Has the militant Left taken over the British Medical Association?
Harry de Quetteville and the Investigations Team report on the civil war dividing the doctors’ union
It seemed to be a breakthrough. Ten days ago, on the evening of Wednesday October 27, with the Government and GPS locked in toxic confrontation, representatives from NHS England and doctors’ union the BMA held emergency talks. Soon, news began to emerge of a muchneeded détente.
In fact, it was the beginning of a roller-coaster five days that would see a leading voice of moderation on the doctors’ side dethroned, the union’s radical rump preparing for industrial action, and Britain’s primary care system pitched into an extraordinary new crisis.
The immediate cause of the fallout could be traced to the middle of last month – when Sajid Javid, the Health Secretary, announced £250million to help GPS through the winter.
But the cash came with strings attached, notably that doctors increase the number of patients that they see in person, which at 61 per cent of consultations still stands 20 per cent below pre-pandemic levels (and is a figure inflated by some telephone consultations being classed as “face-toface”).
“League tables” of surgeries seeing the fewest patients in the flesh were to be published, as were the names of those GPS earning more than £150,000. The public was even to be allowed to rate doctors by text.
While such moves enforcing the accountability of high earners might have appeared uncontroversial to patients who have struggled ever harder to see their GP, the BMA reacted with fury. It responded with a blow-by-blow rejection of the reforms and, on October 21, a week after they were announced, convened an emergency meeting of its general practitioners committee (GPC).
The result was devastating – regional groups of GP surgeries known as Local Medical Committees (LMCS) would be called upon to “disengage from any participation with the implementation of that [reform] plan”. Most significantly, however, was the decision to ballot members on industrial action. “No union ever considers industrial action lightly…,” noted Richard Vautrey, chair of the GPC, “but general practice has now reached breaking point.”
If it was a hardball move to shock Javid and wring more concessions from government, it seemed to work, as the two camps met in its wake that Wednesday evening. Sure enough, the GPC soon began to brief details of what seemed like a truce. The league tables would be abandoned. A campaign to address rising levels of abuse directed at GPS was hatched.
A BMA spokesperson described the result as “significant concessions” meriting “serious consideration”. The crisis, it seemed, was over.
In fact, it was only just beginning. Back within the ranks of the 66-strong GPC, fury was growing among more radical members that the committee leadership had sold out to the Government. According to one source with close knowledge of the matter, a hardcore group of about 12 let it be known that, instead of delivering a truce, they regarded the outcome of the talks as insufficient, and grounds for war.
The problem was Vautrey. A mild-mannered 57-year-old, who practises at Meanwood Health Centre in Leeds, he had chaired the GPC since 2017, and been part of its executive team since 2004. Yet he was hardly a political firebrand. A gathering of the GPC was called for Saturday October 30, exactly a week ago.
Then, as members assembled on a private email group discussion, it soon became clear that, as the source puts it: “Some were very unhappy, saying ‘No, there hasn’t been a breakthrough [with the government]!”
At first it seemed like little more than a squabble. Vautrey apologised for the emollient tone of his briefings after the talks. But one in the know says that for a fringe minority it wasn’t enough. Members who had been pushing for a harder line with government, now began calling for a vote of no confidence in Vautrey’s leadership: “He was certainly being pushed,” says the source.
For Vautrey, the stress of trying to reconcile the in-fighting of the GPC as well as perform his own GP duties and balance family life (he has two sons) proved too much. As Saturday became Sunday, he decided that it was time to go. “There’s only so much kind of fighting you can do,” says the source.
A BMA spokesman confirmed that he left under his own steam: “There has been no formal application for a vote of no confidence.”
On Monday of this week, the news became public. Even as Vautrey went, the triumph of those with a more radical agenda was becoming clear, as the BMA launched its indicative ballot on industrial action. “Essentially a good man, [Vautrey] has been crushed,” says a doctor with long experience inside the BMA’S corridors of power. “He... wouldn’t want to be leading a strike, or ‘industrial action’, during a pandemic. He’s a man of integrity, and he wouldn’t want his patients harmed. For him it is the end of a nightmare.”
For patients, however, the nightmare may only be beginning, as the action mooted in the wake of his departure gathers pace. Yesterday, physical reminder letters about the ballot began arriving in GP surgeries; next weekend, the voting closes; and at the end of the week following that, results will be announced – on the same day, ironically, that Vautrey’s successor will be elected.
