Editors Note: This is a guest blog from Ankush Dhariwal. It is a personal opinion and posting it on the PMFA News website is not an endorsement of the opinions. However, for those working in the NHS, and in the private sector in the UK, there is a significant lack of understanding of some of the issues facing our junior doctors. The junior doctors of today are the specialists of tomorrow and what they think and the opinions that they hold are of relevance for us all.
Why I don’t trust the BMA – and why it matters – 24 January 2017
I’m a trainee doctor in England, and I used to be a BMA member. I have no personal issue with the BMA, and they have done me no personal harm. I have written this article as a means to inform my colleagues as to what has been happening, and to encourage people to inform themselves about these issues. This article is intended for all doctors and medical students, and may be of interest to the wider public.
In it, I argue the BMA has failed at its job of supporting doctors, and I will make use of references wherever possible to support my statements.
1. What is the BMA?
The BMA is a trade union for doctors. It has over 167,000 members at the time of writing, is based in a lovely grade 2 listed building in Central London, and has an income from membership fees of around £50 million a year [1].
A simplified structure of the BMA is as follows: at the top is the Council, the current Chair of which is Dr Mark Porter. It has subdivisions that look after various groups of doctors, such as the General Practitioners’ Committee, and the Junior Doctors’ Committee. A ‘junior doctor’ is defined as a doctor in training who is not yet a consultant.
2. Why does it matter?
The BMA is the only trade union that currently has rights to negotiate with the government over doctors’ contracts, and is currently negotiating the new consultant contract. They are therefore the only barrier between the government, and doctors’ terms and conditions of work – i.e. pay, hours and protections.
The government is currently in a position where it has to save £22 billion on the health service, and it is already doing so aggressively. Labour costs are not insignificant – and so it is quite possible that there will be further attacks on our contracts as time goes on.
Without a union that is open, honest, and accountable to its members, our profession will be vulnerable to continued attacks from the government. Harming doctors harms the NHS, which potentially will harm patients. In short, a failing BMA will have detrimental effects on us as individuals, on our patients, and on the profession that we have all worked so hard for.
3. A chequered past
The BMA was criticised heavily when it supported the controversial new Medical Training Application Service (MTAS) for doctors applying for training jobs, despite its members opposing the system. This ultimately led to the resignation of the Chair at the time, Jim Johnson, in 2007 [2]. The MTAS issue led to a grassroots movement of doctors, Remedy, with up to 12,000 doctors as members, which opposed the scheme using methods including marches and direct legal challenges [3].
Many also criticised the BMA’s role in failing to secure pensions protections in 2012, with a motion being proposed (and failing) that the BMA had failed in its role as a trade union [4].
4. Junior Doctors Contract 2016
Introduction
In November 2015, after the government threatened to impose a new contract on doctors, the BMA balloted its members. Of 37,700 who voted, 98% voted to strike. The profession was galvanised, and united. The BMA told us it would do all it could to oppose any detrimental changes to our contract, and encouraged doctors to join.
After strikes, a new contract was proposed. An explanation of the new contract can be found at www.bma.org.uk/connecting-doctors/my_working_life/b/weblog/posts/the-new-junior-doctor-contract-explained-a-guide-for-junior-doctors-and-medical-students. This contract was supported by the Chair of the Junior Doctors Committee (JDC) of the BMA, Johann Malawana, at a time of political uncertainty – we had just voted to leave the EU. Despite this, 58% of the BMA members who were balloted voted to reject the new contract. This prompted Johann’s resignation [9].
WhatsApp leaks
Later, it emerged that there had been significant discrepancies between what BMA members had been told by the JDC, and what the executive of the JDC had been discussing amongst themselves in a WhatsApp conversation. For example, Johann Malawana said to the group “The best solution may actually [be] to… force them to impose against our support” [5].
The official BMA response to this leaked conversation was that “Private discussions should not be mistaken for the agreed strategy of the BMA Junior Doctors Committee” [6]. Currently, Johann holds a voting seat on BMA Council [7].
