8 July 2008 - Tom Smith on the today's health policy debate.

I’m on my way to the BMA’s Annual Representative meeting in Edinburgh, really interested to hear what doctors are saying (off camera) about the latest stage of the reform programme.

Do BMA representatives see opportunities for greater clinical control? Do they believe that quality will be prioritised? What do they think is going on now in the NHS, and how do they see their role in reform?

In Friday’s BMJ (5 July 2008) Fiona Godlee’s editorial said ‘there’s one crucial aspect of Darzi’s vision that will happen only if doctors across the NHS step up to the plate: much greater leadership from clinicians. If this review is, as Gordon Brown has said, a once in a generation opportunity, the next generation of clinicians and patients won’t forgive us if we fail’.

Yesterday was the first day of the ARM, and included debates on primary care and speeches from the chairman of council, Hamish Meldrum, and the chairman of the GPC, Laurence Buckman. Were they stepping up to the plate?

In a sense, yes. They were definately shuffling.

It is not easy to do so in the angry auditorium that the ARM often is. In the debates, doctors complained about the Government’s public stance towards them, particularly GPs who feel attacked. Today’s Guardian puts it this way - ’doctors hit out at the Government's "continued attacks" on the medical profession and its use of "gunboat diplomacy". They accused ministers of systematically undermining general practice, saying their negative attitude worked against the interests of patients.’

While Hamish Meldrum’s speech, yesterday, was today reported as anti-Government rhetoric, the speech contained a very important paragraph. Meldrum was arguing that the BMA should shift from away opposing policies outright to proposing additions, revisions or leading change.

“We have a choice. We can follow the cynical, pessimistic road, worry about being tainted by association with the implementation process, and cavil and criticise from the sidelines. We might keep our principles pure but I would suggest that it's on the sidelines that we'll stay - increasingly marginalised, increasingly irrelevant, increasingly ignored. Alternatively, we can get talking, get involved, get engaged, take a leading role, not with some sort of blind and unquestioning acceptance but with eyes wide open. We must be prepared to be outspoken if the talk isn't the right talk, if the involvement is patchy or token, or the engagement superficial and unrepresentative. If we don't roll up our sleeves and get really involved, we leave the field open to others or, worse still, the good things that we want to see happen, will not happen. I don't want that, I'm sure you don't want that and I don't intend to let that be the case.”

Of course doctors have issues with reform, but the “fight” between the BMA and the Government has been blown out of proportion on both sides. What doctors fear is not necessarily reform, or even competition: it is the idea they are being set up to fail.

Laurence Buckman illustrated this point in his speech. He says GPs are not afraid of competition. What they object to is “the distorted market in which we are being forced to compete”. The implication is that with a level playing ground, doctors are happy to compete for patients.

What doctors fear is not necessarily reform, or even competition: it is the idea they are being set up to fail.

Like Meldrum, Buckman cited the Next Steps Review and its message that the Government wants to work through clinicians. He said he would hold them to that pledge - "but if they don’t listen to us, then we will show our patients what politicians are trying to do to their services. According to Healthcare Republic, Laurence received a standing ovation.

,It is important that we listen to what doctors have to say about reform - and listen carefully rather than look for words and phrases that confirm what we expect them to say. Very often, the rhetoric is for the auditorium, but there is an overall message to a wider audience.

As Darzi suggested a wooing of clinicians – encouraging the prospect of clinicians leading services change - there are some signs that doctors are willing to be courted.