Speech from the Chairman of Council
Mr James JohnsonMonday 28 June 2004
Mr Chairman, it is now almost a year since I was elected Chairman of Council and this is the first time that I have had the privilege of addressing you and the RB. But first I should like to join you in welcoming members to this Conference to Llandudno and to Wales. Mae’n braf i fod yma yng Ngogledd Cymru am y tro gyntaf. (It’s a pleasure to be here for the first time in North Wales.)
I want to tackle three subjects today – none of them surprising choices – patients, doctors and health. Patients – in the context of choice and a multi-provider NHS; doctors - their careers and the support they need from the BMA in a changing environment – and the wider public health challenges we still need to address.
Firstly Patients
The legislation that created the National Health Service received the Royal Assent on 13 November 1946. It was the day I was born, so I have a sort of Midnight’s Children relationship with the NHS. I grew up with it. I am committed to it and I have worked in it for 35 years. Looking round the conference hall, I see no one who isn’t a child of the NHS.
The NHS is almost a national religion. But a monolithic approach to the health service severely limits choice. Choice for patients – and indeed choice for doctors. Choice, one can hardly fail to notice is currently the only show in town. The Labour Party has come to choice somewhat belatedly considering until recently, as the Times pointed out last week, Labour regarded choice as an unnecessary distraction. The Tories espoused it in principle but in reality did very little to provide it.
In a system that has limited capacity, has finite resources and for most of the last 30 years has been strapped for cash, choice has seemed an unnecessary luxury. Of course, exercising choice has consequences. Exercising my choice may limit yours and the better-off, middle class patient will work the system and reap maximum benefit from it.
Health will never be a true marketplace. Patients do not enter or leave it at will; they are dependent on the expertise of doctors, nurses and others; major decisions may be made for them while they are unconscious and generally they can not afford to take their custom elsewhere.
But choice is good – it’s certainly good for political speeches and manifestos-in-the-making. More importantly, it is right in principle - and is what we want for ourselves and our own families. But the capacity to deliver choice must be put in place. As doctors we can – and should – separate out the reality from the rhetoric.
We can sit Canute-like in conference halls in London or Llandudno and decry choice if we wish, but we will make ourselves irrelevant and we will be ignored.
Much better to work with patients to explore the boundaries of choice. That is why I made it an immediate priority, as a new chairman of Council, to set up a patient liaison group. We have already established a plain speaking but constructive working relationship. I hope that some of you will have the opportunity to meet their co-chairmen Barbara Wood and Stuart Burgess as well as other members of the group over the coming year.
We have reached a defining moment in the history of the NHS - with the two major political parties both saying that health care no longer needs to be provided by the state just because it is paid for by the state.
The Secretary of State, John Reid reassures us that the amount of healthcare provided to the NHS from the private sector will not grow to more than 10 – 15% of the total NHS output. But he may underestimate the speed at which markets can react when lucrative opportunities present themselves – and the NHS will be a £100 billion market in three or four years time.
The private sector itself is already affected by the Choice Agenda. They stand to lose perhaps half of their corporate business as waiting lists fall, because employers will no longer feel the need to insure their employees in order to get them back to work quickly. To respond to this corporate threat, they will need to secure replacement business by meeting the standards and offering services at the new NHS tariffs – a cheap and cheerful private insurance.
Make no mistake about this – whether the next Government is Labour or Tory, we face a fundamental shift in the balance between public and private provision. At present this is only a vision for England but the other nations of the British Isles cannot fail to be affected by the wind of change blowing through the English Health Service.
There are some major challenges to overcome. One of these is to help the most vulnerable, the most disadvantaged and the chronically ill to navigate the system and exercise meaningful choice. This is something I want to pursue with our patient liaison group and with other partners. We must not let “choice” mean choice for some and the devil take the rest.
A second glaring difficulty is capacity. Choice implies spare capacity and we are still woefully short of the doctors, nurses and health professionals we need to run a proper, 21st century service. The medical workforce is expanding – and I give due credit to the Government for investing in new medical schools. Over 32,000 new doctors have joined the profession since 1997. Even allowing for spin and double counting, that is serious progress.
But the effect of reduced hours and the rising number of women and part-time doctors in the profession will largely mop up this increase in doctor numbers. The effect of the Working Time Regulations alone requires 3,700 extra junior doctors this year rising to 9,900 new doctors when the limit for junior hours drops to 48 hours in five years time (2009).
There is another reason why this increase is not enough. Throughout the history of the NHS, we have relied on other countries to fill our NHS manpower gaps – both for nurses and doctors. As the fourth largest economy in the world we are still doing so – still taking doctors away from countries like South Africa and nurses form the Philippines , who need them more than we do. It’s a shameful record of exploitation. Surely after over half a century of the NHS we should be producing enough doctors to look after our patients.
Operation Thank you – which starts later this year, is a belated but sincere effort to pay tribute to the many thousands of doctors from India, Pakistan and Bangladesh who have been a mainstay of the NHS for the last 40 years and have often received scant acknowledgement or suffered outright discrimination.
Our President, Sir Brian Jarman, has done the profession and the public a huge service by demonstrating so clearly that doctors make a vital difference – the vital difference- to improving outcomes for patients. Put simply, hospitals with the highest ratios of doctors also tend to have lower mortality rates – when all the other variables such as case mix and social deprivation have been excluded.
So let us keep making the case for an expansion of the medical workforce. Today’s junior doctors want a better work life balance than people of my vintage. And rightly so. The pace of hospital life is faster and the pressures on general practice more intense. Working excessive hours at an intense pace is no longer sustainable as a lifelong working pattern. Nor is it good for patients.
