On Budget day, Barry Jackson was invited for afternoon tea at the office of the Secretary of State for Health. Tea was served with icing on the cake. Along with other mandarins of medicine, the President of the Royal College of Surgeons watched with delight as Gordon Brown delivered his billions to the National Health Service. Afterwards, Jackson and a handful of fellow luminaries repaired to No 10 for a meeting with the Prime Minister, who enlisted their support for the salvation of the NHS.
"He said he hoped the profession would work with government, and we all said we would; that this was a very exciting collaborative project. We were at one." Given the spirit of euphoria in which this pact was made, one expects Jackson to be wholly upbeat about the destiny of the NHS. Instead, his support for Blair comes oddly threaded with doubt.
I ask if there is a future for an NHS funded purely from general taxation, and he says: "The government believes, rightly or wrongly, that it can be done if it 'modernises' - their word, not mine. There are those who believe it is not possible. I have to be honest. There are quite a lot of Fellows of my college who don't agree with the government and who think it will not happen. If the government and the professions can't come up with a properly working NHS, given all the funding that has gone in, then three or four years down the line, one is inevitably going to have to look at another system. That is when the question of insurance, hypothecated tax or greater expansion of the private sector will have to be reconsidered by whichever government is in power."
Does he believe that Blair's last-ditch rescue mission of the NHS can work? "I would like to think it could be done, but I am not confident it can be. However, I will do all I can to try and make sure it happens . . . If the government's strategy does not work out - and it may not, though I hope it will - then alternatives will have to be faced."
Quashing his fears on the future of an ever more costly NHS, Jackson has just joined the launch of the "speed of access" working party, one of the groups assembled by Alan Milburn to help devise a national strategy plan.
We meet on the previous day, in Jackson's gorgeously antiquated office at the Royal College. ("The pigs' heads and bits of bodies are upstairs", an adviser tells me.)
Although he is an arch-reformer, whose modernising instincts contrast with his arcane surroundings, "modernisation", as applied to the NHS, is a word Jackson chews over in the manner of someone ingesting a suspect oyster. "I don't know what it means. That is the government's term. Three months down the line, the working parties have to find a blueprint that will work. Whether they will or not, I don't know. I hope desperately that they do, but I can't guarantee it." Given this uncertain prognosis, one wonders quite what he might say, had Blair not locked him, and others, so skilfully into the reform process. That Jackson still chooses to air doubts suggests both the gravity of his reservations and his adherence to openness and transparency: at one time rationed virtues in the Royal Colleges.
He, a popular head, has just been elected for his third presidential stint; confounding those who initially whispered that Barry was unlikely to cut it in this august world. A gastrointestinal surgeon at St Thomas's Hospital and consultant surgeon to the Queen, Jackson was an Essex boy who left school at 16 and worked for a firm making surgical instruments. Finally, he took medicine as a mature student, acquiring a wife and a baby before he qualified.
Now he oversees less glorious personal outcomes: too few specialist training posts and consultants' jobs; and, for those who do make it, empty operating theatres, overwork and the black accolade of presiding, in the fields of cancer and heart disease, over the worst records in Europe. I ask him how bad the picture really is.
"Very bad. We desperately need more consultant surgeons to maintain standards and train the next generation. Morale among surgeons is lower than I can ever remember. There is frustration over waiting lists, delays, cancelled operations; being told to operate on a less clinically important patient rather than someone more urgent, in order to diminish waiting-list time. If I have one message to the government, it is to raise the morale of the surgical workforce."
This litany echoes the sentiments of Lord Winston, whose views in the New Statesman on the state of the NHS were, Jackson believes, a catalyst for the vast boost in health spending. "I think the government had been thinking of increasing funding for a long time. Winston's comments focused their minds." One of Winston's gripes - viewed as particular heresy by Labour spin-doctors - was that the government had failed to abolish, as promised, the Conservatives' internal market.
