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Inaugural address by Sir Anthony Grabham, BMA President 2002-3

Wednesday 3 July 2002

My first taste of medicopolitics was in 1950, when as a 20 year old medical student I took part in a weekend course in BMA House to learn about the emerging NHS, about the BMA, and about medicopolitics.

At that time my principal concern was whether or not I would ever actually become a doctor, and the idea of becoming president of the BMA seemed as likely as my becoming the first man on the moon.

So I have to say that becoming president of the association, and following in the footsteps of Charles Hastings - albeit after 170 years - is, for me, quite overwhelming and I am therefore extremely grateful to the association, and to all my old friends and colleagues - many of whom are here tonight - for helping me along the road to this office of which I am very proud indeed. I am also daunted by the requirement to give this address, following as I do many truly distinguished presidents. It is quite a challenge.

I looked back for guidance to two of the most memorable since I attended by first RB in Folkestone 30 years ago.

Probably for me, the most memorable was that of a very distinguished professor of medicine - I won't identify him - but he was extremely erudite. He had a wonderful flow of ideas and of language, but he was still flowing after more than an hour and at that stage he began to lose his audience – and he began to lose them both metaphorically and literally.

The audience - those who were awake – began to slip away quietly, but in increasing numbers through the back and side doors of the hall. His terrible mistake, of course, was that he was coming between the audience and its traditional strawberries and cream.

So I have learnt that lesson and can assure you that will not happen tonight. I have arranged for all the doors to be firmly closed and nobody will be allowed to leave, unless they have a doctor’s certificate.

I have gone further and have asked John Chisholm and the GPC negotiators to fix an appropriate fee for such a certificate. The GPs are very good at that sort of thing.

I have also asked Peter Hawker and the CCSC for help, but Peter told me that consultants would not dream of charging a fee – but, of course, a case of decent wine would be acceptable.

The second memorable presidential address came from Prince Charles on our 150th anniversary in 1982, when Charles, as candid and challenging as ever, told us that he had always thought that the letters BMA stood for British Money Association. (Many a true word). He then went on to lecture us on our shortsightedness, and the great value of “alternative medicine”. That went down very well.

I might say that the audience then took some revenge in what was probably the most disorganised, riotous and disgraceful reception ever seen at the Festival Hall. Again, the arrangements were such that the Prince was coming between the BMA members and the food, and that is a very bad mistake. The Prince, in fact, was a very good and generous president and he was soon forgiven for his candid speech.

What I learnt from that was that you can be candid and the association will forgive you in the end – especially if you are heir to the throne. But do try not to get between members and their food – a very important lesson. But coming back to my first taste of medicopolitics in BMA House in 1950, the NHS was just beginning with its high aims, of a tax based, comprehensive health service, free at the point of delivery and when I got back to my medical school in Newcastle I was required to write an essay on the emerging NHS and its future.

Now, those of you who know me may be suprised to learn that in those days I was a very awkward fellow – always argumentative and always questioning received thinking.

Even then I could not see how the country (then relatively poor) could provide a truly comprehensive health service for everybody and for it to be entirely free. It didn’t seem to me to be attainable.

I wrote my essay in two sections, and I gave them the title of two popular songs of the day. The first being the great Judy Garland song “Somewhere over the rainbow” and the second being, “Beyond the blue horizon”. I thought they were reasonable comments and quite witty. The professor of medicine however, was not amused and told me severely, “Grabham, I’m not sure of you’re a sceptic or a cynic, but don’t worry you’ll grow out of it!” Now I’m not sure if I have grown out of it, bit I will leave that to you to judge.

Clearly, there is not time tonight to go into great detail over the arguments and counter-arguments surrounding the methods of provision of health services, but at my age, you feel that you have to start clarifying your thinking and attitudes. You can’t hedge and sit on the fence any longer, waiting for something to turn up – there just isn’t time left.

I have, therefore, been trying to clarify my thinking and reach conclusions after 50 years on the two great obsessions of my life – the NHS and the BMA. And I possible should emphasise here that the broad conclusions are entirely my own, and not those of the association. And I should also say that I have never had any affiliation with any political party.

My formative years in Newcastle before, during and after the war, and at the inception of the health service, coincided with a period of severe economic depression. There was widespread unemployment, poverty and disease. Tuberculosis was rampant, malnutrition and its consequence common, infectious disease – including poliomyelitis – were widespread. And so against that background the concept of the NHS was widely welcomed – although the BMA did have some significant reservations – and it seemed to be right for its time, particularly so in its aim of equity of access for all.

There was, therefore, broad acceptance of the NHS and its aims, and in the years that followed there was always, of course, a feeling that we needed more and better health services, but there was also a feeling that things would slowly but steadily get better. There was also a persistent view, however, that the NHS was seriously underfunded, but we understood the economic pressures facing the country, and we accepted the problems in the hope and expectation of improvement in the future.

There was, however, always an “affordability gap” between what patients needed and what could be afforded by the NHS.

