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Independents' Day

Meldrum's keynote speech in full

BMA chair Dr Hamish Meldrum delivered his keynote speech to the BMA's Annual Representatives' Meeting this morning. Here is his speech in full.

Welcome to Liverpool.

Last year we were in Edinburgh, the city of my birth. This year it's Liverpool, the city that, for so many of my generation, provided the iconic musical and cultural background to our formative years.

I was tempted to toss a few Beatles' song titles into my speech to see how many of them you might recognise but I was worried that the only one that might keep coming up was "Help"!

In any case, this is not a time to be dwelling on nostalgia, since I fear that the NHS and the profession are facing some of the biggest and most serious challenges ever, as we move from a period of sustained growth in resources to one of, at best, stagnation in funding, and at worst, stringency, hardship and even cuts, in our health service.

That, combined with a tainted and hamstrung political system, a devastating loss of public trust and confidence in politicians as a result of their perceived greed and corruption, and a government and a Prime Minister who, rather than leading, simply seem to be clinging onto power, does not make for a happy state of affairs. However, as I hope to point out, even the bleakest times bring with them possible sparks of optimism and opportunity.

But first, I want to pay tribute to all those who have supported me through another challenging year for the BMA – my deputy chairman, Kate, the other chief officers, and colleagues in the various committees of the BMA and, of course, the wonderful staff of the BMA. With them, the job is still difficult, but without them it would be absolutely impossible and I'd ask you to join with me in thanking them warmly for all their hard work and support.

I also want to apologise, in advance, to my colleagues in Scotland, Wales and Northern Ireland, that so much of what I am going to say is particularly focussed on the health service in England. In saying that, I'm not assuming that everything is hunky-dory in the Celtic nations but what I will say is, if you think you've got problems, you should see ours!

Before the world financial crisis hit last autumn, the BMA year began with the usual varied collection of issues and problems.

For our junior doctors, the difficulties of MMC and MTAS, though not completely resolved, had been largely replaced by the expressions of unpreparedness, by some, for the impending introduction of the European Working Time Directive. Whilst none of us in the BMA have ever underestimated the challenges and difficulties that the EWTD presents, we had decided early on that one solution which wouldn't work was simply to stick our heads in the sand and hope that it wouldn't happen!

Another solution we didn't believe in was to cross our collective fingers, legs - and any other bits - and hope that, when it did happen, everything would be all right.

The BMA has worked tirelessly to try to ensure that this important piece of health and safety legislation can be implemented, yet, at the same time ensuring that we can protect the quality of junior doctor training and protect the safety and the quality of the care we give to our patients.

That means looking at the length of training, how we train, the apportioning of time between training and service, the selective and controlled use of the individual opt out and of derogation and the planned expansion of consultants in certain key areas.

There can be no excuse for those trusts that have spent the last decade dragging their heels. Our doctors deserve better and our patients must not be let down.

With leadership and cooperation – a theme I will be coming back to later – these problems can be overcome and I commend the work of Andy Thornley and his colleagues for the commitment they've given to this difficult task.

For our medical students, along with their ongoing worries about ever-mounting debts, came concerns about potential changes to the selection process into the foundation programme. Furthermore, the economic climate has set back hopes of widening access to medicine, adding new barriers to aspiring doctors wishing to pursue a career in medicine.

For their teachers, the medical academics, we have been dealing with the repeated threats to funding and to contracts as universities and deaneries try to balance their books. Yet I applaud the fact that their commitment to the profession, to their students, and to health care, never wavers.

For SAS doctors, there were the continuing delays and other problems – certainly in some parts of all four countries – about the implementation of their long-awaited "new" contract. For these doctors, who contribute such a vital role to our health service, such recognition is long overdue and the continuing delays are not acceptable.

GPs, having at last received a very modest increase in resources after three years of cuts, were hit by the seriously flawed patient experience survey which changed the basis on which their performance was judged and rewarded.