Problems with the new contract
One of the biggest criticisms of the new contract was that it discriminates against women. This is because pay does not increase on an annual basis, which particularly affects less-than-full-time trainees (LTFT) who are predominantly women with young children. Other groups who may be disadvantaged are those who work in specialties with non-resident on call (NROC) as well as those who wish to take time out for academic purposes, or to re-train in another specialty. Another concern, albeit refuted by the BMA [8], was that the new pay system meant people would work more unsocial hours. Whether this will happen in practice or not remains to be seen.
The new contract also invokes new mechanisms, such as a ‘guardian’, and ‘exception-reporting’. There is anecdotal evidence that exception-reporting is being discouraged. Indeed, guidance published on the BMA website advises trainees to “be brave” when exception reporting, and that “you are likely to meet some resistance” [10].
In addition, the BMA has not come up with any practical way in which to actually report exceptions – fortunately, an app (Doctor Focused) has been designed for this by doctors independently of the BMA. Finally, according to the opinion of an independent award-winning lawyer, the new contract does not have whistle-blowing protection (covered in more detail later).
To strike or not to strike?
The replacement for Johann, Ellen McCourt, was faced with a government that planned to impose the new contract, despite its rejection by the BMA membership. To combat this, she called for a series of five-day strikes. These strikes were later suspended.
To this date, no clear reason has been provided as to why this happened. It was decided at a meeting of the JDC, and no minutes of this meeting have been released. An email from Dr McCourt stated: “feedback from members from every region in England, as well as the views of the wider profession, patients and the public in considering the next steps on the dispute. Our primary consideration in coming to this decision has been our overriding concern about patient safety, the care we provide every day and the ability of the health service to deliver this care.” [11]
Notably, the feedback referred to has never been officially published by the BMA. Surveys had been sent out by local branches of JDC. The data from these have been published on the Facebook group Junior Doctors Contract Forum, although have never been formally acknowledged by the BMA. The data [12) show that:
- Under 4,000 doctors had replied – most doctors had not been sent a survey at all.
- The majority of doctors (who replied) would have participated in shorter strikes.
In addition to this data, a survey conducted on the Facebook group showed that out of 2806 doctors 2650 (94%) would have participated in three-day strike action [13]. This information was made available to JDC members.
Despite the BMA’s own data and the Facebook data showing that the majority of respondents would favour shorter strikes, no formal attempt to properly survey all doctors was ever conducted, and all plans for industrial action were cancelled. This meant that the only tool left available to oppose contract imposition was abandoned – opening the door for the contract to be imposed.
Other influences?
It is also clear that Mark Porter, Chair of BMA Council, the group that oversees the whole of the BMA, was opposed to strikes. In fact, prior to the decision to suspend strikes, he is quoted publically as saying doctors need to “take a step back” – somewhat undermining the JDC [14].
It appears he has previously attempted to influence JDC. A previous Chair of the JDC was quoted in the WhatsApp leaks as stating “I remember what happened when he joined our meeting in September, can you encourage him not to try and sway us please?” and that previously he has “tied [their] hands” [5]. In an internal BMA memo, Dr Porter stated the decision to suspend strikes was “made for good reason”, namely “members over-riding concern about patient safety” [15].
Current situation
In response to negative feedback from members following the decision to suspend strikes, Ellen McCourt resigned as JDC Chair [16], and was replaced by Pete Campbell, her previous deputy.
Pete told us that a decision had been made to cancel strikes – abandoning the 98% mandate mentioned at the start – in return for new negotiations. At the same time, Mark Porter told BBC Radio 4 the opposite of this – namely, that the BMA would not be negotiating improvements to the contract, but would be helping the government to implement the new contract [17]. At the time of writing, Pete Campbell has stated “talks with the government are not progressing satisfactorily” [18]. It therefore appears no concessions have been made. The JDC will next meet in February 2017 to decide its course of action.
Finally, FY1 doctors are due to start on the new contract as I write this. Their pay will be determined by the banding of their previous job – therefore by chance, some will be paid more than others, for doing the exact same job. This was predicted when the new contract was proposed, yet the BMA (to date) does not have an effective solution, which will potentially lead to significant inequality. In fact, the BMA’s advice on the issue does not even mention this as a problem, and simply states “it is important to note that no existing junior doctor should see their pay reduce in any way as a result of moving to the new contract” [19]. Some FY1s are negotiating locally, and one hospital has decided to put all FY1s on the same banding.
