank you, Professor” by a Chairman employed by
WD &HO Wills, Chairman of a committee heavily weighted by employees of that
admirable company. Water was not fluoridated. My second example recalls work I
was doing with young drug addicts, in the course of which I was supporting
efforts by the Bishop, Oliver Tomkins, to establish a hostel for the
rehabilitation of young patients. The newly appointed Professor of Mental
Health, whose Saturday morning sessions I attended when I could get free of
Immunisation and Vaccination sessions, offered me sinister advice, to retreat -
“We don’t want these people in Bristol, Macara, let them go to Birmingham”.
Per contra, altruism did sometimes win. A controversial Brook Clinic was
proposed to offer vulnerable young people contraceptive advice and support as
appropriate. We deployed, largely thanks to Sarah Walker, case histories which
so impressed the same Committee as had rejected fluoridation, that they agreed
to cooperate in setting up a clinic. The lesson was that individual case studies
are much more effective than cold statistics, although you need to show that you
have an evidence-base if only to impress the politicians. I also learned very
early that patient and self interest groups and NGOs (non-Government
organisations) in the jargon, were natural allies of public health, as they
still are. Hence one accepts every invitation to assist them. So it was that I
devoted a precious free evening to addressing the Bristol Diabetic Society.
After my best efforts, the Treasurer invited me to specify my expenses. When I
declined, as one does, she insisted upon knowing how much they would have been,
and I calculated something like a shilling and tuppence (it was a long time
ago). She bemused me by opening an empty tin and counting out into it, from
another tin, the exact sum, one shilling and tuppence. In answer to my enquiry
as to what she was doing, she said “Well you see it is like this doctor, when we
have a kind gentleman like you, who comes and speaks to us for nothing, we save
it up until we have got enough for a really good speaker”. I have never had a
more priceless anecdote for after dinner speeches.
Another early lesson was to look to the appeal to enlightened self-interest,
which applied strongly (Dr Dowling will recall this) in persuading GPs on the
one hand, and Health Department staff on the other, to embrace the provision of
health centres, in which Bristol was a leader.
Now I turn to the University of Bristol by which I was about to be employed
for the next 34 years with the remit to introduce a one month course for medical
students and to work with my senior departmental colleagues to build-up the
Public Health Department in which they had teaching status with the MOH (Robert
Wofinden) as the titular professor who was paid £100 a year. Cornford in his
matchless Cosmographia Academica, had shown, long-ago, how Machiavellian
university politics are: more so then in political life because those concerned
are a good deal more intelligent but no more scrupulous. For example, as many of
you will recall, any adverse decision against a member of staff, was always take
“in the man’s own best personal interest”, of course. Only the gender has
changed somewhat and a favourite, infuriating ploy of our aforementioned
professor of mental health, when he was embroiled in a heated debate, which he
often was because he was an infuriating chap, was to diagnose that “Dr …… is
clearly disturbed”. That’s called pulling rank. But my first anecdote relates to
the time when I found myself elected as one of two non-professorial staff
representatives on Senate, (I think it was 1969). I had the temerity to move
that there should be no smoking in meetings of the Senate. Discussion went
gratifyingly well, until the Professor of Electrical Engineering, Gordon
Rawcliffe, a martyr to asthma, lumbered to his feet, puffing furiously at his
inhaler. I thought, this will clinch it. By jove it did. To my dismay he opposed
what he described as “my young friend, “because”, he said, “although I
personally abhor smoke, we must defend our individual liberties against these
well-meaning public health people”. “ His young friend, had a salutary lesson,
no less relevant 36 years on when we are still trying to persuade the Prime
Minister and the Government at long last to save non-smokers from pollution of
enclosed public places by smokers. Anyhow the outcome of this debacle was that
the new Vice Chancellor, Alec Merrison, who was a very good friend to many of
us, raised my spirits afterwards by congratulating me on my failure and
advising, “Come back next year inviting Senate to make a self-denying ordinance,
voluntarily, as an example to the University”. I did, and with the support of
the Chair, we had a smoke-free Senate in a University built on tobacco money in
the blessed earlier era of innocence.
