The Five Giants [New Edition]: A Biography of the Welfare State. Nicholas Timmins
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that to partake in medical politics doctors needed money and time. At a time when many GPs in poorer areas were low earners, the representative body meetings were ‘inevitably weighted in favour of age, affluence, private practice and the suburb’. In other words, those who had least to gain as doctors from a National Health Service were more likely to be those who voted at the BMA’s very public and well reported meetings, and the decisions of those meetings were strongly reflected in the interpretation of events and advice that BMA leaders then put to doctors in the rash of plebiscites between 1946 and 1948. Bevan found, as Lloyd George had put it in 1911, that ‘a deputation of doctors was a deputation of swell doctors’.62
Dain, Hill and the members also remembered history. Lloyd George had, to an even greater extent than Bevan, refused to negotiate with the medical profession over the National Insurance Act. In 1913 the BMA had assembled 27,400 signed pledges from family doctors refusing to participate until its terms were met. Ironically, in a position that was reversed in the 1940s, it had then been the consultants, who were unaffected by the measures, who largely orchestrated the opposition.63 When the 1911 Act came into force, however, GPs fearing they would lose potential patients to rivals, suddenly signed on in droves, leaving the association routed, divided and humiliated. This time, Dain and Hill, desperate to maintain the doctors’ unity and preserve the BMA, repeatedly consulted the troops, calling special representative meetings and holding plebiscites which only helped give publicity to the more furious opponents of the proposals.
The doctors also had good grounds for their suspicion that a full-time salaried service was the ultimate goal. Ernest Brown, a National Liberal, had proposed it; it had been Labour policy since 1934; and as recently as April 1943 the party had reiterated the proposal for all doctors, not just GPs, in A National Service for Health. That document had included a bar on private practice for those employed by the state.64 Bevan had formally rejected this part of party policy. Michael Foot records that he ‘desperately wanted the patient to have free choice of doctor. He saw it as the best safeguard against poor service from the general practitioner.’65 He was to tell the Commons that to make doctors salaried would mean allocating patients to doctors and vice versa. Capitation, on the other hand, encouraged the doctor to provide a good service in order to attract and keep the patient who could move if dissatisfied, but he also wanted a small basic salary to allow young doctors to keep body and soul together while they built up a practice.
If Bevan rejected a salaried service, that still left him with his own back-benchers to placate for dropping party policy. Twice in the second reading debate in April 1946 he remarked that the profession was not ripe for a salaried service, adding: ‘There is all the difference in the world between plucking fruit when it is ripe and plucking it when it is green.’ Arthur Greenwood only compounded their suspicions by declaring in the wind-up to the debate: ‘What was published by my party in 1943 … we of course stand by.’66 The BMA and its leaders heard only those sentences, not Bevan’s repeated assurances that there would be no full-time salaried service. In addition Grey-Turner, the BMA’s official historian, concedes there was ‘an emotional, even political,’ undercurrent to the dispute. ‘When [in 1945] Churchill in his own words was “immediately dismissed by the British electorate from all further conduct of their affairs”, many in the middle classes were uneasy.’ Statements by Labour ministers such as ‘we are the masters now’ and Shinwell’s declaration that he did not care ‘a tinker’s cuss’ for the middle classes only compounded that feeling. In the middle of the dispute Willesden Borough Council attempted to force all its employees, its medical officers included, to join a trade union. (The BMA at this stage was, jealously and proudly, not one.) Doctors did not have to be paranoid to see that as another straw in the wind.67 Such attitudes and actions ‘provoked resentment and belligerence in professional people,’68 and doctors, if anyone did, considered themselves professionals.
Thus throughout the dispute-wracked months between April 1946 and 5 July 1948 – vesting day for the National Health Service – the argument was repeatedly heard that Bevan’s plans for GPs were ‘the thin end of the wedge’ and ‘could lead, sooner rather than later’ to a full-time salaried service with ‘doctors becoming a branch of the civil service’. The consultants were told that would be their fate too, once they took salaries in the nationalised hospitals, despite the distinctly favourable terms Bevan had contrived for them. Given that no one quite knew what a nationalised hospital meant, even though the Emergency Hospital Service had provided a national system for seven years, the fears may have been groundless. That did not at the time make them as ludicrous as they later appeared to be.
The BMA, let alone the profession, was in practice of course never united. Webb-Johnson for the surgeons described the Bill as ‘bold and statesmanlike’.69 Moran repeatedly defended it, accusing opponents of distorting the arguments and resorting to slogans. The surgeon Henry Souttar, the immediate past president of the BMA who had chaired the Medical Planning Commission, pronounced it ‘exceedingly good’.70 Professor Johnstone Jervis, President of the Society of Medical Officers of Health, declared it ‘incontestably the greatest thing that has ever been done in social medicine in any age and country’.71 And while the British Medical Journal bitterly attacked Bevan, The Lancet argued for the plan. Many newspapers sided with the doctors and the Tories in their objections. But the then more numerous Labour-supporting papers backed Bevan, and The Times and the Economist both gave the plan a consistently favourable press.
The detailed and tortuous course of the battle between Bevan and the doctors has been well told elsewhere72 and a number of issues other than the central one of whether doctors would become full-time salaried civil servants and thus denied clinical freedom and free speech, wove in and out of the dispute. But the Bill achieved its Royal Assent in November 1946, at which point a BMA plebiscite showed 54 per cent of doctors opposed to entering detailed discussions on NHS regulations (including pay) with Bevan.
The three Royal College presidents intervened. In January 1947 they wrote to Bevan seeking assurances and clarification on key issues including the basic salary. Bevan was proposing this should be £300 pa – enough to get a young doctor started, hardly enough to make him a state employee. The presidents’ action, the equivocal ballot result, and Bevan’s conciliatory reply cornered a special BMA representative meeting into starting talks.73 These dragged on through 1947 to break down at a meeting in December when Bevan, who had been all milk and honey throughout the year, exploded. According to Dr Solly Wand, ‘he threatened us and raved at us. He waved his finger in the air and said that if, as a result of anything the profession did, the number of patients who signed on was much less than 95 per cent, he would make serious reductions in capitation fees.’74 The breakdown came because the BMA was still demanding such extensive changes that fresh legislation to construct a new and very different Act would have been needed. Bevan declared that Parliament decided the law, not doctors, and refused to let them dictate to the government.
In January 1948, with Hill insisting that the months of negotiation had made it ‘absolutely clear that these proposals mean and are intended to mean a whole-time salaried service under the state’, another plebiscite was held.75 The doctors were told that the independence of medicine was at stake. The British Medical Journal declared that Bevan’s refusal to amend the Act, ‘strengthens this belief’.76 The BMA council’s message to the membership stated that the issue was not money or compensation, but ‘the intellectual freedom and integrity of the profession’. If a majority voted against the service, including 13,000 of the 20,000 GPs, the BMA would advise the profession not to join the NHS.
The result was overwhelming, and stunning for the government: 84 per cent of doctors voted, and 86 per cent of those (including 17,000 general practitioners) were against accepting service under the Act.77 Bevan, who had been under growing pressure for months from Morrison and others who had seen the whole enterprise as likely to end in tears unless the doctors were placated, refused to waver. He issued a terse statement. ‘The Act will come into operation on 5 July in accordance with Parliament’s decision.’78
Some newspapers, the Observer and the Glasgow Herald included, called for his resignation. Between the February ballot