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Doctors, Politics and Pay Disputes: ‘pressure Group Politics’ Revisited

Published online by Cambridge University Press:  27 January 2009

Theodore R. Marmor  and
David Thomas
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Extract

Studies of medical politics usually emphasize one of the following types of inquiries: (a) analyzing the internal politics of medical organizations, as with Oliver Garceau's classic study of the American Medical Association; (b) describing and explaining the roles individual physicians play in the political life of the community as voters, officials, or citizen participants in civic life; or, (c) assessing the impact of medical groups and organizations on public policy, particularly health policy. Harry Eckstein's widely known study of the British Medical Association is primarily a study of the third type, a discussion of the channels of influence, the tactics, and the effectiveness of the BMA in shaping public policy to its ends.

Type
Articles
Information
British Journal of Political Science , Volume 2 , Issue 4 , October 1972 , pp. 421 - 442
Copyright
Copyright © Cambridge University Press 1972

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References

1 Garceau, Oliver, The Political Life of the American Medical Association (Cambridge, Mass.: Harvard University Press, 1941).Google Scholar

2 See, for example, Glaser, William, ‘Doctors and Politics’, American Journal of Sociology, LXVI (1960), 230–45.CrossRefGoogle Scholar

3 A number of books exemplify or include this type of investigation: Burrow, James Gordon, AMA: Voice of American Medicine (Baltimore: Johns Hopkins Press, 1963)Google Scholar; Badgley, Robin F. and Wolfe, Samuel, Doctors’ Strike; Medical Care and Conflict in Saskatchewan (New York: Atherton Press, 1967)Google Scholar; Stevens, Rosemary, American Medicine and the Public Interest (New Haven: Yale University Press, 1971)Google Scholar; Glaser, William, Paying the Doctor (Baltimore: Johns Hopkins Press, 1970).Google Scholar

4 Eckstein, Harry, Pressure Group Politics: The Case of the British Medical Association (London: Allen & Unwin, 1960), p. 15.Google Scholar

5 Eckstein, , Pressure Group Politics, pp. 33–4.Google Scholar

6 In the Preface he refers to ‘the hypotheses in Chapter I’, (Eckstein, , Pressure Group Politics p. 7Google Scholar) of which this presumably is one.

7 As Eckstein perhaps suspects by once referring to his own ‘theoretical framework’ in half quotes. Eckstein, , Pressure Group Politics, p. 7.Google Scholar

8 Eckstein, , Pressure Group Politics, p. 34.Google Scholar

9 Eckstein, Harry, Internal War (New York: The Free Press of Glencoe, 1964), pp. 5–6.Google Scholar

10 ‘To sum up the argument in very general terms, pressure group politics in its various aspects is a function of three main variables: the pattern of policy, the structure of decision-making both in government and voluntary associations, and the attitudes – broadly speaking, the “political culture” – of the society concerned. Each affects the form, the intensity and scope, and the effectiveness of pressure group politics, although in each case the significance of the variables differs structure, for example, being especially important in determining the form of pressure group politics, policy especially important in determining its scope and intensity. I will sketch broadly, in light of these major variables, the conditions under which the Association acts as a pressure group.’ Eckstein, , Pressure Group Politics, p. 38.Google Scholar

11 Eckstein, , Pressure Group Politics, p. 88.Google Scholar

12 The Spens report recommended that general practitioners as a group should receive raises and specified the net amounts to be earned by various proportions of them (in 1939 values): three-fourths were to earn at least £1,000 net a year, one-half over £1,300, one fourth over £1,600, and about 10 per cent over £2,000. Mr Justice Danckwerts’ decision of March 1952 applied a betterment factor of 100 per cent for 1952 and of 85 per cent for 1948, and used a percentage of 38·7 per cent for practice expenses, both higher than the BMA’s original claims. In addition, maximum lists were reduced from 4,000 to 3,500 patients; a special ‘loadings payment’ of ten shillings per patient would be paid for patients in the range 501 to 1,500 on doctors’ lists; and the ‘basic salary’ was abolished and replaced by an ‘initial practice allowance’ of £600, £450, and £200 payable only in the first, second, and third years of practice. Eckstein, , Pressure Group Politics, pp. 127,148.Google Scholar

13 Eckstein, , Pressure Group Politics, pp. 84–91.Google Scholar

14 Eckstein, , Pressure Group Politics, p. 89.Google Scholar

15 Eckstein, , Pressure Group Politics, p. 95.Google Scholar That this particular issue on which we focus is not idiosyncratically chosen is acknowledged by Eckstein when he refers to ‘the most important trade-union activity of the Association, pressure for greater remuneration’. Eckstein, Pressure Group Politics, p. 96.