The introduction of teaching in general practice to medical students was an
opportunity to apply Cornford’s Machiavellian advice. My dear Chief, Robert
Wofinden, who held the titular Chair, secured the promise of a grant to support
the introduction of students having an attachment to general practice in an
experimental scheme. The attachment was to be to the pioneering Michael Lennard
in the new slum clearance estate of Hartcliffe. This initiative, in the mid-60s,
failed predictably to secure support from the medical faculty and the grant was
lost. Coincidentally, that was at the exact time that I introduced my public
health course and with Michael’s assistance, I wove contributions from general
practitioners into a course which was based in the community, with many visits
in small groups to illustrate the principles and practice of epidemiology and
social medicine. Inspired by colleagues in the educational field, I dared to
apply an evaluation of the course. To my great relief, both the evaluation and
the course itself proved remarkably popular. Indeed, the evaluation was so
popular among the students that other departments were forced, with a marked
lack of enthusiasm, to follow suit. But better was to come. The medical
students’ society, Galanicals, led by a splendid succession of Presidents who
have all gone on to make their mark in the profession, had tasted nectar and
demanded more. So it was that we in public health had the delicious
responsibility of responding to demand and were able to obtain four more weeks
to provide for an attachment to both urban and rural general practitioners.
Opposition from the traditionalist professor to general practitioners “teaching
heresies”, as they saw it, was allayed in a Machiavellian fashion, by persuading
the socially orientated departments to appoint individuals to work with me in
carrying out the new scheme. So we had representatives of child health, mental
health, general medicine and care of the elderly, joining me in assuming
responsibilities for a faculty course in what we called “medicine in the
community”. The whole-hearted response of the GPs, who were unpaid, was
inspiring and the results, as many of you will know, notably Michael Whitfield,
who had joined Michael Lennard, was gratifying, although some 15 years had to
pass before money was found and we had to find it didn’t we Michael, to
establish a GP Unit staffed by Michael Whitfield and David Jewell and I was able
to hand over the baton.
Back to 1974 which brought a crisis to the infant University public health
department when the reorganised NHS poached our staff. I was very fortunate in
being able to appoint Robin Philipp, who managed, with Ralph Midwinter, Bill
Poulsom and myself, to keep the show on the road. But we had lost our professor
and Robert Wofinden was terminally ill. We had also lost the staff from the old
public health department and the back-up of the local authority. As acting head,
an unenviable position at the best of times, I had to fight off flagrant
take-over bids by predatory hospital departments. I intended to say, “which
shall be nameless” but why should they be nameless? They were mental health,
child health and medicine. I suppose it was a sort of backhanded compliment for
what we had done, but that was not appreciated. The future was bleak: but then
again, taking inspiration from Cornford, I found an opportunity. I had been
elected, I think only because I was a pain in the neck, to the first Board of
the new Faculty of Community Medicine, as it was miscalled, now Public Health,
at that time and I discovered a vacancy to represent it on the Department of
Health Central Manpower Committee. I went along to that Committee and managed to
persuade it that every regional health authority should have a specialist in
health care planning and I came back to tell our RMO, Ian Sutherland, who didn’t
want one. He was not best pleased until I revealed my ploy. This involved our
good friend Alec Merrison again. As it happened he was Vice Chairman of the
Regional Health Authority and so it was that we were able totally bypassing the
predators, to appoint a full-time Professor in Public Health and thereby to save
the Department of what is now Social Medicine. As a quid pro quo, I took on the
Healthcare Planning side, which did me no harm.
A less happy recollection I have of that time was of our friend, the
Professor of Mental Health, who had become Dean, wrenching from the Department,
the Health Visitor Course which we had run for 20 years, making it clear that he
thought that “teaching these people had no part in a University Medical
Faculty”. Robin Philipp will remember he was pioneering courses for occupational
and environmental practitioners, but all that was blighted and the Health
Visitor Course became the forerunner to the thriving Health Faculty of the
University of the West of England. That could have been the University of
Bristol. Time and discretion preclude further examples of the duplicity (and, at
times bigotry) of University colleagues. Thirty years on, I doubt whether much
has changed, except for the malign influence of the research assessment exercise
distorting priorities.
