Gareth Millward
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Sick notes are a waste of time
Doctors’ labour and medical certification at the birth of the National Health Service

In 1949 there were 390 types of medical certificate covering legislation in England and Scotland. With the additional lingering burden of providing medical reports for wartime rationing, it was no surprise that general practitioners regularly complained that sick notes were a burden. Some went so far as to call them ‘a waste of time’. And yet they would be crucial to the operation of the welfare state set out in the Beveridge Report. This chapter discusses how these complaints represented a tension between the state and the medical profession over doctors’ professional autonomy and prestige. Time was viewed not only as a resource necessary to perform their jobs. It also represented the relative power doctors had over their own practice and their relationships with their patients. The chapter uses documents from the National Archives and medical journals in the years immediately preceding and following the formation of the NHS. Analyses of these have typically focused on remuneration and Bevan’s attempts to ‘stuff their mouths with gold’. Sick notes and time allow historians to move beyond explanations of economic self-interest and show the importance of professional autonomy to doctors. Further, the chapter provides an understanding of the role expertise was envisioned to have in the wider post-war welfare state by citizens, politicians, civil servants, and the experts themselves.

In 1949 the Inter-Departmental Committee on Medical Certificates (the Safford Committee) published its report, confirming to British doctors what they had long suspected.1 Sick notes were everywhere. Doctors could be compelled to write a plethora of certificates for myriad ministries to ‘prove’ that their patients were entitled to services, payments, access, or exemptions. There were 390 types of certificate covering twenty-seven government departments in Whitehall and Edinburgh. While a Lancet editorial accepted that many of these regulations were hangovers from the wartime economy and ongoing rationing of food and resources, it still found the burden of certification on doctors hard to justify.2 The Kent and Canterbury Local Medical Committee of the British Medical Association (BMA) put it bluntly: ‘the present regulations […] are a waste of time both to doctor and patient alike’.3

Time was central to discussions about medical certification in the 1940s. As the BMA’s evidence to Safford argued, ‘the onerous nature of certification can be rightly understood only by an appreciation of the proportion of his [sic]4 time which a general practitioner is required to give to this work’.5 Time was something that could be spent or wasted; taken or wrested back. General practitioners (GPs) sought to protect their time from tasks considered unworthy or unnecessary and to devote it to more rewarding or important work. Using correspondence in medical journals and procedural documents from the final months of the war, through the foundation of the National Health Service (NHS), and on to the publication of Safford’s report in 1949, this chapter shows that sick notes represented how GPs understood and expressed their collective professional identity. They regularly referenced time – alongside other concerns about state interference in their practices and their social duties to their patients – in their arguments about sick notes, showing how time was bound up with wider anxieties about professional autonomy. It both was an expression of the threat and was used as a method of understanding it. Since these issues did not begin or end in the 1940s, this type of analysis affords us the opportunity to examine how these arguments manifested themselves in other periods.

Sick notes and time

As Martin Moore explores further in this volume, time took on a new significance within general practice in the NHS era – for both the patient and the doctor. This chapter, too, stresses that the meaning and management of time were contested. Sick notes, however, add another wrinkle in that they extended beyond the medical sphere – beyond the doctor–patient relationship – and into the workplace. In ‘Time, Work-Discipline, and Industrial Capitalism’, E. P. Thompson described the development of the clock as a technology employed by bosses to exert control over the actions of workers. As labourers moved away from agrarian economies to working in factories, Thompson argues, business owners had to discipline workers to arrive at work at a specific time and perform tasks with an appropriate level of effort for an allotted period.6 Thompson’s thesis has been complicated since it was published. It is Western-centric, downplays the clock and time discipline in ecclesiastical and business settings before industrialisation, and has been shown to be overly teleological in the wake of the desynchronisation of labour and cultural patterns in the de-industrialised, globalised, digital world.7 Still, the issue of discipline remains important for sickness certification. For while bosses might wish to control workers’ movements and actions during (or even outside) ‘employment hours’, exemptions are regularly made. Thompson notes that once time became a battleground for industrialists, workers were able to exert pressure to limit working hours, introduce paid leave, and demand higher rates of pay for overtime.8 Similarly, sickness was regularly invoked as a ‘legitimate’ reason to not work.9

The test of the medical side of this ‘legitimate’ status – the sick note – was by far the biggest drain on doctors’ time.10 For illnesses of three days or longer, an insured worker could claim sick pay from National Insurance authorities by providing a ‘sick note’ from their doctor. Depending on the length of the illness, ‘intermediate’ certificates could be sought at regular intervals, and a ‘final’ certificate was provided to declare a person fit enough to return to work.11 Friendly societies, trade union ‘sick clubs’, employers’ schemes, and private insurance companies could also request medical reports for access to their benefits (each of which had different qualifying criteria).12 These institutions and the 1911 National Health Insurance system had existed before the war,13 meaning that the sick note was not a new bugbear for doctors in the 1940s. Indeed, sick notes had become increasingly common since the nineteenth century as a way for large organisations to determine eligibility for sickness schemes as traditional forms of control (sick visiting and vouching for members’ characters) became less viable.14 Experiences with ‘panel patients’ certainly coloured GPs’ views of what the post-war sick note landscape could look like.15 However, the scale and political sensitivity of notes in the proposed health service created new challenges.

