BMJ  2006;333:660 (23 September), doi:10.1136/bmj.333.7569.660

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Personal views

Where are the medical voices raised in protest?

Aneuran Bevan, having to create the NHS in the face of medical opposition, famously claimed to have stuffed consultants' mouths with gold, splitting the medical profession and giving himself the leverage to create the health service he envisaged. The GPs continued to resist Bevan's plans over concerns that he might try to make their profession salaried, but on the appointed day the NHS appeared as promised. The health service was founded on the principle (or "concordat") that the government would fund health care but leave its operational running to the doctors.

Doctors say they no longer have the will or power to stop reforms

Nearly 60 years later we find ourselves with a government committed to changing Bevan's NHS to a form its founder would surely struggle to recognise. The medical professions—such hard negotiators during the NHS's creation—have become the ones we look to first to preserve what is valuable in the NHS. The doctors, through the royal colleges and the BMA, have a long history of blocking reform that could damage their professional interests or that might adversely affect patient care. In the 1960s and 1970s government attempts to introduce a greater managerial element into health organisations were blocked because it was perceived to be against the ethos of the NHS. In the 1980s and 1990s the first internal market reforms were opposed through a vigorous campaign that saw that introducing a market into the NHS might destroy it. We saw poster campaigns representing Margaret Thatcher's plans for the NHS as a bulldozer. Although the reforms were introduced, doctors made sure they had their say in public, and the reforms' implementation was surely diluted as a result. The language of competition was quickly reduced to that of "contestability," and we saw the replacement of Kenneth Clarke, the architect of the internal market, with more conciliatory figures, as the government recognised that it had to secure medical professionals' compliance to keep the NHS working.

How things have changed. In the past six years we have seen reform on a scale never before attempted in the NHS. The prime minister continues to say he wants to increase the pace of reform; however, it is not just the sheer speed of reform that makes it distinctive, but also its breadth and depth. The concordat between the government and the medical profession has broken down, with doctors having criticised the levels of funding afforded the NHS. The government, on the other hand, has found ways to interfere in medical practice on a remarkable scale. Some of this was a continuation of a trend, as performance measures were extended into medical life through the resource management initiative and clinical audit. But Labour has gone much further.

After a few short years of funding increases, we now find ourselves in more familiar territory where budget deficits are headline news but in a new context in which job losses are being demanded to resolve them. The new contracts for consultants and GPs, often blamed for the deficits (BMJ 2005;331: 251[Free Full Text]), mean that we hear tales of governance managers turning up at 2 am on bank holidays to check whether the doctors who are meant to be on duty are available. GPs have done well out of the points system on which their income is based, but their compliance with the system is an indication that they are far more willing to conform than in the past; and there is always the potential for the government to adjust the incentives and so interfere with their practice in an unprecedented way.

The chief medical officer's proposals for the reform of medical regulation (in Good doctors, safer patients, www.dh.gov.uk) take reform even further, suggesting that its two most central elements—control of the register and medical education—be placed in the hands of committees over which the medical professions would have much less influence. These reforms seem more radical than commentators in this journal dared imagine (BMJ 2005;330: 1504-6[Free Full Text]). If we add in the vagaries resulting from the PFI process, then we have a reform agenda that seems to sweep away Bevan's NHS across the board, blurring the boundary between public and private not only in financing the service but also in the provision of care (BMJ 2006;333: 61[Free Full Text]).

All of which leaves us with the question: where are the medical voices raised in protest? One conclusion might be that the advantageous terms offered to consultants and GPs in the last round of contracts has meant that the main groups of doctors have once more had their mouths stuffed with gold and that the government no longer faces any concerted opposition to its reform plans. Another conclusion is that the medical profession wholeheartedly approves of the government's reforms—but this does not seem to square with the opinions expressed by the doctors I speak to every week, who say they no longer have the will or power to stop reforms that they believe to be, as one consultant put it, "sheer bloody vandalism." This is perhaps the most depressing conclusion of all, as it seems to indicate that the long history of medical resistance to health policy is gone for good. As the same consultant said to me, "We had our chance to stop this in the 1980s, but now we're too late." I hope this is not the case.

Would Aneuran Bevan recognise today's NHS? Credit: TOPFOTO

 

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Centre for Public Policy and Management, Manchester Business School ian.greener{at}mbs.ac.uk

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IG has published widely in the areas of health policy and management and has a role in an academic centre at the forefront of UK policy analysis.

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