I move now to the international scene, to recall how crucial the factor of
chance is in our lives. Back in 1968, when I had been in post for only five
years, Professor Wofinden asked me, in time honoured fashion, to prepare a paper
for him to deliver on my evaluation of our new undergraduate courses, to the
first meeting of a WHO sponsored initiative in post-graduate public health
training, which was to become ASPHER -The Association of Schools of Public
Health in Europe. At the last minute he was indisposed and I went to Zagreb in
his place, accompanied by Ralph Midwinter, to give my own paper. At that time
this was a revolutionary contribution, which led to my becoming Secretary
General of that successful venture five years later, and developing it for 14
challenging years. That work in its turn led to many missions for the WHO,
initially in Europe, and eventually throughout the world where I became a sort
of roving academic ambassador for Europe with a flattering status which belied
by lowly standing at home. I was thereby privileged to witness from the inside
both the success and the failure of major international efforts to eradicate
pandemic diseases, specifically Small Pox (success) and Malaria (failure). The
ambitious Malaria-eradication campaign which was started in the 50s, foundered
not only because of the development of resistance to the drugs and the
problematic association with DDT and organophosphates, but mainly due to the
failure of the last, surveillance phase after successful eradication. It was the
absence of a basic public health infra-structure which proved fatal, although
even where one was in place, too often, concealment of reintroduction of the
disease from surrounding areas, resulted from the anxiety of fieldworkers to
avoid blame. In consequence, Malaria is back with a vengeance with falciparum
predominant. In stark contrast to that failure is the success of the Small Pox
eradication campaign which started in 1967. It had the great advantage, of
course, of the absence of a vector but lessons had been learned. Painstaking
case finding reported by runners in remote rural areas, led to targeted
vaccination and quarantine. There was more. I vividly remember the banner
headlines in the English language newspaper in Rangoon, in late ‘77, “Triumph
for Burma” it read, about the eradication in that country, with attribution to
the role of the WHO relegated to small print. The strategy there of centralising
the organisation but decentralising subsequent credit was masterly and as so
often in successful projects, in Dean Henderson, from the Johns Hopkins School
of Public Health, there was a master in charge.
Personal behaviour is frequently crucial. Come with me to Sri Lanka, to a
rural demonstration area near Colombo, where an earnest young lecturer was
extolling the virtues of the new tube well, equipped with its own rope and
bucket behind him. The students had an excellent view of a village woman coming
up with her own bucket, which had doubtless been used to dispose of night soil,
lowering it into the well with her own rope and making off happily with a full
load. My gentle suggestion that the purity of the water should be monitored,
(the MOH was a former postgraduate Bristol D.P.H.) led to the expected finding
of a high coliform count plus other predictable nasty contaminants.
Switch to another continent, to the Sudan, and to my task as a WHO
consultant, to evaluate a 5-year USA child health project in the Nile villages
north of Khartoum. Kwashiorkor was endemic although abundant protein swam
invitingly in the river and clucked ubiquitously around every courtyard. Indeed,
fish and eggs were sold in the market in Omdurman for cash which was used to
buy, what do you think?, Camel cigarettes and the disgusting local beer. What
rational explanation rather than commercial gain, was there for the deprivation
of the children? I was assured that it was simply that the fish stank and the
eggs came from the dirty part of the chicken which was also taboo because it
came from the egg: an inevitable pun and a striking example of irrational local
taboos. A case for health education, clearly. But in the same population,
evidence of the limits of the effect of health education was seen in the
prevalent infibulation of young girls. Many mothers had been persuaded against
allowing their daughters to be so mutilated but they had to propitiate their own
mothers. It was the grandmothers who were resistant to good advice and the
mothers had to take the girls to gynaecologists who would make a few cuts and
bandage them up, in order to suggest that tradition had been served. Such
problems of lifestyle and personal habits are often confounded by politics but
not always obviously.
Take family planning and visit Thailand in the late 70s. A dynamic voluntary
movement, led by an economist named Mechai who featured in the Reader’s Digest -
and that is a great accolade – and who had the advantage of support from one
cousin, the venerated King, Bhumipol and another cousin who was Head of the
Department of Public Health, and who had published a paper in the International
Journal of Epidemiology, showing that condoms had failed in Thailand because
they were the wrong size for Thais. Where do you think the fieldwork was done?
