He said: 'There is no doubt that there is a mood of despair in the air today. There is despair about the mood of alienation and demoralisation in the NHS. There is despair about the place of doctors and the future of the profession in the health care system.'
Echoing remarks by the Rt Rev Mark Santer, Bishop of Birmingham, in his sermon the previous evening, Dr Macara said that the reasons were not hard to find. Co- operation had been supplanted by competition, the internal market was uncontrolled and ill-managed and doctors were set against each other, 'all to serve a perverse philosophy of winners and losers'.
Amid applause, cheers and finally a two-minute standing ovation, Dr Macara told the BMA annual representatives meeting in Birmingham that business plans now overrode decisions about patients' needs and that 'treatment, except in emergencies, has now become a national lottery'.
He criticised hospital league tables, irresponsible expectations of the Patient's Charter and the business culture that put managers before patients. He gave notice that an imposition of performance-related pay would be the last straw. They were determined to reform the reforms, he said.
In a thinly disguised attack on Mrs Bottomley's 'vision-of-the-future' speech in Brighton last month, he said: 'There is a fatuous irrelevance in envisioning the future with disregard for the realities of the present.' Referring to her predicted 40 per cent reduction in beds within 10 years, he said: 'To crown the absurdity, the author of that study now announces that the real estimate was 25 per cent, but he rounded up to be more impressive.'
Dr Macara went on to say that the Government's plans for local pay arrangements could destroy the NHS. 'The divisive and outdated device of local pay bargaining . . . can only increase inequity between different hospital and community units because it will be, to quote the Secretary of State, 'linked to the success of organisation', not to the provision or quality of care.
'The policy could not be more deliberately designed to destroy professionalism. The Government's naked intention is revealed in the Secretary of State's own words - 'local pay will be an important management tool'.'
In a placatory statement, Mrs Bottomley said she was sorry that Dr Macara had not acknowledged NHS successes. 'Behind Dr Macara's sound-bite salvo lies a constructive agenda, much of which the Government can share.'
Speaker after speaker at the meeting of 600 doctors representing all branches of the profession, criticised aspects of the reforms for creating a two-tier system and imposing unfair rationing.
Dr Hector Spiteri, a family doctor from Essex, described different arrangements for patients, served by different health authorities, at the new King George Hospital in Ipswich. One patient had been given a six-week date for her hysterectomy, while a next-door neighbour had been told she had to wait about 18 months, he said.
One man needing treatment for pain had been seen immediately, while another was told that he had to wait an indeterminate number of months. 'The reality is that there is inequality of access in a multi-tiered service, which is not acceptable in a humane, civilised and developed country,' Dr Spiteri added.
Dr Joan Black, from west Berkshire, said that it was not acceptable for people to be accorded hospital treatment only on the basis of their age. She described one policy of not offering heart surgery to people over 75 and another where there was an age limit for the provision of heart drugs. 'No patient should be discriminated against on the basis of age, sex, race or marital status. The only judgement is clinical need and the likelihood of benefit,' she said.