When the new National Insurance and National Health Service began operations on the ‘Appointed Day’, 5 July 1948, it was part of GPs’ terms of service that they had to write sick notes for claims to National Insurance benefits without remuneration. This followed the Beveridge Report plan, under which all insured workers would be entitled to free medical care and comprehensive social security benefits. They were to work in tandem. The health service would see patients quickly, before symptoms became too serious, providing the latest medical care. This would reduce chronic health problems, allowing employees to work harder and for longer.16 Comprehensive sick and industrial injury pay under National Insurance would encourage employees to look after their workers’ health. It would also mean that workers could afford to take proper time off work, convalesce fully, and therefore prevent relapses. In turn, this would put fewer strains on the health services in the long term, improving productivity and reducing costs.17 The increase in economic output would therefore pay for this new service, as Clement Attlee argued in 1948, but only if the workers played their part.18 Productivity was an important part of Labour’s economic policy in the 1945–51 governments. With money to invest in innovation and new equipment in short supply, attention focused on the effort of individual workers.19 As the Beveridge Report made explicit, doctors would have to reprise their pre-war gatekeeping role to ensure that the system did not collapse: ‘The measures for control of claims to disability benefit – both by certification and by sick visiting – will need to be strengthened, in view of the large increases proposed in the scale of compulsory insurance benefit and the possibility of adding to this substantially through by voluntary insurance through Friendly Societies.’20 The universality of services meant that GPs would see more patients and be compelled to write more certificates than under the old National Health Insurance panel system. The NHS and new sickness benefits therefore had the potential to significantly increase the number of certificates they would be required to write. But more than that, this imposition on doctors’ time was directly caused by the state’s claims to medical labour for maintaining not just its health but its wider welfare state systems.

This link between time and professional autonomy was tied to professional identity and, ultimately, professional power. Traditional sociological definitions of professions describe groups with specialised knowledge that regulate their members through codes of conduct and gatekeeping qualifications.21 Professionals have defended autonomy on the basis that freedom of action – underpinned by unique expertise and self-regulation – enables practitioners to devise novel solutions to complex problems.22 However, this reflects how professionals see themselves rather than providing a historically robust view of the changing role and manifestations of professionalism. It presents an exaggerated dichotomy between the ‘occupational professionalism’ of (in this case) doctors and the ‘organisational professionalism’ of welfare-state-imposed oversight. In fact, doctors and state institutions have coexisted for decades as a ‘hybrid’, drawing power and legitimacy from each other.23 David Armstrong and Michel Foucault famously have both traced the disciplinary power dynamics of modern states underpinned by medical knowledge and the moral authority of certain types of scientifically derived expertise.24 As Rudolf Klein puts it, the NHS has always been a ‘double bed’, occupied by both the state and the medical profession.25 It is therefore not necessarily that the ‘occupation’ and ‘organisation’ are incompatible logics, but rather that they can coexist within the same system for mutual benefit.26

Still, the changing power between the medical profession and central government in the 1940s created new tensions which provide vital context for the resistance to sick notes discussed here. Charles Webster and Rudolf Klein have argued that the central concern for doctors at the foundation of the NHS (and in the BMA’s subsequent battles with the Ministry of Health) was money.27 Indeed, negotiations over remuneration had been a consistent feature of the BMA’s relationship with the Ministry of Health at least since the introduction of National Health Insurance,28 and as Andrew Morrice has shown, had coloured the BMA’s relationships with local public and private organisations at the turn of the twentieth century.29 However, it is also clear that conflict with the government was not solely about money. As Morrice’s work on the Edwardian BMA and Jane Lewis’s examination of the negotiations over the GP contracts of the 1960s and 1990s demonstrate, professional autonomy was more important to the medical profession than is often acknowledged.30 Instead, both money and time can be seen in relation to professional power rather than the ends in themselves. When GPs complained about the time taken by medical certification and the various organisations demanding it, they were making important interventions into the battle for their (occupational) professional autonomy. And while this may not have been the primary concern of BMA negotiators when they persuaded Bevan to ‘stuff their mouths with gold’,31 sick notes were not some triviality; nor were they a moral fig leaf to mercenary demands on the Exchequer. That the Safford Committee in 1949 was established to address doctors’ concerns about the burden of medical certification and the amount of correspondence on the matter in the medical journals in the 1940s suggests that this was no small matter and that the organisational professional structures within the welfare state were able and willing to compromise. That there continued to be such negotiations over the burden of certification throughout the rest of the century shows that it remained so.32

This chapter brings together these issues by splitting the debates around sick notes and time into three areas. The boundaries between them are porous and are descriptors rather than hard analytical categories; but they are designed to give a general overview of the main arguments and the relationship between the profession and the state. First is the idea that sick notes were an absolute waste of time. That is to say, in most cases the job was pointless and not something with which doctors ought to be burdened. Second is the argument that sick notes were a relative waste of time. While medical certification might be something that doctors were capable of doing, even a useful public service, there were myriad other tasks that were more important. Sick notes therefore took time and professional expertise away from where they could do most good or, more cynically, away from where doctors would prefer to act. Third, the chapter concludes with sick notes as an avoidable waste of time. Here, doctors accepted that medical certification would be necessary and an inevitable part of the new health service. However, they negotiated with government, business, and labour leaders to reduce as far as possible the need for sick notes in certain areas of the economy. This, ultimately, would be the stance taken by the BMA, and a key example of how GPs’ ‘hybrid’ professional status evolved during the 1940s.33

Absolute waste of time

It would be incorrect to assert that the medical profession saw no value at all in medical certification. However, there was a sense that many of the demands placed on GPs by the government, businesses, and their patients were unnecessary. In other words, there was a discourse around medical certification that denied that sick notes were ‘real work’; rather, at least in the volume currently experienced, they were an imposition on GPs’ time and, therefore, professional autonomy.