Yes, by sex workers in a local brothel, part-owned by a member of the Department
staff who had invested shrewdly. Mechai had a sure touch for the psychology of
human behaviour. His gaily coloured condoms were on sale at three different
prices. When he was challenged about the inequity of an inferior product for the
poorer consumer, he replied that they were all identical. Smart. He organised
choral competitions and championships for the performance of songs lauding
family planning with prizes which included a new school, or a new clinic. It was
massively successful and was in stark contrast with Burma next door. There I had
been impressed by the priority given to preventative child health programmes in
the most remote rural areas involving nutrition, immunisation and vaccination,
hygiene, and other aspects of child care, but no family planning. Fortuitously I
had met a group of medical students from Mandalay in a remote northern village,
hours from the nearest road, through rat and cobra-infested paddy fields, which
yielded abundant protein which was, of course, served for lunch. I sought an
explanation for the posse of goons standing around in dark glasses and with
bulging shoulders, and was informed that one of the students was a daughter of
the President. She kindly invited me to dine with Dad on our return to Rangoon.
I was able to praise him upon his child health services and to raise the
question about family planning. He looked directly at me and asked, “how many of
us Burmese are there?”. I replied “I haven’t counted them all myself personally,
but I reckon about 36 million”. He said “exactly, and how many of these little
yellow bastards up the road are there?” referring to China. I said “oh, give or
take a billion or so”. He said “exactly, and you want us to have family
planning”.
That shows the influence of politics but religion also plays a significant
role in such matters. Returning to the Nile villages survey and family planning,
the researchers claimed that the uptake of family planning during the 5 years of
the programme, had increased “significantly from 3.7 to 5.1%”. Statistically
significant perhaps, but what was really significant was the parlously low level
which was attributed to the opposition of the local imams who had not been
consulted. Islam has not proscribed family planning done in a certain way and
the imams might have been won over if they had had an explanation of what it was
intended to achieve.
I must refer to the importance of relevant information for health care
planning which was illustrated by the European Collaborative Health Services
Study which ran for over 10 years from 1977 and involved alumni of Professor Bob
Logan of the London School of Hygiene and Tropical Medicine in 11 European
countries. As its Secretary, I saw the value of collecting basic data about
need, demand and supply which enabled challenging hypothesis to be made, such as
the extent to which different ratios of numbers of doctors to nurses reflected
roles, notably Portugal with a one to one ratio, compared with the UK with 6
nurses to each doctor. The most useful outcome, however, was in Mostar - that
beautiful ancient town in Bosnia, which was so tragically destroyed in the civil
war which followed some time after Tito’s death. Our study there of the
secondary care needs of the local population enabled the size of the planned new
hospital to be reduced from an intended 1200 beds to around 800 with the savings
devoted to additional resources for primary care. Would that we had a similar
study in Bristol?
One must enter a caveat that things are not always as they appear. I recall
Alec Merrison’s ill-fated Royal Commission on the NHS set up by a Labour
administration, which had the misfortune to report in 1979 to the new Thatcher
administration. Consequently, it was largely ignored. There was much perplexity
about a graph in the Report which showed a strong positive correlation between
the number of doctors and the perinatal mortality rates in different Western
European countries. How could it be that mortality was higher where there were
more doctors? The paradox was explained by the fact that countries which have no
numerus clausus and which fail to control the number of medical graduates, also
neglected to produce enough preventative health workers, such as community
nurses and health visitors and midwives who are more relevant to the survival of
neonates then doctors are. Whatever the imperfections of our health statistics,
they are at least basically accurate although they are spun for political
advantage, but they are not corrupt as was the case in the Soviet empire where
they reflected political fantasy, not reality. The adjustment to their figures
at the end of the Cold War has been painful in the extreme and later on in this
Session, Martin McKee will be telling us about that. Much can be said about the
issue of human resources, what we used to call manpower, and the universal
failure to plan sensibly. Our record in the UK is scarcely commendable but pales
alongside the politics of the European Directives on postgraduate medical
education and doctors’ working hours which bedevil our best efforts today. It is
cold comfort that in the centrally controlled Soviet economies, the quality of
care was depressed by the lowly status accorded to doctors and other healthcare
practitioners, about whom the politicians were nevertheless paranoid.
