Resident doctors plan to strike for five days from 17 December. The strike is organised by the BMA, the doctors’ trade union, and will be the fourteenth since March 2023. The resident doctors argue that their pay is 20% lower in real terms than it was in 2008 and want it restored to that level. They have chosen to strike just before Christmas to maximise the impact of the strike. Wes Streeting, the Secretary of State for Health, says that the government has increased resident doctors’ pay by 30% in the past three years, and he refuses to negotiate about pay.

I’ve been reading in Nick Timmins’s magnificent book The Five Giants: A Biography of the Welfare State about what has until now been the bitterest battle between doctors and the government, and there may be lessons for today. The main lessons, I suggest, are that patients suffer and ultimately both sides lose. Whether or not there are useful lessons, the story makes for good reading.

The battle, which was fought between 1974 and 1976, was primarily over “pay beds,” beds in NHS hospitals where NHS doctors could treat their private patients. When negotiating with doctors over the creation of the NHS, Aneurin Bevan had allowed doctors to continue with their private practices as well as work in the NHS. The left wing of the Labour Party had never liked the compromise.

In 1974 about 60% of consultants did private practice, and many would earn much more from their private practice than from their NHS work. There was antagonism between the 60% who did private practice, “the gentlemen,” and the 40% who did not, “the players.” Those who did private practice very much needed the pay beds because most of the few private hospitals were little more than nursing homes and unsuitable for complex care.

There were two general elections in 1974, and Labour won both, the second with a bigger majority. Their manifesto included a commitment to ‘phase out private practice from the hospital service’. It would in effect mean an end to most private practice, reducing consultants to employees of a state monopoly, something they had resisted strongly in the negotiations over the creation of the NHS. “We are fighting for the independence of the profession,” said Walpole Lewin, the BMA’s chairman of council.

Barbara Castle, the Secretary of State for Social Services, set out to implement the manifesto. Timmins describes her as “red-haired, vivacious, ferocious, intelligent, a fighter all the way.” During her battle with the consultants she also had to battle with GPs and junior doctors, but the battle with the consultants was the most intense one. It involved not only the pay beds issue but also negotiations over a new contract, which had been underway since 1972.

Up against Castle’s burning determination was, writes Timmins, “the iron will of Anthony Grabham who, although only forty-four, had become the consultants’ chief negotiator…He came from a line of Conservative salaried public servants – police inspectors and fire chiefs – and had been ‘absolutely torn’ between being a doctor or a lawyer. He had been known to vote Labour as well as Conservative, having grown up in the wake of the Thirties depression and been influenced by treating the smashed bodies of miners as a young Tyneside doctor in the early 1950s. But in his own phrase he ‘instinctively loved the battle’ and he brought to the previously gentlemenly conduct of government/doctor negotiations all the icy fire of a Tebbit-like Conservative shop steward, operating to a brief. He could be silkily rude. His instincts lay with the NHS, but he believed even more strongly in protecting what he saw as the interests of doctors, once memorably remarking, à la General Motors, that ‘happy doctors make happy patients’. He was determined to preserve private practice.”

I came to know Tony Grabham well as he was the chair of the BMJ Board when I was the editor of the BMJ and chief executive of the BMJ Publishing Group. We were very different but worked well together. I saw him weeks before he died and wrote his obituary. https://www.bmj.com/bmj/section-pdf/891755?path=/bmj/350/7997/Obituaries.full.pdf Grabham said of Castle that she “said what she thought—a terrible weakness in a politician.” She described negotiating with Grabham as being “shot at with silver bullets,” and told a colleague that he was greedy and arrogant but “the best negotiator I ever dealt with and a huge force in committee meetings.” Timmins reports a senior doctor saying that Grabham was “the man who singlehandedly did more damage to British medicine than any other.” The two statements are not incompatible.

The consultants had already taken 16 weeks of industrial action when Castle proposed a plan to phase out pay beds and to license the private sector to ensure that private beds never exceeded the combined number of private hospital and NHS pay beds at March 1974. “The response not just of the BMA but of the medical Royal Colleges and the provident associations was,” writes Timmins, “apocalyptic. Castle’s package was damned as ‘sovietisation’. Unprecedentedly, some seventeen medical organisations united to declare that the proposals carried ‘totalitarian’ implications that could lead ‘ultimately to the justification for the watch tower, the searchlight and the Berlin Wall.”

