Read BMA chair Dr Hamish Meldrum's keynote speech to the Special Representative Meeting.
Welcome to this SRM – your opportunity, together, to help shape the difficult decisions that the BMA needs to make in the face of potentially the biggest reorganisation the NHS in England has faced in its 63 years.
The decisions you make today will have a profound effect on your profession, your patients and the future shape of our NHS.
The Government's proposed reforms have far-reaching and potentially irreversible consequences for how the NHS is run and the way we deliver care to our patients.
This is your opportunity to scrutinise the proposals, to consider their impact, and ultimately to decide how best to influence the direction of health policy in England.
It's a day when we need to ask ourselves what we should do that is genuinely in the best interests of the profession and our patients.
And, of course, it's a day when it may be easier to ask such questions than it will be to find the right answers and make the right decisions and, in that, it's not dissimilar to the last time we held an SRM, in 1992.
Then, as now, much of the debate was not so much about the nature and depth of our concerns – on which there was, and is, much agreement across the profession - but more about our strategy for dealing with them.
It is difficult to argue against the some of the claimed, high-level objectives of the government's reforms – greater clinical involvement in the design of services, better patient information and engagement, greater professional independence and less ministerial interference, and a focus on quality outcomes rather than crude targets – all things we've been asking for, for years.
We really must stop asking for things!
But, as on so many occasions, it's the reality not the rhetoric that counts and it's the reality that is causing all the problems.
Because, what we have is an often contradictory set of proposals, driven by ideology rather than evidence, enshrined in ill-thought-through legislation and implemented in a rush during a major economic downturn.
It is the same basic ideology – of competition and choice – that the previous Labour administrations believed would reform public services, but it goes much further, much faster, with no heed to the massive risks it brings to all that is good about one of the best health systems in the world.
From first publication of the proposals in the white paper back in July, the BMA – along with many other health unions, professional bodies, think tanks and commentators – has strongly opposed the many elements that we believe will damage services.
But, as well as seeking greater clarity across the board, we have also tried to identify and improve those aspects – such as proposals for clinician-led commissioning and an independent NHS board – that have the potential to bring safeguards and benefits to patients and the profession, and that reflect policies that previous ARMs have called for.
A few have mistakenly and mischievously labelled this approach as, ‘BMA support for the proposals'.
But it's a funny kind of support that generates headlines in national newspapers like, 'BMA says reforms run the risk of disaster' or, 'BMA warns health reforms are a massive gamble'.
It's a funny kind of support that produces highly critical responses to the white paper consultations so far, setting out seventy-seven pages of detailed concerns and risks.
And it's a funny kind of support that leads to months of intensive lobbying, increasingly successfully, of MPs and Peers from all main parties to persuade them to act against many of the proposals. And on that note, although we can't claim all the credit, I do believe that all that hard work has been very instrumental in achieving the support for our views that we saw from the Liberal Democrats at the weekend.
Our position has hardened and intensified further since publication of the Bill, partly because the government showed little sign of listening to us – or anyone else really, regardless of how vehemently or how completely we criticised it. But also because the legislation is massively permissive and, in many parts, ambiguously drafted – opening the door to even more radical consequences and greater contradictions than the original proposals.
So, let no one be in any doubt; I do not support this bill; the BMA does not support this bill; the profession – as shown by our recent MORI poll and in meetings up and down the country - does not support this bill.
Now, we will spend some time today telling the government exactly why that is the case – and that is very important. But we have to do much more than that.
What we have to decide today is how we move on from here, how we are most likely to achieve change, how we support our colleagues – and yes, how we best defend our NHS. And, given the current position of the legislation and the increasing pressure we are seeing on the government, this SRM – and the decisions you take today – are both timely and crucial.
Two weeks ago, we did achieve a modest but significant change to the legislation. We got rid of one of the worst features of the bill – the clauses that would have allowed price competition and differential pricing between NHS and private providers. Modest, yes; certainly not a triumph, certainly not "peace in our time", but a small step in the right direction. The legislative process still has a long way to go and there will be opportunities for further changes but will it be enough? Can we achieve more?
How likely is it that the coalition government – to whom this legislation is second only in importance to sorting out the economy – is going to buckle and withdraw this bill? Most commentators and political analysts believe it to be unlikely in the extreme.
