The BMA and the NHS

Charles Webster is official historian of the NHS. We invited him to look at the relationship between the BMA and the NHS since the NHS’s beginnings

The inauguration of the National Health Service and its main anniversaries have been marked by solemn declarations of commitment by the main parties, but these figure less prominently in the collective memory than episodes of dramatic confrontation and interminable negotiations. Still fresh in the memory are the rows with Kenneth Clarke over the 1990 contract and the internal market reforms. Klein called these events “the biggest explosion of political anger and professional fury in the history of the NHS.”¹ This was certainly the biggest of the many skirmishes that took place during the recent, eventful 18 years of Conservative government.

The radicalism and controversial character of the government’s policies undoubtedly merited strong reaction, but it would be dangerous to conclude that the tangles with Kenneth Clarke were on an unprecedented scale. Indeed, it is arguable that the BMA possesses an unenviable record for assaults against the government of the day on matters great and small. Even periodic pay disputes, such as the one in the mid-1950s that led to the Pilkington commission on doctors’ and dentists’ pay, or the one resulting in the 1966 contract, were associated with menacing demonstrations of force on the part of the BMA.

Taking the past 50 years as a whole, it is arguable that the most concerted attack by the BMA occurred during the term of office of Barbara Castle, who in 1975 was embroiled in confrontations over pay, both the consultants’ and junior doctors’ contracts, and, most potent of all, the phasing out of pay beds. On one occasion the secretary of state was kept at the negotiating table from 4 pm to 7 am the next day, a marathon event surely meriting an entry in the NHS book of records.²

Summary points

• Since the beginning of the NHS the relationship between the BMA and successive governments has been characterised by battles

• Over the life of the NHS the BMA has turned full circle, to the point where in the 1990s it vigorously defended the system it rejected 50 years earlier

• Now the BMA finds itself in genuine agreement with the government’s general approach and most of the necessary conditions for a working partnership now exist

Inauguration of the NHS

None of the above examples bears comparison with the events preceding the “Appointed Day.” Kenneth Morgan rightly pointed out that the conflict between the BMA and the government over the shape of the future health service lasted longer than the second world war.³ The assault by the BMA on the government’s plans began in earnest in 1943, and the ceasefire was not declared until a few weeks before the NHS began in July 1948.

As they became adept at shooting down the plans of successive ministers and increasing their control of events, the aggressive appetite of the BMA leadership became ever more difficult to satisfy. This accounts for their fury when Aneurin Bevan came on the scene. He not only evolved an entirely new plan for the health service and proceeded with the relevant legislation without consultation with the negotiating parties but, after the NHS Act was in place, he proved a determined negotiator, capable of dealing with critics from the many quarters objecting to his plans.

By 1947 Bevan had successfully overcome opposition from the local government associations, the voluntary hospitals, many groups among the consultants, the Socialist Medical Association, and even from enemies within the Labour cabinet. Of the major interests, only the BMA remained unpacified. Although the gap between the two parties narrowed, their relations deteriorated, until in the opening months of 1948 both sides resorted to abuse on a level not witnessed before or since. In parliament Bevan called the BMA leadership “raucous voiced” and “politically poisoned,” and he accused them of engaging in organised sabotage of the NHS Act.⁴ The BMA leaders responded in like manner, and they were supported in a huge tide of distracted letters, large selections of which were included in the BMJ and the Times. In these letters Bevan was habitually portrayed as a totalitarian dictator. Similar passions were stirred up on the other side. Weary negotiators from the Ministry of Health showed every sign of shell shock. One of them recorded that the chief negotiator (and future permanent secretary) thought that “the present leaders of the BMA are like Hitler, utterly evil, and that any concession would merely confirm their hold on the profession.”⁵

Events soon disproved this gloomy prognosis. The combatants speedily settled their differences, and the health service began on 5 July 1948 in an atmosphere of tranquillity. Overnight Bevan was transformed from totalitarian monster to charismatic leader, and everyone was keen to be impressed. This reputation has persisted, and such miscalculations as his tactless handling of the BMA have now been largely forgotten.

Fifty years of mutual distrust

Looking back on the acrimonious negotiations of the 1940s, it now seems incredible that trivial differences over the extent of availability of the basic salary, the legal status of partnerships, or arrangements for disciplinary tribunal appeals could ever have justified the fury of the reaction orchestrated by the BMA leadership. One is forced to the conclusion that the parties were separated by more genuine and deep seated differences, for which these technical issues acted as surrogates in dispute. This mutual lack of confidence has plagued the NHS ever since its inception.

The sources of these deeper tensions are best manifest with respect to the status of the general medical practitioner, always one of the main focal points for medicopolitical conflict. The BMA has tended to fear that governments are motivated by a hidden agenda; accordingly, their natural reaction is to adopt a defensive posture and divine sinister motives behind any scheme emanating from official sources. For its part, the government has generally regarded the independent contractors as anomalous players, liable to run away with the scarce resources of the health service, and therefore treated them, at best, as potential delinquents. This atmosphere of mutual suspicion has, of course, not been conducive to the best interests of the health service, and until recently it has prevented the development of primary care achieving the priority it deserves.

