ABSTRACT
The concern of this chapter is the campaign conducted by the British Medical Association (BMA) in the early twentieth century to improve the pay and conditions of doctors working in ‘contract practice’. This was the contemporary term for any medical work provided on a subscription or capitation basis, as opposed to the fee-for-service payments customary in private practice. Numerous types of organisation employed doctors to provide contract medical services, and these became an important source of income for the majority of family practitioners.4 They ranged from the friendly societies (like the Foresters and Oddfellows) through provident dispensaries and works schemes (such as colliery medical clubs) and included commercial concerns such as medical aid societies and life assurance companies. These were, almost without exception, lay-controlled organisations, but the term ‘contract practice’ was also applied to private doctors’ clubs organised by doctors themselves and to employment in the public medical services.5 They offered a wide variety of benefits to their members, of which medical attendance could be but one, and this variety was further compounded by widely varying rates of capitation, rules, rates for family members and terms of service. The attitudes of doctors, organisers and users of these services also varied in each locality. Numbers covered by contract practice are difficult to estimate, owing to uncertainty over the proportion of friendly societies which offered a sickness benefit; the most optimistic estimate is that three-quarters of those eventually
By the close of the nineteenth century, however, relations between doctors and lay organisers were deteriorating rapidly in many areas, and the sporadic ‘local difficulties’ that had occurred previously were becoming more complex and rancorous. Broadly, the objections were that capitation rates were too low to provide a reasonable standard of medicine without pauperising the doctor, that subscribers or organisers were too demanding or clinical workload unreasonably onerous, and that people who were wealthy enough to afford full private fees were subscribing to contract arrangements. Doctors began to use professional bodies such as the Medical Defence Union, the BMA and General Medical Council (GMC) to redress their grievances, and friendly societies for their part organised new forms of contract practice to overcome opposition, such as medical institutes which employed a full-time medical officer. The BMA’s campaign attempted to cut off the supply of doctors to organisations which did not operate according to principles the Association had laid down. This was enforced by the threat of professional ostracism and boycotting of doctors who continued in posts of which the local BMA branches disapproved.7 However, in many instances where organised resistance was tried, there were local or incoming doctors willing to enter into these contracts or to undercut the rates of their professional brethren. Thus whilst contract practice had begun as a concession to the sick or provident poor and as a useful way to build up a practice, many felt it had become nothing more than a systematic method of obtaining medical attendance at a low price.