We want to train more doctors, but I stress, more fully trained doctors. We must avoid creating a new underclass of SHOs perpetually treading water while they wait for an elusive training place in their chosen specialty. Patients deserve fully trained doctors – and we have to provide them without working them 72 hours a week. Never again must we create a career cul de sac for doctors and then compound the error by trapping our overseas trained colleagues in it. I am delighted to see the Staff and Associate Specialists Committee taking its place as a craft committee within the BMA and pledge to do my utmost to support its drive for a new contract - and soon.
Mr Chairman, the advent of the European Working Time Directive for juniors is only six weeks away. I pay tribute to the Herculean efforts of Simon Eccles and his team in doing more, much more, than any other body to prepare the NHS to be ready in August. The Hospital at Night project will not only help compliance with the Working Time Regulations but will arguably provide a better standard of care at nights and weekends for our patients.
It’s a pity the Department of Health didn’t get round to this two years ago as implementing these excellent proposals in the next six weeks is virtually impossible. Young doctors must not be coerced, cajoled or bullied into signing away or simply ignoring the rights which this Government signed up to on their behalf. If they are put under pressure, I pledge the full support of this Association in helping them. That is what membership of an organisation like ours is for.
One section of the profession or another has been engaged in tortuous contract negotiations since 1999. I am not going to dwell on them in detail – save to praise the effort and commitment of my colleagues from the JDC, CCSC and GPC – and to remind you that despite the difficulties that remain to be sorted out, each new contract represents real progress.
The juniors’ contract provided a powerful financial lever to oblige Trusts to reduce doctors’ hours – and where hours are still really excessive at least our junior colleagues are benefiting from punitive compensatory payments.
The consultant contract too offers new opportunities for a better work life balance at a fairer rate of pay. The only problem was the Department of Health made the mistake of believing its own propaganda about consultant working patterns. Trusts now find they cannot afford to pay consultants for the sessions they are genuinely working and on which the Trusts rely to reduce waiting times and provide a 24 hour acute service at full capacity and full stretch.
For GPs there is a ground-breaking new national contract that by association also benefits those on local PMS contracts. It is built around an evidence-based quality and outcomes framework unique in the world. It will give GPs greater job satisfaction, deliver better care and improved outcomes for patients, and provide substantially higher incomes. It allows family doctors to hand over their out of hours responsibility to their local Primary Care Organisation. And gives PCOs the chance to modernise the out of hours service and provide fully integrated health care at nights, weekends and bank holidays.
This is the time to pay tribute to John Chisholm, chairman of the GPC for the past seven years, who has announced he is standing down from that role. John has had the courage and tenacity to steer the negotiations on the new contract to a successful conclusion. His never failing optimism, steadfastness and attention to detail saw the negotiating team through some dark days. John, you will be missed.
Colleagues, I remain a practising surgeon. It is a job I love and from a very young age was the only one I ever wanted to do. It gives me a reality check when I disappear into the parallel universe inhabited by civil servants and Ministers. It means I can challenge some of the wishful thinking that leads to spin and gimmickry. But my experience is primarily of the hospital service and the role of Chairman of Council could easily fill every waking hour. I am therefore very grateful to Council for accepting my proposal for a deputy chairman and absolutely delighted that Sam Everington is the first to take on this role.
In Sam we also have a colleague with a really strong track record on equal opportunities. He along with Aneez Esmail as the new co-chairman of the Equal Opportunities Committee, are set to carry on the excellent work begun by you Mr Chairman in making the Committee a real force for change - a key component of the Diversity Agenda that we are debating this week.
The Government is today debating the Human Tissues Bill – we are pleased that our concerns over education and research have been listened to. But we are very disappointed that the Government has chosen not to allow a free vote on the question of presumed consent for transplantation. Every year around 400 people die because a donor can’t be found – that’s more than one person every day. The Government must take action to change this
I have not been too hard on the Government thus far, because it is not the BMA’s role to be Her Majesty’s Opposition. It is our role to speak up for our patients and the profession, to do so on the basis of sound evidence and to try to make change work for all of us. But I cannot bite my tongue on two public health issues where Government has been both dilatory and disgracefully complacent – on smoking and on sexual health.
It was a proud moment for the BMA to see three decades of campaigning come to fruition with the ban on tobacco advertising.. But the Government cannot rest on its laurels. It must take the next step and ban smoking in enclosed public places. It must provide real, sustained investment in smoking cessation programmes. It is simply not good enough for John Reid to wring his hands like a latter day Marie Antoinette and say “let the poor smoke”.
I am a vascular surgeon working in one of the most deprived areas of the country. I regularly have to amputate the legs of chronic smokers – and they are not generally from social classes ABC1. I do not know an asthmatic child who would not benefit from a smoke-free home.
And on sexual health, we have an avoidable scandal. Nearly 90 years ago, at the time of the Great War, we instituted a service for what was then called venereal disease that was free, rapid and totally confidential. Nearly a century later in some parts of the country patients turn up at a GUM clinic only to be given an appointment in six weeks time. What use is that? What sort of public health service is that? Mr Chairman – where is the CHOICE in that? Our campaigning has succeeded in securing some extra cash for GUM services, but nowhere near enough. This is an area where walk-in clinics and same day service really would help.
Mr Chairman, the Government has announced its NHS Plan. We should wish it well. It can only be developed with the help of all our doctors. The NHS has been described as the greatest gift from the people of this country to the people of this country. We must all ensure that the NHS moves with the times and that the BMA plays a major part in shaping its future.
Mr Chairman, I move.
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