The war had made many doctors wary about the demands of medical certification. The state had shown that it could lean on doctors’ expertise and time to direct the economy and apportion scarce resources. It was widely acknowledged that both rationing and sick leave were the major contributors to increased workload, given that they affected the most people and required detailed examinations and form-filling on the part of (usually) GPs.34 Once peace returned, many doctors wished to be free of the burden. These arguments represented a desire to renegotiate the balance between GPs’ pre-war occupational professionalism and the organisational professionalism that had been tolerated during the exceptional circumstances of wartime.35 ‘We doctors never asked to be the controllers of the nation’s milk-supply’, wrote one anonymous GP in The Lancet’s ‘In England Now’ sketch column, ‘and we would be heartily glad to be rid of the whole time-consuming and thankless job.’36 Another anonymous physician added:

I found during the war that each new restriction or Government order brought its crop of certificate-addicts to the surgery. This afforded an excellent opportunity for mass-education, the effect of which seems to be lasting. I lost several patients who were convinced they were unfit for fire-watching, for brown bread, for travel by public transport and other novelties; I spent quite a long time telling them, free of charge, what does and what does not constitute a real disability. I am now on the friendliest of terms with them.37

It was not just the physical act of completing paperwork or ‘mass-education’ that required doctors’ labour, however.

The time taken up by the patient wanting a certificate is not simply the time needed to reach a decision and sign the paper. A mother wanting extra coal opens the interview by requesting examination of her baby’s chest; only when the child has been stripped and examined is her true purpose disclosed. Others ask quickly enough for the form, and then say: ‘While I am here, doctor ...’ going on to explain some minor disorder which in itself would not warrant their coming to the surgery. There is thus good reason for reducing as far as possible the number of attendances for forms and certificates.38

As these examples show, the burden of legal requirements was compounded by the behaviour of patients – whether through attempted abuse of the system or ignorance of their eligibility for state aid.

Time was also an issue within the larger question about whether GPs would become direct, salaried employees of the Ministry of Health. Sick notes had been burdensome during the National Health Insurance era, too, and did not emerge ex novo in 1948. Yet many GPs had been able to supplement their incomes (and indulge their professional interests) through other contracts in the inter-war years.39 As salaried employees, they would now have these avenues cut off. Moreover, if doctors were civil servants dependent upon the Treasury, with whom did their loyalties lie? A Lancet editorial in April 1946 argued that ‘the public should be brought to understand why the doctor who signs a certificate should be free from the control of those who administer insurance benefits’.40 A group of doctors from Reading similarly warned that doctors would ‘no longer be able to protect the interests of their patients’.41 Autonomy over time mattered to these doctors, and this was bound up with autonomy over action and the ability to choose whether to write a sick note in each individual circumstance. This argument reached its peak when the Lord Chancellor, Sir William Jowitt, argued in defence of salaried GPs by stating:

No one could have been, as I have been, Minister of National Insurance, without realizing that the success or failure of all our schemes depends in a very large measure on our getting satisfactory certification. If we are going to have lax – still more, dishonest – certification, then all our schemes are going to break down on that rock. I have a most profound regard for the medical profession, and for their standard of honour, but I am bound to tell your Lordships that I did come across cases – not many – where there were two competing doctors, where one was strict with his certification and the other was lax. The people who were on the panel of the strict doctor were inclined to leave that panel and to go on the panel of the lax doctor, not because the lax doctor was a better doctor, but because from the lax doctor they could more easily get certificates.42

The reported and presumed bad behaviour from patients or doctors in these utterances shows what doctors and government officials were reacting against. Yet it also reveals that many patients saw sick notes as part of the service from their GP. Thus it was not just the government of the welfare state demanding access to doctors’ time and expertise. Patients – whether on their own initiative or because a public or private organisation demanded it – expected to have access to the medical certification system. GPs had a professional incentive to provide this as well as, under the capitation system, a financial one.

Regardless of whether GPs were to be remunerated by capitation or salary, it was possible to argue that sick notes were a waste of time because they bore little relation to the doctor’s opinion on the patient’s wellbeing. Under a capitation system similar to National Health Insurance, there was the danger that certificates would be a way of keeping patients sweet and maintaining a GP’s income. Under a salaried system, examinations could be overly weighted towards the needs of the Treasury, actively harming the health of the patient by not allowing proper convalescence. In either case, time would be wasted on needless consultations and long explanations. As a gatekeeping device, the resources expended on sick notes could appear to be disproportionate. The BMA’s evidence to Safford repeated these points.43 This absolute resistance to the organisational demands from government on professional autonomy, however, was only part of the story. Doctors recognised that while they valued the freedom of an ideal-type occupational professionalism, they also had responsibilities towards the state and British society.

