Intended for healthcare professionals


Divided we fall (yet again)

BMJ 1994; 309 doi: (Published 29 October 1994) Cite this as: BMJ 1994;309:1100
  1. T Grabham

    “Hang together or, most assuredly, we shall all hang separately,” “Unity is strength”, “United we stand - divided we fall,” - all time worn cliches but relevant to doctors today, facing an intransigent government that has little regard for the views of our - or any other - profession. Doctors have wide and varied responsibilities, and inevitably many separate representative bodies and a somewhat diffuse leadership have developed.

    The “premier division” contains three or possibly four players: the General Medical Council, the royal colleges (and their conference), and the BMA. To these well defined groups may be added academic medicine and research together with many other smaller but important groupings, such as the Overseas Doctors Association and the Medical Women's Federation. The effectiveness of these bodies varies with the issues under consideration and the abilities of their current leadership. By and large, most seem to perform well when operating within their own specialist fields. But most have less authority and influence when dealing with the more general issues that face the whole profession such as broad medicopolitical matters, the great ethical problems, manpower, and training.

    Lately the profession's ability to influence the government seems to have declined (if not disappeared), and our standing in the eyes of the world has been somewhat eroded. The most obvious manifestation of this was the profession's failure to modify the government's plans for reforming the NHS, either during the consultation period or during their passage through parliament. Once the proposals became law the profession accepted the will of parliament, and most doctors have tried to make the reforms work. As, however, it observes the bureaucratic morass that is emerging, together with the fragmentation of the NHS, the drift towards privatisation, and the decline in morale, the profession (as is its duty) continues to offer advice to the government - advice that is largely disregarded. Changing this government's mind by reasoned argument no longer seems an option. Nor does changing governments - but it surely behoves us to re-examine how we present ourselves and our policies, in the hope of finding a more effective machinery than the one that has failed us in recent years.

    When dealing in narrow specialist fields it is right for specialist bodies to take the lead and speak with their undoubted authority. But today, few decisions are wholly specialist; most of the important problems that we face cross the borders between several, if not all, of the numerous medical spheres of influence. When faced with serious challenges how much stronger the profession would be if the great medical institutions and their leaders responded only after full consultation with their colleagues and, whenever possible, in a united fashion.

    One little known example serves to make the point. When the profession faced an ideological attack on private practice by the then Labour government we initially reacted traditionally, each group responding in a slightly different way and with varying degrees of vigour. When, however, we saw that we were failing to convince the government by separate and reasoned argument a meeting was arranged with the then prime minister, Harold Wilson. On the advice of Lord Goodman, one of the shrewdest political minds of this century, it was agreed that all of the presidents of the royal colleges, together with the leaders of the BMA, would attend the meeting but that there would be only one spokesman, who would present the views of the profession as a whole.

    During the meeting both the prime minister and the then secretary of state (Barbara Castle) tried to entice individual presidents into the debate and so break the impressive unity of the profession. They failed, and, apart from the usual exchange of courtesies, only one voice spoke for a united profession. The meeting proved to be the turning point in the campaign, and a radically modified and broadly acceptable bill emerged. (The credit for the success of that meeting undoubtedly lay not with the advocate, but with those leaders who gave their solid and silent support.)

    By contrast, a recent episode showed the converse of that exercise in collaboration and consensus. When the difficult ethical problem of patient confidentiality during the provision of advice on contraception to minors emerged we saw the unfortunate spectacle of respected colleagues in the General Medical Council and the BMA in apparently open conflict when what was required was careful discussion and consideration of the views and arguments of the other party.

    If today the profession could show the same degree of unity as we did over private practice our influence would be appreciably enhanced. If the profession (or, rather, the leaders of the bodies representing the profession) accepted the need for better collaboration and communication then the precise constitutional details would be of secondary importance. Clearly the great institutions would be unwilling to surrender their ultimate independence of thought and action to any supreme body. But the current relatively informal links based largely on occasional and casual meetings have proved inadequate.

    The formal liaison between the hospital doctors of the BMA and the presidents of the royal colleges through the Joint Consultants Committee is not perfect, but it shows how independent bodies can work together effectively and harmoniously without losing their independence. A similar arrangement with a reasonably formal machinery, a wider membership, and a wider agenda would undoubtedly be of great value to the profession. It would further strengthen the profession's position if individual bodies and their leaders avoided independent discussions and negotiations with government over issues affecting the whole profession. Though tempting and well intentioned, such independent exercises can and will be used by the government to divide and rule the profession.

    The problems facing medicine today demand that our leaders know each other well. They must talk to each other frequently and should understand and take into account the views of other bodies when developing their own policies. Finally, they should do their utmost to present an authoritative and united front on behalf of the profession in the constant battle to maintain professional standards.

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