The results of industrial action were that “out-patient sessions were cancelled, waiting lists grew, even the casualty department closed on alternate weekends in some places, while more than one patient found themselves anaesthetised and then not operated on because the doctor’s time was up.”

BUPA, one of the provident associations, had already hired Lord Goodman (known in Private Eye as Lord Two Dinners) to advise them, and he was soon advising the BMA and the royal colleges as well. Goodman later wrote in his autobiography “Some of the doctors were essentially reasonable men, [but] alas, not many.” Goodman was close to Harold Wilson, the Prime Minister, and often worked as Wilson’s fixer. With Wilson’s approval he moved from acting for the doctors to being an undeclared intermediary.

Timmins describes how Goodman met with Castle in his “ ‘gloomy’ Portland Place flat, one wall dominated by an awesome Graham Sutherland portrait of its massive owner. Goodman was late, his housekeeper plying Barbara Castle with a silver teapot and the thinnest of cucumber sandwiches as she stamped her foot with impatience.”

Timmins quotes Goodman’s account of meeting with the doctors: “The first thing to do is to resume discussions with the Secretary of State,’ I told them. The howl of dissent that came from the entire room staggered me. ‘Never,’ they said, ‘will we meet with that woman’… ‘How [then] are we to make any progress? Who will you meet?’ Rather grudgingly a voice said: ‘The Prime Minister.’”

Goodman wondered about informing Castle what the doctors thought, but in the end he didn’t. He went straight to Wilson, who met with the doctors. Goodman advised that only Grabham speak, presumably to avoid the “madmen.” “At Downing Street on 3 December 1975,” writes Timmins, “the very broad outlines of what was to be the settlement were agreed with the doctors, although almost a fortnight of daily, secretive and fraught negotiations followed including a meeting like ‘a French farce’ at Goodman’s flat in which the doctors were closeted in the living room, Castle and company in the dining room, with Goodman shuttling between them.”

The BMA put the proposal to the consultants, who voted 4438 to 2048 in favour on “a 54 per cent turnout that was paltry given the passion that had been aroused.”

Over the next years the size of the private sector increased enormously both in the number of beds and the number with insurance. “By an awful irony,” writes Timmins. Barbara Castle became “the patron saint of private medicine.”

The doctors might have been said to have “won,” but Timmins concludes that both sides lost. “The violence of the doctors’ language, the misogyny with which Barbara Castle was attacked as ‘the Red Queen’, and most of all the sanctions they applied to patients all seriously undermined their standing with public and politicians alike while splitting a profession many of whose members took no part in the action. BMA membership dipped sharply. Sir George Godber, recently retired as Chief Medical Medical Officer, wrote to The Times to declare that ‘it must be axiomatic that a doctor cannot strike’, and suggesting that he could no longer remain a member of a body ‘which is prepared to pursue its objectives by methods harmful to patients’. Lord Goodman, having acted for them, similarly damned the doctors for failing to halt their action while they balloted. They were causing, he said, ‘anxiety, pain and even the risk of death’. Doctors had a unique standing because of their tradition of service. ‘If doctors of all people forsake this tradition and support the view that “everything goes” to achieve their ends, we are well on the road to anarchy and the abandonment of parliamentary procedures in favour of naked coercion.”

The BMA also lost. It “may have confirmed its position as ‘the shock troops of the middle classes’ as its leaders sometimes liked to see themselves. But they had done so at the price of their secretary becoming known as ‘Docker Stevenson’ and the BMA as the ‘British Money Association’. Their moral authority to condemn industrial action by others in the NHS had gone, and the Tories, as much as Labour, marked the BMA down as a deeply troublesome and offensive trade union, a professional cabal which, like the teachers in education, seemed to have too much power and needed to be cut down to size. Within the BMA’s own ranks a horrified sense of ‘never again’ developed. Dr Elston Grey-Turner, shortly to become BMA secretary, recorded that many doctors found the action ‘deeply repugnant’. It was to be the last war for at least twenty years at the end of which the BMA could in any real sense claim victory.”

Today’s resident doctors would probably like to meet with the Prime Minister and do a deal over the head of Streeting, as Grabham and his acolytes did in 1975. But that isn’t going to happen because the Prime Minister in a weak position wouldn’t dare to go above Streeting’s and the BMA—partly because of its antics 1975—no longer has the power to make it happen.

The likely result is that everybody loses, patients most of all.

Addendum: I know that years after this bitter dispute Castle and Grabham met at dinner at the houise of a mutual friend and had a wonderful evening remembering their great battle.