Slowly but steadily, however, the combination of the rising cost of medical technology, the change in size and age of the population, and increasing patient expectation fuelled by political promises, seem to widen the affordability gap and, if anything, the gap now seems to be getting even bigger.

It seems to me that in very broad terms the quality of health services in this country seems to follow the rule of thirds.

One third of NHS medicine is of the highest quality. It is something that we can celebrate – something that we can be proud of – very proud indeed! The second third of medicine is reasonably goo. Most medicine and treatment, when you get it, it quite satisfactory and adequate – and when you consider what the country is paying for its health care, we can again be reasonably satisfied – thanks largely, I have to say, to the devotion and efforts of the medical and nursing professions.

So, broadly, two thirds of the NHS is very good or reasonably good. It is, however, the last third which I believe to be of very great concern. The well established and persistent picture of masses of patients, many of them suffering, waiting weeks and months for initial consultations followed by further waits of weeks and months for necessary investigation, is, for me, wholly unacceptable.

The picture of more than one million patients waiting and waiting for operations – many for more than a year – is equally unacceptable. The picture of anxious patients waiting for hours and hours and hours in crowded casualty departments is now commonplace and is, again for me, wholly unacceptable.

The picture of ordinary, elderly patients having to use their limited life savings and forced to pay for operations in the private sector is again wholly unacceptable.

The list could go on, but I believe that there are many other defects in the current NHS which are equally unacceptable.

Looking at this lowest third of the NHS performance, we are in terms of availability verge on Third World medicine in what is one of the most affluent countries in the world.

One of my greatest anxieties is that over time we suffer an attenuation of concern. Society and governments and even the profession sometimes begin to regard these problems as very unfortunate but somehow inevitable, the norm, something which cannot be changed or can be changed only at some time in the future.

Tomorrow, or the next day, or the day after that. This change is, of course, what we’ve been waiting for now for over 50 years.

So many patients are undoubtedly suffering terribly, but now the pressures on doctors themselves are becoming equally terrible. Day in and day out doctors find that they cannot give patients the time and treatment that they clearly need, and that in turn leads to persistent stress for many doctors. I want to quote here from an obituary which appeared in the BMJ in February this year. It was the obituary of one of the country’s best professors of surgery – one of the best from almost every point of view.

One small part of a major obituary reads as follows: “On Sundays he would worry about the patients whose surgery would be cancelled next day for want of a bed, when the hospital had surgeons, theatres and operating crew available. He felt he had to live a lie to patients, telling people that he and his colleagues were going to help them when he knew that for want of resources, they were not, and he felt the need of more facilities for patients. His unflinching honesty sometimes got him into trouble: he knew that the NHS wasn’t improving, and said so.

John Farndon was professor of surgery in Bristol and he died from a heart attack on 6 February 2002 at the age of 56.

That was John Farndon but I get the impression that all over the country there are doctors who are anxious, stressed, overworked and demoralised because they can’t look after their patients properly.

Why else are so many middle aged doctors leaving or planning to leave the NHS just as soon as they can get their pension? They possible still like medicine itself, but they can’t practise properly in large parts of the NHS. Observing these persisting and growing problems for both patients and doctors I have been reviewing my own attitudes to the NHS and in particular I note with real sadness that the equity of access to care, which was one of the great aims of the NHS frequently today means equity of access to poor or indifferent services, unless, of course, you happen to one of the growing numbers of private patients.

I repeat however, that there is much that is very good in the NHS, but I fear that there is now so much that is so bad and so persistent that one can no longer allow the good to obscure the frankly bad.

I had recently come to the conclusion that if the underfunding of the NHS, with all its problems had persisted for over 50 years it was unlikely to change now, and I had come to the view that we should be carefully and critically reviewing other health care systems – possibly along continental lines of social insurance rather than a tax based health care system.

I know that this view is not widely shared in society or in the BMA, but after 50 years of underfunding it seemed reasonable to at least consider the alternatives – particularly in those countries where the health services clearly work better than the NHS. It did not seem too revolutionary a thought. It just seemed to me, that in a civilised society, in a wealthy country in the year 2002, there is something wrong somewhere with the system.

I had come o this view very reluctantly (as a child of the NHS) and I have to confess that I was both surprised and delighted when I learned of the Chancellor of the Exchequer’s statement in his spring budget. He seemed to be acknowledging, frankly and for the first time, the chronic and severe underfunding g of the NHS and he was proposing to correct that underfunding by a major increase to be in place by the year 2007 – 8 – increasing from the current £65 billion a year to £105 billion by 2008.

The question for us all is therefore, can we now justifiably begin to feel that the problems of the NHS have been acknowledged and that the “cure” is in sight.

Well, here I am going to follow the Prince of Wales’s example and be candid. After the first euphoria wore off, I began to wonder just how much we could rely on what are essentially political promises. We all know about political promises. These promises have brought much needed relief to the government in a very sensitive area.

I am quite sure that the chancellor will increase taxation through national insurance, but I am not so sure that all of the promised increased funding will appear – or not in the promised timescale.