Relative waste of time

While certificates were ‘a chronic irritant’, not all doctors saw sick notes as an absolute waste of time.44 Indeed, the BMA acknowledged that sick notes were important. The problem was that they took an increased proportion of the doctor’s time. As the association’s evidence to Safford argued:

It is recognized that the issuing of medical certificates where reasonably required is an essential part of the practitioner’s duty. It is vitally important, however, to ensure that it does not take precedence over his clinical work. Bearing in mind the probability that under a comprehensive health service the demand for medical treatment will increase, it is urgently necessary to conserve medical man-power by reducing to a minimum the time spent by a practitioner in non-medical work. It is indeed particularly important that the needs of patients who attend upon the doctor for treatment during his surgery hours should not be sacrificed to the interviewing of people who call solely for the purpose of obtaining a medical certificate.45

If patients saw sick notes as a service, so did many doctors. They were an important part of treatment for struggling patients and families. One anonymous practitioner wrote that ‘I do not find my [National Health Insurance] patients abuse their claim on my time and attention.’ Indeed, in the doctor’s experience, National Health Insurance patients were less likely to demand certificates for fear of being scolded, whereas private patients felt more entitled. The doctor felt that ‘it is difficult to see any alternative’ to sick notes, and, if these really were such a drain on time, perhaps healthy paternalism was a better approach than rejecting sick notes altogether. ‘Obviously the doctor knows best’ about whether a sick note is necessary, ‘but the patient can be made to know better too, if a little time and trouble is taken to educate him. It sounds like a vast and tedious programme; in practice it boils down to “weaning him off the bottle” – unless the doctor himself believes the bottle is necessary.’46 Even the sceptical doctor whose ‘certificate-addicts’ had created bother was ‘inclined to regard [certificates] as a necessary part of treatment’, especially when the (usually male) head of the household was incapacitated. To the patient, the doctor wrote, ‘it is a matter of deep concern whether his family are or are not provided for. […] From his point of view the certificate […] covers the greater part of his anxieties, and the doctor cannot reasonably complain because he has the power to allay them by the stroke of a pen.’47 Seeing sick notes as part of a patient’s treatment meant that they were not an absolute waste of time, and was a clear acknowledgement that GPs had bureaucratic as well as biomedical therapies at their disposal. Thus the boundaries between social services or social security and medicine were blurred and had been before 1948. Doctors already dedicated their time to what might be termed ‘social’ issues. The debate around sick notes and the restructuring of health and social security simply emphasised the interconnectedness of welfare. This, in turn, highlighted moral questions about whether GPs ought to fill out a sick note as readily as they might write any other prescription.

Moreover, family doctors possessed an expertise in diagnosis and treatment, intimate knowledge of their patients, and regular contact with both authorities and the public that no other profession had. By default, therefore, if there was to be any medical certification it would be performed by the family doctor. The need to control access to the privilege of sickness status within insurance funds, rationed goods, and employment law meant that this was bound to be the case.48 As the Lancet put it, ‘nobody else is capable of taking [medical certification] on, so we must make the best of it’.49 But this in itself was the problem. The BMA ran a plebiscite of its members to see whether they were in favour of the upcoming NHS which returned a majority for ‘no’. This outcome was mostly related to pay.50 However, one London GP believed that ‘the majority was so great because a free profession, with a great record of service in peace and war and almost a monopoly in knowledge and understanding of medicine, has been treated as so much technical labour’.51 As Moore has shown with regard to diabetes care in the twentieth century, the idea that doctors’ expertise might be better suited to scientific or highly skilled matters than mundane, routine work has a long history.52 ‘The […] monotonous signing of one’s name on certificates’, wrote a ‘National Health Doctor’ to the Manchester Guardian, meant that ‘one had not the time nor the mental alertness to deal with the really ill’.53 A ‘private medical practitioner who asked that his name be withheld’ wrote a column in the Daily Mail announcing he was leaving the profession because of the burden.54 Form-filling as part of the government machine was no life for a medical practitioner.

Even for those doctors who acknowledged that writing sick notes was important, there was considerable debate about whether it was important enough to justify the time taken up by the task. A group of doctors from Fleet, Hampshire, claimed that the NHS would become ‘unworkable because of the greatly increased demand on the practitioner by the minor sick and certification, leaving him insufficient time for adequate treatment of the really ill’.55 Another argued that this would ‘interfere with the time available for those needing medical attention’, implying that sick notes were not ‘real’ medical work.56 These fears were not unfounded according to Henry Morris-Jones, a Liberal Member of Parliament and GP from Wales, who wrote in The Times that ‘certification […] is so cumbersome that it is physically impossible for anyone with a capitation list large enough to make a living to spare the time for a proper examination of the patient’.57 Doctors had limited time, and it was vitally important to them how it was rationed. GPs spoke explicitly in terms of patients who were higher or lower priorities, using the severity and time-sensitivity of certain diagnoses as examples. David Armstrong shows that this too was a long-running perception within the medical profession, and a supposed ‘lack of time’ was something that GPs internalised as part of their professional identity.58 It might well be important to a patient needing a medical certificate that they could receive one; but what if the house call or surgery visit prevented someone with a more serious condition from receiving timely treatment?

