British Medical Association (BMA). The doctor’s union has always had an, at best, ambivalent relationship with the NHS, having tried to stifle its birth and keeping some distance through an independent contractor status ever since. True to form the BMA failed to defend the health service during the Health and Social Care Bill – rather its role was that of assisted dying, but with of course an appropriate bedside manner. Such a relationship is not felt across the board, and many of the strongest supporters of the NHS are now leading members of the BMA Council, although the extent to which this translates into effective action by the union remains to be seen. Its actions during the long, and at times uncertain, passage of the Bill were however those of confusing the debate, censuring effective opposition, and micromanaging its progress.
The first element was most keenly expressed by the BMA calling for withdrawal of the Bill, rather than outright opposition to it, a distinction that would no doubt warm the hearts of both Orwell and our good friend Mitchell Wylie. The former meant only tinkering at the margins of the Bill, making some right sounding noises about its privatising potential but by and large going along with the wishes of Richmond House. The BMA leadership – notably Chairman Hamish Meldrum and his lieutenants Richard Vautrey and Laurence Buckman – could claim to have been seduced by the prospect of GP leadership of the commissioning function and hence of the bulk of the health budget, as well as maintaining some bargaining power with the Department.
However it became clear even at an early stage that the GP role in CCGs would be mainly titular and confined to rubberstamping decisions made by their commissioning support organisations. In many ways it could hardly be otherwise: doctors are trained to treat patients, and are not schooled in the ways of procurement, population data analytics, estate management, finance or the host of other tasks that are required. Indeed leaked Departmental guidance revealed that such support would best be delivered ‘at scale’, which as the BMA itself admitted, would “give large private companies ‘an in built advantage’ making it very difficult for the new commissioners to employ their own staff or contract to local organisations” or to “compete against large established commercial organisations such as KPMG or UnitedHealth”. It should also be mentioned that the DH was at the time actively engaged in the market creation of such services to offer ‘business intelligence’ to CCGs.
As such the reception of GPs to the new form of commissioning was decidedly mixed. A large entrepreneurial cadre with links to the private sector (See Leadership) fully embraced the CCG concept as did the BMA leadership, though others were not so happy. The BMA’s London Council, for example, on learning that 39 CCGs in the capital could draw on “intensive support” from the likes of PwC, Capita, McKinsey, and KPMG, demanded an end to equivocation, outright opposition to the Bill, and Meldrum’s resignation. Instead the grandees closed ranks and severely censured the London members, warning them to observe the principles of collective responsibility or risk bring the organisation into disrepute. The BMA did subsequently however mount an online petition against the Bill.
More recently the junior members have mounted a defence of the health service, though this looks uncomfortably like a tag on to their financial claims. Some may disagree but there seemed to be a singular lack of strike action during the passage of the Bill, but then again as far as the NHS is concerned, ambiguity and equivocation, not to mention a close eye on the purse strings, have always been the BMA’s bywords.