Profile: Scalpel to blunt an axe: Dr Sandy Macara: He is leading the BMA out of the sickroom. But where to? Jack O'Sullivan reports

IF Virginia Bottomley hoped that her National Health Service reforms might at last be edging into public and professional acceptability, she had reckoned without Dr Sandy Macara. Last week Dr Macara, the new chairman of the British Medical Association, fulminated against the Government's changes in a tirade worthy of an old socialist rally. Delivering a stirring sermon to his flock at the BMA's annual conference, he likened the crisis to Milton's Paradise Lost - 'a classic allegory of the fall of man which may be applied to the decline of the NHS as a treasured national institution'. The reforms had failed the Conservatives and failed the nation, he declared.

In clipped tones reminiscent of Andrew Cruickshank in Dr Finlay's Casebook, he warned: '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 professions in the healthcare system.'

Mrs Bottomley's familiar litany of statistics is no match for such oratory, which brought a two-minute standing ovation for a man hampered in his teens by a stutter. Doctors who feel sidelined by the changes, threatened by new managers and angered by performance-related pay had found a champion. They may not have left Birmingham with a firm idea of how to tackle the Government. But Dr Macara certainly made them feel better. 'He has given us the heart to carry on,' said Dr Tony D'Souza, a public health consultant from Surrey.

It was a triumphant maiden conference as chairman for Dr Macara. Last year he ousted the incumbent, Jeremy Lee-Potter, in a palace coup. His predecessor's softly-softly, behind-the-scenes approach to ministers won few plaudits in the conference hall and achieved little tangible advance for the BMA. Dr Macara's task was to raise the political temperature and echo the megaphone diplomacy that was the BMA's response when the NHS reforms were first brought forward by Kenneth Clarke in the late 1980s. .

He is part of a long Scottish medical tradition, still visible at the top of British health care. It includes Alan Langlands, NHS chief executive, Kenneth Calman, Chief Medical Officer, and Sir Robert Kilpatrick, president of the General Medical Council. More important, he is also part of what, until recently, was probably the most successful interest group in politics.

Dr Macara, after all, is nothing more than a trade union leader, defending, with a revenue of pounds 40m a year, the interests of 90,000 highly-paid workers. Others unions have tried to give the appearance of transcending sectional interest: the rail workers speak of their concern for the passengers, the teachers for the pupils. But only the BMA really brings it off. 'Patients will suffer unless doctors get more,' is, the medical correspondents joke, one of their staple stories. If politicians and public believe it, it is because the doctors believe it themselves.

Macara genuinely sees the NHS as the bastion of a British tradition for equity and fairness, one of the few institutions that treats citizens in a classless manner. But the BMA's past clashes with Labour governments have been no less bruising than those with Conservatives; it was when Barbara Castle was Minister of Health in the 1970s that they threatened mass resignations over pay. Indeed, the NHS came into being only after the most protracted battles between the BMA and Aneurin Bevan. Then as now the language was apocalyptic: one former BMA secretary accused Bevan of setting himself up as a 'medical Fuhrer'.

Dr Macara, a slight, dapper figure, looks like a member of Labour's Scottish establishment. Admired for his integrity, honesty, and sense of duty to the less well-off, he would seem to come from the John Smith stable. As a young doctor he saw poverty in Glasgow. Yet Sandy Macara was a member of the Conservative Party until the recent changes in the NHS. He sat on the national committee that formally handed the leadership to Harold Macmillan after Suez. He might easily have stood for a parliamentary seat. His tale is a testimony to the way many traditional One Nation Tories have lost faith in today's Conservative Party.

ALEXANDER Wiseman Macara was born in May 1932 in Irvine, Ayrshire, to a family immersed in religion. Father and grandfather, each named Alexander, were Presbyterian ministers. Both were orators, the older of the Old Testament tradition ministering in Denny, Stirlingshire, the younger more poetic, a lover of Browning. They led a privileged life in a large manse with three acres.

