Introduction:
A few months ago a private BMA Council members' web-site began receiving a number of apparently self-congratulatory messages from the great and the good.    Unfortunately as the site is confidential I am unable to repeat those messages here but suffice to say they eventually got under my skin so much that I felt compelled to reply.    I received the anticipated negative response.  The tragedy goes on as British general practice, long eulogised by GP leaders as the jewel in the crown of the NHS, is steadily and rapidly destroyed by the very contract which those same negotiators so determinedly spun on to their colleagues.  Interestingly, one of the beneficiaries of this privatisation was the leader of the GP negotiating team.

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A tragedy to general practice

Sorry, chaps, I cannot read this thread of self-justifying tosh any longer.   It’s not as though the “constructive engagement” methods so well described by some members of the negotiating teams have achieved a great deal over the years.  It was precisely those methods which are currently being eulogised on this thread which got GPs into the mess they are in.

Wilson , in 1989-90 was an absolute disaster.  Even Kenneth Clarke had to come to his aid in Parliament on one occasion. 

Hamish is correct but very restrained in saying “the BMA (was) weak in opposing it (the 1990 contract)”.  Laurence goes further believing that the BMA was “supine” but even he does not go far enough.  It was servile but Wilson did not have “BMA cotton wool” on his hands and far from “parking his tanks on the lawn” he was talking frequently to Kenneth Clarke.   If he had chosen to use them he had very effective tanks. In the form of a very angry profession ready to resign if asked but he chose to tell Clarke at an early stage that resignation was not an issue.  Hardly the most effective tactics to adopt.  After that, despite constructive engagement with the government, it was game, set and match. The contract was imposed and the downward spiral of general practice took a major twist.   Incidentally, Wilson was dealing, not with a government resting on a powerful majority but with a much weakened, unpopular one.  

The reputation of the BMA/GMSC plunged amongst GPs – except with the ones who benefited from fund-holding.  That was probably the first time that general practice became visibly split.  The seeds for the future were sown.

The Bogle years yielded nothing conclusive except even more subservience to one government or another over the Review Body Reports, most of which were ignored by government despite howls from the BMA for huge increases as GP pay fell behind the comparators.

More recently we have the abysmally negotiated Chisholm contract which has been an even worse disaster than the Wilson one of 17 years ago despite being negotiated, oddly enough, Hamish, from the negotiating table.  And Chisholm, too, had tanks at his disposal but, like Wilson , he dismissed them.

Sure, the new contract has been a more expensive purchase for the government than they anticipated but nevertheless it has presented GPs, practically hog-tied them, into government control and, whilst about it, has destroyed family practice as generations of us and our patients knew it.

OK, so GPs do not have to do some jobs unless they are paid for them - and there’s the nub.  The paymaster has an even bigger whip hand than ever and “he who pipes the music…”    At the same time, general practice lost a great deal of its professionalism to become little better – except, perhaps, in educational standards – than the jobbing gardener who itemises everything he does before presenting an invoice for payment.   GPC may think that is appropriate but many of us do not.

All this would be bad enough but a huge wedge has been driven through the profession as one practice, nay, even one doctor, competes against another to present services to patients sometimes in places far from where patients actually live.   Doctors are more or less encouraged to think “private”, if only by the recent activities of the head of the team which negotiated the contract.   Yet pious words are uttered in defence of the NHS.

The splits within partnerships and between GPs has all the appearance of having been designed into the contract deliberately.

It has struck many of us that the negotiating team had got one style of contract in its mind, that that suited government and that that was what GPs would be bamboozled (remember, it was an incomplete, though heavily “spun” contract when presented to the profession) into accepting.

There never was a Plan B and those who claim there was are probably being less than honest.   Why did you, John, dodge my questions in Council on that matter?

Little of substance was told to GPs as the negotiations went on (Yes, there were several letters but more in a “there, there, little children”, vein than informative) and when there was an outcry leading to a Special LMC Conference meeting, the GPC leadership virtually ignored Conference’s decisions (as they have a right to do) the very next day and went its own way.  By the time colleagues really knew what was going on it was, effectively, too late to change anything but the small details.  Certainly it was too late to abandon the form of the contract presented to them.   The negotiators knew best.

Trust in GPC declined, I think you could say.   That is the consequence of “being reasonably restrained in public” and, as John put it, of “constructive engagement”.    Considering the damage done to the profession there seems to me to have been little “constructive” about it. 

John says that the BMA has neither the power nor the right to bring down governments.    He is wrong on both counts.

In 1989-90 the government was so weak and unpopular that the BMA could have contributed massively towards its downfall.  In fact, it could have triggered a chain reaction to do so.  Some would say that that would have been in the country’s best interest!

It has the right to do so, as every citizen has that right, given enough support.  In 1989/90 it probably had that support and it was wrong not to use it in the furtherance of its members’ cause.

Hamish, being unusually defeatist, suggests that “if implacable opposition were to work it would need complete unity of purpose both within the BMA and the wider profession, something which is unlikely to happen”.

Wrong!   But it would need leadership.

Given effective and gifted leadership the troops will follow.  There have been many such examples in history.  Some wrong-headed leaders led their troops “over the top” to disaster, as at the Somme , but the troops did follow them. More enlightened leaders have led to victory.   Sadly, GPs have been without such a leader for most of the past 20 years.   Politicians with their own agendas there have been in plenty, yes, but leaders, none.

Of course the BMA must remain ”within the tent”.  Who suggests anything else?   It’s what you do whilst you are there that counts and that is where the BMA has been so signally wanting.     “Constructive engagement”, which seems to mean “softly, softly, let ‘ee monkey go”, has failed  and failed again, and what’s more has lowered the reputation of the Association whilst doing so.   Laurence, implying that only he or GPC know best, revealingly, includes those who oppose current views amongst “the enemy around us”.  

He has a jaundiced but none-the-less accurate picture of this government and its politicised civil servants.  I fear, however, that he holds himself and the Association in low esteem if he thinks that “freezing us out” would help any government’s cause.     It is unlikely, I hope, given good leadership (again) that the BMA would go quietly.   It very likely knows too much, so don’t worry, Laurence, about “pissing off the civil servants” or Number 10.  It’s a national sport nowadays.  Oh, and cheer up!   “The enemy are all around us”, indeed! 

I too believe in being “within”.  That’s why I was elected to Council so many years ago.  There was no chance of changing GMSC from the outside, so within it had to be, tanks and all.

Unfortunately, GMSC and GPC have equally been “within” when negotiating but even when they had effective weapons they have been ineffective.   For the past 20 years or so, GPC tactics have been wrong (what was the word,  “supine”?) and, so far, remain wrong.   I hope that the current leadership under Hamish will reflect urgently on that.

However, in a throwaway remark Hamish also seems to have jaundiced view of our Association’s power.   If the BMA is not “so important and powerful” and that “governments (can) ignore it” and go “elsewhere for advice” quite what are the members paying their huge Trade Union subscription for?

You, Hamish, are the BMA to GPs.   The job is what you make of it.

David  

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Postscript
The outcome of the foolish new GP contract will be the inevitable privatisation of general practice, its splitting into units available from many different sites and the ultimate demise of the family doctor concept.  It is already happening throughout the kingdom.  The less profitable rural areas may be the last outposts of family doctoring.   The rest of the country will see the deprofessionalisation and the regimentation of medicine as doctors follow the pressures and diktats put upon them by inefficient and unwise government ministers.    None of this will be to the ultimate benefit of GP patients.