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The NHS: Sixty years of conflict and compromise

Published on 02/07/08 at 12:00am
The NHS's 60th Birthday is being celebrated across the country

The headline of the Evening Standard reads: “The Doctors say No! 89% against present plan”. Is this the reaction to Lord Darzi’s latest ideas to introduce polyclinics? Or is it perhaps an uprising at the introduction of competition into primary care?

Well, no, it’s a little older:  it’s a front page story from February 1948, and part of a battle that almost killed off the National Health Service before it was born.

Led by health minister Aneurin Bevan, the creation of the NHS was one of the biggest gambits ever in British politics history, and one that would change the country forever.

The NHS is today probably the UK’s most cherished national institution, widely loved and admired by the public. But general practitioners were fiercely opposed to its introduction sixty years ago, and fought Bevan tooth and nail on the issue.

Gladiatorial relations between the British Medical Association and the government of the day has been one of the constants of the sixty years of the NHS. In 1948 GPs were the backbone of the new service, and sixty years on they remain so, overseeing the vast majority of patient interactions with the service.

Just as Gordon Brown is staking his reputation on the NHS today, sixty years ago it was Bevan’s career that was on the line, and his most vociferous and dogged critics were the BMA.

Before 1948, GPs were entirely private operators, and they were furious at the idea of being turned into a nationalised industry or a kind of civil servant. BMA secretary Charles Hill declared war on Bevan in a fierce battle against what was felt to be the enslavement of the profession.

And just as Brown has recently co-opted the renowned surgeon Ara Darzi to spearhead his own NHS reforms, Bevan also made allies with a powerful consultant. Bypassing the GP-led BMA, he sought an alliance with Lord Moran, president of Royal College of Physicians.

Bevan promised to pour government money into the then debt-laden hospitals, while allowing consultants to retain their freedom and letting GPs continue to be independent contractors.

Bevan famously stated afterwards that he had “stuffed their mouths with gold”.

Some critics think the government continues to “stuff their mouths with gold” – if occasionally accidentally – as with the new general medical services (nGMS) contract introduced in 2004.

A National Audit Office report from February this year found the average pay of GP partners has increased by 58% in three years and that general practitioner services

have cost £1.76 billion more than expected when the contract was negotiated.

Fighting government reform

In the 1970s, there was to be another titanic struggle between the doctors and a Labour government. Health Secretary Barbara Castle declared herself determined to “finish what Nye [Bevan] had started” in 1975, planning to remove the last trace of private practice from the NHS by eliminating  ‘paybeds’ from hospitals.

The BMA was furious and disputes were so heated that on one occasion Castle was kept in negotiations from 4pm to 7am the next day.  Castle eventually had her way the following year, but Margaret Thatcher reversed the decision when she became Prime Minister in 1979, and private wards remain to this day.

But other Thatcherite policies provoked the ire of doctors, in particular the internal market introduced by Ken Clarke in 1990. This became another battle royal, with the BMA launching a huge PR campaign against the plans, involving TV, radio and newspaper advertising, posters and 11 million pamphlets, which doctors handed out to patients.

Clarke accused the BMA of being “extremely unscrupulous”, and pressed ahead with the reforms. He told them: “Every time I mention the word reform, you reach for your wallets.”

The BMA today

The BMA has recently clashed with ministers over extended opening hours and the introduction of “polyclinics”, which are to be rolled out across London from next year. It opposes what it sees as creeping privatisation via competition (scrapped and then re-introduced by Blair), which it says undermines the basic principles underpinning the NHS.

At its conference in July, current BMA Chairman Hamish Meldrum said the health service was being run like a “shoddy supermarket war”, and a  key complaint is that government do not listen to the frontline.

But does the body have the influence it once did? Some older GPs feel that reforms and changes in demographics mean its power is on the wane.

Stephen Head began working as a GP in 1976 and has seen the profession change in many ways over this period. He says the last few decades have seen a creeping dependency on government in a way that was not seen before the 1966 GP charter, before which GPs had real ownership of general practice.

The charter gave GPs financial incentives to expand and take on partners and upgrade their practice buildings. Head says these changes locked GPs into the NHS, making it very difficult for them to walk away after this point.

On the other hand, the 2004 GMS contract was all about “divide and rule”, says Head, ending financial incentives to promote or become a partner in a practice. He says the trend is now for partners not to replace themselves when they retire but hire salaried doctors instead.

“The younger generation of salaried GPs often don’t want to get involved in the politics of the profession so there is not the same solidarity, and they don’t have the same loyalties.”

The BMA is therefore now dominated by the older generation of more independent-minded doctors.  Dr Head says the new generation of GPs have different priorities, and favour extended hours, personal career plans, and flexible working to fit in with young families.

The rise of other more government-friendly bodies such as the NHS Alliance, and the promotion of other healthcare professionals, such as nurses and pharmacists, means New Labour has steadily undermined the power base of the BMA.

But the government’s reforms to shift care away from hospitals and into the community means its reliance on GPs is as great as ever – and that means the bickering, the conflict and the compromises will undoubtedly continue.


Emily Pears and Andrew McConaghie

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