Jeremy Laurance: The early skirmishes in a long war

There is a neat symmetry to yesterday's disclosure by the British Medical Association that half of Britain's expensively educated junior doctors are contemplating a career abroad. After the fiasco of the applications system for NHS training posts left many of the best qualified without even an interview for their next job, thousands are said to be voting with their feet and quitting these shores.

Until a decade ago, the migration was in the opposite direction. The NHS has been dependent since its inception on hiring doctors from overseas, who were mostly dispatched to the least glamorous jobs in the least attractive parts of the country where UK graduates were reluctant to go. Now, for the first time, the NHS is self-sufficient in doctors, thanks to the huge expansion of medical schools since Labour came to power. Having plundered the world in the past for its medical expertise, it is payback time for Britain.

It is true that junior doctors have plenty to complain about. But the BMA, one of Britain's most powerful trade unions, thanks to its highly educated, highly paid membership, is extremely successful at banging its own drum. While the juniors have genuine grievances, they are also members of a professional elite that is better paid and better resourced than ever before, thanks in large part to the BMA.

Why, then, are doctors so angry and disillusioned? Only last week the National Audit Office (NAO) reported that consultants had enjoyed a 27 per cent pay rise over the past three years, taking average pay to £110,000, while their hours of work had fallen. Yet they are grumpier, and some even confessed to clock watching, according to the NAO . GPs, too, whose pay has risen even more spectacularly and whose average earnings now outrank consultants', complain of being turned into paper pushers, practising "cookbook medicine", scoring points and hitting targets.

The dismay extends to nurses and administrative staff, who have threatened strike action over their staged pay awards, and managers struggling to balance books - one-third of NHS trusts ended last year in deficit - who are disheartened by constant NHS reform.

Ministers may wonder what has gone wrong, after five years in which the NHS budget has grown faster than at any time since its foundation, waiting lists have plummeted, cancer and heart disease deaths have fallen, and even hospital food has improved. Lord Warner, the former health minister who resigned at Christmas, remarked this week that the productivity gains in the NHS had been disappointing given the size of the investment, accounting in part for the pervasive air of disappointment.

The truth is that many of the problems the NHS faces are intractable. Medicine today is less about curing illness than helping people live with their chronic disease, be it cancer, diabetes or the aftermath of a stroke. An ageing population, and advances in medicine that mean more can be done for each patient, add to the pressures. Working in the NHS is like painting the Forth bridge - a neverending struggle to stave off the forces of decay.

It is remarkable, then, that David Cameron's Conservatives have chosen to kick the issue of the future funding of the NHS into the long grass. By committing his party to a tax-funded health service free at the point of use, Mr Cameron has in effect ruled out all other options for at least a decade.

Yet money will be the NHS's key problem after this year, when the growth rate slips from its current annual 7 per cent to an expected 3 to 3.5 per cent. Voices, still on the margins but growing louder, are being raised about the need for top-up payments to supplement NHS care. The private health insurer Western Provident Association launched a scheme yesterday to help tackle the postcode lottery in cancer drugs, by offering NHS patients the right to receive any cancer drug recommended by an oncologist but not yet available on the NHS, in return for a small annual premium.

At least half a dozen cancer drugs are due to come on to the market in the next few years, costing up to £100,000 a year. Specialists say this will be unaffordable by the NHS, and the WPA scheme is mischievously aimed at causing maximum embarrassment to the Department of Health, which forbids the mixing of private and NHS care.

This is an early skirmish in what is set to become a long and painful battle. Optimists say the NHS has always been deemed unaffordable, and yet it has survived. Pessimists say the cost pressures building are on a scale never seen before. On its outcome will depend not only the future of the NHS's doctors and nurses, but of its patients too.

j.laurance@independent.co.uk