Mr James Johnson, Chairman of Council
Speech to ARM 2005
27 June 2005
Introductory remarks
Mr chairman, it is a great pleasure to welcome everyone here to Manchester for the annual representative meeting.
I live and practise as a surgeon only 30 miles away in Runcorn so I feel I am playing at home this week. I want to start by acknowledging and celebrating the successes we have achieved over the last eventful year - some of which you have just seen in the film. These successes would not have been possible without the tremendous hard work of the staff and your elected representatives and I thank you all.
The GPs and consultants are now working to modernised and generally well received new contracts. Our medical students and junior doctors have led the way in modernising and reshaping post graduate medical training and negotiations have at last been started for a better deal for staff and associate specialist colleagues. We must all work to support the drive for reward and recognition of these doctors. We have made some very real progress in public health and although the state of academic medicine remains a matter of grave concern, the BMA has worked hard and successfully to reassert the clinician voice in health and public policy. We must build on that in the year ahead.
Chairman, you are modernising the way the ARM does business - the open debates we will be having this week cover important but difficult areas of policy and it is right that we should grapple with them. It is also important that we hear what Ministers have to say, and that we enter into dialogue with them to shape the future of health policy.
Reform and choice agenda
We doctors are an interesting mix; both innovative and conservative. We are clinically innovative but we tend to resist and oppose managerial or structural reform. That is particularly true when we have had no part in its development.
This dislike of have things imposed on us is paradoxically one of the things that make us good doctors when we are face to face with our patients. Our ethical wellspring, as clinicians, is the interest of the individual patient. Patients have good reason to be glad that this is so. It makes us go the extra mile. We will argue the case for the better but more costly drug; we will keep on adapting the treatment regime to help our patient recover or gain respite. But it can give us too narrow a focus when we are faced with utilitarian plans which focus on getting the most for the nation's money in terms of whole populations rather than individuals. The greatest good for the greatest number is not a morally or ethically inferior starting point - it's just different - and it's probably the right one for health ministers, public health doctors and even medical and clinical directors.
As doctors, we have a certain attachment to evidence. We are comfortable with the vast edifice of randomised control trials, pilots and cohort studies. We try to apply the same principles to policy making and to health reform. We wanted to see the results of the evaluation of the NHS Direct pilots before NHS Direct was rolled out nationwide. Mr Chairman, I fear we were whistling in the wind.
When it comes to Ministers, I should have said the greatest good, for the greatest number in the shortest possible time. Just because this Government is entering its third term, doesn't mean it isn't in a hurry. Politicians are destined to think in the short term. Where a problem is incapable of a short term fix, decisions - just look at pensions - get put in the "too difficult" drawer. Asking a politician to pilot and evaluate is like asking a teenager to make their bed and keep their room tidy.
So let us spend our energy where it can make a difference. Independent sector treatment centres are a good example.
Here we have an initiative around which doctors can comfortably unite in opposition.
The debating points are easily made. Treatment centres will cream off the easier, more profitable cases leaving the NHS to pick up the pieces. NHS costs are bound to be higher because they deal with the more difficult and complex cases. The NHS can't opt out of its responsibilities for emergency work. How do you have a seamless service with lots of different providers? And how will we safeguard the training of junior doctors?
But Mr Chairman, treatment centres are here and probably here to stay given the cross party consensus on diversity of provision. They are addressing a real gap. We know that unless you ring fence facilities for elective treatment, our wards and ITU beds will always be full of emergency admissions. I think we should take pride in the fact that NHS will continue to pick up the most complex and difficult cases. It is what we do best.
But if we are going to have a multi-provider NHS - and we have moved fairly rapidly along that road since we met in Llandudno last year, then competition must be fair and the playing field levelled out. We began with the playing field anything but level. We were playing uphill all the way. In fact the odds were stacked against the NHS hospitals.
I am really pleased that because we have been able to press that point home with Government, the guaranteed volume of work for treatment centres will no longer be part of their contracts - no more sweetheart deals that disadvantage NHS hospitals and leave primary care trusts and GPs with no choice but to refer their patients to the treatment centre.