Even in their moment of victory at the weekend, the talk from Shirley Williams and Evan Harris was not about abandoning the whole bill; it was about calling for, "major changes to the Health bill".
Of course, given the choice of having this bill – only slightly amended – or no bill, I suspect I know what the majority might say.
But we need to be realistic about where we are now and what we wish for, because, even without this bill, the way the NHS is being run in England is far from perfect.
The market in healthcare has been present for over twenty years and it is here, now.
Private providers are competing for and providing, NHS care, now.
Decisions about the design and delivery of clinical services are being taken with minimal clinical advice, now.
PCTs and SHAs are imploding, now.
There are threats to our national terms and conditions and – as we saw last week – our pensions, now.
Education, training and workforce decision making isn't working well enough for doctors or the service, now.
Above all, the NHS is facing its most significant financial challenge for decades, now.
Even if we were successful in preventing the whole Health and Social Care Bill being passed – which would be no mean, and probably, unachievable feat – these massive challenges will still remain.
So among the questions you will have to ask yourselves today, is not only whether we can prevent a bill becoming law, but whether you, me, our colleagues out there, would be less or more able to influence the current problems if we did?
Just remember, not all the critics of this bill share our concerns. Many – and not just those within the Conservative party – do not believe there should be a bigger role for doctors in the design of the delivery of healthcare; many believe that, not only should the private sector have a much greater role in providing healthcare, it should also take control of commissioning it.
You could be left with the worst of both worlds – a continuing market in healthcare, with increasing competition from the private sector, but with even less medical influence than we have now, just at the time when, because of the financial pressures, we most need sensible and expert decision making.
Yet again, others will argue that by appearing to be in charge but with little realistic power to influence, GPs and their colleagues are being set up to fail; to take the blame when things go horribly wrong.
And so again, you need to ask the question – who would you trust to make the right decisions in difficult times – the profession, the managers - or the politicians – and, more importantly, who do the public trust and who will they blame if or when things go wrong?
Challenging questions; difficult answers.
Our survey of the profession showed that there is a wide range of opinion, not so much about the dangers of many of the reforms, but about how the profession – both individually and collectively - should act and respond.
I'm not surprised by the wide range of opinion and I respect the genuinely held views of those who promote their opinions with passion and with vigour. That's what a strong and representative trade union and professional body should be all about.
But whatever we do today we must remember that, above all, we are medical professionals; we must search for the best outcomes for our patients as well as for the profession, even in the most difficult situations. And it's not just about the impact our decisions will have today, it's about their effect in the future too.
Whatever our individual views are, this is not about particular sectional interests or high-profile personalities – it's about flawed, ill-conceived polices and it is those that we must attack.
Apart from the dangers to the NHS in England, there are dangers to our profession and to the BMA, if we create unnecessary or avoidable divisions, within branches of practice, between branches of practice, even between the four nations of the UK.
We are at our strongest when we are united. Playing into the hands of those who seek to divide and rule will only make our task of opposing - what we all agree are the most damaging aspects of the government's reforms - more difficult.
Lastly, I would urge you not to tie the hands of those who work and negotiate on your behalf, in what is, a challenging and fast-moving situation. To be effective we need flexibility – the ability to respond quickly as things change.
There are huge dangers in putting all your negotiating eggs in one basket, however strongly you may feel that that is the right thing to do. That would be a bit like relying on one single treatment option in a critically ill patient, with complex medical problems, rather than marshalling a range of options and using them and tailoring them to the patient's response.
So, I'll leave you with a question that's not so easy – but is probably the most important one to be addressed today. How do we oppose everything that is wrong with this bill while working as hard as we can to get things changed - on the ground, in the media, in Whitehall and in Parliament?
But maybe the answer is not as difficult as we think – medicine is a profession that requires a delicate blend of science and art, idealism and pragmatism, instinct and skill, vision and practicality.
As doctors you are all too aware of the impact your decisions have on your patients, both now and in the future.
This is your challenge today. Use the opportunity wisely, because, be in no doubt – the profession, our patients and the NHS, need these qualities now more than ever.
BMA chair Dr Hamish Meldrum BMA chair Dr Hamish Meldrum Watch the full speech here