I am not imputing bad faith to the chancellor, but, inevtiably, one remembers that politicians do sometimes change their minds, ministers themselves are changed, governments change, and surely we would not be entirely surprised to hear that for good reason, because the economy has changed or because of the desperate needs of transport, of education, or the crisis in pensions, or the war in the Middle East or the oil crisis of the inflexibility of the profession, etc, etc, the promised increases have had to be delayed by a year or two or three or four.

So, I have to confess that I remain somewhat sceptical about the value of these promises – we’ll have to see and I still suspect that a different model of health care provision will have to be looked at some time in the future, although I recognise, as apolitical realist, that that is not on the cards in the immediate future. These promises will for a time stop that sort of speculation and debate.

Irrespective however, of the promised growth of funding in the future we still have a series of major problems right now, and we have to consider are there any things that could be done to help the situation right now.
If the Prime Minister or the Secretary of State were to say “Come on Tony Grabham, forget all the BMA rhetoric, tell us what we could reasonably do now to help the situation.“ If asked, I would suggest the following steps which have limited financial consequences.

1. Try to get a better working relationship with the profession. Try to show greater respect and gratitude to doctors for what they do. Many doctors feel undervalued. Try to make them feel like colleagues and partners with you in a common cause rather than difficult employees who have to be managed.
   Please try to stop the spinning and briefing against the profession. These activities are damaging to our relationship and therefore to the NHS.
2. Stop creating unreasonable targets and expectations from the general public and accept honestly and openly that some form of rationing and delay is inevitable in an underfunded service and it is not the fault of doctors.
3. Try to stop the manipulation of statistics and the spinning of facts surrounding the NHS. When it is found that some figures have been manipulated, it means that neither we, nor the general public know what we can or cannot believe, and so we start to doubt everything. That is very damaging.
4. Try to create a situation and an atmosphere and incentives whereby experienced doctors of 55 to 60 years of age actually want to go on and enjoy practising medicine in the NHS rather than planning and yearning for early retirement. If you could do that it would be a tremendous achievement and of enormous value to the NHS.
5. Try to make sure that well trained and highly motivated young doctors are appointed as consultants as soon as possible and not held back by artificial barriers. It is a terrible waste of energy and enthusiasm.
6. Do not allow purely financial constraints to close down existing services, such as surgical wards and intensive care beds, purely to keep within budgets, or to make artificial “efficiency savings”. Do allow some local intelligent financial flexibility.
7. Do start to listen to the advice of the profession. For years and years we have been arguing the case for better funding and for more doctors and nurses and that advice has been disregarded by successive governments up to no. The professions know what is needed for the NHS and the professions want the NHS to work. We spend our lives trying to make the NHS work. Please listen when we offer advice.

These sort of ideas of course will not cure all the ills of the NHS overnight, but if you could some of these things now, at least we could feel that the government was doing everything possible to work with us as partners in a noble enterprise.

Most of these ideas will not cost much money, but if there is a cost anywhere let us get on with it anyway. The money is promised. Let us see the colour of that money now.

In summary, therefore, there is much good in the NHS, but there are also terrible problems. I acknowledge that there are no quick fixes but there are some fairly small things which could be done now and which could make a real difference to morale, attitudes and, therefore, to patient care. And if the government did some of these things the profession should and would meet the government more than half way and would help to create a better atmosphere.

So to my 50 year view of the BMA. Time does not allow much analysis or comment. I would say broadly, however, that I wish the NHS was as well run and as healthy as the BMA. Voluntary membership is at an all time high and the finances of the association have never been better.

I know that the association is not complacent and that major reviews are necessary and they are being carried out.

I would only offer areas for concern and consideration.

1. We must never forget that our prime role is to look after the interests of our members, although we do, of course, have wider responsibilities, including a duty to cooperate with the government in the development of the NHS.
2. To be truly democratic and effective we need much greater involvement in our activities and affairs by women doctors. The arguments are, I think, self-evident.
3. We need greater input into our affairs from members from overseas. Again self-evident.
4. We need greater input from ordinary non-political doctors in divisions – not necessarily through the existing divisional structure but I believe that somehow we need to get more ordinary doctors involved in our affairs – if only to vote in our elections.

Finally, bringing my views on the NHS and the BMA together I would say that the NHS need support, stimulation and, sometimes, valid, balanced criticism and advice and there is no other body which can do this with such authority as the BMA. If watching very closely and fairly we find that the government’s latest plans and promises do not work out then that advice may well be that we should look again at other successful healthcare systems.

May I now close by reminding ourselves of Charles Hastings’s original aims for the association and that was to set up a society which was to be “both scientific and friendly” and I think that if he was here this week in Harrogate he would be well satisfied.

I would remind you too of the great motto of the association “with head and heart and hand” and to that I would now add with respect “and healthy scepticism”.

Ladies and Gentlemen, thank you for being so patient. I think I can see the doors are now being opened and I think it is time for strawberries and cream and possibly a glass of wine.

I think we all deserve it!