In this sense, the relative waste of time is created through the GP’s lack of capacity to prioritise. This is not seen as a failing of the individual doctor, but as a systemic problem caused by excessive demands from outside bodies. Patients acting in their own interests had (or would have) the right and ability to call on doctors’ services as part of the NHS. As the regulator of sickness benefit and rationing,59 the government created both a demand on doctors’ time and an obligation for GPs to comply. Therefore the battle for occupational professional autonomy was at odds with the organisational requirements of the 1940s British government. Whether this was expressed in terms of efficient use of time, relative importance of certain tasks, or the professional desire to perform ‘stimulating’ labour, this debate preoccupied the medical profession.

Avoidable waste of time

The debates above show that GPs were frustrated with the amount of time taken up by sick notes. Yet they also acknowledged that medical certification was part of their duty to the patient and to wider society, and a task that only they were fully qualified to perform. Therefore the BMA, the government, and other interested bodies negotiated new regulations and practices that would reduce as far as possible the demands on doctors’ time. By eliminating avoidable tasks, doctors would have more time – and therefore more professional freedom – to spend on what they considered to be worthier pursuits. This clear example of ‘hybrid professionalism’, of compromise and negotiation between the state and the medical profession, shows not only how important time was to doctors, but also what they were willing to concede.60

In some ways the new welfare state with its centralised and standardised structures had the potential to streamline medical certification. Four months into the new service, a Lancet editorial noted that ‘no serious objection has been voiced against the certificates issuable under the National Insurance Act’, at least in terms of their legal and medical legitimacy.61 Rather, there were complaints that National Insurance, which involved six types of sick note, could be rationalised somewhat.62 While negotiations over governmental medical certification continued, the main source of grievance was the demands of the private sector. Even though doctors could charge for sick notes demanded by clubs or employers, they were ‘a grave annoyance to many, who believe all such further certificates should be abolished by using the insurance certificate for these purposes’.63 One Surrey doctor even complained that he had been asked by a patient to provide a certificate so that his patient could be moved up the queue for a new washing machine.64 These were outside the purview of the Ministry of Health, Ministry of National Insurance, and BMA. There were, however, compromises reached with industry. The washing machine example may have been excessive, but there was an acknowledged need for employers to know whether a worker was sick for leave or occupational sick pay purposes. It was agreed that, at the request of the patient, National Insurance offices could send copies of sick notes to employers, therefore reducing the need to write multiple certificates or perform repeat examinations. This required an agreement between business groups, trade unions, and the government that the detail on a standard National Insurance certificate would be considered adequate for most purposes.65

Employers and trade unions continued to support sick notes. In their evidence to Safford, both the British Employers’ Confederation and the Trades Union Congress expressed their view that sick notes were not only an important part of industrial relations, protecting the rights of both the worker and the business owner, but also a potentially rich vein of statistical information that could be used for preventative public and occupational health policy in the future. Still, they agreed with GPs that the bureaucracy surrounding medical certification was unwieldy for the medical profession, businesses, and workers alike.66 A letter to the Birmingham Mail expressed this through an amusing hypothetical story of a male worker forced to either drag himself ill to the doctor’s surgery or oblige the GP to make a house call for a common cold. The author expressed sympathy for the employer (who needed to protect the business), the worker (who needed to protect his job), and the doctor (whose time was strained) all over a minor two-day illness.67 The National Insurance certificate became once again the centre of attention. While the British Employers’ Confederation expressed a preference for a more detailed, epidemiologically focused form for the collation of absenteeism statistics, all parties agreed that the reproducibility and generalisability of the National Insurance sick note would reduce the bureaucracy on doctors and allow other bodies to collect useful medical evidence for welfare purposes.68

This highlighted the tensions between the occupational professionalism of the GPs and the organisational demands of the welfare state. Sick notes were not just an important part of the individual relations between doctor, patient, National Insurance, and employer; they served a wider purpose for statistical data gathering, surveillance, and public health priorities. The government could therefore not dispense with sick notes entirely. However, it did make efforts to alter the bureaucratic procedures surrounding them to minimise their impact on GPs’ time, workers, and other administrative staff involved in processing them. This process emphasised that ‘the welfare state’ was not simply a handful of government departments or the willingness of the Treasury to provide funding. Neither was it centrally dictated, top-down imposition. Various ministries, employers, workers, and a host of medical specialisms (from GPs through occupational health specialists to public health administrators and beyond) argued with each other about the relative need for sick notes, the bureaucratic procedures surrounding them, and the amount of resources – including time – that should be dedicated by each body to ensure that the sick note system worked for all parties.69 But this also meant that other bodies and arms of the welfare state could place demands on doctors’ time, deciding what constituted the core functions of the GP’s job and utilising the time and labour of professionals for their own needs.


This chapter has analysed a brief moment in the history of general practice. The debates around medical certification in the late 1940s, however, give us insight into how doctors negotiated their professional autonomy within a welfare state that gained increased control over public services. Moreover, these debates around certification were not solved by Safford’s recommendations. The BMA, government, and employer and employee organisations would continue to negotiate sick note regulations throughout the NHS era. Each negotiation reflected wider political concerns about the form and function of the welfare state.70 Medical certification was about more than a procedural spat between doctors and the ‘state’ in its widest sense.