Indiscretions, such as telling the truth, were savagely punished. The Head of
the Central Institute for Advanced Medical Studies in Moscow, a most civilised
man who had been a generous host when I lectured on his WHO course, disappeared
(professionally at least) following an international meeting in Manila, where he
criticised his regime’s policy; and the Head of Nursing in Lublin in Poland was
demoted following a WHO Workshop in Warsaw, for which I was the rapporteur,
during which she had conversations in our hotel lounge with Margaret Hall, then
Chief Nursing Officer of Scotland, who was an old fellow student. Bugs and spies
were ubiquitous. It was an open secret that the Soviet block members of the
staff of the European Regional Office of the WHO in Copenhagen, had meetings
every Monday lunchtime, convened by one of its most junior members, who was the
KGB agent in the office. He was a useless Russian public health academic, who
commissioned a survey which Ralph Midwinter and I carried out on the teaching of
public health in Europe which he eventually spiked because he didn’t like it. To
be fair, however, the Soviet system did at least provide a basic health-care
infrastructure which collapsed in tears everywhere which I saw for myself, on a
gruelling WHO mission to Georgia in 1994.
The final section of my testament brings me home to the UK and the challenge
of promoting the public health within the privileged position of an office
holder in the BMA and other professional organisations such as the Royal
Colleges and the GMC . Inevitably political friends and foes figure, hopefully
without malice. My very first encounter with a Government minister had been
representing colleagues in the British Medical Students’ Association as its
Grants and Welfare Secretary, 50 years’ ago. We were concerned about the
iniquities of the Means Test for student grants. It was a salutary shock to
learn that as a supplicant you have no clout, even with the BMA notionally
behind you.
My next, most memorable meeting, was in 1984 in the den of the then Home
Secretary, Willie Whitelaw, who, surrounded by hunting prints on the walls and
flanked by po-faced senior civil servants, courteously received a BMA delegation
wisely reinforced by John Walton as GMC President, to take issue with a police
and criminal evidence Bill which would have given legal access to confidential
personal health information without knowledge or consent to the police, her
Majesty’s Customs, the immigration authorities and the Inland Revenue. Whitelaw
listened carefully to our expressions of outrage, which were not feigned, then
rounded on his hapless minions, “Who is responsible for this nonsense?” and
receiving no answer, summarily discharged them to purge the Bill of its
offending clauses. That was very impressive and I would dearly have liked to
have been present, some years later, when the Prime Minister, Margaret Thatcher,
received another delegation comprising the Presidents of the three senior Royal
Colleges. One of them, asked later, what he had said to the Prime Minister
replied, “Oh I said three words, three times”. “Really, and what were these,
President?”. “But, Prime Minister”. Cut to the Secretary of State for Health
when I was suddenly propelled into the limelight as Chairman of Council of the
BMA in 1993 and a much maligned Virginia Bottomley revealed a genuine commitment
to the public health when she hosted a sparkling reception for the Regional
Director of WHO, Jo Asvall when I was President of the European Forum of Medical
Associations. A loyal member of a troubled Cabinet, Virginia was the hapless
victim of abysmal briefings from of her civil servants which made our debates in
the Today programme embarrassing. After one such encounter, she was moved to
express her true feelings and I could no longer see her as an enemy. I was glad
to be called in aid when she held a Press Conference to present examples of the
encouraging cross-Government initiatives at the local level under the Health of
the Nation policy, which owed much to Donald Acheson as CMO, but when questions
were invited, all that the mass ranks of the media wanted was to excoriate her
for the Government’s failure to take effective action against the Tobacco
industry (“the Merchants of death”) as I have dubbed them. She turned to me to
offer the defence that she could not give, which was to identify the Treasury
and ambivalence about disreputable sources of income, as the villains of the
piece.