For their consultant colleagues, it was worries about the future of their hospitals – particularly in London – and that changes to the provision of services were being carried out simply for political or financial reasons rather than for good clinical ones.

Of course, the BMA itself is not immune to the effects of the recession but despite that, we are always trying to improve the services we provide to our members. In addition to looking at the quality of these services, we have continued our policy of increasing support for members in the regions and, if our regional coordinator pilots prove successful, will hope to roll these out during the coming year.

But this needs money, your money, and we can only make these improvements if we look for savings in other areas.

On the professional side, the BMA fought off the insidious Clause 152 of the Coroners and Justice Bill which threatened to derail the good progress that had been made on electronic patient records and confidentiality. Let's hope that the new Home Secretary will not try to reintroduce that one!

In addition, we have pushed forward our continuing campaigns on a variety of public health issues including smoking, alcohol and climate change.

I know that some of our members wonder why we get involved in matters such as climate change, claiming they are not part of our core business, but if even half of what the experts say about this problem are to be believed, the threat to our health and that of our children and grandchildren could well be greater than HIV, malaria and pandemic flu put together and if that isn't a reason for getting involved, I don't know what is.

The BMA will continue to campaign on this issue, both separately and with others – at the same time doing everything we can to put our own house in order and trying to practise what we preach by reducing our own carbon footprint.

I mentioned pandemic flu and I certainly don't underestimate the potential problems that this is causing and could cause in the future. So far, the preparations we have made and that the BMA has been closely involved in, have worked quite well, though there have been some problem areas usually when local trusts think they can do better by departing from national guidance.

I want to commend all the work that has been done but, particularly, that of Peter Holden in the GPC and Richard Jarvis from our public health committee. There has also been great support from Frank Wells and the Retired Members Forum, who have worked tirelessly to produce a list of our retired doctors who would be ready and willing to help out in an emergency.

As yet, we haven't seen how well the UK will respond to the effects of a full-blown pandemic, but what I can say and where I can reassure the public, is that, whatever the crisis, you can rely on the doctors of the UK to step up to the mark.

Earlier this year we had the scandal of mid-Staffordshire and also the case of Margaret Haywood, the nurse who was struck off by the Nursing and Midwifery Council for taking part in a whistleblowing, Panorama programme. Now whilst I am not going to comment on the rights and wrongs of an individual case – particularly one which is under appeal – what I will say is this.

Such cases send out completely the wrong message to those health professionals who might want to speak out about unacceptable conditions in their workplace.

They also say a lot about the target-driven culture that has infested the NHS in recent years and that seems to put financial outcomes for trusts above clinical outcomes for patients.

I make this pledge today. The BMA will support any member who, through the proper channels, including the BMA, speaks out about unacceptable standards of care in the NHS. We have already produced guidance for our members and, through askBMA, have a dedicated advice service on whistleblowing. We will not tolerate a substandard service for our patients and we will not tolerate a culture of muzzling or bullying of our staff.

Revalidation is something that will affect all doctors and it's something which, if properly implemented, can benefit both patients and the profession. The key is in the phrase "if properly implemented".

We must ensure we have a system that has been tried and tested and is essentially the same in all four countries of the UK.

We must ensure we have a system which is equitable and fair to all doctors, irrespective of their area of practice or type of employment.

We must ensure we have a system that has minimal bureaucracy and doesn't end up with half the profession chasing round the country revalidating the other half.

Above all, we must ensure we have a system that is properly resourced, both in terms of the individuals who will have to undertake it and the service that will have to implement it.

Let there be no doubt – the BMA supports revalidation for doctors, but not at any price.

I want to return to where I started – the financial and political crisis that is facing our NHS, how it may affect you but, more importantly, what we can do to minimise the impact on the working lives of doctors and the care of our patients.

From the profession's point of view, there is no doubt that there are going to be those who want to put pressure on our incomes, the medical workforce and our pensions.

Whilst we should be realistic and not expect inflation-busting pay rises and an infinite expansion in medical manpower, I can assure you, that we are not going to allow doctors to be the scapegoats for the failures of the politicians or the bankers.

