Introduction

This chapter explores the relationship between the state and the medical profession characterised by Rudolf Klein (1990) as the ‘double-bed’. It is one of the distinctive organisational features of the NHS identified in Chapter Two.

The ‘double-bed’ relationship between the state and the medical profession is one of mutual dependence (Klein, 1990). The creation of the NHS gave the state an effective monopoly on the employment of the medical profession because of the relatively small size of the private healthcare sector. As such, the medical profession became effectively dependent (as a group) on the state for its employment. On the other hand, the state was also dependent on the medical profession because, in order for a health service to work, it clearly needed doctors. Doctors are highly qualified professionals with a long training and considerable expert knowledge, and so they are scarce within the economy. The state hardly has the option of simply employing new doctors if it does not like those it has inherited. In addition to this, doctors are archetypal professionals, having high status in society because of their high pay, their strong social connections with the great and the good, and their unique ability to literally be able to save lives. If medics and lawyers are the elite professionals, then the medics are perhaps the most prestigious of all.

The state was dependent on the medical profession not just to run the NHS, but also to ration care within it. Because healthcare systems cannot provide every possible treatment for every single person, especially in a cash-limited health system such as the NHS, it is doctors who are implicitly given the role of working out who gets access to its care and resources. General practitioners have had a gatekeeping role in deciding who gets referrals to hospitals and who does not, as well as being responsible for limiting prescriptions. Hospital consultants, on the other hand, have often had to work with out-of-date equipment in crumbling buildings, with access to their services limited by long waiting lists. Rationing for much of the NHS's history has not been explicit, but instead has operated as a function of the system by limiting access to care through the gatekeeper system, then through waiting lists if a referral was made.