Medical Führer: Why The BMA Called Nye Bevan A Dictator

Why the BMA actually resisted the founding of the NHS

We need to go on a journey. A journey that informs us about the history of our profession. As doctors, knowing the foundations of our healthcare system, its key figures and its history is vital for preparing us to face its future challenges. Many of these future challenges touch on themes and issues seen in the past.

Dr A. J. Cronin’s best selling novel The Citadel, published in 1937 was not just a book, it is seen as a moral journey. It follows the protagonist, Dr Manson who began as a young, idealist Scottish doctor motivated by scientific rigour and public service. He quickly became disillusioned and tempted by money and fame, only to arrive full circle at the end of the novel when he rediscovers his earlier values.

The Citadel exerted huge influence on society as people began seeing entrenched interests as an impediment to good care and scientific truth. It painted the medical profession as a fortress of privilege. Some say Bevan’s NHS reforms were born out of the influence of Cronin’s work.

Bevan vs BMA

The government calls its new 10-year plan innovative and revolutionary, but if you really want to see what an ambitious programme for health social security looks like you have to back in time to when Europe was still reeling from a world war and national debt was spiralling out of control.

The post-war Labour government and its health secretary, Nye Bevan saw this as an opportunity to change the health landscape in the new world. Bevan was a Welsh miner from a Socialist family and went about creating a medical system which ensured that every person, regardless of background had access to medical care that was free at the point of use.

Huge change and the upheaval of the status quo can often lead to resistance and one of Bevan’s biggest hurdles in the establishment of the NHS was the BMA. The BMA’s chief secretary at the time, Charles Hill, was a staunch believer that healthcare should be funded by insurance and not taxation. One needs to understand, that before the founding of the NHS, doctors made significant money through charging patients directly for services.

Honorary contracts with prestigious hospitals meant that most of their income came through private work. Those hit hardest by paying these small fortunes were the lower-middle classes, and in response, they backed Labour’s election campaign and its promise for a more affordable healthcare system.

The BMA and many of the doctors in its leadership ranks were anxious that the business model that allowed for their comfortable lives was under threat and set about challenging this through some scathing attacks on Bevan.

Letters from the BMA archives show descriptions of Bevan as “a complete and uncontrolled dictator” and even, a “Medical Führer”. The BMA claimed that only 4,734 doctors out of the 45,148 polled were in favour of an NHS. Bevan struck back with a fiery half hour speech in the commons, repeatedly going after the BMA accusing the union of being “politically poisoned” and “consistently misleading its members”.

Stuffed Their Mouths With Gold

There were another group of doctors who offered far less resistance to Bevan. This group were the ‘Local authority medical doctors’ who were employed by local councils and worked in municipal hospitals which were often run by local authorities. They had much lower status and income than their consultant counterparts and advocated for all hospitals, private included, to be brought under local authority control. This was to the dismay of the nation’s consultants who prized their independence and private contracts.

Bevan’s new ‘utopian’ vision of healthcare acquired support across the House of Commons, but he knew the project was impossible without significant support from the senior doctors who would be running the service. Doctors wielded significant power at the time and were clear in their desire to avoid becoming employees of the state.

In response to the qualms of the BMA, Bevan, in his own words, “Stuffed the consultants’ mouths with gold”, ensuring that doctors who agreed to work within the new health service could continue their private practice contracts, as well as securing a system of ‘distinction awards’ on top of generous consultant salaries offered by the government. In return, he nationalised all hospitals, bringing power to the hands of the central government rather than local authorities.

Bevan went on to formalise and create the National Health Service which opened its doors on July 5th 1948 and contained 5,000 consultants and 480,000 hospital beds.

The current battles between the BMA and the country’s health secretary may not exactly mirror those of Bevan’s era, but the feud lives on and we imagine that many doctors today would appreciate an extra mouthful of gold…

Is This a Tactical ‘Smash and Grab’ From The BMA?

The BMA’s quick mobilisation into strike action took even their most ardent supports by surprise. Barely two days after the passed ballot and a secured six-month mandate for strike action, the BMA were quick to follow up with five days of planned industrial action. As we look at this closer, we can ask: Was there a political incentive to the speedy mobilisation?

The BMA is enjoying its time in the sun. One could argue that the last time we saw trade unions levy this sort of power over Westminister, the year was 1979 and James Callaghan’s government was holding on for dear life. What was the next thing the Unions saw after bringing down Callaghan’s government?

Thatcher and the 1980 employment act which banned secondary picketing and imposed secret balloting on strike votes. Could history be telling us of what is to come for the BMA’s power if the political climate carries on the same way...

Political commentators look at Reform UK’s lead in the general polls and suggest that if a right-learning government succeeds Starmer, they may jump to clip the union’s wings as Thatcher did in the eighties. Acknowledging this, BMA HQ may have concluded that now is the best time to act and to act strong.

The BMA could be intending to squeeze every drop out of the current government, knowing what is to come if the nationwide UK polls turn out to be accurate come next election.

The Inequality That The Rota Doesn’t Show

What is the ‘free-time gap’ and how does it influence careers in medicine?

