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Depends on professional unity and respectful dialogue between the government and the profession
This year marks the 175th anniversary of the BMA. The association has been centrally involved in the evolution and stewardship of the medical profession and has made contributions to national and international health that go far beyond its role as a representative and negotiating body. It has had an important role in debates on abortion, euthanasia, global conflict and the proliferation of nuclear weapons, AIDS, genetics in medicine, and human rights. It must also take a good deal of the credit for the present ban on smoking1 and, of course, for this journal.
The BMA took a highly conservative and aggressive stance against Bevin's plans for the National Health Service (NHS) in the 1940s, but 50 years later found itself almost in step with the health departments after the abolition of the internal market. However, this sense of common purpose is now much more difficult to discern.
The BMA has been faced with many difficulties in engaging with the complexities of 21st century medicine and a highly politicised health service. The Shipman, Bristol, and Alder Hey enquiries,2 3 4 and a litany of errors, shook the foundations of public trust and professional confidence. Against a background of escalating healthcare costs, rapidly changing workforce and population demography, and the impact of the European Union, there have been recent difficulties with computerisation of the NHS and the postgraduate training system, doctors' contracts, and revalidation. The role of doctors, careers in medicine, and the future of a publicly funded health service have all been questioned.
As far as the health service is concerned, it is ironic that some countries where the commercialisation of health care has developed unchecked, and others wishing to develop cost effective equitable health systems, have looked to the NHS as a role model. The NHS has, historically, provided universal coverage, ready access, and high quality care for an enviably low proportion of gross domestic product, although this is beginning to change. The reason for this change seems to be the political manipulation of the NHS by a health department that either does not understand or has forgotten what has made the NHS a success. It has disastrously underestimated the extent and importance of hard work, commitment, professionalism, and pride in the service among its workforce. This has resulted in a progressive deconstruction of general practice, the transformation of hospital contracts into a shift system, the introduction of bizarre organisational arrangements in the name of patient choice, and widespread demotivation and demoralisation.5 6 Little surprise that relationships among patients, doctors, managers, politicians, and the media have become dysfunctional. And no surprise too that many of the NHS reforms have simply drained the new money.
Has the medical profession, in its retreat from out of hours responsibility and personal continuity of care, its support of market values, and its acceptance of central control finally sold out? Or, is it that the NHS reforms have somehow eroded the conditions under which professionalism and altruism flourish? Altruism is, after all, sustained by appreciation on both sides,7 just as professional respect and esteem are earned by the provision of compassionate care.
To say that the medical profession must unite to reaffirm its core values sounds like a statement of the obvious, but it is probably right. The profession certainly can't afford division. Ever since the NHS was formed, there has been an inevitable separation between primary care (general practice and community medicine) and secondary care (hospital medicine), which has often caused tension between professionals. Current funding arrangements—including practice based commissioning8 and payment by results9—could aggravate these differences. Similarly, friction between doctors and health service managers needs to be tackled by collaborative working, including greater participation of senior clinicians in the management of health services.
Medical education and the nurturing of professional values have an important part to play, particularly in moving towards a “new compact” between patients and doctors, put forward by Ham and Alberti, which spells out the rights and responsibilities of the government, the profession, and the public.10 Serious consideration should be given to proposals made recently to take the NHS out of party politics by creating new governance arrangements.11 All of this must be firmly underpinned by authoritative and consistent dialogue between the profession and the media.
These suggestions do not represent an agenda for a return to some lost, golden age of medicine, but rather an opportunity to reassert its enduring roles and values, which have been obscured by political and organisational turbulence. After the Cabinet Office's capability review of the Department of Health,12 there are signs that a new political administration may consider better ways of working with medical leaders and the NHS. The importance of doing so cannot be underestimated.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.