When the National Insurance Bill was first introduced in 1911 no provision was made for general practitioners to participate in the administration of the new state health insurance scheme. But the British Medical Association was determined that the profession should have a voice in its day-to-day running. It therefore ensured that locally elected committees of general practitioners (Local Medical Committees) were given statutory recognition in the 1911 National Insurance Act as the representative voice of the ‘panel’ doctors.
The 1911 Act required the Local Insurance Committee (the forerunner of the NHS Executive Council, the Family Practitioner Committee and latterly the Family Health Services Authority) to consult all general practitioners participating in the health insurance scheme on a wide range of matters via the LMC.
After the LMCs had been set up, a national committee was established within the BMA to represent the interests of ‘panel’ doctors in negotiations with government. This national committee, the Insurance Acts Committee (the forerunner of the General Medical Services Committee), was recognised by government as the authoritative voice of general practitioners.
It was not surprising that the Liberal Government agreed to these arrangements for representing general practitioners. The success of the 1911 health insurance scheme depended on the willing co-operation of a large number of independent practitioners.
The profession supported the introduction of a state medical scheme but was strongly opposed to a salaried service; it recognised that the loss of the independent contractor status would undermine the freedom of doctors to practice without state interference, and ultimately put patient care at risk. General practitioners feared that government would seek to direct them in their day-to-day treatment of patients.
This commitment to the contractor status remains a guiding principle of the GMSC. Indeed, had it not been for the tenacity of its forerunner – the National Insurance Acts Committee – on this crucial issue, general practitioners could have been drawn into a salaried service (as were their hospital colleagues in 1948). The well tested and proven value of the contract for service with the local insurance committees led to the preservation and extension of this type of contract when the NHS was established in 1948. The Local Insurance Committees – the predecessors of the FHSAs -knew that this contract worked successfully and were active in ensuring that it was preserved in the new NHS structure.
The formal establishment of an LMC
In order to function and raise the funds necessary for its operation from its constituents, an LMC, under paragraph 12(4) of the NHS and Community Care Act 1990, must obtain formal recognition by the FHSA. This involves submitting its proposed constitution to the FHSA. If the authority is satisfied that the committee will be properly representative of the doctors concerned (this has both numerical and geographical implications) it will be recognised.
To assist LMCs in drafting their constitutions, the Department has produced a model constitution which was included in circular HSG (91) 14, Recognising Local Representative Committees, issued on 23 October 1991. The model does not preclude local variations, and several of these have been approved. If an LMC decides to alter its constitution, the amendment should (if prepared in accordance with that part of the constitution dealing with amendments) be submitted to the FHSA for approval to ensure that the committee continues to be recognised as the LMC.
When a committee is recognised by the FHSA as representative of the general practitioners in an area it becomes the Local Medical Committee and thereby acquires certain statutory functions which it is required to perform.
The statutory recognition of the LMC has many parallels in other parts of the public sector. The legislation enacted during the 1940s to bring public utilities and major industries into state ownership made explicit provision for the recognition of trade unions and professional associations for the purposes of negotiation and consultation. A notable feature of the statutory recognition accorded to LMCs is that it was granted almost 40 years earlier by the National Health Insurances Act 1911. Indeed, it is the earliest example of statutory recognition being accorded to an organisation which is representative of those who work in a publicly funded service.
The statutory recognition and functions of the LMCs are presently defined in Sections 44 and 45 of the National Health Service Act 1977 (as amended by Schedules 3 and 5 of the Health and Social Security Act 1984). These were originally defined in the National Health Act 1946; the 1977 Act consolidated and the 1984 Act amended these provisions. They were further amended by the NHS and Community Care Act 1990 (Section 12(4)).