These debates give us a window into how professionalism mattered to doctors. Time, as an expression of autonomy and power, was an important element of working conditions for GPs. The BMA fought for recognition of this. While it is clear that, as previous studies have shown, money was the main concern in the NHS negotiations, time cannot be separated entirely from remuneration. This was not strictly about ‘pay and conditions’ in the traditional sense of limited working hours, overtime, paid leave, and the like. Rather it was intrinsically tied to the occupational professionalism and professional identity of doctors in the 1940s. Both were under threat from the demands placed on doctors’ time by myriad regulations and increasing numbers of patients eligible for free-at-the-point-of-use healthcare.

These arguments could be articulated because of the circumstances of the 1940s. Beveridge’s proposals were not the first to link social security, economic policy, and medical services, but the Attlee government’s particular form of these systems placed unprecedented focus on the potential for state oversight and co-option of the medical profession. Similarly, businesses and workers had come to rely upon, and expect the presentation of, sick notes to negotiate access to services and to protect their financial interests. The organisational imposition of ‘the welfare state’ therefore needs to be understood in its widest sense – not just as the demands of the Ministry of Health or Ministry of Social Security. Cultural histories of the NHS, perhaps the most enduring of those post-Poor Law institutions, are well placed to explore this territory.

As GPs complained at these impositions – an absolute waste of time – they also acknowledged their legal, social, and moral obligations to the wider state. Thus for the majority of correspondents to the medical journals, sick notes were framed as a relative waste of time, one that could be reduced in severity and made avoidable through negotiation. Doctors, through the BMA, and the government therefore understood the need for a hybrid of occupational and organisational professional logics, even though at face value they appeared to be mutually exclusive. The course of those negotiations in turn says much about what the British welfare state valued in, demanded of, and conceded to the medical profession.


