Dying from a bad case of dogma

Most doctors are disillusioned with the way the NHS is going. We are faced with an intransigent and unpopular government that continues to trample on our professionalism and ignore our advice.

Individual doctors respond differently to this frustrating state of affairs - their age and economic circumstances being important. My response is to leave the NHS, and I am one of a growing band retiring early or as soon as they can. As BMA council chairman, I spent three years trying to re-establish a working relationship with the Government. By 1990, when I took over, my predecessor, John Marks, had all but broken off diplomatic relations and contact was minimal.

I believed that an alternative approach of conciliation and dialogue might achieve better results. This was not Munich, after all, but a profession disagreeing with an elected government.

I reasoned that the politicians were sufficiently big to realise that they had got it wrong. They had accepted bad advice but could accept better if it was not accompanied by face-losing public clamour. I was encouraged by the replacement of the ebullient Kenneth Clarke by the thoughtful William Waldegrave.

Nevertheless, I failed, just as Dr Marks had failed, and I believe the present BMA council chairman, Sandy Macara, will fail when dealing with our present political leaders. For at the root of the NHS changes lies political dogma.

This dogma is that all forms of central administration should be replaced wherever possible by markets - the exception being, of course, political control. Just as the old Soviet bloc politicians believed in state Communism and a command economy, so thisgovernment is wedded to markets and competition.

Such absolutism can only fail when applied to such a large and complex institution as a national service providing diagnosis, treatment and care for all citizens. What is ironic about the reforms is that, having pushed this doctrinaire snowball off the top of the hill, the Government repeatedly tried to interfere with its course to Hell by "managing the market".

The result of all this for doctors is a ratchet. After the first cathartic changes brought about by the 1989 White Paper Working for Patients, the jaws of the trap have closed little by little on the medical profession.

Initially, salaried medical staff were to keep their national employment terms - fundamental to the success of the hospital service when the NHS started in 1948. Then new consultants could be offered local contracts (but juniors could not); now it seems even doctors in training may have local contracts. This last point is significant to me because national contracts for juniors were one of the few concessions won from Mr Waldegrave when I was chairman.

Similarly, at the start salaries would still be recommended by the Doctors' and Dentists' Review Body. Now, despite opposition, the Government has instructed hospital trusts to prepare action plans for local pay for all staff, whether covered by a reviewbody or not. The intention is to incorporate performance-related pay into this across the board. These steps would bring medical staff under the full control of managers and boards, who themselves are under the control or patronage of the Health Secretary.

In general practice, once a critical mass of fund-holders has been built up, I have little doubt that an assault will be made on their independent contractor status so that they, too, will be brought under control.

Cannot the Health Secretary, Virginia Bottomley, and her colleagues see the dangers of subjugating the profession in this way? Being a doctor is not the same as being a business executive or an advertising man or an industrial worker.

To the doctor what matters most is the patient, not his or her employer - whatever the entrepreneurs, like Roy Lilley, newly arrived in the NHS to spread the Thatcherite gospel, might think. If it were otherwise, doctors would not occupy the position of trust in this country that they do. I, for one, am not prepared to trade this for a mess of performance-related pottage.

The Government may or may not believe that its latest NHS reorganisation is delivering a better service for patients and/or that it is more cost-effective - the consequent transactional costs are certainly astronomic. However, what matters most for ministers is that they are more popular.

Unhappiness among the clinical staff can be ignored unless the public perceives that this is so serious that the whole service is under threat. When this happens, and I believe that it is now beginning to happen, credibility is lost and, with it, elections.

Mrs Bottomley, whatever her caring qualities, seems to have lost that credibility as Health Secretary and will no doubt be moved in the next cabinet reshuffle. But her successor is unlikely to be allowed to do anything radically sensible about any of theissues that have forced the profession into confrontation with the Government these past many years.

If this is the case, doctors will have to recognise that their traditional conservatism and their professional ethos is at greater threat from a Conservative than from a Labour government. We are valued less than managers, boards and authorities put overus. The window-dressing from ministers about involving doctors in management is largely tinsel. Lions led by donkeys have a habit of eating the donkeys in the end and John Major would do well to remember this.

My message is not the one I would have liked to send on my retirement from the health service. Those who work in it are the salt of the earth but have been let down by politicians in the grip of dogma.

The writer retires as a consultant haematologist next month from Poole Hospital NHS Trust. He is a member of the General Medical Council and was BMA council chairman from 1990-93. This article is reprinted from `BMA News Review'.

Robert Winder's column will appear tomorrow.