POLITICS
The British Medical Association: just a mild dose of proctalgia
SIMON HEFFER
This year the taxpayer will provide £37.4 billion for the National Health Ser- vice. The NHS is treating more patients than ever before. Yet the new chairman of the British Medical Association, Dr Alexander (`Sandy') Macara, is dissatisfied with this performance. Last Sunday he told Sir David Frost on television that he had been 'almost physically sick' over the intro- duction of the internal market, with its inevitable winners and losers. The BMA had, in recent years, been a respectable professional organisation, conversing and co-operating with the Government under the chairmanship of Dr Macara's ousted predecessor, Dr Jeremy Lee-Potter. Now, Dr Macara's hyperbole signals a return to the 1980s, when, in its instinctive opposi- tion to all the Government tried to do with the NHS, the BMA strove to become a white-collar variant of the National Union of Mineworkers, in the vanguard of the fight against Thatcherism.
`Whether,' said Dr Macara, 'there is a health service in the year 2000 depends on whether there is the political wisdom to stop and think what is happening.' Dr Macara has thought about what is happen- ing. 'There will be lots of individual units simply competing with each other.' But in `simply competing' those units will, as Dr Macara does not say, provide a more effi- cient service for patients. There used to be no division in the NHS between the providers of health care and its purchasers. Health authorities performed both func- tions in a soviet-style system that allowed no competition and therefore little or no scope for efficiencies. Now that most hospi- tals control themselves as NHS trusts they, or more particularly the managers who run them, have to try to outdo each other in the hunt for contracts and resources. This is good for patients, because a measure of success will often be how quickly waiting lists are cut. It is good for doctors who wish to earn more money by working harder. It will not, though, be good for bad doctors.
Why these reforms should be such an emetic to Dr Macara is a mystery. By increasing efficiency they release more money for patient care, something the BMA is supposed to be keen on. As well as hospitals competing for patients, GPs can control their own budgets, rather than being tied by health authorities. They can act as the businessmen and entrepreneurs that, as independent contractors and not state employees, they should be.
`Profit' is an ugly word for Dr Macara and his allies; and, sadly, has been a con- cept regarded with ambivalence even by certain Tory health ministers. Yet profit is a motive force in the NHS now, much to the confusion and dismay of the BMA. Most hospitals, and more and more GPs, are being paid by results. Forty per cent of GPs are now in fundholding practices, because of the cash incentives and indepen- dence fundholding brings with it. The queue to join them is lengthening. Until last week the BMA was opposed to fund- holding. However, at its annual conference, at which the sickened Dr Macara was elect- ed, the association's representatives also (with delightful paradox) agreed to drop this opposition. So many BMA members are fundholders that still to object would have been not just doctrinaire, but fatuous.
In 1948 the BMA opposed the introduc- tion of the NHS. Its reputation for good judgment has been maintained ever since. In the 1960s it asked GPs to send in undat- ed letters of resignation from the NHS when its leaders had fallen out with the Wilson government. Needless to say, the mass resignation was not carried out. The GPs' secure income from the NHS was too attractive. In 1985, when Mr Kenneth Clarke was a minister at the old Depart- ment of Health and Social Security, he had to endure a hysterical campaign by the BMA over his justified, and successful, attempt to limit prescribing of expensive proprietary drugs. Dire warnings about loss of clinical freedom were issued by the BMA, which pledged to fight the proposals to help spare the poor unfortunate patient. More to the point, they were fighting to spare the poor unfortunate doctor, who throughout the 1970s and early 1980s often received bribes from drugs companies (sometimes as substantial as computers, but more often in the form of free trips to `conferences' in exotic locations) in return for prescribing certain expensive products. The BMA's scare campaign on the limited prescribing list was perhaps the most shameful it has ever waged. To judge from his recent pronouncements, though, Dr Macara regards it as something to emulate.
Militant BMA leaders — and not all of them are — see the association's members (three in four practising doctors in Britain) as a cohesive, collective force of workers to be deployed against interference by the management. It is suspicious of reforms that give doctors a certain independence from the state, or which lead to greater rewards for individual effort. Such reforms inevitably diminish the power of the BMA. Mr Clarke is clever enough to have realised that the establishment of fundholding and trust hospitals, which he instituted as Secre- tary of State for Health, would divide the medical profession and allow him to rule. The reforms are now a powerful weapon for Mrs Bottomley, the Health Secretary. Dr Macara is more experienced and com- mitted than most of the self-important nonentities who rise to the top in medical politics. He will be a taxing adversary for her, and will in particular test whether she has the wit and the courage to use the weapons Mr Clarke fashioned for his suc- cessors — including her.
The Health Department's response to Dr Macara has been a tough one. Just as he was demanding an end to the reforms, Dr Brian Mawhinney, the Minister of Health, was announcing a new policy to intensify the application of the internal market. Pur- chasing power in the NHS is talked of nakedly as 'a powerful mechanism for change'. What this means is the prospect of putting hospitals out of business if they do not provide services cheaply enough. The message from the Health Department is that they have not given into the BMA in the past, and they will not do so now.
Such robustness will give Dr Macara something to get his teeth into. But there are other, as yet unspoken, challenges that Mrs Bottomley and Dr Mawhinney must face up to if serious savings are to be made. The former NHS director of personnel, Professor Eric Caines, has argued that the million-strong NHS workforce is 200,000 overmanned. Three-quarters of the £37.4 billion goes on pay. Having been attacked for her decision to retain regional health authorities even though the hospitals they used to police have opted out, Mrs Bottom- ley is now said to see that many NHS bureaucrats are superfluous and must be sacked. The strategy seems to be to cement the reforms by the next election, and to cut out the dead wood afterwards. If Mrs Bot- tomley is unsure how to do it, her colleague and predecessor in the Treasury will no doubt be willing to give some advice.
Previous page
