Speech from the Chairman of Council, Dr Ian Bogle, CBE
Monday 30 June 2003
Chairman, members of the Representative Body. This is my last speech as Chairman of Council.
I prefer to say my goodbyes in private, but I must begin by offering my thanks to BMA staff and Council colleagues for their support over the past five years.
This can be a lonely job at times, but their commitment, their encouragement and their companionship have helped keep my spirits, and my sanity, intact.
I have been at the helm of the BMA during one of the most interesting and challenging periods in its history – moves towards greater openness and accountability in assessment of performance and fitness to practise, three major contract negotiations and a government modernisation programme that will have far-reaching consequences for the future of the health service and the future of the medical profession.
When I leave this stage for the last time on Thursday, I will be bowing out of medicine and medical politics for good.
The one memory that will linger long after the sweet taste of negotiating successes and the sour taste of acid encounters with self-serving secretaries of state have left my palate is the creeping, morale-sapping erosion of doctors’ clinical autonomy brought about by micro-management from Whitehall which has turned the NHS I hold so dear into the most centralised public service in the free world.
The stifling of innovation by excessive, intrusive audit and the imposition of Department of Health diktats.
The shackling of doctors by prescribing guidelines, referral guidelines and protocols.
The suffocation of professional responsibility by target-setting and production-line values that leave little room for the professional judgement of individual doctors or the needs of individual patients
No doctor has any trouble signing up to genuine, evidence-based efforts to drive up standards and improve the quality of services to patients.
But the paranoid centralism which has characterised this and previous governments’ handling of the NHS will not lead to improvements in patient care. It will turn professionals into bean counters answerable not to their patients but to politicians, auditors, commissioners and managers under pressure to deliver on edicts, priorities and targets emanating from Richmond House.
I’m nearing the end of a 40-year career in medicine – a career that I have loved and from which I have drawn enormous personal and professional satisfaction.
Nothing comes close to the unspoken but absolute trust that exists between patient and doctor, to the privilege of being let into people’s lives and people’s thoughts, to the patient who says ‘Thank you doctor, that helped’.
But when I look back over my career and how the practice of medicine has changed in that time, there is one thought I cannot shake from my mind. The challenge, the responsibility, the risk that I relished, and that I regarded as being fundamental to my professional status, have all but disappeared.
When I first went into practice against the wishes of my father, who was a doctor himself but wanted me to be a dentist because the pay was better, I wasn’t interested in financial rewards. I wasn’t interested in adulation from awe-struck patients or being hero-worshipped by nubile young nurses. I wasn’t interested in achieving immortality as the discoverer of some rare and exotic disease.
I became a doctor because I wanted to help people who were ill or in distress. I earned £9 a week and I was on duty for four nights out of seven.
My motivation and my satisfaction came from knowing that I was able to apply my knowledge and exercise my judgement free from control or interference from outside the consulting room.
I felt free, and safe, to do what I thought was best for those in my care.
I was only in my early 20s when I faced my first life or death test - a seven-year-old boy with a congenital heart condition, in heart failure, and sent home from hospital to die because the surgeons didn’t think he would survive an operation.
I discussed the options with his mother – let him die or take a chance with radical treatment that might save him.
With her consent, I administered four times the recommended adult dose of a powerful diuretic new on the market in an effort to get him fit for surgery.
I wasn’t even sure whether the drug was licensed for use in children, but I was sure that if I did nothing he would be dead within a week.
His condition improved dramatically, and after I’d fought tooth and nail to get the surgeons to see him again, he was operated on and survived.
That seven-year-old is now a strapping 48-year-old with children of his own.
I took a risk in the hope that it might save a boy’s life. I wouldn’t take that risk now.
I am in no doubt that my career would be on the line if I acted outside accepted protocols for the treatment of certain conditions.
I accept, like all of us do, that national standards, quality markers and assessment of individual and team performance are essential in a modern, patient-centred NHS.
Transparency and accountability are the counterweights to clinical freedom.
But remove the responsibility, remove the risk, remove the challenge in practising medicine and you remove a large part of what being a doctor is all about.
We spend a lot of time at the BMA talking about low morale in the medical profession and what needs to be done to address it. We have rightly identified workload, work intensity, patient demand and increasing bureaucracy as factors contributing to its continued downward spiral.
For me, and I suspect for many of my colleagues who are contemplating early retirement, leaving medicine in mid-career or asking themselves early on in their careers whether medicine was the right choice for them, the biggest demotivator has been the deprofessionalisation of medicine brought about by protocols, guidelines and government targets.
Ministers and managers have muscled in on the doctor-patient relationship, and we now have a healthcare system driven not by the needs of individual patients but by spreadsheets and tick boxes.
Clinical decisions have been taken out of clinicians’ hands and the fundamental NHS principle of care based on need and need alone has been superseded by the principle of care based on numbers.
Targets are set nationally without any appreciation of what they might mean for individual doctors sitting in consulting rooms with individual patients.
If you set targets for the treatment of one group, you automatically disadvantage others whose clinical need may in fact be greater.
If you set targets for access to services, you encourage those providing the services to give more thought to throughput of patients than to what is actually wrong with those patients and what their individual treatment needs are.
Our own survey of A&E consultants carried out in March this year after a pre-announced seven-day Health Department audit of waiting times in casualty departments in England uncovered the extraordinary lengths to which some hospitals will go to pull the wool over the auditors’ eyes.
More than half bussed in temporary staff, and bussed them back out again as soon as the audit was over.
A quarter made staff work double or extended shifts.
Sixteen per cent cancelled routine surgery so beds would be available for patients admitted through A&E.
