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Three cheers for Doctor Anthony Goldstein who, with reckless courage,
is mounting a private prosecution against the General Medical Council, accusing
that august body of ‘abuse of power’. He can hardly hope to triumph. Private
citizens have small chance of denting the authority of the Establishment
– and certainly not at their first attempt – but Goldstein may well inspire
a debate which could run and run and ultimately force a large and healthy
change in the way all ‘closed’ trades and professions manage their affairs.

Goldstein is upset because many highly qualified and experienced doctors
who have sweated away for years in order to acquire expertise in some branch
of medical practice are largely denied the chance to use and profit from
their special skills because nobody is allowed to know they have them.

In Britain the medical specialities, from obstetrics to orthopaedics
and from paediatrics to transplant surgery are virtually the preserve of
hospital consultants employed by the NHS or the medical faculty of a university.

There is no legal bar to any registered medical practitioner (me, for
instance) opening a clinic, or negotiating a foothold in a private nursing
home or hospital and, claiming to be an expert, offer to treat any kind
of malady. But the chances of attracting sufficient custom to provide a
living wage would be remote.

This is in large part due to the peculiarly British convention which
ensures that a specialist will only deal with patients who have been referred
for treatment and advice by their own family doctor. This has nothing to
do with any rational idea that consultants ought to be protected from clients
whose needs do not demand their peculiar skills (although it happens to
be a convenient tradition for a state medical service). It all began about
a century ago when most GPs were sturdy all-rounders performing nearly all
the tasks which are now the preserve of specialists.

Every family doctor was adept at delivering babies and accustomed to
cutting out an inflamed appendix, either in the local cottage hospital or
even on the patient’s kitchen table. The doctor would also take full charge
of the patients with heart disease, diabetes, pneumonia, syphilis, anaemia
and many another condition which today command specialist attention. The
jack-of-all-trades nature of the family doctor’s daily round was as much
a matter of necessity as choice. Even as recently as the outbreak of the
Second World War there were only some 3000 consultants, compared to more
than 20 000 GPs.

The ‘specialist’ caste emerged more by accident than by plan to make
the best use of available skills and resources. Doctors were trained in
the great voluntary hospitals under the tutelage of eminent physicians and
surgeons who had achieved appointment to the honorary staff – ‘honorary’
because they worked for nothing, filling their beds with the sick poor who
were ‘fortunate’ enough to suffer from some sufficiently interesting malady,
or whose condition made them ‘good teaching material’. These panjandrums
made their living exclusively from the private patients they treated in
their consulting rooms in places like London’s Harley Street, at home, or
in private nursing homes. The voluntary hospitals were their power base,
where they made their reputations. Their ‘charity’ work was essential to
their worldly success. There were few specialists because only the larger
towns and cities sustained such institutions and (just as importantly) a
rich reservoir of prospective paying customers.

However, the humble GPs began to resent the competition for well-heeled
clients presented by the hospital glamour boys, with their subtly advertised
expertise. A really ugly internecine feud threatened, but in the end this
could only have harmed business and damaged medicine’s brand image, which
was one of the profession’s principal therapeutic weapons before the days
of effective drugs. So, something like a century ago, the provincial doctors,
represented by the youthful British Medical Association, came to an agreement
with the royal colleges, which were the hospital doctors’ guilds.

The bargain was that the physicians and surgeons who set themselves
up as specialists would not see any private patient except at the request
of the customer’s own GP. The provincial doctors now felt secure, and were
happy to send some of their more puzzling patients (those who could manage
the fee) to a consultant colleague for a second opinion. (Hence the title
‘consultant’, which is not found in medicine outside Britain.)

Family doctors still went on doing anything they felt to be within their
competence (and maybe a good deal else besides), and not many people ever
did visit a specialist. But since the patricians were fairly thin on the
ground they did well enough out of the deal. Instead of having to attract
their own patients they were able to sit back and await the arrival of those
referred by their former pupils, or by local doctors who knew of their fame.
Everybody was more or less happy.

The whole system was taken over intact when Aneurin Bevan and the Labour
government established the NHS in 1948. Ever since the consultants have
done their best to maintain their monopoly over the provision of specialist
medical care, and it has been in their interest to restrict the number of
doctors qualified or recognised as competent to provide such care. Terence
English, president of the Royal College of Surgeons of England, recently
told me that the rich ‘merit awards’ which can double the income of top
NHS consultants amount to peanuts compared to the money they can earn in
their ‘off-duty’ private practice. Hence the desire to restrict the exploitation
of the market to the few.

To apply for a job as an NHS consultant these days, you not only have
to have passed stiff postgraduate examinations (such as the MRCP and FRCS),
but you must also have served your time in a number of approved posts as
a senior ‘junior’ hospital doctor. In other words, you must have shown,
by both learning and experience, that you are thoroughly well qualified
for the job.

But though many are called, few are chosen. And that is what Goldstein’s
protest is all about. The country is littered with highly and expensively
trained ‘specialists’ who are not able to practise their skills because
they have failed to get elected to the consultants’ club. So they go into
general practice, or go abroad, or otherwise deprive us of the benefit of
their special skills. The General Medical Council holds the records of these
frustrated aspirants to the medical nobility but will not reveal their names.
Goldstein (who is one of them) says this is wrong. We should know who they
are and be able to make use of them.

It is scandalous that any profession should indulge in a restrictive
practice which, in the interests of a privileged cadre, prevents some of
its competent members from exercising their much-needed talents, and denies
the nation the fruits of costly apprenticeships for which it has had to
pay good money.