NHS historian Geoffrey Rivett looks back at the various clashes between the medical profession and government since the inception of the NHS. In a follow-up analysis, our Chief Executive Nigel Edwards examines the political damage that is often done when ministers go head-to-head with the medical profession.
A familiar problem
As long as our service is paid for from central funds (and may that be forever) ministers cannot avoid the hot seat.
Since the start of the NHS, medical staffing has been a problem. So big a problem has it been that ministers have regularly been drawn into the furore.
In 1946–8, general practitioners did not wish to become state servants and consultants were anxious about private practice and their salaries. Aneurin Bevan was central to the resolution of these problems – only he had the authority to do the necessary deals. The establishment of a Review Body on pay in 1962 was an attempt to take some of the heat out of the issue.
Thereafter, most of the day-to-day work was undertaken by officials in the Department of Health, with the appropriate British Medical Association (BMA) committees. This worked so long as there were no major issues. But such crises recurred. The GPs’ Charter negotiations of 1964–5 succeeded because, with a GP strike looming, Kenneth Robinson (the Minister), Sir George Godber at the ministry and Sir James Cameron (on behalf of the profession) hammered out an agreement that led to the renaissance of practice.
In 1975, Health Secretary Barbara Castle moved to phase out private practice and battle was again joined. Chief Medical Officers (CMOs) had generally considered themselves the link between government and the profession. But Castle excluded the CMO, Sir Henry Yellowlees, from key meetings, only to meet her match in the cold determination of former BMA Chairman, Anthony Grabham, who spoke for a united profession. A compromise was agreed, but at the cost of long-term damage to relationships. Doctors have long memories – the underpayment of GPs by Poor Law Boards in the 19th century soured the introduction of the NHS almost a century later.
I was tentatively offered the lead medical manpower post in the Department of Health in 1984, but my immediate response – that it was ‘a crown of thorns’ – ensured that it went elsewhere. Nevertheless, when a new GP contract was on the table in 1990 I was deeply involved as an official. However, it was Kenneth Clarke, then secretary, who ultimately faced down Michael Wilson of the General Medical Services Committee.
The decision to devolve much negotiation outside the Department to NHS Employers, partly to give the appearance of a reduction in bureaucracy, has meant the loss to the Department of permanent, coherent in-house expertise. In 1990, when I was involved in negotiations, we paid GPs 1–2 per cent more than we had intended. In 2003/4, without substantial ministerial and departmental involvement, an eye-watering increase was agreed.
In an ideal world, rational agreements would be possible. But government, the NHS and the medical profession do not operate in a rational world. Shroud-waving was commonplace for 19th century hospitals raising charitable money. The tradition persists to this day.
The function of the politician has been said to bring the random into decision making. Ministerial involvement is sadly inevitable – Bevan regretted the way the smallest items could land on his desk. As long as our service is paid for from central funds (and may that be forever) ministers cannot avoid the hot seat. The strength of their position is that doctors have, in reality, no other employer to turn to. The weakness is that they have no other workforce to employ.
No one wins in medico-political warfare
In and of itself, this situation shows how far Andrew Lansley’s version of the role of Secretary of State for Health has failed to take root – even among senior politicians within the same political party.
As Geoffrey’s history suggests, ministers often lose when they take on the medical profession. Even when the doctors win, this often leaves the profession feeling disgruntled. As Geoffrey also says, the BMA and other doctor leaders have long memories – the profession will ensure that the fight is not forgotten and there is likely to be resentment for years following. Even if the Government prevails, morale will be damaged and many junior doctors will likely carry this clash with them into their future NHS careers.
The involvement of the Secretary of State also serves as a lightning conductor for political dispute, leading to some odd decisions and the deployment of broad-brush stereotypes. For example, the negotiations in the 2000s were based on an assumption that consultants were on the golf course and/or doing private work – they weren’t.
A second example is the way that the restrictions on consultants working out of hours were put into the consultant contract by a previous secretary of state (not the BMA) because the focus at that time was on availability for elective surgery.
These insights are often forgotten in the white heat of today’s contract rows, which are increasingly played out on social media in front of a hungry, 24/7 news culture that is following every step of the story.
Given all of this, it is unclear why the Secretary of State has been willing to put himself at the centre of this or the #Imatworkjeremy battle. There was no clear need to do this and he could have relied on NHS Employers, NHS Improvement or other parts of the system to do the negotiating. Instead, the impression has been created that he picked a fight.
In and of itself, this situation shows how far Andrew Lansley’s version of the role of Secretary of State for Health has failed to take root – even among senior politicians within the same political party. His arrangements put the Secretary of State at a significant distance from this sort of day-to-day politics.
This row might also reflect a wider political push on trade unions and their role, but taking a longer view of history suggests that getting employers to talk to their own staff might be a better model.
Rivett G and Edwards N (2015) ‘The junior doctors' contract dispute: lessons from history’. Nuffield Trust comment, 16 November 2015. https://www.nuffieldtrust.org.uk/news-item/the-junior-doctors-contract-dispute-lessons-from-history