Last year, when we were an integral part of the conference on the role of the doctor, it was clear just how important and, indeed, how unique the role of the doctor is, the distinctive contribution we make to the delivery of health care and how crucial we are to the NHS. Whatever the problem is, cutting back on doctors is not the answer.

On a wider level, the profession is ready to work with whichever governments are in power, to look at the hard choices, to make the tough decisions but on the basis of evidence, fairness, equity and trust, not just as apologists for another round of failed policies.

And there will be hard choices.

But first, we need to do everything possible to protect the healthcare budget and not concede that swingeing cuts are either inevitable or necessary. But I know, and I think you know, that the days of plenty are over and that, above all we need to be honest with ourselves and, even more so, with the public about what the likely funding is going to be for healthcare over the next few years and to debate, with them, the difficult choices that will have to be made.

For too long they have been promised, as The Guardian journalist Polly Toynbee observed recently, "Scandinavian-style public services on US-level tax rates".

But that doesn't mean that we change the basis on which our NHS is funded.

We must resist the siren voices who claim that, by moving to an insurance-based system of funding, we will make the NHS either better or fairer. There is little evidence that such systems reduce demand; they are certainly more expensive to operate and it cannot be argued that they are fairer than raising money from general taxation.

However a health service is provided, one way or another, the public pays. In a system of social solidarity, which is one of the founding principles underpinning our NHS, taxation based on the ability to pay must be the fairest, the simplest and the best answer.

The epitome of insurance-based medicine is the US. It would seem particularly perverse that, just as it appears that President Obama wants to move away from that discredited system, some in the UK should be arguing that we move further in that direction.

Already some of Obama's critics – on both sides of the Atlantic – are lining up to protect their commercial interests and trying to convince him that he should not try to change the US healthcare system. With exorbitant medical bills being the biggest cause of bankruptcy in the USA and at the risk of being presumptuous, I have just three words of advice to give to president Obama about US health reform; "Yes you can!".

And here's another reason we don't want to move to an insurance-based system. Even with the much more generous mix of state provision and private insurance that they have in Australia, when I was there last month, I passed several people begging in the prosperous streets of Melbourne and Sydney with placards stating that they could not afford their medical bills. Conference, I NEVER want to see that on the streets of the United Kingdom!

But there are things that we can do to improve the quality of care for our patients and to try to reduce increases in demand.

First, we need to vastly improve the outcomes' data for the services we provide. What drives quality in clinicians is knowing that they are doing a good job – even that they're doing it better than their colleagues!

Second, we must look seriously at the issue of service redesign to provide care more efficiently. I know that will worry some of you and that you will think we are dancing to the government's tune. No way! I'm talking about difficult decisions but ones that are made for evidence-based, clinical reasons not purely for political or financial expediency.

Third, we need to put a much greater emphasis on lifestyle services to reduce morbidity and hence need.

Fourth, it's imperative that we adopt a healthy ageing strategy to reduce the dependency of the elderly population and narrow the gap between healthy life expectancy and overall life expectancy.

Just as with tackling climate change, we need a whole-system and across-government approach to improve the health of the public, with every citizen involved from the prime minister, downwards – or upwards, depending on your point of view! Only that way will we slow the inexorable rise in pressure on our National Illness Service and cope with the financial and clinical challenges that lie ahead.

Of course, none of these alone will solve the problems for the NHS and we must look at how we can use scarce resources more efficiently, where we can cut out waste and unnecessary expense.

So what nuggets of advice do I have for England's new Health Secretary? Well, here's a few for starters.

Andy, you can cut out the waste and inefficiency of hiring expensive management consultants to try to solve the ills of the NHS. We can tell you what's wrong with the system and we come a damn sight cheaper than McKinseys or KPMG!

