Is modern really so dependable?

Consultants in the National Health Service have rejected a new contract that might have increased their income by up to 20 per cent in return for more flexibility in their working time and practices. In effect they decided that it was better to reject more money than to accept more management. In doing so they demonstrated that some public sector workers can get away with resistance to modernisation, and they caught their own representative body in the BMA off-side, prompting leadership resignations and much soul-searching. The implications of this resistance are significant, not just for hospital specialists, but for the whole health service.

The resistance to modernisation is not new, but on the contrary is at the heart of medical professionalism. The BMA resisted Labour’s formation of the NHS in the 1940s because it wanted more private practice, and resisted Conservative attempts to privatise the NHS in the 1990s because it wanted a big public service to meet its members’ needs, as well as those of the nation. Modernisation is always a problem, and as understood by New Labour poses a threat to professionalism, in two senses.

The first is that control over working hours is particularly important to those specialists who have part-time NHS contracts and extensive private practice commitments. More evening or week-end working in the NHS might erode evening or week-end working in the commercial sector, necessitating potentially difficult re-organisation of private work. Increased flexibility and responsiveness in the NHS may even reduce waiting times and increase satisfaction with the service, neither of which aid private practice growth. This modernisation, therefore, will be resisted as it was most forcefully in southern England (where the private sector is strongest) and least forcefully in Scotland & Northern Ireland (where commercial medicine is weaker). The converse geographical variation is visible in service re-configuration in hospitals, with newer styles of working and providing medical care being more evident in the north of Britain than in the south.

The second threat is different. Modernisation may mean slowly breaking down all the barriers to the quasi-privatisation of the public health service, moving it to a decentralised mode of organisation where accountancy matters more than meeting needs. In a worst-case scenario the new primary care trusts may become responsive purchasers of services from public, charitable and for-profit providers and detach themselves from needs-led provision. The NHS will then fragment into local services providing different types of health care (despite the attempts of regulatory bodies to prevent this), and will hire and fire staff accordingly. Specialists who allow themselves to be ‘managed’ into this situation may well see their positive capacity to match services to public needs undermined. Resisting the modernising contract might then make sense, as resistance to fragmentation rather than to managerial control. At stake here is the positive side of medical professionalism, its commitment to good clinical care.

What will the BMA do? It has little option but to listen to its members, which may mean easing the new contract in, perhaps in a modified form, in Scotland and Northern Ireland, and seeking its modification in the south of Britain. Fragmentation may then proceed by another route, as the NHS changes faster in the north than in southern England. The national (UK wide) contract for specialists may shrink to four different national contracts, probably with regional or local variations. Whether the BMA will be able to retain its near-monopoly position as the representative of the medical profession is an open question, but if it loses its authority managerial pressures for changes in professional behaviour will intensify. We should anticipate a long period of conflict between the medical profession and the state machine, at all levels.