The new contract and the BMA – summary
The BMA has failed to oppose the imposition of a rejected contract, has misled its members, failed to seek and represent the opinions of its members, and has failed to plan adequately for the situation that increasing numbers of doctors are finding themselves in.
They have also failed to acknowledge the multitude of mistakes that have been made, thus preventing any realistic attempt to look at what has gone wrong, why it has happened, and how it can be resolved.
When challenged with the above criticisms, the approach by many JDC members has been to state that if you don’t like it, you should get involved and fix it. However, this attitude fails to acknowledge that when this all started, doctors were extremely involved. Doctors took Jeremy Hunt to court, participated in marches, held Meet The Doctors events, joined and supported the BMA, responded to ballots, and even tried in small ways to tackle the wider problems facing the NHS, such as by forming the NHS Choir.
The fact is, we have reached this position despite involvement from caring and motivated doctors. Even today, members of the JDC include passionate and motivated doctors. It is clear to me that the problems are not limited to who is on the JDC – they are deeper and more pernicious, and include the actions of the BMA’s leadership, as well as its underlying structures (for example, the fact that communication between JDC members, and JDC meetings, are confidential, as well its underlying organisational complexity. Until these problems of openness, transparency, and accountability are recognised, they cannot be fixed.
5. Whistle-blowing
It has been made clear by an expert lawyer, Employment Silk of the year James Laddie QC, that the new doctors contract does not provide trainee doctors with whistle-blowing protection [20]. In basic terms, this means that if a doctor comes across unsafe practices and reports it, they could lose their training number. This is because Health Education England (HEE), which arranges training, is not technically an employer, and so whistle-blowing protection laws do not apply to it – this is essentially a loophole.
Dr Chris Day lost his training number after he alerted a hospital to the fact that of the three ITU doctors expected, only one (himself) was present for a night shift. He is making a legal appeal to challenge this loophole. The BMA offered to help him, but abandoned him at the last minute without explanation [21], and continues to fail to support his important case. Fortunately, he has been able to crowdfund the money required, and I would encourage you to read about and support his case at www.54000doctors.org.
Initially, the BMA denied there was a loophole with whistle-blowing [8]. Later, it somewhat confusingly claimed it had fixed the loophole [22]. It continues to ignore the opinion of James Laddie QC, and continues to mislead members into believing that they have whistle-blowing protection. In addition, JDC members have provided incorrect information from the BMA’s legal team about this issue [23].
Finally, you may have heard of the case of Professor Edwin Jesudason. He is another whistle-blowing doctor, who was forced out of his job by his Trust after doing so. He sought BMA help, and he states the BMA’s legal team advised him to drop the case, accept a settlement, and destroy evidence. When he refused to do so, the BMA decided to sue him for £250,000, putting him at risk of bankruptcy [24,25].
6. What can we do?
You may disagree with things I have said in this article, and I’d encourage you to do so – but most importantly, I’d encourage you to keep yourself informed.
This issue will affect our profession for years to come, and will have an impact on our careers and our lives. It will also affect the wider NHS. To disengage from it will allow our profession to be steamrolled by a government who perceives the NHS as a financial burden. There are 54,000 doctors in training. If we can unite together, and speak with one loud voice, we can demand that our union represents us, and we can help challenge the wider cuts to the NHS. If we stop paying attention, we will be partly to blame for the consequences.
Staying informed is challenging, especially where the only ‘official’ source of information is the BMA, which cannot be relied on. Many doctors used to use the Facebook group, however it appears that this is less frequently used now. I personally would recommend that more people use it – even occasionally – as it is a source of other information, and is open to opposing views. It is also a quick and easy way to access information when time is somewhat of a luxury.
I feel that the BMA has failed in its role as a trade union. I believe it has failed, despite motivated members and doctors working for it. Therefore, I believe it is fundamentally flawed, and I do not think that the solution is limited to more people getting involved with the JDC, although this would certainly be a good start. Perhaps this is the only positive way forward, and perhaps my views are overly cynical. I certainly know there are many who significantly disagree with my approach, and that’s fine – as long as people are informing themselves, thinking about things, and engaging, then we can potentially get somewhere. Without that, we have no chance.