A later episode was less amicable. The occasion was an august reception to
launch the Department’s new Research and Development Policy which still survives
today. By an unhappy coincidence, that very day the BMJ had published its leader
criticising the Government’s “fascist” policy, as Richard Smith described it,
and I had the ambiguous distinction of making banner headlines in the
ever-waspish Evening Standard, slating the Department of Health’s civil
servants, for planning to impose performance-related pay which the BMA was
opposing with a fine disregard for the hypocrisy of distinction awards. Anyhow,
Richard and I shared a taxi and walked in together just as Virginia was
welcoming the high-powered audience. Breaking off from her script, she rounded
on us with splendid invective. Richard knew when to remain silent, but I was
moved to reply with mock contrition that if she did not know what was going on
in her own Department, it was my solemn duty to tell her. The following morning
I received a predictable outraged letter from her permanent secretary, normally
a mild man, with protestations of neutrality which I was happy to endorse.
I move on to a very different reception, and an ostensibly different
Government. The scene, Number 10. The occasion, a bash for New Labour lovies,
pop stars, media celebrities and the like with a sprinkling of more conventional
guests, including Leslie Turnberg, President of the Royal College of Physicians,
soon to be ennobled as a Labour peer. Our daughter, monitoring the TV coverage
of arrivals from our holiday chalet in Scotland, which we had forsaken for the
day, was bemused as the cameras scanned Sylvia and me walking in, to hear the
commentary, “there are also a few ordinary guests”. Inside, one fell to
chatting, as one does, with Alan Milburn, then Minister of Health to Frank
Dobson as Secretary of State. Some imp prompted me to pull his leg over the
volte face over the private finance initiative, which Labour had robustly
condemned in opposition, with ammunition from the BMA and Allyson Pollock. “Ah”,
replied Alan, “Peter is our expert”, and summoned over Mandelson, so beautifully
described by David Starkey the other night on television as the patron saint of
New Labour. Without turning a hair, Mandelson explained that “we are going to
make it work”. Classic hubris, especially as I knew that Frank Dobson, who we
will welcome next month as our Long Fox lecturer, was at best sceptical about
it. When Milburn came to power, succeeding Dobson, he was no stranger. Notorious
for running a failed bookshop in Newcastle ‘Haze of Hope’ predictably dubbed
‘Days of Dope’, we first met when he, who had been the beneficiary of priceless
briefings from the BMA, which helped him to make his reputation as an opposition
health spokesman, addressed a Consultants and Specialists Association meeting in
York. As the after dinner speaker I had arrived early to hear him castigating
the BMA in the usual way as a reactionary repository of vested interests. This
was well-received by that audience. When I was introduced to him afterwards I
made so bold as to advise nevertheless that before speaking to the gallery, he
should ascertain who were in it. In contrast to Frank Dobson whom he succeeded
as Secretary of State, he was no great friend of public health despite Our
Healthier Nation (of course) which Ken Calman had masterminded as CMO before
moving to Durham as Vice Chancellor, to be succeeded by Liam Donaldson whom some
of us taught. The public health section of the NHS Plan 2000 under Alan
Milburn’s jurisdiction was a pallid reflection of a feisty modernisation action
team chaired by Liam in which we had combined forces to advocate positive public
health policies. Symbolically it appeared as chapter 13, almost as an
after-thought. In marked contrast to Scotland, where a similar exercise put
prevention of disease and promotion of health up front. Nor was Alan any friend
of the profession. Witness his demands for the GMC to set up an interim orders
committee with power to suspend doctors from practice, pending a professional
conduct committee hearing, which was bound to lead to injustice as it has done,
and to extend to 5 years the period which must elapse before reinstatement can
be sought by a practitioner who had been erased from the register. In the
absence of the President on Safari in South Africa, terrorising the wild beasts,
the Registrar asked me as “Father of the House”, (I had been there longer than
anybody else), to Chair an urgent extraordinary meeting of members to give the
immediate response demanded. That response was truly extraordinary. A unanimous
decision, including all the lay members including those who normally failed to
support the doctors, to resist. The President suddenly returned from South
Africa and I never learned what followed because no report of the meeting ever
appeared and I have never seen any response from the Secretary of State, but the
rejected measures were imposed immediately with no reference to any objection
from the General Medical Council.
