Health secretary stands his ground - but still has pay-round joust to come

It has been a week of high politics and heavy politicking. Claim and counter-claim have been relentlessly traded through the public prints and the studio airwaves, with barely restrained rancour at times reminiscent of that other titanic struggle taking place across the Atlantic.

Instead of presidential contenders Al Gore and George W Bush, we have had health secretary Alan Milburn and British Medical Association chair Dr Ian Bogle slugging it out over the chances of the NHS plan's promises on primary care becoming reality by the target date of 2002.

The BMA argues that the government's ambition for every practice to offer appointments within 48 hours in the next two years would need an extra 10,000 GPs, not the 2,000 Mr Milburn has identified. Some hope, says Dr Bogle. But has the BMA's famed political adroitness met its match? The government mounted a multi-faceted defence, undermining its opponent and bolstering its own case.

Dr Bogle, it was pointed out, had signed the very same NHS plan from which he was now seeking to dissent. Were his comments a cheap attempt to revive sagging support from his own members? The BMA was currently involved in negotiating next year's pay rise for doctors, so anything Dr Bogle said had to be interpreted accordingly - and dismissed accordingly, was the implication. Between a third and a half of practices already achieved the 48-hour standard, said Mr Milburn - so why couldn't the rest?

Examples of where this had happened without extra manpower were helpfully pointed out.

Senior medical luminaries such as Professor Sir George Alberti and Dr John Oldham were fielded to take issue with Dr Bogle's doom-laden prophecy, with the chorus ably assisted by the prime minister's official spokesman, Alastair Campbell: remember those scars on Tony Blair's back from battles with the change-resistant public sector, was the subtext.

And indeed, the BMA has made a serious misjudgement if it underestimates the strength of public dissatisfaction with long waits for GP appointments. But though ministers are right to set demanding targets for tackling this, the BMA is not entirely without grounds for concern. It is certainly a fine calculation whether the government's intended means of plugging the GP shortage will succeed in doing so. Tapping into the supply of overseas and refugee doctors, and dissuading some existing GPs from retirement may help draw in and preserve much-needed talent. But it must not be at the expense of quality.

Morale remains fragile in general practice, while expectations for pay have been fuelled by the NHS's extra billions, the chancellor's burgeoning surplus and the proximity of the next general election. Mr Milburn may have skilfully parried the BMA this week; how will he emerge from the far more testing joust of the pay round?