Radical remedies

Skirmishes between the government and the medical profession in recent months - over merit awards for consultants and the way that part-time NHS contracts allow disproportionate time for private practice - suggest that New Labour has learned some useful lessons from its Conservative predecessors.

Kenneth Clarke, Mrs Thatcher's most successful health secretary, pursued two principles to considerable effect (see Five Giants: a biography of the welfare state, Nicholas Timmins, 1994). In his dealings with the British Medical Association (BMA) and other leading medical bodies, he adopted a combative approach, always seeking to 'get his retaliation in first'. Furthermore, in searching for ammunition to use against medical vested interests, he turned to the radical left-wing manifestos of the past, which provided a valuable source of anti-professional tactics.

Anticipating medical resistance to the 1989 White Paper 'Working for patients' that launched the internal market, Clarke recognised that 'the one thing we had to do was to knock the BMA off its pedestal'. To be precise, 'we had to pull them into the mud with us and make it clear that this was just another trade union, actually one of the nastiest I had ever dealt with, and battle it out'. At a dinner of the Royal College of General Practitioners, Clarke complained provocatively about doctors 'feeling nervously for their wallets every time I mention the word reform'.

In addition to mud-wrestling over the introduction of the internal market into the health service, the Conservative government also presided over the imposition of the new contract for GPs in 1990 (payment by rates of immunisation, smears and other screening and health checks) and the 'Health of the nation' White Paper in 1991 (the crusade against the evils of smoking, drinking, cholesterol and sex). These measures amounted to the wholesale implementation of the long-standing demands of the radical public health movement for the elevation of prevention over cure, primary healthcare over the hospital sector, the promotion of health rather than the treatment of disease. While a few radicals grumbled that the government's emphasis on changing lifestyle was excessively individualistic and victim-blaming, this approach was generally popular and the government could easily portray any critics-especially from the medical establishment-as old reactionaries.

New Labour health minister Frank Dobson has evidently found Clarke's approach something of a model. Under pressure to meet his self-proclaimed waiting list targets, he has not only resorted to the old Tory tricks of fiddling the official figures, he has felt the need to go on the offensive against the doctors-and, as a survivor of the days of Old Labour himself, he is no doubt more familiar with the critiques of the old left.

In August Dobson promised to review the system through which the NHS rewards consultants with substantial salary bonuses, the amounts decided by an elite medical clique, meeting in secret, according to secret criteria. No sooner had this pledge been made than Polly Toynbee, a journalist with close links to New Labour, launched a major polemic against part-time consultants who are discovered to be doing private practice when they should be working for the NHS ('Will New Labour end private medical practice of public time?', Guardian, 31 August 1998), blaming them for the persistence of waiting lists.

Both merit awards and part-time contracts are a legacy of the negotiations in the 1940s between Nye Bevan and the leaders of the medical profession over the introduction of the NHS. Bevan's historic comment was that he 'stuffed their mouths with gold' to buy off their resistance to the NHS. Both are undoubtedly outrageous scams, and both have been the targets of left-wing denunciations from the moment of their introduction.

The key questions here are-why now and who benefits? Though waiting lists remain an embarrassment to the government, it has wider objectives: to shift the focus of healthcare from hospital to the community and to extend the machinery of external regulation over the medical profession as a whole. These objectives are helped by the campaign against merit awards and part-time contracts, which implies that doctors are at best self-serving and at worst corrupt. While a few doctors may lose their bonuses and perks, patients are unlikely to benefit: as an intensive care consultant explained in a letter to the Guardian, the key factor limiting operating lists (and hence sustaining waiting lists) is not a lack of medical time, but shortages of hospital staff at all levels because of deteriorating standards of pay and conditions (4 September 1998). The only beneficiaries will be the officials drafted in to monitor medical activity-and the government.

The takeover of once-radical measures and postures and their repackaging as part of the new programme of government has become a central feature in health as in other areas of government policy. One of the last measures introduced by the outgoing Conservative government was a number of schemes within which GPs worked as salaried employees, rather than as self-employed contractors (another concession made by Bevan to the BMA in deference to its small shopkeeping traditions). The proposal for a fully salaried health service was first made by the Liverpool doctor Benjamin Moore in 1910, and codified in the programme of the State Medical Service Association he founded in 1912 (this became the Socialist Medical Association in 1930, and the Socialist Health Association in the 1970s). It has been a central theme in the campaigns of the left-wing Medical Practitioners' Union from its foundation in 1914 up to today.

Given that the recent White Paper on NHS reform insists repeatedly that the government has no intention of changing GPs' contractual status, it is widely expected that it will encourage the spread of payment by salary as part of the wider drive to impose more direct managerial control over doctors.

It is striking that, long after its demise as a significant force in society, the old left lives on in the form of its reappropriated initiatives. Though it is not surprising that New Labour should try to turn the old left to its advantage, it is still difficult to see what socialist virtue it ever saw in causes like the campaign to join the salariat.

Dr Michael Fitzpatrick