A more amusing recollection relates to the time when Millburn was still
Minister of Health and PCTs were first mooted. There was the usual clash with
the general practitioners. Critically timed just before the Annual Conference of
LMCs, followed by the BMA’s ARM, Alan was very anxious to avoid a damaging run
and he sought my advice: he had to be desperate. Knowing that the GPs’ position
was a negotiating ploy, as there was no basis for trust, I cited the metaphor of
a tug of war and suggested that he just let go and concede all that the GPs
claimed to want. For once, win, win.
Now, what of the media? Pursuing their own agenda to win ratings wars and
advertising revenue, one learned that skewed headlines and misleading reports
were invariably the work of sub-editors serving the party line, whilst posing as
champions of the public. Hence reports are often partial in both senses of the
word and there always has to be an angle, preferably something new which can be
turned to advantage. In a Press Conference to publicise our Core Values
Conference in 1994, organised by the BMA for the whole profession, as a
prophylactic reaffirmation of our principles in the face of the gathering forces
of antagonism, Fergus Walsh challenged me to justify what was new. I was able to
reply that it was an historic first in the commitment of the profession, not
only to individual patients, but to society as a whole. Sadly, more often the
lust for sensationism, for blaming and shaming and naming leads to an assumption
that a doctor accused of any offence is guilty until proved innocent if he can
or she can be, which creates a prejudicial climate of opinion in which a fair
trial, whether by a court or the GMC, is compromised. Issues of confidentiality
are a perennial concern, with the constant need to balance privacy and the
sanctity of personal health information against the needs of essential
information for research and teaching and for health care evaluation and
planning. In 1982 the CMO invited me as Chairman of the BMA Ethics Committee, to
set up an expert committee to advise the Department of Health on data protection
in the context of an impending Act to govern computerised data. The good and
great Douglas Black agreed to Chair it and we secured the services of the
leading human rights lawyer, Paul Sieghart, with a dispensation allowing him to
smoke during the meetings at BMA House. (The poor chap died a few years later
from lung cancer.) Having addressed the immediate issue, we proceeded to prepare
detailed guidelines to govern use of all personal health information whether
computerised or not. Our report was shelved, I suspect because it conflicted
with Margaret Thatcher’s plans for the internal market. Scotland was more
prescient, picking it up and applying it. Fifteen years later, Scotland is
well-advanced with its arrangements while England is still failing to employ our
work. Meanwhile the BMA was not passive. Drawing on our experience, we sponsored
private member’s bills to give patients the right of access to their medical
records and to reports prepared for third parties such as insurance companies.
I cannot close without measured reference to the painful paediatric cardiac
surgery problems in the BRI which are being exploited by our enemies to make the
name of Bristol synonymous with all that is perceived through the distorting
prism of corrupt misrepresentation to be wrong with the profession and its
governance and to justify sweeping measures to bring the profession under
political control. I can speak only of what I know and can add to the collective
knowledge of those of you in this room. When demand arose for a national
enquiry, I sought, as Chairman of Council of the BMA, to persuade ministers that
the issue was primarily for them. It was their NHS, their management, or mis-management,
their responsibility for control of resources, their policies on contracts and
financial deficits: hence they should be responsible for any enquiry in order to
obtain all the relevant facts, as otherwise there was a very serious risk of
individuals being scapegoated in a miscarriage of justice. My stance was
successfully opposed by the President of the General Medical Council who was
assumed to be acting from the worthiest motives. When he told me and others,
including his predecessor, the reforming Lord Robert Kilpatrick and all those
who cared to listen in a railway carriage between Newcastle and London, that in
order to save professional self-regulation, he had to make an example of what he
called “my friends in Bristol”. HMG were only too relieved to be let off the
hook. Short-termism again. And the President appointed a panel, of his own
choosing, to adjudicate the charges against our colleagues with himself as
Chairman. The rest is history but not, I trust, forever silence. The current
debate about what is now called in weasel terms ‘professionally-led’ regulation,
demonstrates the futility of hoping that the practice of medicine and the cause
of public health can ever be divorced from political processes. Subsequent
speakers whom I have recruited during this Session will add their penetrating
insights.
I conclude with Calvin’s challenge - Do we make the world our parish, or do
we make our parish, the world? We must try to do both. Thank you for your
attention.
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