16 Eckstein, , Pressure Group Politics, p. 109.Google Scholar

17 Eckstein, , Pressure Group Politics, p. 125 (our italics).Google Scholar

18 Eckstein, , Pressure Group Politics, p. 148 (our italics).Google Scholar

19 Eckstein, , Pressure Group Politics, p. 126.Google Scholar

20 Eckstein, , Pressure Group Politics, p. 126.Google Scholar

21 Highly structured and regular, in Great Britain and Sweden; diffuse and irregular in the United States, where consultation may take place in congressional hearings or through ad hoc meetings with executive officials responsible for public medical care programs.

22 Interview with Sir Donald Fraser, formerly Permanent Secretary of the Ministry of Health (April 1967).

23 Mechanic, David and Faich, Ronald, ‘Doctors in Revolt: The Crisis in the British Nationalized Health Service’, Medical Care, VIII (1970), 442–55, p. 444.CrossRefGoogle Scholar

24 Interviews with both BMA and governmental officials in 1967 provided the basis for this account. These officials, understandably, prefer to remain anonymous. See Mechanic and Faich, ‘Doctors in Revolt’, for a similar interpretation.

25 For information on this episode, see Mechanic and Faich, ‘Doctors in Revolt’.

26 For documentation of these decisions, see Mechanic and Faich, ‘Doctors in Revolt’.

27 Interviews with BMA Secretary and National Health Service officials, Spring 1967.

28 See Glaser, Paying the Doctor, and Section 3 of this paper.

29 Thomas, David J., Postwar Swedish Medical Politics, unpublished research report for US Public Health Service, 1968.Google Scholar

30 Goldman, Ralph M., Review of Harry Eckstein, Pressure Group Politics, American Political Science Review, LX (1961), 141.Google Scholar

31 Abel-smith, B., ‘Health Expenditure in Seven Countries’, The Times Review of Industry and Technology, March 1963, p. vi.Google Scholar

32 Department of Health, Education and Welfare, A Report to the President on Medical Care Prices (Government Printing Office, 02 1967)Google Scholar, and a report published by the Ways and MeansCommittee, July 1971, for evidence of interest in physician incomes and the impact of public programs on those incomes. See also Horowitz, L. H., ‘Medical care price changes during the first year of Medicare’, Research and Statistics Note No. 18, pp. 3–4 (Social Security Administration, 31 10 1967)Google Scholar; Chase, E. T., ‘The Doctors ’ Bonanza’, The New Republic, XV (1967), 15–16.Google Scholar

33 Marmor, Theodore R., ‘ Why Medicare helped raise doctors’ fees’, Trans-action, 09 1968.Google Scholar

34 British Medical Association, A Charter for the Family Doctor Service (London: British Medical Association, 1965), p.1.Google Scholar

35 Confidential interviews with British Medical Association officers and Ministry of Health officials, Spring 1967.

36 Eckstein asserts that negotiations with the British Medical Association are typically ‘intimate’, that the issues are ‘treated as a matter between the Ministry and the profession … the powers of the profession [are] at their maximum, those of the Ministry at their minimum’ (8, p. 125). The two case studies Eckstein presents to illustrate this generalization provide ambiguous support. More important, varying the bargaining tactics and atmosphere across the three countries does not coincide with differences in medical influence on the salient question of payment methods.

37 Abel-smith, B., ‘Paying the Family Doctor’, Medical Care, I (1963), 27–35CrossRefGoogle Scholar; Abel-smith, B., ‘The major pattern of financing and organization of medical services that have emerged in other countries’, Medical Care, III (1965), 33–40CrossRefGoogle Scholar; Glaser, Paying the Doctor; Schnur, J. A. and Hollenberg, R. D., ‘The Saskatchewan medical care crisis in retrospect’, Medical Care, IV (1966), 111–19CrossRefGoogle Scholar; Badgley and Wolfe, Doctors’ Strike.

38 The actors whose views are referred to here are government officials responsible for payment decisions concerning doctors. References to the government are broader, meaning the whole range of actors involved in the fiscal decisions of a modern industrial state.

39 Marmor, , ‘Why Medicare helped raise doctors’ fees’, p. 25;Google ScholarAbel-smith, , ‘Paying the Family Doctor’, p. 27.Google Scholar

40 Abel-smith, , ‘Paying the Family Doctor’, p. 27Google Scholar: ‘The major pattern of financing and organization’, p. 36; Glaser, , Paying the Doctor, p. 26.Google Scholar