The author wishes to thank the members of the ‘Cultural History of the NHS’ project at the University of Warwick for their helpful feedback on previous drafts of this manuscript. This article was originally written at Warwick from research from the Wellcome Trust grant ‘Sick Note Britain’ (grant number 208075/Z/17/Z).
1 The National Archives, London (TNA), PIN 7/368, Ministry of Health and Department of Health for Scotland, ‘Report of the Inter-Departmental Committee on Medical Certificates’, 1949.
2 Anon., ‘Studying the Form’, The Lancet, vol. 254, no. 6592 (31 December 1949), p. 1227.
3 TNA, MH 135/743, British Medical Association, Resolutions of ARM 1948, text of resolution 228.
4 Throughout this period, most documents refer to a generic doctor with he/him/his. This is despite some 6,300 women being on the medical register in 1941 and 9,500 in 1951. When quoting directly from sources, this chapter retains the original pronouns. See Mary Ann C. Elston, ‘Women Doctors in the British Health Services: A Sociological Study of their Careers and Opportunities’, unpublished PhD thesis, University of Leeds, 1986.
5 TNA, MH 135/743, British Medical Association, Statement of the Association’s Evidence to the Departmental Committee on Medical Certification (attached to letter, 17 June 1948), p. 2.
6 E. P. Thompson, ‘Time, Work-Discipline, and Industrial Capitalism’, Past & Present, vol. 38 (1967), pp. 56–97.
7 Emmanuel Kamdem, ‘Le temps dans l’organisation: vers une approche plurielle et interculturelle’, Social Science Information, vol. 33, no. 4 (1994), pp. 683–707; Paul Glennie and Nigel Thrift, ‘Reworking E. P. Thompson’s “Time, Work-Discipline and Industrial Capitalism”’, Time & Society, vol. 5, no. 3 (1996), pp. 275–99; Benjamin H. Snyder, ‘From Vigilance to Busyness: A Neo-Weberian Approach to Clock Time’, Sociological Theory, vol. 31, no. 3 (2013), pp. 243–66.
8 Thompson, ‘Time, Work-Discipline, and Industrial Capitalism’.
9 Phil Taylor et al., ‘“Too Scared to Go Sick” – Reformulating the Research Agenda on Sickness Absence’, Industrial Relations Journal, vol. 41, no. 4 (2010), pp. 270–88.
10 There were many types of medical certificate in the 1940s, but for the purposes of this chapter the focus is on the most common: medical certification for National Insurance purposes. TNA, MH 135/743, British Medical Association, Statement of the Association’s Evidence to the Departmental Committee on Medical Certification (attached to letter, 17 June 1948).
11 National Insurance (Medical Certification) Regulations 1948, SI 1948, no. 1175.
12 Michael Heller, ‘The National Insurance Acts 1911–1947, the Approved Societies and the Prudential Assurance Company’, Twentieth Century British History, vol. 19, no. 1 (2008), pp. 1–28; Jackie Gulland, ‘Extraordinary Housework: Women and Sickness Benefit in the Early-Twentieth Century’, Women’s History Magazine, vol. 71 (2013), pp. 23–30.
13 The new National Insurance – solely concerned with social security benefits and introduced in 1948 – should not be confused with the earlier National Insurance (1911), which covered certain cash benefits as well as access to primary healthcare. In this chapter, the older system will be referred to as National Health Insurance.
14 Forms for noting symptoms and effects had existed since the early modern period across Europe but became more closely associated with qualified physicians during the nineteenth century. See James C. Riley, ‘Sickness in an Early Modern Workplace’, Continuity and Change, vol. 2, no. 3 (1987), pp. 363–85; Charles Hardwick, The History, Present Position, and Social Importance of Friendly Societies (London: Routledge, Warne and Routledge, 1859).
15 Practitioner, ‘The Doctor’s Wife’, The Lancet, vol. 251, no. 6503 (17 April 1948), pp. 614–15; A. W. Harrington et al., ‘National Health Service’, British Medical Journal, 1:4541 (17 January 1948), p. 120. See also A. J. Cronin, The Citadel (Basingstoke: Bello, 2013), originally published in 1937, which contains a scene where the young protagonist is frustrated by the volume of patients simply looking for notes to get them off work.
16 William H. Beveridge, Social Insurance and Allied Services, Cmd 6404 (London: HMSO, 1942), esp. ‘Assumption B’, pp. 158–63.
18 ‘Social Security: Mr Attlee Emphasises “One Vital Point”’, Manchester Guardian, 5 July 1948, p. 5; Labour Party, Let us Face the Future: A Declaration of Labour Policy for the Consideration of the Nation (London: Labour Party, 1945).
20 Beveridge, Cmd 6404, p. 58. See also Deborah A. Stone, ‘Physicians as Gatekeepers’, Public Policy, vol. 27 (1979), pp. 227–54.
21 Carina Schott, Daphne van Kleef, and Mirko Noordegraaf, ‘Confused Professionals? Capacities to Cope with Pressures on Professional Work’, Public Management Review, vol. 18, no. 4 (2016), pp. 583–610; Eliot Freidson, Professionalism: The Third Logic (Cambridge: Polity, 2001).
22 Freidson, Professionalism.
23 Mirko Noordegraaf, ‘From “Pure” to “Hybrid” Professionalism: Present-Day Professionalism in Ambiguous Public Domains’, Administration & Society, vol. 39, no. 6 (2007), pp. 761–85; Schott, van Kleef, and Noordegraaf, ‘Confused Professionals?’
24 David Armstrong, Political Anatomy of the Body: Medical Knowledge in Britain in the Twentieth Century (Cambridge: Cambridge University Press, 1983); Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception (London: Tavistock, 1973). See also John V. Pickstone, ‘Savoir médical et pouvoir des médecins de la révolution industrielle à l’État post-industriel: autour de Manchester’, Genèses, vol. 82, no. 1 (2011), pp. 75–94.
25 R. Klein, ‘The State and the Profession: The Politics of the Double Bed’, British Medical Journal, 301:6754 (3 October 1990), pp. 700–2.
26 Schott, van Kleef, and Noordegraaf, ‘Confused Professionals?’
27 Charles Webster, ‘Doctors, Public Service and Profit: General Practitioners and the National Health Service’, Transactions of the Royal Historical Society, vol. 40 (1990), pp. 197–216; Klein, ‘The State and the Profession’.
28 Anne Digby and Nick Bosanquet, ‘Doctors and Patients in an Era of National Health Insurance and Private Practice, 1913–1938’, Economic History Review, vol. 41, no. 1 (1988), pp. 74–94.
29 Andrew Morrice, ‘“Strong Combination”: The Edwardian BMA and Contract Practice’, in Martin Gorsky and Sally Sheard (eds), Financing Medicine: The British Experience since 1750 (London: Routledge, 2006), pp. 165–81.
30 Jane Lewis, ‘The Medical Profession and the State: GPs and the GP Contract in the 1960s and the 1990s’, Social Policy & Administration, vol. 32, no. 2 (1998), pp. 132–50.
