3 July 2008 - Tom Smith on clinical engagement

On the one hand, the Darzi review places great stress on clinical engagement; on the other health minister Ben Bradshaw seems determined to maintain political pressure on GPs. Every newspaper today reports his comments that in some places GPs have a “gentleman’s agreement” not to take on each other’s patients. If it were true, it would undermine choice in the NHS, making it difficult for patients to move practices.

On the Today programme this morning, Sarah Montagu asked John Canning whether he believed it was. The ever polite GP negotiator said he didn’t believe that Bradshaw would lie, but that he had never heard of such an arrangement - “I don’t believe they exist”.

Canning says there are disincentives to take on new patients –there is less money for new rather than existing patients. “Do you accept then that these arrangements need to change?” asked Sarah Montague. Yes”, says Canning and “the current disincentive to taking on new patients is not what the BMA wanted. John Canning says he wants a system where money follows the patients.

Then Sarah Montague got to the point – the state of BMA-government relations. “How would you describe them?” Canning went for the phrase, “not as good as they could be”. He said “a spiral of argument” had dragged relations down – he wanted to work positively and “move forward”. Montague then asked, “given that the government clearly think you are resistant and obstructive, can you work together?” “I’m sure we can”.

This story illustrates the limitless appetite of the media for a story about fights between the BMA and government, but more than that, it shows a problematic inconsistency in tone within the Department of Health. One Health Minister, Lord Darzi, talks about providing opportunities for doctors with a view to appealing to innovative clinicians, while the other reiterates his view that doctors are working against the interest of patients.

Is this a plan, one wonders - are Darzi and Bradshaw playing good-cop, bad-cop? Is there a schizophrenic element to policy development? Most probably, it is the case that Bradshaw’s ire is specifically reserved for the BMA, rather than GPs generally, and that, despite Darzi’s emphasis on professional opportunities, he might share some of the same concerns about the behaviour of some doctors – didn’t he use the word, “laggard” recently?

The thing about the word, “laggard” is it suggests a small number, lagging behind. Darzi’s use of the word isn’t necessarily inconsistent with his view that doctors can play a leading role in service development. The problem with Bradshaw’s comments is that he suggests doctors are a “club” and are acting in concert to block reform.

The difference in tone is important. Does the Department of Health believe that doctors are the barriers or the means of service change? Fundamentally, do doctors work for or against the interests of patients?

There needs to a more sophisticated approach to clinical engagement: one that is positive about the leadership abilities of doctors, challenging them to lead service improvements, building on the Darzi review.

There has long been debate about clinical engagement means, and perhaps it should change over time, but while engaging doctors should be challenging , supporting professional excellence, there is a risk that at present it is employed in a quasi-military sense, in terms of the government engaging the enemy.