One of the main ways that the Labour government has not taken the National
Health Service in a socialist direction is the "Private Finance
Initiative", for the funding of premises.

However the following announcement last week marks a significant turn in
the move from General Practioners, the bed-rock of the British NHS,  being
petty bourgeois independent professionals, to being regulated employees in
a social system of production.

Even under the former Conservative government, the policy was to gather
together GP's in better organised collective practices, performing a number
of multi-disciplinary health tasks. The catch was that the Conservatives
were boosting the GP's practices as surrogate customers with their own
fund-holding budget in order to promote an "internal market" within the
gigantic NHS, one of the largest state economic units west of the former
iron curtain.

This NHS worked on the communist principle of to each according to his
need. (It had been modelled on collective health schemes set up in the
colliery towns of South Wales). But the GP base was a petty bourgeois mode
of production. 

Now within two years of the election, the Labour Government has brought
separate fund-holding GP's, with very little strident opposition, into
Primary Care Groups covering populations of 100,000, and has dropped talk
of an internal market.  These PCG's may become Trusts directly managing
much of local health care. 

The formulas on this note that all GP's may remain independent
self-employed agents. The sub-text is that the government is opening the
door to them being directly employed by their local primary care trust. The
material logic of all this is that health care has moved beyond what a
professional can do in his/her front room, with a nurse attached, and needs
skilled managers, and complex information systems. A complex social form of

Now the announcement on Friday sets up, again without effective opposition
from the professional bodies, a mechanism of quality control for the
medical labour force. This brings them an important step closer to being
employed, highly skilled workers. 

This is a prosaic step in realising the dramatic words of the Communist
Manifesto, in one of the increasingly important sectors of the economy,
health provision: 

"The bourgeoisie has stripped of its halo every occupation hitherto
honoured and looked up to with reverent awe. It has converted the
physician, the lawyer, the priest, the poet, the man of science, into its
paid wage-labourers."

Whether this step is one that ultimately favours socialism, as I believe,
or a more rational delivery of an essentially bourgeois state health
system, it is certainly a more socialised form of organisation of the service.

I would have thought that other capitalist countries need something similar
to the British system of general practitioners who can broker access to
specialised health resources,  in order to move towards socialised health

Extract from the somewhat hyped press-release follow. 

Chris Burford


Friday 12th November 1999

 Health Secretary Alan Milburn today published ground-breaking
 proposals to tackle the problem of poorly performing doctors.

 The tough new proposals, aimed at protecting patients and driving up 
 standards, will ensure that all NHS doctors provide a first class 
 service, using their skill, education, dedication and commitment to 
 give the very best possible care for their patients.

 Current NHS disciplinary procedures are bureaucratic, legalistic and
 ineffective. The new measures would ensure that NHS trusts and
 health authorities must be able to take action quickly to detect
 emerging problems and resolve them quickly and fairly.

 The comprehensive package of measures will:

 - ensure that all NHS doctors' practice is monitored to pick up 
 problems early, ensure that poor performance is tackled swiftly, and 
 ensure tough action is taken in response.

 The proposals, drawn up by Chief Medical Officer Professor Liam
 Donaldson, completely overhaul key aspects of the the NHS, which
 have remained largely unchanged since 1948.

 For hospital doctors the plans would end the protracted delays,
 expensive suspensions on full pay, and legalistic inflexibility of
 the old arrangement through four key reforms:

 - all doctors to participate in external clinical audit and take part
 in an annual appraisal of their performance.

 - they set up new independent and impartial "Assessment and Support 
 Centres" where doctors suspected of poor practice will be referred. 
 They will be looked at to see if they need retraining, or if their 
 poor standards cannot be put right the centres will advise employers 
 accordingly who can the take necessary action as well as notifying 
 the GMC.

 - they make clear that doctors being investigated for personal
 misconduct (for example sexual assault, fraud) or failure to meet
 their contracts (for example not turning up for a ward round or
 outpatient clinic) will be subject to exactly the same disciplinary
 process as any other NHS employee.

 For GPs the proposals would mean they:

 - have to participate in external clinical audit.
 have annual appraisals of their standards.

 - may be suspended by Health Authorities where there are serious

 - may be referred to the new Assessment and Support Centres where they
 will be looked at to see if they need retraining, or if their poor
 standards cannot be put right the centres will advise health
 authorities, who will ensure action is taken including notification
 of the GMC.

 The NHS Tribunal which has in the past been crticised as slow to
 take effective action to safeguard patients will itself be reviewed.

 Alan Milburn, Health Secretary, said:

 "The Government is modernising the NHS to give patients the highest
 standards of care. The vast majority of NHS doctors are excellent.
 Many are the finest in the world. But I am determined that the very
 small minority of poor doctors do not tarnish the reputation of the
 medical profession as a whole. I will not turn a blind eye to poor

 "The present arrangements for dealing with poor performance and
 allegations of poor clinical performance do not serve the interests
 of the patients, doctors or the NHS as a whole and need to be

 "Patients interests are at the heart of these proposals. The
 changes we are introducing will help give patients wherever they
 live fair, fast, high quality services."

 Professor Liam Donaldson, Chief Medical Officer, said:

 "These proposals seek to set out a new system in which everyone
 concerned - the profession, their regulatory bodies, the NHS and the
 public - can work together to ensure the very highest standards of

 "Early intervention is the key to protecting patients. This
 framework will provide the mechanisms for quick diagnosis and
 provide the employer, the patient and the doctor concerned with an
 objective assessment of the nature and seriousness of the problem
 and the action needed to address it."

 The Chief Medical Officer's proposals offer a seachange in the way
 poor practice is dealt with on the part of a small but significant
 number of doctors. They are the third leg in the Health Secretary's
 drive to modernise standards in the NHS.

 The first leg is setting clear national standards through care
 blueprints for major conditions such as cancer, heart disease and
 mental health. And through the new National Institute for Clinical
 Excellence to advise on the best treatments for patients to help end
 the postcode lottery of care.

 The second leg of the standards is the new Commission for Health
 Improvement to help make sure the national standards are being
 followed in all hospitals and primary care.

 And the third leg of the modernisation is about individual doctors.
 That is what today's proposals are about. They support local
 clinical governance, and aim to fit closely with the GMC's new
 revalidation procedures.

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