The discord of the 1940s left its direct mark for more than a generation. The sources of tension are not difficult to detect. For example, the chairman of the BMA Council in 1948 accused Bevan of trying to establish a “whole-time State Medical Service,” and he confirmed that the BMA was unrepentant over its advocacy of a health service based on the old National Health Insurance system.⁶ Bevan took the BMA at its word, and the government’s plan for unifying the health service in each locality was scrapped: under the executive councils of the NHS, independent contractors were allowed to continue the National Health Insurance form of administration, but at the price of isolation from the rest of the health service. General practitioners were thereby dispatched into a professional wilderness, and morale suffered accordingly. The Ministry of Health preoccupied itself with punitive controls, and for no sound reason it even imposed a moratorium on such potentially constructive developments as health centres.

It was therefore entirely predictable that general practice would drift into a state of crisis. The breaking point duly arrived in the mid-1960s. On this occasion, greatly to the credit of the BMA leadership and the health department team led by the minister Kenneth Robinson, a new accord was reached. The family doctor charter and the 1966 contract satisfied basic grievances and included sufficient inducements to provide general practitioners with a new sense of professional purpose.

Reorganisation of the NHS, which also reached the agenda in the 1960s, offered a second chance for the BMA to play a more constructive role. On this occasion, however, the doctors again became the victims of their bunker mentality. Although it had helped to launch the whole reorganisation process by its participation in the Porritt exercise, the BMA first lost confidence in the Porritt proposals and then attacked them when they emerged in the form of the 1968 green paper on NHS reorganisation. For the remainder of the reorganisation process, the BMA played a predominantly negative role, as in the 1940s, attacking each scheme for reorganisation as it came along. Predictably, following the course of 1948, the BMA successfully resisted local government control of the health service or the functional unification of health authorities at the level of a locality. With respect to England and Wales, the BMA secured perpetuation of the National Health Insurance form of administration and, thereby, the continuing isolation of the independent contractors under the new family practitioner committees.

This issue exposed a split between London and Edinburgh. The Scottish BMA, which was by this time completely relaxed about integration, willingly abandoned the protection of a separate family practitioner committee. The detrimental effect of the English and Welsh arrangement for the health service generally and for primary care in particular was highlighted by a variety of reports, most influentially by the Harding committee⁷ and the Merrison royal commission.⁸

By this stage most of the traditional fears concerning a state medical service were largely irrelevant, but the regional and area health authorities of the 1974 structure were subject to the same kind of demonisation. Consequently, when the Merrison royal commission on the NHS came down on the side of widely supported demands for assimilation of family practitioner committees and area health authorities in England and Wales, this was contested by the BMA and its allies.⁹ On this occasion, to its discomfort, the Conservative government conceded to the BMA and agreed to even greater statutory separation of the family practitioner committees, which represented the course of events followed in the 1980s. This victory confirmed that Bevan’s state medical service could be completely stripped of its threatening features and be rendered innocuous, even congenial, to the BMA.

The wheel turns full circle

During the 1980s the BMA had even more reason for satisfaction on account of the immunity conferred by the family practitioner committees against such draconian measures as cash limits and the Resource Allocation Working Party. However, the BMA had merely constructed a fools’ paradise. From 1979 onwards it was evident that the ramshackle bureaucracy of the health service represented a compromise at odds with the ideology of a government that had fully absorbed the BMA’s discarded hostility to a state medical service. To their cost, neither the BMA nor the medical profession more generally took sufficient account of warning signs of the Thatcher government’s hostile intentions towards the existing health service. The BMA and its associates undertook no prudential defensive measures. They neither mounted an equivalent to the Porritt exercise nor any other plan for sustaining the crisis ridden health service.

Their input into the government’s confidential review of the health service in 1988 was therefore minimal. Indeed, this exercise was treated with a degree of complacency that is now difficult to understand. It seems that the royal colleges of physicians and general practitioners even failed to make submissions. The other medical submissions were characterised by complacency concerning the maintenance of the status quo. The BMA was, in fact, one of the more energetic petitioners. Its evidence discussed the merits of the internal market, but it failed to address the issue of self governing hospitals or most of the other major changes which the white paper Working for Patients advocated.¹⁰ With respect to the behaviour of the BMA, the review process closely followed the pattern of the past. As with the overhauls of 1948 and 1974, the government was left to take the initiative, but its schemes were treated with suspicion and subjected to a campaign of destructive criticism.

Paradoxically, over the life of the NHS, the BMA has turned full circle to the point where, in the 1990s, it has vigorously defended the system that it had decisively rejected some 50 years earlier, just as in the 1940s it defended the National Health Insurance system that it had rejected in 1911.

This ideological shift possesses singularly fortunate consequences for the current Labour government. For the first time in the history of the modern health service, the BMA finds itself in general agreement with a government’s general approach towards overhauling the health service. Both sides reject the internal market and seek a return to the broad principles of 1948. For the moment, the BMA detects little evidence of a sinister unstated government agenda, while the government has taken the unprecedented step of placing primary care professionals in the driving seat of the new system. For the first time this century the BMA and government have established most of the necessary conditions for a working partnership. If this could be consolidated, the NHS looks set to approach the millennium in a better sprit of harmony than has existed in its entire existence.

Figure.

Former and future ministers for health: Aneurin Bevan and Barbara Castle in 1951. The BMA battled memorably with both