Among those going out of their way to remind GP surgeries about the ballot is the Cambridgeshire LMC, run by chief executive Katie Bramallstainer and chair Diana Hunter. “Received your @BMA_GP email re: the indicative ballot?” their LMC tweeted on Tuesday, retweeted by Bramall-stainer, who added: “Links will be shared on our News tomorrow.”
Both women, it turns out, are on the GPC from which Vautrey had just been ousted: Hunter as the regional member from Cambridgeshire and Bedfordshire; Bramall-stainer as chair of the UK LMC conference. Sources told The Daily Telegraph that Ms Bramall-stainer, along with Dr Matthew Mayer, her deputy at the UK LMC conference, were known to be frustrated that Vautrey was not taking a strong enough stance with the Government and had been among those driving his expulsion.
LMCS “generally take a more extreme view” than other members, according to one insider. They have, for example, long been unhappy with the last renegotiation of GPS’ contracts, in 2019. Led by Vautrey, it unlocked £2.8billion more money.
But it also came with the requirement to set up Primary Care Networks (PCNS), which some thought extended government oversight into GPS’ fiefdoms.
“Some people called it a Trojan horse,” says a source. Indeed that winter, at their annual conference, LMC representatives voted to support a motion that they were “disgusted” with the way the new GPS contract had been negotiated, and another saying they had “no faith” in the PCNS.
There are even rumours that, frustrated by the “moderation” of the BMA, LMCS may now be considering setting up a rival union. Vautrey told The Telegraph that, alongside the GPC, “the Local Medical Committee conference at which new policy would be set, provided an opportunity to hand over… responsibility to a new chair”.
Regardless of the precise identity of those leading the GPC putsch, however, the BMA – like many trade unions – is open to its agenda being set and its elections dominated by a militant minority.
Just as the Labour Party was hijacked by Momentum, the wellorganised grassroots activist movement deploying savvy control of social media, so doctors intent on protest have realised that the levers of power are all too easy to pull.
“At regional level it takes f--- all to swing a [BMA] election,” one poster reportedly read on an internet forum for junior doctors mooting strike action recently. “Can we take over the BMA?,” noted another. “Serious question. I’m starting to think we can. If we [rejoin] to vote in elections, and used our numbers, we could purge these losers. Elections for reps seem to be won by low double-digit numbers of votes. I quite like the idea of taking over the BMA. These d---heads aren’t ready for us.” Others on the forum noted that if radical members were inserted at regional level, some would inevitably graduate to national committees like the GPC.
“We need moderate voices in the BMA, those who put patients first, those who remember why they went into medicine, and not extremist militants who want to take on the government,” says Peterborough MP Paul Bristow, member of the health and social care select committee.
Unfortunately for those holding similar sentiments, it is election season at the BMA. Campaigning to join its ruling council, held every four years, is effectively already under way, ahead of polls next spring. “It’s very easy to orchestrate a campaign to get certain people, with let’s say Left-wing views, elected, because the turnout in an election for the BMA is about eight or nine per cent of members only,” says someone with experience of such elections. Indeed, she says, “we saw quite a lot of that in the last election”.
When it comes to GPS, there is also what the source called “the secret the BMA doesn’t want you to know” – that it represents only “about 45 per cent of GP partners, possibly less”.
Industrial action, in other words, can be coordinated by members elected on the turnout of a tiny fraction of a union, which itself represents less than half of doctors.
But if they are not all in favour of industrial action, most GPS do have complaints, and not just about face-to-face consultations. Last Monday, as Vautrey was resigning, the BMA slammed the Chancellor for refusing to tweak “punitive” tax arrangements on their pensions. This is because so many doctors accumulate pension pots of more than £1.1 million, above which higher taxes kick in.
As a result, even as most people foresee working longer, GPS are quitting ever earlier, with current retirement age below 60.
That raft of early retirements is, according to Javid, partly why the Government is finding it impossible to meet its manifesto pledge to recruit 6,000 extra doctors by 2025. “We are not on track,” he told the health select committee on Tuesday. “Obviously anyone, whether a GP or not, has the right to move to part-time or, in some cases, they might retire earlier than otherwise.” The use of locums was an issue too, Javid added: “I think it is always better, where you can, to have someone who knows you and knows your medical history. I think that is important.” The knock-on effect of the fact that people “are not able to get through to their primary care services in the usual way,” he said, was clear. “I can tell you that a significant portion of people are turning up for emergency care [at A&E] when they could have actually gone to their GP.”