Second, Andy, you can cut out the waste and inefficiency of the Private Finance Initiative. A recent analysis by the University of East Anglia reckoned that the government could save £2.4 billion – yes £2.4 billion – if it bought out the private finance contracts in the NHS. Yet what do we see – the ludicrous spectacle of a government giving taxpayers' money to private companies so that they can fund PFI contracts to build our public hospitals!

All because Gordon Brown wanted to keep public spending off one part of his balance sheet so that he could deliver on his golden rules. Well, like so many things with this government, the gold has turned to dust and the public and the profession have seen through their three-card trick.

Even Lord Darzi admitted last week that the government was "having a re-think" about PFI.

Ara - don't re-think it – get rid of it!

But the best advice of all, Andy? End the ludicrous, divisive, expensive experiment of the market in healthcare in England.

Although we've been arguing against the market for years, some people have been questioning why we are upping our campaigning now. Well I'll tell you.

Never has there been a better time to abandon the wasteful bureaucracy of the market. Never has there been a better time to ensure that we use scarce public money for quality healthcare, not for profits for shareholders. Never has there been a better time to ensure that we protect our scarce resources to train the future generations of doctors. Never has there been a better time to put the care of patients before achievement of rigid financial targets. Never has there been a better time for the various parts of the NHS to cooperate rather than to compete. Never has there been a better time to insist on a publicly-funded, publicly-provided and publicly-accountable NHS.

A health service of the people, by the people, for the people.

So my message is, don't play around with our health service. It's not a toy you cast aside and replace with the latest product off the shelf when you've tired of it. It needs looking after. It's our NHS, make it yours too.

I also urge everyone in this hall and all doctors watching or reading about this ARM -

sign up to our campaign and to its principles and do it today.

I want to end with three more messages – one for the public, one for the politicians and one for the profession.

To the public, I say this. You have an NHS of which you can be proud. It is not perfect and it can be better and, working together, we can make it so. Like an old friend, there is a danger that you can take it for granted, expect that it will always be there for you and not work to support and develop the relationship.

We want you to be involved, to have your say in the services that you pay for, but not in a superficial, consumerist way, the way politicians seem to think matters, but as true partners in the care that you receive.

To politicians – of whatever political hue, because, in terms of their NHS policies, there's little to choose between them – I say this.

Be honest with the public and the profession. Stop trying to outbid each other about who's going to spend more or cut less. It's not a very edifying spectacle and the public and the profession has seen through the charade that seems to happen every time an election is looming.

Give real and believable meaning to the phrases "Clinical Engagement" and "Clinical Leadership". For too many doctors they are just empty rhetoric, paying lip service to medical involvement, appearing to seek docile followers rather than challenging leaders.

We have the talent; We have the expertise; We have the drive;We have the commitment; We have the belief; But we will not be taken for fools.

Above all, I say to the politicians, be bold, be brave – don't cling to failed policies just because you think you might lose face if you are seen to have changed your mind. It's a sign of strength, not weakness, to admit that new circumstances need new policies.

And, lastly, to the profession, I make no apologies for repeating the challenge I issued last year.

We have a choice. We can be cynical, pessimistic, worry about being tainted by association, and carp and criticise from the sidelines. We might keep our principles pure but I would suggest that it's on the sidelines that we'll stay – increasingly marginalised, increasingly irrelevant, increasingly ignored.

Alternatively, we can keep talking, keep involved, keep engaged, and take a leading role, not with some sort of blind and unquestioning acceptance but with our eyes wide open.

If we don't show true leadership and get really involved, we leave the field open to others or, worse still, the good things that we want to see happen, will not happen. I don't want that, I'm sure you don't want that and I don't intend to let that be the case.

Challenging times, hard choices, difficult decisions – for the NHS, for our patients, for the profession and for the BMA.

A time when it would be easy to dwell on our differences, to indulge in petty squabbling about the details, and lose sight of the broader picture.

Of course there are issues where we don't all agree, but there are many more issues that unite us and it is on these we must concentrate this week if we are to have any chance of success, if we are meet the challenges, to make the right choices, to focus on the difficult decisions and to really Look after Our NHS.

Thank you.

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