Tuesday 13 December 2011

Campaigning against unpopular NHS reforms: Debunking the “Kenneth Clarke” myth

As co-chair of the NHS Consultants’ Association and a member of BMA Council it is clear that the vast majority of medical politicians that I meet share the same concerns about the coalition Government’s plans for increasing privatisation and marketisation of the NHS. However, there is also a clear divide in opinion of how best to address these concerns and counter the damaging effects of these unpopular reforms. The key argument for taking the more conservative approach of “critical engagement” rather than the more militant “outright opposition”, is that it is crucial to stay in the “tent” to retain influence and remain at the negotiating table in order to achieve positive changes and minimise the most damaging aspects of the reforms. Withdrawing from the tent will simply leave room for other less savoury organisations to dictate, whilst organisations like the BMA will simply be sidelined.
I have been struck by the number of times that this argument is also accompanied by discussion of the BMA’s 1989 “Kenneth Clarke” campaign. The story goes that the BMA lost influence because of it’s campaign against the Working for Patients White Paper, which introduced the internal market and purchaser provider-split. There were two BMA Special Representative Meetings (SRMs) during this period that called for a campaign against the NHS reforms, which resulted in the infamous slogan:
What do you call a man who ignores medical advice? Mr Clarke”.
(A fascinating account of this campaign can be read in Dr John Marks' (BMA Chairman at the time) book chapter here, which includes pictures of some of the campaign leaflets!)

Despite the campaign, the bill was still enacted, and it is said that this campaign was the main reason why the BMA has been excluded from policy making ever since. This campaign “failure” has become the mantra of those who think that aggressive campaigning will only damage the BMA. However, it is important to set the record straight on the Ken Clarke episode because it has been misrepresented and misunderstood. It is a total myth that the "Ken Clarke poster" froze out the BMA from future involvement in contributing to health policy. The actual historical facts can be found in this article by Professor Rudolph Klein - "State and Profession: Politics of the double bed"  BMJ 1990), which is a must read

Klein wrote that the 1989 White paper:
was the first time in the history of the NHS that the medical profession was systematically excluded from the decision making process leading up to the review; an exclusion which may perhaps explain the subsequent bitterness rather more than actual policy content.”

The exclusion of the BMA therefore came before any campaign, and the exclusion was in fact a major reason for the “Ken Clarke” campaign. Klein describes this well:
“Indeed, the BMA's subsequent advertising campaign served largely to advertise the fact of the profession's exclusion. It drew attention to the profession's loss of privilege: in happier, corporatist days the profession had its own direct and private links with civil servants and ministers -an iron triangle of consultation that turned out to be made of cardboard in the 1980s.”

Klein’s analysis is in keeping with Nigel Lawson’s autobiographical account in “The View From No 11”. (Lawson was of course Chancellor of the Exchequer at the time). On page 614 of his book he described how a new review group to develop the NHS reforms would:
need to be small and entirely internal. The professionals, once they knew it was going on, would not be backward in giving us the benefit of their advice – and, more fruitfully, we could always get the opinions of politically well-disposed practitioners informally”

There were only seven people on this review group, which included Thatcher, Lawson, John Major and Roy Griffiths (the former Sainsbury’s chairman and author of 1983 Griffith’s report). They met for a year before Kenneth Clarke published the outcome in the January 1989 White Paper, Working for Patients.

So it is clear that the BMA was excluded right from the beginning and it’s exclusion from the policy making process had nothing to do with the “vitriolic” Ken Clarke campaign. However, this myth has persisted and I believe that it has actually contributed to a lack of similar action from the BMA ever since. Lawson states in his diaries that “The opposition from the BMA, once so strident and vituperative, is now little more than a wimper”
This year’s emergency BMA Special Representative Meeting about the current reforms was actually the first one since the Ken Clarke era.

I also think it is important to understand that the profession was left out because a key plank of the Working For Patients reforms was about diminishing the power and autonomy of doctors. This is important for market based reforms, because markets cannot function well in the framework of a powerful professional bureaucracy (more of this in a future blog). Since market reforms have dominated the last 20 years of policy making, I believe that this is actually the most important reason why the BMA and other healthcare professional groups have been largely excluded from the policy making process.

Although Thatcher’s conservative party got their reforms through, it is important to note that the opposition from the BMA did actually have some lasting impact on the Tories, who were rendered "toxic" on the NHS. The last White Paper of the Tory administration, A Service with Ambitions (1996), was remarkable for its lack of mentions for markets and its promotion of partnerships instead. (See Ian Greener’s book: Healthcare in the UK, p 103). However, Greener goes onto to say:
"Clarke still created an important principle that policy makers almost routinely follow today - that it is not necessary to consult organised doctor groups when planning NHS reform" (ibid, p108)

What we are seeing at present is in keeping with Greener’s analysis. There is no chance that the corporatist days are going to come back, whilst we have a marketisation/privatisation agenda on the table. The BMA has been ignored right from the start and the Government has recruited it’s own medical professional advice from smaller unrepresentative organisations like the National Association of Primary care (NAPC), which I’m sure Nigel Lawson would label as today’s “politically well-disposed practitioners”.

Now that the Ken Clarke myth has been put to the “double bed”, and it is clear that the BMA has so little influence on policy making, I believe there is every reason for the BMA to fight a hard and aggressive campaign against Lansley’s NHS privatisation bill. There is nothing to lose and everything to gain. Moreover, the BMA has been given the mandate to oppose and campaign against the bill by its ruling Council, and this is what it must do if there is any chance that we are going to save the NHS.
The BMA should also note that it gained an extra 2,000 members during the Ken Clarke campaign (and only lost 20!)

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