For one GP with more than 20 years’ experience as a GP both inside the NHS and as a private practitioner, such a situation is enraging.
Speaking anonymously, he describes a primary care system which has moved from serving patients to serving doctors themselves.
The root of this change came in 2004, he says, with the introduction of a new General Medical Services contract which, critically, included a so-called Quality and Outcomes Framework (QOF), under which surgeries could be paid extra for hitting any of 146 targets – measuring enough patients’ blood pressure, for example, or treating them for asthma.
But tickbox treatments, says the GP, meant some doctors started gaming the system. Practice partners were even able to hire locums to see patients while they creamed off the QOF payments. “It created a greedy, greedy society in general practice,” he says. Suddenly, some patients were profitable while others were a burden. “The GPS start negating things that don’t earn them money – if an 85-yearold has an ear plugged with wax, they can’t hear. But it’s not worth it to the GP. You make more money out of chronic kidney disease. It became engineered towards a system that would make the surgery money.”
If QOF started the rot, he says, Covid has accelerated it. “Covid has created a convenient alternative agenda,” he says, “it has allowed this diabolical way of practising medicine.” He means patients struggling for appointments and being seen remotely.
“Of course it is more convenient for the GPS,” he says. “It’s a nice way to work. But the system has gone drastically awry. You cannot have a picture of a lump and diagnose it.”
In a way, he added, the public became complicit in this new deal, insulating GPS from criticism by clapping every Thursday – as it turned out, for a service many would soon come to feel they could no longer access. “I have every respect for hospital workers on the front line,” the GP says, “But I’m not going out and clapping on a Thursday night [for GPS].” He tells of one friend, an A&E consultant above retirement age and from an ethnic minority. “He was vulnerable. But he went in. And he’s disgusted with general practice… with its knee jerk tendency to say ‘Call 111 or go to A&E.’”
“I feel ashamed calling myself a GP,” he added. And while many GPS feel there is now a campaign against them, he says there is not – merely patient dissatisfaction. “There is not a campaign against [GPS]. I can’t tell you how many times a day people say they’re disgusted with the service.”
Now working in private practice, he has a long list of first-hand case studies of patients who have come to him in extremis, having been failed by their NHS GPS.
“One had a melanoma on the back of her neck. She was told over a screen it was nothing to worry about and prescribed steroid cream. Now it has metastasised... A lady in her 80s with lower back pain – prescribed paracetamol over the telephone for six months. When she came to see me, her spine was full of cancer... A woman with a cough whose GP would not see her, said it was just a virus. Like a lot of people self funding, she has a CT scan, finds out she actually has cancer deposits in her ribs and her sternum, probably won’t be here by Christmas. Someone turned round [to her] and said ‘I’m sorry, you’re just a casualty of the Covid era’.”
‘Covid created an alternative agenda. It has allowed this diabolical way of practising’
GP speaking anonymously
‘I feel ashamed calling myself a GP. I can’t tell you how many people are disgusted with the service’
For this GP, such cases suggest that “there are more indirect casualties of Covid than direct”.
It is as though Covid is the latest battle in a running war that began in 1946 with the creation of the NHS. Then GPS insisted that they remain independent, rather than salaried. For 75 years since, they have cherished their remove from government control. With every intervention that strips away some of that independence, from QOFS to PCNS, GPS wonder what they are getting back. Some fight tooth and nail to retain their independence. Others, with every rule imposed, adopt a work-to-rule mindset.
So though it is easy to blame bureaucracy, the stress of the pandemic, underfunding or broken recruitment promises for the militancy of some GPS, the answer may be more prosaic: “Essentially it’s about control,” says the source familiar with the putsch at the GPC. “There are people in high places through all parts of the NHS who would like to see a salaried service.”
When the current battle in primary care is seen as this battle for the very soul of the GPS’ identity, it’s easy to see why it is so raw. GPS themselves are not sure which way to tilt – whether they want the freedom yet commitment of yesteryear, or the oversight yet financial rewards of today. Each has its advantages.
Within the BMA, various camps are mobilising to ensure they are the ones setting the future course.
Whoever wins the battle it is unlikely to be patients – some of whom are sure to lose their lives while it is being fought.