A long way from WorcesterBMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39269.717454.59 (Published 12 July 2007) Cite this as: BMJ 2007;335:72
The BMA has now been in existence for a century and three quarters. Such longevity is impressive. Rival bodies, including an earlier British Medical Association unrelated to Charles Hastings' creation, proved transient. The BMA of 2007 is, of course, a very different creature from its earlier incarnation, the Worcester based Provincial Medical and Surgical Association of 1832. Now, headquartered far from its place of origin and operating under a different name, it performs different functions in a much changed medical context. It has faced numerous challenges in the past, and its continued existence has not always been assured. It seems safe to assume, however, that it is well on its way to a bicentenary.
The BMA, originally named the Provincial Medical and Surgical Association (PMSA), was established by some 50 medical men in the boardroom of Worcester Infirmary on 19 July 1832. Charles Hastings, “the best known physician in the Midlands,” was the driving force behind the new body and the dominant personality within it for over 30 years. The association was not set up to act as a professional ginger group or press the case for medical reform, then a topical issue under the influence of Thomas Wakley's Lancet. Neither was it created to advance a public health agenda. Its main purpose was to provide a “friendly and scientific” forum that would allow provincial practitioners to advance and exchange medical knowledge.
Medical politics did not reach the forefront of the association's activities for some years. Initially, the Lancet welcomed the PMSA's foundation, but before long the acerbic Wakley turned hostile, describing the association as “a most disgraceful abortion.” Such invective did not stall the association's growth. Ten years after that first gathering in Worcester its membership had reached a healthy 1350. The association was also well on the way to acquiring control of a weekly journal, the Provincial Medical and Surgical Journal (called British Medical Journal from 1857), through which members could communicate.
Wakley's disillusionment with the PMSA owed much to its failure to adopt his radical views about medical reform—that is, the way in which the profession was educated, certified, and regulated. He favoured confrontation with the professional elites, whereas Hastings and his colleagues preferred a more emollient approach. In time, however, Wakley recognised the merit of the PMSA—he even became a member—and praised the association's efforts as the reform question came to a head. The BMA, as it was known from 1855, played an important role in securing the passage of the Medical Act 1858 which, for all its flaws, established the General Medical Council, drew a line between qualified and unqualified practitioners, reserved public appointments for the former, and created a system of professional self regulation. Of the GMC's 24 founder members, eight, including Hastings, were BMA members. The association had, once and for all, become a potent force in medical politics.
National health insurance
Once it became active in medical politics the 19th century BMA was an effective campaigner in many spheres, including Poor Law medical practice, quackery, alternative medicine, public health, military medicine, and contract practice. The defence of professional interests was one consideration, but protecting the public—for example from the manufacturers of fraudulent, sometimes harmful, “patent” medicines—was another. In the early 20th century the association faced its biggest challenge to date when Asquith's Liberal government, mainly in the person of the chancellor of the exchequer, Lloyd George, proposed a system of national health insurance for manual workers and other employees with earnings of less than £160 a year. The BMA was not opposed to an insurance scheme. Indeed, in 1909 it published plans of its own for “the organisation of medical attendance on the insurance principle.” But the association was adamant that its members would not be exploited as they had been under the Poor Law and by sick clubs in the past. Confrontation with the government ensued and thousands of BMA members voted to refuse service in the new scheme. Lloyd George offered concessions but the association overplayed its hand and was ultimately obliged to climb down as it became clear that many doctors actually were willing to serve. Once the new system was in place it proved a boon not only to patients but to the many doctors who escaped that bane of private practice, the unpaid fee. When the prospects of an NHS loomed in the 1940s, many practitioners were reluctant to see the end of National Health Insurance.
Birth of the NHS
Early in the second world war it was widely recognised that arrangements for the provision of medical services to the British people were likely to change with the return of peace. The BMA has sometimes been seen as wholly opposed to the introduction of a national health service, but in reality its annual representative meeting approved a state system “for the whole community” as early as 1942, baulking only at any suggestion of a full time salaried service. Until the election of a Labour government in 1945 the BMA and wartime coalition had little difficulty in agreeing the terms of the new service, but with the firebrand Welsh socialist Aneurin Bevan at the Ministry of Health, association and government were soon on a collision course. Before and after the passage of the National Health Service Act 1946, acrimonious negotiations took place, with Charles Hill (the “radio doctor”) and Guy Dain to the fore for the BMA. For a time it seemed that practitioners would decline to enter the service. But with concessions from both sides, wiser counsels eventually prevailed. Weeks before the new service was due to begin, a special representative meeting voted to cooperate. It was not long before the profession came to see the merits of the NHS; when, in 1962, the American Medical Association attacked the service, the BMJ deplored the Americans' “cheapness and vulgarity,” insisting that the United States had much to learn from Britain and Europe.
Recognition of the merits of the NHS did not mean universal approval of its terms and conditions of service. For years, many general practitioners felt undervalued, under-resourced, professionally isolated, poorly paid, and overworked. The 1950s and 60s in particular saw a spate of inquiries into general practice, some of which led to improvements—at least for a while. The BMA's record in negotiating change was chequered, with the occasional embarrassment and several triumphs. Agreement on the charter for the family doctor service (1966), with its emphasis on group practice, suitable premises, employment of ancillary staff, and the prioritising of preventive medicine, was a high point. “The BMA,” the Lancet noted, “has won a clear victory.” A subsequent fight concerned hospital “pay beds” and consultants' private practice within the NHS. The Labour government that came to power in 1974 was committed to phasing out both. Barbara Castle, the minister responsible, had a personal commitment to the cause and was determined to confront the profession. But the BMA had more cause than the minister to be satisfied with the outcome. As Charles Webster has noted, by the end of James Callaghan's administration more than five years later, Labour had failed to eliminate pay beds from the NHS while succeeding “in stimulating rather than repressing the private sector of health care.”