Macara's father was a restless spirit who kept a rose garden of international fame, entertained the working men's guild on the pianoforte and organised youth festivals and operettas in Irvine. 'His world was the parish and his parish was the world. That was a model that I believe I have unconsciously followed. He was the parish social worker and we were his assistants, mother and myself.

'I grew up with the assumption that one was at the heart of the community. It was a terribly exacting childhood. You were the minister's son, expected to win prizes at school, be a model of behaviour. There were expectations I could not meet. My father had been a great footballer, played for the Scottish schoolboys, and a superb golfer. I could not match him.'

His mother Marion had been a civil servant in London before marrying. She was an ideal minister's wife, but frustrated at being limited to that role. Her son never quite understood her nor felt understood. He still grieves that she seemed unable to appreciate how he could be a doctor and not actually treat patients.

At six, Macara fell ill with paratyphoid fever, acute appendicitis and whooping cough. He was 12 before he attended school regularly. But during three months in hospital he found his vocation. 'The young consultant was an almost God-like figure. He saved my life I suppose. Tom Anderson went on to be Professor of Public Health and was my mentor when I was a student at Glasgow University. I decided I wanted to be a medical officer of health. It was like being a clergyman. You had your own community. Dad encouraged me. He felt that, as a Christian, I would have two strings to my bow. I don't feel that I have let the family tradition down.'

The highly competitive and driven young Macara was the dux (first in studies) at school. But at university Tory politics grabbed his attention and failed exams delayed his graduation by a year. His grandfather had been an independent councillor and friend of Tom Johnston, a Labour minister in 1929-31 and a towering figure in Scottish politics.

'In Irvine, there were only three sorts of politicians that counted. The Scot Nats were clearly odd, so no one took them seriously. To me, the Moderates - now they would be called Conservative - were by and large the sensible, middle-of-the-road, worthy types of citizen. Some of the Labour councillors seemed to be bitter people. There was a certain sense of class war about them. There was still some mining in the area and I remember how the conditions were deplorable. It is only now that I can understand the bitterness. That jarring note was not the spirit of the church. It clashed with our ethos.'

Dickson Mabon, later a Labour MP, tried desperately at university to change his mind. ' 'You are the son of a minister,' he said. 'You don't have much money. You understand how ordinary people live. Why do you want to be with that lot?' It shook me. It was not the way I saw it.'

Macara's life as an active Tory did not, he says, last beyond his thirtieth birthday. By then he had left Scotland for the London School of Hygiene and Tropical Medicine. He thence pursued an academic career in public health at Bristol University and enjoyed a steady rise in medical politics. He met his future wife Sylvia in Bristol during a weekend training course. She comes from a similar background - a Baptist, hardworking family. A zoology and chemistry graduate from Cardiff University, she is now a deputy head teacher at a girls' independent school. They have two children, Alexandra, 21, and James, 18.

Dr Macara is likely to enjoy a full five-year term as the BMA's chairman. Leaders who make their names as opponents of the Government rarely face internal threat. As one insider said: 'Jeremy Lee-Potter achieved a fat zero out of 10 in his dealings with ministers. But the membership would be more likely to accept a fat zero from Sandy because he makes them feel good. The danger is that, without criticism, the leadership avoids facing up to where the BMA should position itself.'

The toughest issue now for Dr Macara is not the conference hall but setting out a positive agenda. Despite the past week's public posturing, he is more respected by ministers than was Dr Lee-Potter. Performance-related pay for hospital doctors will be the key issue. Splits within his own organisation over GP fundholding, now adopted by 30 per cent of family doctors, will make it difficult to find a satisfactory solution to that problem.

Dr Macara is not a particularly creative thinker. He is, in his guts, a conservative, fighting for what he fears will be lost to fragmentation and competition.

But he has the sense to seek help from within his organisation. And he has a clear vision of a classless health service. It seems rooted in what may have been a mythical Irvine of the past, perhaps even a mythical NHS. But it is a powerful vision that has caught the mood of the times.

(Photograph omitted)