Some doctors make medic relationships look easy, working around the on-calls and night shifts. Then there’s the female medics in our community with non-medic partners who come home and explain why the cardioversion they performed for the first time this afternoon was a big deal. Relationship dynamics are vital, particularly for our female colleagues, who now make up around 60% of graduating medical students in most Western countries.

Mind The Gap

Naturally women in medicine have high aspirations, but for many there are also big workloads at home too. According to the 2024 Gender Equity Policy Institute report, women working part-time have 16% less free time than their part-time male peers, and for women working full-time, the gap is 12%. The report termed this the “The Free-Time Gender Gap”.

The busiest group of all are women aged 35–44, ironically in the ‘peak years’ of their career. The earning potential in these years is supposed to be highest. The reduction in one’s spending power today aside, we know from previous On-Call posts, that your final defined benefits pension is not solely based on how long you contribute for, but how much you earn annually whilst in the scheme. A female consultant or senior registrar having to significantly cut their hours or delay their training will end up with a much smaller pension pot come retirement.

Marriage doesn’t seem to help either: married women take on far more housework than their single peers as per the same study, while married men find just a few extra minutes of chores compared to single men. Even in cohorts without kids, women still carry more of the unpaid work at home, even after accounting for their hours, education, or marital status.

Free Time = Career Capital

We love the phrase ‘free time is career capital’. It perfectly captures the idea that whilst we may not live in times or in a country where your gender explicitly decides whether you can progress to the next career hurdle, there are numerous implicit factors at play that do - including the free time disparity.

Free time enables a trainee to prep for an upcoming exam, to write that paper they keep delaying or to sharpen up their clinical skills. Free time can keep burnout at bay, fosters health and wellbeing, and allows for locum work. When time is scarce, these opportunities are the first to give way.

A phenomenon that very much still exerts a major influence on who progresses through the ranks of medicine is time invested in the job. Cutting back on clinical commitments and time spent on one’s portfolio is a sure way to impede career progression.

No Unified Path

It of course goes without saying that not every female medic’s path will look the same. Some want to go full tilt at their careers, some value more balance. The job of the system and the job of partners is to support whatever version of success they choose to pursue.

The free-time gender gap may be invisible on a rota, and might not make headlines like pay gaps or glass ceilings, but its effects ripple quietly through careers, pensions, and personal wellbeing…

“I haven’t looked at people storming down the hospital corridor the same way since a colleague told me to walk everywhere as quick as possible so you look like you are busy and on a mission. This thereby reduces the chances of getting stopped for a chat.”

“Driving to work the other day and I see a huge queue of people at 7.30am trying to get a GP appointment. People of all ages were present: The elderly who looked sick enough to warrant a full day in bed and the working-age individuals who have taken time off their jobs at a productivity-cost to our economy. For how much longer will this GP booking fiasco continue”.

“When the consultant strolls in at 9am with coffee in hand and asks the night team why there is still a patient on the board left to be clerked - trauma unlocked”

“Don’t ask me where I’d be and how my Ortho on-calls would have gone without McRae’s orthopaedic trauma”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

The University of Edinburgh was the centre of the Scottish Enlightenment. Alongside remarkable thinkers such as David Hume, Edinburgh University also housed thinkers that pushed pseudo-scientific and racist beliefs such as phrenology, a discredited belief that suggested skull shape could be used to denote intelligence. To read more about the practice and the response from Edinburgh Uni, here is a review in The Guardian

How the BMA deals with strike exemptions is becoming an increasingly contentious issue, with some claiming that hospitals are suffering due to their own mismanagement and failure to cancel elective work to arrange cover. Others say the BMA is playing with patient safety. The story is covered this week in The Times.

Weekly Poll

Last week’s poll:

Did you participate in the recent industrial action?

…and whilst you’re here, can we please take a quick history from you?

Something you’d like to know in our next poll? Let us know!

‘Contaminated’ Meta-Analyses and The Rise of Retracted Trials

We can only practice evidenced based medicine if the evidence eco-system is reliable. A trial may be retracted for various reasons, such as the identification of errors in the methodology or data analysis. Crucially the practice of retracting poor evidence is a strength of the scientific process, not a weakness. There is nothing unscientific about turning your back on ideas when new evidence reveals them to be false. In fact this willingness to revise or discard ideas often sets the scientific method apart from other ‘routes to knowledge’ where beliefs are often treated as fixed or infallible.

We should be concerned however about the recent rise in the number of retracted trials, especially when these trials are still included in systematic reviews and go on to inform clinical guidelines. Based on the work of Xu and colleagues, after the exclusion of retracted trials, the results of 8% of meta-analyses changed direction and the results of one in six meta-analyses changed statistical significance.

This was astonishing for the On-Call team to read and highlights the need to review all meta-analyses carefully to ensure that retracted data is removed and findings re-calculated. Whilst science remains our best route to knowledge, it is not without limitations. The more we pressure doctors to publish through the offering of points, and the more we ignore negligent editorial practices by journals, the more bad science we encourage.