Since I believe the BMA has huge flaws that must be addressed, I have written an open letter of a Vote of No Confidence in the BMA (https://goo.gl/forms/3DZUTkgSM4IbL1ty2), addressed to Mark Porter, which currently has 684 responses. I would be grateful if you could read, sign, and most importantly share the letter, as well as this document, amongst your colleagues. The aim of the letter is notto bring down the BMA (even if I was so self-deluded) – it is to get doctors to call their union to account, to force them to address the situation at an organisational level, and ultimately to generate positive change. I believe the BMA couldbe a great union; however, as it currently stands, it is simply not fit for purpose.
The letter also includes an email address field, which is optional, but would be useful for trying to keep motivated doctors informed and up-to-date with events surrounding the contract, and wider issues surrounding the NHS.
There has also been some debate about whether or not to remain a BMA member. I personally have left the BMA, as I felt I was paying over £30 a month in return for disappointment. Over 2000 doctors have left the BMA in the past two months alone. Others feel that they must remain within the BMA for any hope of change, and others feel that some form of union representation is important. Other unions do take doctors, such as Unite, and HCSA. HCSA are trying to gain recognition for contract negotiation with the government [26].
My personal view is that union membership can be helpful, such as with individual contract disputes, however I feel that even if HCSA does gain negotiating rights, the government may simply continue negotiating with the BMA – and certainly the current consultant contract is being negotiated with the BMA.
There are significant challenges facing doctors, and also facing the NHS. Let us not forget that, regardless of what I say about the BMA, or what your own personal views are, the government has imposed this contract on us, and the same government is proceeding with the Sustainability and Transformation Plans that will lead to service cuts and negatively impact patient care [27].
I therefore feel that the issue is in part a political one. Certainly, if you are concerned with the state of the NHS, it is apparent that a vote for the Conservatives is a vote for privatisation. Some people do not feel privatisation is necessarily a bad thing, and it is certainly a complex issue. My personal view is that privatisation of health will ultimately harm patients, and that if we are to do all we can for our patients, we must become politically aware.
Thanks for reading – and again, please feel free to share this with your colleagues, and online, via social media etc!
References
1. A rough estimate, assuming an average fee to be £25 a month per member (the actual fee varies based on year since graduation, and in fact this may be an underestimate as the standard fee is £36).
2. www.bmj.com/content/334/7603/1074.3
3. www.onmedica.com/newsarticle.aspx?id=021242f3-c2cc-4aa6-a322-655d3b3bbcfd
6. careers.bmj.com/careers/advice/BMA_responds_to_junior_doctor_committee_leak
7. www.bma.org.uk/about-us/how-we-work/uk-and-national-councils/bma-uk-council/people
9. www.bma.org.uk/news/2016/july/junior-doctors-say-no-to-new-contract
10. www.bma.org.uk/connecting-doctors/b/work/posts/six-ways-to-get-the-best-out-of-exception-reporting
11. Email from Ellen McCourt.
12. www.facebook.com/groups/1703752843188523/permalink/1858586784371794/
13. www.facebook.com/groups/1703752843188523/permalink/1859360104294462/
15. www.facebook.com/groups/1703752843188523/permalink/1869028236660982/
17. www.bbc.co.uk/programmes/b082sy4h
18. www.facebook.com/groups/1703752843188523/permalink/1891586711071801/
19. BMA 2016 Contract Information booklet www.bma.org.uk/advice/employment/contracts/junior-doctor-contract-2016 (BMA members only.)
21. www.54000doctors.org/thecase/8-the-bma.html
23. www.facebook.com/groups/54000doctors/permalink/1742467029407726/
24. https://sharmilachowdhury.com/2014/06/30/bma-sues-whistleblower-surgeon/
25. https://vimeo.com/100747028 (Video of Prof Jesudason speaking at BMA meeting.)
26. www.hcsa.com/news-views/news/2016/09/update-on-hcsa-national-recognition.aspx
27. www.theguardian.com/society/2016/nov/18/ae-cancer-and-maternity-units-to-close-in-major-nhs-overhaul
