Comparisons with the Miners’ Strike of 1984 come naturally when talking about the British Medical Association. But whilst we remember a straight-up confrontation, it was only careful Government planning and an undercurrent of irresistible technological change that made Thatcher’s belligerence viable.
The Government’s dispute with the doctors’ union continues to escalate, with junior doctors preparing to hold the first full walkout in the history of the NHS.
Writing in the Daily Telegraph, James Kirkup gives the recalcitrant medics a warning from history. He warns that the BMA is repeating the mistakes of the National Union of Mineworkers, over-estimating the nation’s dependency on their members.
That Britain’s economy could survive without British coal was unthinkable, right up until it wasn’t. Kirkup argues that technological progress and competing models of provision mean that our monolithic state healthcare provider may soon find itself similarly outflanked.
But whilst that might be true, it is by no means certain that we have reached this point now. For all that Arthur Scargill’s attempt to topple Margaret Thatcher is the stuff of legend, it shouldn’t eclipse the fact that there were plenty of miners’ strikes before that final confrontation and the miners won most of them, enjoying public sympathy as they did so.
Jeremy Hunt could end up being a modern-day Margaret Thatcher, bringing truculent trades unionists to heel and unleashing modernity on one of the UK’s totemic industries. Or he could be Edward Heath.
As Simon Jenkins points out in today’s Daily Mail, public support for the NHS is currently bulletproof. This makes it incredibly hard to reform: in fact, the public health lobby have convinced many politicians that it is easier to reform the public than to make a serious attempt to reform public services.
“Cost to the NHS” is thus one of the main pillars of modern drives against smoking and obesity. But setting aside any liberal qualms we might have about that, it isn’t clear that this represents a viable long-term solution.
Anybody who the state ‘saves’ from a tobacco or food-related death will still die of something, and the NHS will pay for it. If that person is forced to live a long life then they will likely end up costing the NHS far more than they would had they died younger – the increasing ability for medical science to prolong our senescence is by far the greatest structural challenge the service faces.
Treating expenditure on smoking and obesity-related health problems as money that can be straight-up saved, without accounting for the inevitable transfer of the burden to other parts of the health budget, is therefore extremely disingenuous.
Assuming that we can’t force people do be so healthy that we can afford the NHS, we’re then still confronted with the need to reform it.
It may be that needless deaths caused by industrial action lead to a dramatic sea change in popular attitudes, but as it stands we’re a long way from a place where “wholesale reform via head-on confrontation” seems likely to work, even as a last resort.
Rather, Conservatives should have a long-term, strategic vision for healthcare reform which involves the piecemeal adoption of decentralisation, liberalisation and modernisation in doses the public will tolerate.
Obviously there are a huge number of things this could involve, and Party policymakers should canvass widely for proposals. But when it comes to tackling the outdated and overweening influence of militant unions in the NHS, here are two suggestions.
In his article, Kirkup mentions “the George Washington University study that estimates 85 per cent of a typical doctor’s work can be done perfectly well by a “physician’s assistant” with a fraction of the training or wages.”
If that is the case, perhaps one way to increase staff supplies in the service – without resorting to controversial over-dependence on foreign nurses – would be some form of ‘Territorial NHS’, or Health Service Reserve, modelled on its military counterpart.
Volunteers would receive pay, training, and legal rights to take time out of their ‘civilian’ life to work for so many weeks of the year in the NHS. This shouldn’t be impossible: the Armed Forces reserves already offer recruits the opportunity to train in a huge range of technical skills.
A larger, flexible pool of ‘physician’s assistants’ would reduce the NHS’s dependence on full-time professionals. This would not only ease immediate wage and staffing pressures, but make it easier for management to respond to future shifts in demand.
Like any nationalised industry, one of the major problems facing the health service is its need to predict future demand without the aid of psychics. The long training current staff require makes it impossible to rapidly adjust to unexpected demand (without importing labour, that is.)
A ready pool of capable staff, which can be topped up relatively quickly, could thus plug gaps as they arise and make it easier to do that with British personnel.
Given public affection for the NHS, and the esteem in which its staff are held, there’s no reason to think that recruitment would be impossible.
The other way the Government could clip the BMA’s wings would be to diminish their capacity for strike action.
One could approach this task in at least two ways. The blunt-force approach would be to declare doctors, at least, to be one of the essential professions – such as the police and the military – whose members are forbidden to strike. If the junior doctors keep up their current antics this may well become politically possible.
But another way would be to step up the decentralisation of the NHS and make hospital trusts legally-distinct employers.
At a stroke, this would bring the public sector into line with the private by making politically-motivated, industry-wide strikes impossible.
This is because, with sympathy strikes and secondary picketing illegal, trades unions can only call strikes over a specific grievance with an individual employer. In the private sector this has led to conciliatory, service-based unions.
But because all public sectors workers are ultimately employed by the Government, they have been spared the effects of this legislation.
Making hospital trusts independent would not only mean the end of the national strike, it would also yield other benefits. By employing staff on private sector terms such essential and sensible reforms as locally variable and performance-based pay, as well as rational, private-sector pensions, would be as irresistible as they have been in the private economy.
Faced with an incentive to innovate and reduce costs, some trusts may even start to innovate with things like the “production-line” surgical hospitals pioneered by Devi Shetty – channelling the savings into other areas.
It would also mean that in the event of a dispute at any trust, the Government would not be on one side of the table, under political pressure and with the easy out of simply paying up from taxation or borrowing.
One day, the BMA will have their 1984. But it would be complacent to assume that this is it, or that bloody-mindedness alone will bring it about. Conservative strategists owe it to themselves, and to the country, to lay the groundwork properly.