If we were to liken the NHS to a large cruise ship crossing the Atlantic then doctors would be the crew. From time to time over the years, the Shipping Company (the Government, in this analogy) has threatened dramatic changes in how the whole enterprise runs. This always causes enormous disquiet amongst the crew but ultimately only ever seems to lead to people rearranging the deckchairs on the poop deck. The Big Man Aft (or BMA, for short) is the link between the crew and its officers (for GPs, NHS management). Some like him, some despise him but many just ignore him.
The BMA has significant difficulties in delivering the leadership their members want. Complications of trade union laws, the cliquey world of medical politics and the lack of interest most doctors show for attending any sort of meeting, mean there are often communication problems amongst doctors trying to promote or engage with political activity.
This was emphasized at this year’s BMA Conference when the delegates voted down a motion that suggested last year’s strike action was a debacle, a damp squib and a big mistake. In the debate itself, few disputed these descriptions, but they still could not bring themselves to vote against the central committee who had orchestrated the whole shambles.
We never wanted to strike
The fact that the vast majority of doctors did not strike suggests that the profession wants to turn to other, more professional, forms of protest. For instance, the Health & Social Care Bill says it is illegal for GP practices to leave CCGs, and GP practices could have their funding revoked for not paying for CQC registration.
But surely we live in a Western democracy. Why have we allowed Governments to pass laws that insist on us belonging to organisations?
Our most powerful political card is the potential non-compliance with commissioning. The Government have built their health strategy around this philosophically-potholed policy. The BMA say their hands are legally tied. But the place to test and debate legality is a court room, so that is where we should be threatening to go. If we believe in the NHS we need to be prepared to fight for it in court rather than on a picket line.
Back to the cruise ship, which has just entered foggy waters; no-one is sure where it is heading. The officers are concentrating on entertaining the passengers and keeping the shipping company happy. Most of the crew take the pragmatic view that, while they are on the ship, they might as well do their best to sail it safely.
The main problem, of course is that there are too many passengers on the ship. The shipping company does not want to address this problem and are quite happy with their ‘iceberg solution’. The officers are trying to convince the crew that being more efficient with gangways and passenger traffic will overcome the fundamental space/people imbalance. But the BMA and all the crew need to continue to loudly point out that these strategies are not going to work.
This will be a difficult political message to convey since neither the Government, NHS managers nor patients wish to hear it. It is political suicide to threaten the concept of a free NHS, and patients do not want to pay any more tax.
But doctors need to contribute to the vision of a sustainable NHS should look like in the future: after all, if the ship goes down, it is the crew and passengers who will be the biggest losers. The BMA needs to take a lead in helping us formulate and construct our vision, even if this requires the discussion of many unpalatable choices. We need to fight for our principles, and call politicians and the public to their senses about their unrealistic wishes.
The message from our professional leaders needs to be clearer. We need a website easily accessible by grassroots GPs informing us of what is going on and why. Every day each of the UK’s 30,000-plus GPs sees 30-plus patients. This adds up to a million political opportunities a day to influence voters regarding the direction the NHS needs to travel in. If we all deliver the same message, we will be an unstoppable psephological force.
And so back to our allegory: the Big Man Aft may need to be brave. He has always been scrupulous to never break his contract, never do anything that could in anyway be interpreted as illegal. However, if as the fog clears it appears we are heading into icy waters, he may need to weigh up what is the morally responsible position to take. Telling the crew to keep cleaning the cabins, conducting the orchestra and serving the food or instigating mutiny.
Small defiant breaches of contract would soon have the passengers asking questions, the company up in arms and, if all the crew are complicit, the officers might decide to change course – rather than continue full steam ahead towards the iceberg.
Dr Anthony O’Brien is a GP in Silverton, Devon and chair of Devon LMC.