31 A quotation attributed to Bevan when he explained how he persuaded consultants to accept the imposition of the new health service. For examples of its invocation, see I. J. T. Davies, ‘The National Health Service Consultants’ Distinction Award Scheme – History and Personal Critique’, Journal of the Royal College of Physicians of Edinburgh, vol. 28, no. 4 (1998), pp. 517–34; Geoffrey Rivett, From Cradle to Grave: Fifty Years of the NHS (London: King’s Fund, 1998).
32 See files in TNA such as MH 98/1818; BN 60/25; BN 118/10; PIN 35/72; PIN 35/150.
33 Noordegraaf, ‘From “Pure” to “Hybrid” Professionalism’.
34 TNA, MH 145/742, Association of Municipal Corporations, Medical Certificates, Memorandum of the Special Sub-Committee of the Public Health Committee for submission to the Minister of Health’s Committee on Medical Certificates, 4 May 1949; Anon., ‘Professional Problems in War-Time: Representative Body of the British Medical Association’, The Lancet, vol. 238, no. 6160 (20 September 1941), pp. 347–9.
35 Schott, van Kleef, and Noordegraaf, ‘Confused Professionals?’
36 Anon., ‘In England Now’, The Lancet, vol. 248, no. 6428 (9 November 1946), pp. 691–2.
37 Practitioner, ‘The Doctor’s Wife’, The Lancet, vol. 251, no. 6508 (22 May 1948), pp. 811–12.
38 Anon., ‘The Act in Action’, The Lancet, vol. 252, no. 6534 (20 November 1948), pp. 823–5.
39 These opportunities included appointments as medical referees, services to companies, and other part-time medical officer work. See Webster, ‘Doctors, Public Service and Profit’; Digby and Bosanquet, ‘Doctors and Patients’.
40 ‘The Bill: Attitude of the B.M.A.’, The Lancet, vol. 247, no. 6398 (13 April 1946), pp. 546–7.
41 D. H. S. Boyd, S. F. L. Dahne, B. P. Hill, P. W. F. McIlvenna, D. T. R. Morris, R. Q. Parkes, A. H. Price, and J. Sellick, letter to The Times, 21 June 1944, p. 5.
42 Hansard, House of Lords, vol. 143, col. 928 (31 October 1946).
43 TNA, MH 135/743, British Medical Association, Statement of the Association’s Evidence to the Departmental Committee on Medical Certification (attached to letter, 17 June 1948).
44 ‘British Medical Association’, The Lancet, vol. 246, no. 6362 (4 August 1945), pp. 148–50.
45 TNA, MH 135/743, British Medical Association, Statement of the Association’s Evidence to the Departmental Committee on Medical Certification (attached to letter, 17 June 1948), p. 2.
46 Practitioner, ‘The Doctor’s Wife’ (17 April 1948).
47 Practitioner, ‘The Doctor’s Wife’ (22 May 1948).
48 Stone, ‘Physicians as Gatekeepers’; Deborah A. Stone, The Disabled State (Philadelphia: Temple University Press, 1984).
49 Anon., ‘In England Now’.
50 Klein, ‘The State and the Profession’; Webster, ‘Doctors, Public Service and Profit’.
51 Lindsey W. Batten, ‘National Health Service’, British Medical Journal, 1:4550 (20 March 1948), p. 561.
53 ‘National Health Doctor’, letter to Manchester Guardian, 18 October 1949, p. 6.
54 Anon., ‘Why I’m Giving Up Doctoring at 40’, Daily Mail, 5 November 1948, p. 2.
55 Harrington et al., ‘National Health Service’.
56 T. C. Jameson Evans, ‘National Health Service’, British Medical Journal, 1:4544 (7 February 1948), pp. 273–4. Emphasis original.
57 Henry Morris-Jones, letter to The Times, 31 August 1949, p. 5.
59 And, as we have seen, many other areas of the welfare state. See TNA, PIN 7/368, Ministry of Health and Department of Health for Scotland, ‘Report of the Inter-Departmental Committee on Medical Certificates’, 1949.
60 Noordegraaf, ‘From “Pure” to “Hybrid” Professionalism’.
61 Anon., ‘The Act in Action’.
62 The six were ‘first, final, intermediate, convalescent, monthly and voluntary’. See ibid.
63 Ibid.
64 Basil S. Grant, ‘National Health Service’, British Medical Journal, 1:4544 (7 February 1948), p. 273.
65 TNA, PIN 7/368, Ministry of Health and Department of Health for Scotland, ‘Report of the Inter-Departmental Committee on Medical Certificates’, 1949.
66 TNA, MH 135/741, British Employers’ Confederation, Committee on Medical Certificates. Statement of Evidence Submitted to the Government Committee, 5 March 1949; TNA, MH 135/742, Trades Union Congress, Evidence to Committee on Medical Certificates, 9 December 1948.
67 TNA, MH 135/741, press cutting, letter by W. R. Lord to Birmingham Mail, 9 March 1949.
68 TNA, MH 135/741, British Employers’ Confederation, Committee on Medical Certificates. Statement of Evidence Submitted to the Government Committee, 5 March 1949; TNA, MH 135/742, Trades Union Congress, Evidence to Committee on Medical Certificates, 9 December 1948; TNA, MH 135/742, Association of Municipal Corporations, Medical Certificates, Memorandum of the Special Sub-Committee of the Public Health Committee for Submission to the Minister of Health’s Committee on Medical Certificates, 4 May 1949; TNA, MH 135/743, British Medical Association, Statement of the Association’s Evidence to the Departmental Committee on Medical Certification (attached to letter, 17 June 1948).
69 These debates would become more pertinent from the late 1940s onwards. See, for example, Medical Research Council investigations into coal mining, Royal Ordinance Factories, Post Office, and Metropolitan Police absenteeism statistics. Cecil Roberts, ‘Post Office Medical Services and Morbidity Statistics’, Monthly Bulletin of the Ministry of Health and the Public Laboratory Service, no. 7 (September 1948), pp. 184–201; E. R. Bransby, ‘Comparison of the Rates of Sick Absence of Metropolitan Policemen before and after the war’, Monthly Bulletin of the Ministry of Health and the Public Laboratory Service, no. 8 (February 1949), pp. 31–6; R. B. Buzzard and W. J. Shaw, ‘An Analysis of Absence under a Scheme of Paid Sick Leave’, British Journal of Industrial Medicine, vol., 9, no. 4 (1952), pp. 282–95; R. B. Buzzard, ‘Attendance and Absence in Industry: The Nature of the Evidence’, British Journal of Sociology, vol. 5, no. 3 (1954), pp. 238–52.
70 Detailed investigations and negotiations over medical certification occurred regularly across the rest of the century. Three key examples are the renegotiation of the GP contract in 1966; a threat by doctors to stop writing sick notes in 1975; and the move to end medical certification for illnesses under one week in length with the coming of Statutory Sick Pay in 1983. See TNA, PIN 35/150; PIN 35/436; BN 118/46.
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Posters, protests, and prescriptions

Cultural histories of the National Health Service in Britain

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