Page last updated at 09:15 GMT, Thursday, 26 June 2008 10:15 UK

The struggle for control of the NHS

By Chris Bowlby
BBC News

Barbara Castle
Barbara Castle took on the doctors over pay beds
"Keeping the doctors happy - that's the story of the NHS"

So concludes Rudolf Klein, veteran historian of one of our most popular but controversial institutions, which is just about to celebrate its 60th birthday.

At the same time, he adds "keeping them happy while also making them accountable" is the real problem.

And if you listen to today's debate about NHS reform you are listening to a new version of this very old political game.

As every politician tackling health care knows, sooner or later the doctors' influence has to be faced.

And the doctors themselves, right from the creation of the NHS, have seen themselves as resisting politicians and administrators who don't understand clinical need.


Far from welcoming absorption in 1948 into a new nationalised organisation, many doctors resented the idea that they would become state employees.

Kenneth Clarke
The BMA had never lost a fight in their opinion
Kenneth Clarke

One senior figure in the British Medical Association (BMA) called the original NHS plan "the first step, and a big one, towards National Socialism", with the Minister of Health as a "medical Führer".

So the new NHS did not emerge from a new national consensus but more from a tricky series of compromises which stored up trouble for the future.

While hospitals were taken into the most direct form of state control, consultants retained huge powers over how they were run.

Tony Rains, a young doctor in the early NHS, recalls it as a time - hard to imagine in today's NHS - when: "We just got on with our work, we didn't have to report to anybody".

Sir Liam Donaldson, now chief medical officer for England, found as a junior doctor that hospitals were run by strict hierarchy.

"The doctors' mess was like a military mess", and lofty consultants made sure their juniors working very long hours did the really hard work.

Unfinished business

In the 1970s the left-wing Labour health minister Barbara Castle tried to complete unfinished socialist business from the 1940s by abolishing the private "pay beds" that allowed consultants to do private work in NHS hospitals.

I had bad dreams about administrators
Professor Tony Rains

After a long struggle another awkward compromise was reached.

Ironically, the whole episode boosted the creation of private medical facilities, some of which are being used by today's Labour government to carry out NHS work.

Ever since, the struggle for control of hospitals has intensified.

When the Thatcher governments of the 1980s brought in new managers from outside, consultants like Professor Tony Rains were appalled by what they saw as unnecessary bureaucracy.

"I had bad dreams about administrators," he said. "I used to end up in my dreams fighting with them".

But Roy Lilley, one of the new managers, saw consultants as "the barons, they were untouchable, they just wouldn't engage in the management process".

GP rows

Even more bitter have been the running skirmishes between government and the GPs.

BBC NHS at 60 logo
As the NHS turns 60, BBC News is giving it a health check. Watch out for reports, features and analysis on TV, radio and the web.

They regularly threatened to resign from the NHS en masse during disputes over pay and working conditions.

And the 1980s saw an especially turbulent time when the BMA was up against Kenneth Clarke, a combative health minister.

"The BMA had never lost a fight in their opinion," recalls Mr Clarke.

During a particularly fierce dispute over changes in GPs' budgets, even Mrs Thatcher wobbled: "Charlie Haughey, the Irish prime minister, persuaded her you should never fight the doctors, it's politically disastrous, and she tried to persuade me to postpone it".

In the end those reforms went through, and New Labour accelerated change. But the battle lines are now more complex.

Doctors are more fragmented as a group - more international, increasingly salaried rather than self-employed, with many more women doctors, who may not look on the career in the same way.

Big changes

Devolution has created increasingly different health services in different parts of the UK.

Sir Liam Donaldson
Sir Liam Donaldson drew parallels with the army

Technology is also driving great change in the way doctors work.

And patients' influence is growing.

There is less deference than before, more stress on accountability after cases such as the murders by GP Harold Shipman or child deaths at Bristol hospitals, more suspicion of doctors' demands over pay and conditions.

And yet the ideal of the "family doctor" is still potent.

Away from the political wrangling, generations of NHS doctors have been pillars of their communities, especially in areas where need is greatest but resources most limited.

Julian Tudor Hart, who became a doctor in the 1950s, began in a surgery in a poor part of London that was in a pub, with ancient facilities.

And when he moved to work in the South Wales coalfields he realised that, compared with hospital consultants or GPs in affluent areas, we "were a rank slightly higher than shit".

For decades he worked one in three nights, with full days to follow.

"The doctor's whole family suffered. It was a rewarding life because the patients were so grateful. But it was a killer."

That kind of career may be over. The struggle between doctors' aspirations and those who run the NHS is not.

The NHS at 60 - National Doctors, presented by Chris Bowlby, begins on BBC Radio 4 at 2000 BST on 26 June.

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