The New Statesman Profile - British Medical Association
Tony Blair may think it a conservative force, but it has been weak in protecting the health service.
The British Medical Association (BMA) describes itself as an independent trade union, claiming to protect its members' professional interests. Its mission statement is "to promote the medical and allied sciences, and to maintain the honour and integrity of the medical profession". As a member, I am supposedly kept up to date on clinical issues, advised on contracts of employment and terms of service and assisted in the resolution of disputes in the workplace. It promises me aid in matters of medical ethics and, as a bonus, will help me with financial planning, guide me on taxation and pensions and provide me with access to preferential personal loans.
The BMA, with its 120,000 members, claims to be "the voice of the profession"; and it is indeed officially recognised by the government and the pay review bodies as the sole representative of all NHS doctors in hospital and community services. It doesn't sound a very sinister or dangerous body, yet nobody was in much doubt that, when the Prime Minister denounced "conservative forces" at the Labour Party conference, Tony Blair had the BMA in mind, along with hereditary peers, fox-hunters, Civil Service mandarins and Labour activists.
The charge is a familiar one, but many doctors may wonder why the BMA should attract so much political hostility. It has always struggled to convey some sort of unity in a profession that has so many squabbling branches and conflicting interests. The stresses of financial and managerial accountability have simply heightened the divisions, leading to internecine squabbles over matters such as ward closures, hospital reconfigurations, the constitution of primary care groups and management of inadequate budgets. While we doctors fight among ourselves, the politicians can portray us as arrogant, self-serving and smug, clinging to our "we-know-best" mentality (not a charge that could be levelled at anybody at Millbank, of course) and stubbornly resisting change.
Yet as a profession we doctors have had to absorb increasing pressures to increase our workload while saving money, find time to train junior staff and carry out audits, attend endless meetings on contracts, continually medically educate ourselves and come to terms with clinical governance, drop-of-a-hat litigation and trial by tabloid.
What has the BMA done for its members during these trying times? Well, it has introduced a round-the-clock counselling service for stressed doctors, a sort of in-house Samaritans. Yet on the closures and mergers of the London teaching hospitals proposed by the Tomlinson report in 1992, the BMA has remained silent, lest it be seen as too pro-London. It swallowed the lie that London's loss would be the nation's gain and failed to represent the interests of London's consultants or to heed the argument that London was not oversupplied with beds. As the thrust of Tomlinson was to sacrifice hospitals to give more money to primary care (a promise as bare as Old Mother Hubbard's kitchen furniture), the BMA (two-thirds of whose members are general practitioners) set out its stall to be anti-London and anti-hospital. So much for representing the whole profession.
On the matter of junior doctors' hours and pay, the BMA faced a rebellion when the "good deal" it thought it had wrung out of the government was rejected by the juniors; and quite rightly so. It announced agreement on a new pay structure for juniors before it had been put to the junior doctors' committee.
The BMA claims to protect standards, yet it has not been vocal in highlighting the dangerous consequences of the restructuring of specialist training. The apprenticeship of ten years or more as a registrar and senior registrar often included a substantial period of clinical research. This taught the ability to interpret scientific data with a critical mind and allowed a seamless transition into becoming a consultant upon whom the mantle of final clinical responsibility sat comfortably. The new training scheme is only of six years' duration. Lip-service is paid to research, and much of it is clinically irrelevant. The products of this scheme take up consultant posts with less experience than their predecessors. They are therefore more vulnerable to clinical problems they cannot handle and are at increased risk of litigation.
As pot-shots are taken at the profession from all sides, it is currently safer to be a grouse or a fox than a medic. The tabloid press (and some broadsheets) publish unfounded allegations against doctors week in, week out. At the faintest hint of an accusation, and often with no justification, doctors may be suspended from their posts in a blaze of publicity, subjected to persecution on the doorsteps of their homes (with the totally irrelevant market value of their property published as well) and portrayed as mass-murderers.
Take the Bristol Royal Infirmary fiasco. The BMA could and should have taken a fiercely protective position when caring and competent practitioners were pilloried, convicted and sentenced in a process about as fair as that enjoyed by Captain Dreyfuss. BMA spokespeople should have been on all the main news programmes, to make the point ad nauseam that the vast majority of doctors are capable and sound and that one bad doctor is not a reason to vilify the entire crew, any more than is one bad politician or lawyer. True, an anodyne statement of sorts can be found on the BMA web page (if anyone seeking reassurance is sad enough to search for it), where the chairman of the consultants' committee states: "It is dangerous to rush to judgement and make scapegoats of dedicated consultants . . . We are in serious risk of creating a climate of fear in surgery, when every time a surgeon lifts the scalpel in a high-risk case, his or her career is in jeopardy. If the public cannot come to understand or accept this, we risk losing surgeons to early retirement."
Very dignified, but hardly Churchillian. The BMA, if it has any role, should be banging the drum in less esoteric places and driving home the message that if doctors are faced with an inquisition every time someone dies, then anything other than the most straightforward cases will be turned down, and patients who might do well with an operation will not get it. Defensive medicine does not benefit sick people.
It is almost as if the BMA is colluding with the media and politicians to drive down the image and status of doctors. How else could one explain its unwillingness to expose the charades of the previous and current governments in their attempts to hoodwink the public that the NHS is still "the envy of the world"? The Major administration produced the Patients' Charter, a glossy brochure designed to fool people that a week in hospital was akin to a week in the Caribbean. The reality was more a dodgy timeshare in Spain. The illusion is perpetuated by new Labour. Organisations with soothing names such as the National Institute for Clinical Excellence (Nice) and the Commission for Health Improvement create the impression that our beleaguered NHS is excellent and improving. In parts, it is; but no amount of massaging figures can hide the desperately long waits for treatment, the cancelled lists and the crippling debts of the hospital trusts. And the BMA has got nowhere in the fight to increase grossly deficient consultant numbers.
When the BMA does hit the headlines, it seems to shoot itself in the foot. In July last year, after some hasty back-of-envelope calculations, it announced that the availability of Viagra would cost the nation millions and millions of pounds and that GP surgeries would be flooded with work and unable to cope. Yet when Frank Dobson, the Secretary of State for Health, announced that the drug would be rationed, the BMA complained.
The BMA has fiddled while the NHS continues to burn. So why is it accused by the government of being conservative? How can it be resistant to change when it has resisted virtually nothing?
There may be two answers. First, the BMA is no more than an eclectic group of vested interests, as is the entire profession. Second, it values the status quo of the BMA as more important than the honour and interests of doctors. Like a school prefect, it wishes to keep in the headmaster's good books while retaining popularity with its classmates. It can protest, but not too loudly; rock the boat gently, but not capsize it. For in the background lurks the threat of imposition of central control on the medical profession. Farewell to the privileges of the BMA, farewell to self-regulation by the General Medical Council. The BMA may be resisting change, but only to itself, not to the working life of its members.
This could be its downfall. It should not fear confrontation with government and it should defend what it believes to be right. If it does not represent its members' interests without fear and prejudice, and offers only a friendly voice when they are stressed, or a cheap loan, then it must compete for attention with building societies, credit card companies and the AA.
If, however, it remembers that, in the grand scheme, governments are only transient, then the BMA could and should still be in the thick of things, long after the memoirs of the current cabinet are gathering dust on the bookshelves.
The writer is a consultant cardiologist at St Bartholomew's Hospital, London