There are countless other examples of the trickery and ruses used by managers to please their political masters.
Keeping patients in ambulances because the A&E waiting time clock doesn’t start ticking until they arrive in the department.
‘Warehousing’ patients in A&E departments because of a lack of available inpatient beds.
Classifying patients on trolleys as ‘admitted’ to hospital even though they have no access to food or hygiene facilities.
Putting patients on reserve waiting lists so they don’t appear on the waiting list proper.
Admitting patients who are near the waiting time target limit to hospital at the expense of patients whose need is greater but who haven’t been waiting as long.
Pushing through small, swift, non-essential operations at the expense of those that require a theatre or bed space.
And if all else fails, cheat – or as the National Audit Office more politely puts it, make ‘inappropriate adjustments’.
‘Inappropriate adjustments’ identified by the NAO in its investigation into waiting list manipulation included excluding patients from lists until the month of their appointment and telephoning patients to find out when they were going on holiday then offering them admission dates during that period.
You would think wouldn’t you that the government would be distancing itself from these corrupt and immoral practices. Instead, it has turned a blind eye, been triumphalist about its ‘achievements’ and colluded in the deception and doublespeak.
Did you know that the official definition of a bed according to this government is, and I quote, ‘a device that may be used to permit a patient to lie down’?
This rather conveniently means trolleys and examination couches can be counted as beds for statistical purposes. But why stop there? Why not put up hammocks in hospital car parks? Why not ask patients to bring sun loungers and sleeping bags from home?
When the BMA criticises the target culture and warns that the billions of pounds of extra investment in the NHS aren’t affecting the frontline delivery of services on a large enough scale to make a real impact on the public or on the professionals providing those services, we are accused by government of scaremongering and of wanting to veto reform.
Only two months ago, the Commission for Health Improvement, the government’s own health service watchdog, warned that recent improvements in the NHS were at risk because the concentration on short-term waiting targets meant managers were struggling just to keep the show on the road.
Only three weeks ago, the Audit Commission warned that there were too many piecemeal targets which obscured real healthcare priorities, and that trusts were diverting money away from future projects in favour of quick fixes to keep services going.
It called for fewer targets and for ministers to allow NHS managers and medical staff to be left to decide how best to achieve them.
In its own press release on the launch of foundation hospitals, the Department of Health promised that ‘the best hospitals will be freed from excessive Whitehall control’ – a seemingly remarkable admission by the government about the misguidedness of its own approach.
If Whitehall control is excessive, then why not remove it from all hospitals?
The use of targets to drive up quality and measure improvement is not a bad idea.
Good targets, like those for a reduction in death rates from heart disease and cancers, are drawn up by clinicians for clinicians, not by politicians looking for a quick fix to appease an expectant and impatient public.
Politically-motivated national performance targets based on quantity not quality offer no room for local flexibility and encourage short-term gain at the expense of long-term improvement.
Politically-motivated national performance targets based on quantity not quality offer no incentives for managers or clinicians to improve the standard of the services and care they provide.
Politically-motivated national performance targets which come with a threat of penalties and punishment for those who fail to achieve them make honest people dishonest.
Politically-motivated national performance targets have driven a wedge between doctors and managers.
The consultant contract ballot went down in England and Wales not because there wasn’t enough money attached, not because doctors are resistant to reform.
It went down because consultants were not prepared to submit to a level of ministerial and managerial interference in clinical decision making that would have been intolerable, and would have made a mockery of their professional responsibility and their duty of care to their patients.
Consultants who voted against the contract voted against a proposed extension of their NHS hours into evenings and weekends not because they wanted more time on the golf course or more time to do private practice, but because they suspected most managers would want to use those extra sessions to hit politically-motivated productivity targets with no clinical evidence base.
The father of the NHS, Aneurin Bevan, once famously remarked that the sound of a bedpan falling in Tredegar Hospital would resound in the Palace of Westminster.
More than 50 years, and countless restructurings, later, Nye Bevan’s words resonate loud and clear with those of us who have watched successive governments pay lip service to the ideal of decentralisation while at the same time trying to retain their iron grip on the NHS from Whitehall.
Given this government’s obsession with issuing diktats on the minutiae of NHS activity, I’m surprised there isn’t a target for the passing of motions. The auditing of every bowel movement on every ward in every NHS hospital would be a fitting memorial to Alan Milburn now that he has decided to spend more time with his family.
Mr Milburn may not have noticed, but consultants have families too. It is a pity he was not able to appreciate their predicament when he was trying to force them to work evenings and weekends.
There are major challenges ahead for my successor, and for the BMA.
We must persuade government that if it is prepared to engage the medical profession in a debate about the future of the NHS, it can restore the medical profession’s confidence in its handling of the NHS.
We must persuade government to re-open a constructive dialogue with parts of the profession where relationships have broken down.
We must look at our own organisation – at how we work, at how we represent our members, at how we communicate with our members, at how we negotiate on behalf of our members.
And we must not be resistant to change within our own organisation if it will mean improving the way we work, improving the way in which we represent our members, improving the way in which we communicate with our members, improving the way in which we negotiate on behalf of our members.
Above all, we must fight to restore our professional status, and to convince government that the way to deliver sensitive, patient-centred healthcare is to allow doctors to exercise autonomous clinical judgement, and to accept the risk, the responsibility and the accountability that go with it.
At the risk of sounding pompous, medicine is an honourable profession, a noble profession.
I am proud to be a doctor.
The right to practise medicine as a professional and not a government bean counter is worth fighting for.
Please don’t give up that fight.
Chairman, I move.
 | |