Jackson goes further. In his view, new Labour reforms have made things worse. "It is terribly important that a GP can refer a patient to the appropriate specialist centre. A new system, under which extra-contractual referrals were abolished a year ago, makes that more difficult. That is very disappointing and not right for the highest standard of patient care." So is the purchaser/provider split more pronounced even than under the Tories who introduced it? "That is the logical consequence. The answer must be yes."
Such thoughts offer a sombre backdrop to government buzz on improvements, overseen in the most flawed areas by two much-hyped and newish tsars: Roger Boyle for cardiology and Mike Richards for cancer. "I can't speak for cardiology, but I think Mike Richards has an enormous problem . . . There is concern among many of my surgical colleagues that an oncologist has been appointed, rather than someone with a greater surgical knowledge. Surgery is the mainstay." Does Jackson mean that the government is deliberately placing too much stress on cheaper cancer treatment, such as radiotherapy and chemotherapy, rather than expensive surgery?
"I don't think we're going up the wrong route," he says carefully. "But we are going up an alternative route. Radiotherapy and chemotherapy are very important components. It is equally important that there should be strong supportive measures from the government for surgery for cancer." And is that support (one that most patients would take as a given) not forthcoming?
"I hope it's going to be forthcoming. I am working in every way I can to promote that point of view with the government."
But a president's role is not simply to referee a debate between slippery ministers and beleaguered surgeons. Jackson took office just after the release of the General Medical Council report on the Bristol children's heart scandal, at a time when the surgical fraternity was lambasted as protectionist and unaccountable. His mission was first to dispel the image of his Royal College as one of a phalanx of ivory towers answerable, in the words of one commentator, only to God; and, second, to press for revalidation (continuous assessment) of doctors - now at pilot stage - and audit of performance. "We are devising audit programmes, but it is not easy. It's a question of what your markers of success are."
Not removing the wrong kidney, I say, as in the recent Llanelli case. Or not being subject to the ministrations of Dr Rodney Ledward (admittedly not an RCS member), the gynaecologist accused of damaging a procession of women. "Mistakes will occur in any profession. What mustn't happen is sequential mistakes. A key thing is the change in culture. I was brought up to believe that you never criticised a colleague and whistleblowers were sneaks. That climate has altered totally."
Less balmy is the climate of the GMC. Surely Jackson, as a member of the council and an ardent self-regulator, must be disturbed by the ethos of a body which failed to strike off Dr Harold Shipman until after his conviction for mass murder? "I was appalled by that, and I said so when I was tackled on it by Mr Milburn. I didn't discover until later that, legally, the GMC was not empowered to suspend him during the trial under its antediluvian system."
That legal framework, now being revised, is not the only flaw. "I acknowledge the GMC has a very poor public image and is in need of reform. The ratio of medical to lay people is too high. It need only be a majority of one. Its size is unwieldy. 104 members is too high to be an effective body. Its manner of working needs a change, and I shall be taking part in discussions about that."
To drag the GMC into the 21st century is one thing; to rebuild the tottering NHS is quite another. In Jackson's view, this is both the final chance for a tax-funded service and a huge gamble for a prime minister who has staked his reputation on successful health reform. Is there not a danger that such an endorsement may lead to short-term thinking, geared to electoral advantage?
"I think it's potentially dangerous for him (Blair). He recognises that. That's why he's so insistent that something actually happens, so that in three or four years, if this government is still in power, the NHS won't be seen as a great election-loser. He has put his neck on the line. On the other hand, if things don't work out, he might be able to turn round and say the professions haven't delivered the goods."
But fears of collateral damage are left to the future. For now, Jackson is the fulcrum of a see-saw delicately balanced between sceptical colleagues and government aspirations.
"I have little doubt that government will put the best possible gloss on what happens. That is human nature. But at the same time, they have to back up their gloss with hard data. I shall be watching very closely, and so will others."
And what, given the cocktail of new money and old problems, is the best to be hoped for?
"That the public look on the NHS with the same enthusiasm as when I started my career 25 years ago," Jackson says, with the bright smile of a rationalist trying to persuade himself that miracles can also happen.