At my own hospital, I watch with mixed feelings a glittering new treatment centre arising in the grounds of a hospital where there has been little development of any sort in the past few years. Will it be a white elephant? Will it be a cuckoo in the nest, draining resources and destabilising the NHS unit? Or could it work in harmony providing much needed facilities which are currently dangerously scarce -such as radiology.
The challenge is to make the various providers work synergistically to improve patient care.
Complete separation of the independent sector from the NHS would be a disaster. Just look at the clinical problems caused when you can't discuss the results of an X-ray with the doctor who performed and reported the investigation. There has to be measure of integration. And one way of ensuring this is to permit doctors who want to, to work in treatment centres at times when they are not contracted to the NHS.
We have had influence on the direction of travel for treatment centres because we could marshal good evidence. We must position ourselves so that if the BMA says that a particular aspect of a policy isn't working, the Department of Health will immediately act to bring in the required changes. If we can ensure that the clinician voice is heard, and that services are built using our expertise and experience, we can make almost any system work.
"Choose and book" is another example. It has been a fiasco so far, because people who do not work with doctors or patients have devised a system which does not begin to understand the basis on which GPs refer and hospitals organise clinics. This is just a mini example of the much bigger mess that could be coming our way with Connecting for health, if the new systems are not planned with the involvement of the nurses and doctors who deliver the services to patients.
The main reason for failure of large IT projects has been failure to involve the people who will use the system in their development - in this case doctors, nurses and of course patients. And this is precisely what has been going wrong with Connecting for Health.
The few doctors who are helping to develop this project are enthusiastic about the possibilities for transforming the way we practice medicine while greatly improving patient care. But there has been little attempt to engage grass roots clinicians or even the leaders of the professions. The result is a deep scepticism reinforced by negative views in the media of large IT projects. However, if Government is really willing to consult and involve doctors in planning the new system, we can help to get it right both for patients and doctors and save a lot of heartache, embarrassment and wasted expenditure.
Investment
The increase in NHS expenditure we have witnessed since 1997 has been extraordinary. I give the Government credit for that. Unequivocally. And we want it to continue. From the outset, the Government has linked investment to reform and reform to choice.
In the YouGov poll we published yesterday, the public actually placed "choice of hospitals" at the bottom of their list of 10 priorities for the health service. But that's because we all want all our local hospitals to be good.
Top of the public poll was a desire for cleaner hospitals. That's understandable -chairman, how have we got to a stage when in a 21st century health service, resourced as never before, patients are frightened to go into hospital - not because of worries about the procedures, but because they are terrified they will catch a life threatening infection ? We have to help change that.
So choice is not the be all and end all for patients, but it is a real issue. When politicians and the public talk about choice, what they often mean is convenience. For patients with chronic or long term conditions, for the elderly and the parents of young children, continuity of care is paramount. They want to see the GP who knows them.
For the young, the generally fit, for people commuting to work, convenience of care is much more important. They expect to access primary care services in the evenings, on Saturday mornings and at a choice of location. It is a fundamental generation difference that we cannot ignore.
Primary care is the target for the next stage of Government health reforms, with a major consultation during the autumn. With the new GP contract, we are now much better placed to develop primary care services further - because general practice is now a better place to work. We must hit the ground running - saying how we think the unique role of the general practitioner can be developed further. With the right resources, working together, we will find ways to deliver increased choice and convenience for patients.
My message to Government is simple and clear, Let the professionals help you modernise the NHS, to which we are passionately committed. Work with us and your reforms will have a much greater degree of acceptance - and they might just work. Without us - they cannot work.
Public health issues
If we are talking of modernising, I have some issues on public health and on partnership with the profession which need urgent attention. Last year, I was sharply critical of the Government's track record on sexual health services. I am happy to say that some progress has been made but it's painfully slow. The government has set 2008 as the target date to achieve 48 hour access to GUM services nationwide. Meanwhile one in every four people needing GUM services still wait over two weeks to be seen.
So why should we wait till 2008?
