Continued critical support is unrealistic; the British Medical Association needs to move to a stance of outright opposition to the Health and Social Care Bill.
Since the announcement of changes to the NHS in July 2010, the BMA has practised a cautious approach of critically engaging with the coalition's proposals. Concerns which have been highlighted have largely been ignored by the government. The independent trade union and professional association represents over 140,000 members and could be a strong voice. At the Special Representatives Meeting (SRM) of the BMA convened for 15 March 2011 the views of all doctors across the country have the chance to be heard for the first time.
A snapshot survey of doctors throughout the country found an increasing opinion that at the SRM the body must move to all-out opposition to the Health and Social Care Bill. All respondents to the survey recognised absolutely a need for change in the NHS. None felt the proposed reforms represented the correct solution.
"A great bear trap"
Mutually reinforcing clauses in the Bill include some initiatives which might have been welcomed. Some form of clinician-led commissioning was popular amongst those contacted. Unfortunately these are inextricably linked to what doctors perceive to be grave problems.
Commissioning would not place non-GP clinicians on a statutory footing. A consultant in the North East BMA region approved of the principle of clinician commissioning, and recognised the role of GPs as managers in some form but cautioned "it is different to have to make decisions about the wider population".
The fear that increasing transaction costs, estimated in a report  by the Health Select Committee to be 14 per cent of NHS budget, would divert ever more funds away from patient care was raised almost unanimously.
Survey participants felt the BMA's GP membership could have hoped to retain a measure of influence by remaining involved in the progress of the Bill. As the good initiatives remain bound "in the middle of a great bear trap", any form of support should now cease. The sum of its good and bad parts renders the Bill unpalatable as a whole.
The BMA's current stance does not reflect the views of its membership
The BMA is divided at a regional level into 10 councils. Asked how members of the profession are able to express their views, one respondent referred to regional councils as "the most straightforward route". At regional meetings, members have increasingly polled for motions to be put forward pressing the body to abandon its critical stance in favour of outright reform.
At the most recent BMA London meeting doctors voted overwhelmingly for such a motion to be heard at the upcoming SRM. The North East regional council, City and Hackney BMA division and Islington division have submitted similar motions.
The BMA's GP membership, which is apparently set to increase in power if the reforms go ahead, might be expected to largely favour the changes. However, no significant section of its membership provides a mandate for the BMA's continued support of the Bill. A survey by Pulse  reported more than 60 per cent of GPs were in fact against the general direction of the proposed reforms. This was later echoed by a Royal College of General Practitioners survey . A doctor in the North West BMA region cited examples of GPs leaving practice because of the prospective changes, and anticipates this becoming a trend if the Bill is enacted in its current form.
The BMA has reputedly refused to convene an SRM before now; 15 March represents its opportunity to rectify the situation by listening to its membership's increasing calls for outright opposition.
A detached BMA leadership
Asked about being able to present a viewpoint, a second year foundation doctor responded, "being a humble F2 I don't think they would hear me." One consultant referenced the period from the White Paper's publication in July 2010 to the end of the year; regarding his meetings with approximately 500 junior doctors, "most of them did not have a clue what was going on". Forums on the website doctors.net.uk  are one avenue for less senior doctors to express opinion, but as one consultant commented, "ultimately you are in the hands of a very small number of senior people".
The lack of engagement was summarised by a first year doctor in the South Central BMA region "if I was a bit more active in accessing information I am sure I would find it, but junior doctors have not really been made aware through a BMA presence at our teaching sessions or our continuing development events."
The junior doctors contacted all held opinions on the issue. In common they concluded the current BMA policy was too cautious, and that the body had been too slow to react. One foundation level doctor felt the BMA had "reacted to the issue as it became of wider interest in the media". All felt the BMA should oppose the Bill outright.
If the BMA leadership continues its policy, it risks cementing its image as a body detached from its junior membership, who are going to bear the full weight of any changes enacted over the longer-term.
Chaos alongside the cuts
The reality of the cuts, both immediate and over the course of the Parliament is displayed in a spreadsheet available via the Guardian  website. Asked how doctors envisaged managing the cuts and implementing the reforms if enacted, responses ranged from "chaos", "disaster" to simply "I don't see it". Those in areas where cuts have not been announced felt the situation was already "chronically busy, and any more would be unmanageable".
Increased use of expensive agency nurses and locum doctors who often make up the shortfall in care provision was described as economically counter-productive, but necessary given the labour-intensive nature of the NHS.The BMA cannot choose which parts of a law it implements. Moving to outright opposition in the hope of forcing down the Bill was perceived to be the best chance of developing legislation that balances the government aims of cutting inefficiencies and improving services.
The government has at best been unresponsive. Several concerns raised such as ensuring a statutory role in the commissioning process for all clinicians have not been carried through. The White Paper has not markedly altered in its legislative passage since July 2010; a comparison of the White Paper  and resultant Bill  can be made here. Asked how doctors envisaged managing the cuts and implementing the reforms if enacted, responses ranged from "chaos", "disaster" to simply "I don't see it". Those in areas where cuts have not been announced felt the situation was already "chronically busy, and any more would be unmanageable".
"The NHS is a bigger issue politically than forests, and therefore the Whips will be enforcing votes in the Commons", according to one survey respondent. Tory MP GP Sarah Woollaston  was recently banned by party Whips from sitting on a committee charged with scrutinising the legislation. David Cameron discussing the decentralising of public services in the Telegraph  no longer makes any pretence of protection for the health service.
So what will the BMA leadership do? The Government has made its aims clear and health professionals are gathering en masse in opposition. On the evidence and with little time left for manoeuvre the BMA should view its upcoming SRM as the chance to revise the official position.