The BMA has been campaigning to improve the health of children. Last Wednesday we published to massive publicity our report on preventing childhood obesity. We already have one million obese children in the UK, many showing signs of older-age diseases rarely seen in children before - orthopaedic problems, type two diabetes, and so on. Our report spells out what can be done to stop this trend. We have also called for universal childhood vaccination for hepatitis B. The UK is one of the few developed countries that does not routinely immunise babies against the hepatitis B virus. Let's put that right.
We are inching our way towards a ban on smoking in enclosed public places. Scotland is expected to pass its smoking-ban legislation this week. Hurrah for Scotland. In England the public consultation on proposed - imperfect - legislation was launched a week ago. There is every indication that - given the right messages - the government will bring in a total ban. I call on you today, and on every doctor in the country, to give the government the message that if Tony Blair wants to leave a legacy for the public the single most effective thing he could do to protect people's health is to ban smoking in all enclosed public places. Thousands of BMA members have already written in with messages of support - colleagues I am asking you to do it again. Together we can persuade the government that passive smoking disables and kills.
Skills drain
I make no apology for having devoted considerable time and effort this year to addressing the obscene exploitation perpetrated by the English speaking nations of the North on some of the world's poorest countries. In the UK we have around 120,000 doctors practising medicine. The USA employs over 50% of all English-speaking doctors in the world. In Australia, a country of 20 million people, they have 48,000 doctors. In Ghana, which also has a population of 20 million, they have only 1500 doctors in the entire country. In Mozambique, with the same number of people, it is even worse. They have just 500.
I visited Ghana in November last year and since that visit, I have taken every possible opportunity to raise awareness of the skills drain and the calamitous effect it is having on the poorest countries of Africa and Asia. Since 1999, Ghana has lost more nurses than it has been able to train - to the UK, USA and Canada..
Mr Chairman, this isn't live aid, it's reverse aid. Medical education is estimated to cost Ghana 9 million US dollars per year - only for them to lose their qualified healthcare workers to the North. The UK is the world's fourth largest economy. It costs us £220,000 to train a doctor and £12,500 to train a nurse. We can afford it. We must afford it. It is completely pointless for the UK to give 300 million US dollars in aid to Africa if we then systematically rob them of their most precious resource - the skilled people who have the practical ability to prevent and treat disease.
We are not the worst offenders. We do at least have an ethical recruitment policy. But that is not the solution. Living and working conditions are so difficult in Africa, and major shortages exist here in Britain. We don't need to recruit - there is a vacuum effect. It is dramatic and it is set to get far, far worse.
The USA has identified a need for one million more health care workers over the next 15 years. It wants `200,000 more doctors and 800,000 more nurses.
It has no plans to become self sufficient by training more. Health care professionals are a commodity to be bought and sold on the world market. We have to try to get Governments to change course.
Let us be quite clear on this. We are not talking about closing our doors to overseas colleagues. International exchange and collaboration must continue. Two way movement and migration is a good thing. But the rape of the poorest countries must stop.
So that is one very clear moral and ethical priority for the new Government as it chairs the G8 summit next week
Mr Chairman, The BMA has had a good year. We are financially sound. We have a dynamic new Chief Executive; the BMJ Publishing Group has an entirely new top team and is going from strength to strength. Our influence is growing because we use reasoned argument based on facts and we are beginning to see the results of this in areas as diverse as Modernising Medical Careers, Payment by Results, and public policy on smoking, sexual health and other important issues. Sam Everington, the Deputy Chairman of Council has challenged us to address difficult issues such as diversity so that the BMA can become much more representative of the members we serve.
When we decide to use our immense power and influence for good we are almost unstoppable. But we will not make a difference if we are outside the door. The Government, like nature, abhors a vacuum.
If we - the authoritative, evidence-based, professional voice of UK doctors do not engage with politicians on health service reforms, some one else will.
Colleagues, let us have the courage of our deeply held convictions. I believe in the NHS - you believe in the NHS - we have given our lives to it. We don't fear change, we welcome it. But let us make sure the changes are ones that really work, for the managers, for the nurses, for doctors but most important of all, for the patients. Let's get inside the room where decisions are made and help shape the future.
