BRITISH MEDICAL JOURNAL
13 NOVEMBER 1976
hoped that nothing would happen to endanger patients in any way. Nevertheless, their action was solely in their own interests, to try to force amelioration of their own remuneration and terms of service and to diminish their work load. It is now evident that industrial action by doctors has had effects far beyond the ordinary withdrawal of labour. In industry arrangements are made to try to deal with potential emergencies during a strike-for example, in aiming to ensure essential services and supplies to hospitals and patients. Similarly, doctors' industrial action would be expected to include such emergency plans and, indeed, has done so. But there are experienced trade union leaders outside the medical profession who would prefer doctors not to take industrial action and deplore it in the interests of humanity. They do not expect doctors to "fight" industrially any more than doctors would do so in war. Some doctors have declined to join in any industrial action: many have done so reluctantly. Their justification was belief in the strength of unity and dislike of "blacklegs." But the argument most commonly used was that the DHSS (aware that it was dealing with a profession unwilling to expose patients to risks) had pressed its advantage beyond the reasonable limit and had provoked the doctors to act. Whether the DHSS recognised its own responsibility to patients was a matter of opinion. In the end the doctors blamed the Department, which in turn blamed the doctors. The feeling that the Department was going beyond the decent limit was aptly expressed by a French colleague in saying, "Ils abusent de votre naivete." Whatever the reason, patients had to suffer the consequences of doctors and the DHSS wrangling over them. This must not happen again.
I offer the following suggestions to the Royal Commission: (1) Doctors must agree that in view of their vocation they will not take industrial action and the DHSS must respect this. (2) A new "civil" (Geneva type) convention should be set up to prevent patients being harmed in disputes between doctors and the Government. (3) The General Medical Council should state that the privileges of registration will be endangered by industrial action and that disciplinary action could result. (4) An independent (probably lay) arbitrator should be appointed to decide whether action by the DHSS has been unreasonable towards a profession pledged not to take industrial action. The arbitrator would also decide whether professional action was contrary to the new convention. Both parties-the DHSS and the profession-must abide by the decisions of the independent arbitrator. I have discussed my views with many doctors of all ages and experience, as well as with lay people. All have encouraged me to express my opinions to the Royal Commission and this letter seems one of the best ways to do so.
WALTER HEDGCOCK Saxlingham, Hlolt, Norfolk
Postgraduate education and the junior doctors' contract SIR,-As it is now generally accepted that medical education should be a continuous process from entry to medical school until retirement from practice, it follows that the quality of patient care is largely determined by the quality of the education. In the past those charged with the responsibility for postgraduate medical education have been scrupulously careful in their efforts to distinguish between what seemed to be purely educational matters and those concerned with terms and conditions of service.
1199
Recent changes in the terms and conditions of service for junior doctors cause grave concern because it is no longer possible to make such a distinction. The forces released by these changes will further seriously disturb the already precarious balance between specialties. Furthermore, if left unchecked they will not only adversely affect continuing education but, by jeopardising the recruitment of staff to centres of excellence, will undermine the very foundations upon which the standards of health care in Britain depend.
of being other than a pawn. But if planning started now our representatives could turn into knights, queens, or bishops (if these are allowed in Scotland). What a chance for the BMA to get things right in one part of the kingdom! D N H HAMILTON
HAMISH WATSON
SIR,-In your account (23 October, p 1023) of the meeting of Council on 6 October, you attribute to me the suggestion that the profession, in order to achieve certain aims, should not co-operate in the implementation of the EEC directives. This statement came from someone else in the Council and not from me. The co-operation or non-cooperation of the profession is irrelevant to the implementation of the directives. The latter are legal provisions governing the mutual recognition of degrees and diplomas and co-ordinating regulations relating to the conditions for the practice of medicine. The carrying out of the necessary administrative duties is a function of the General Medical Council and it is our aim that the GMC carrying out this function should be the reformed GMC. In our observations on the Government's proposals for implementing the EEC directives we have consistently made this clear. In the event, however, if the Government makes the necessary legislative changes without reforming the GMC it would only be the non-cooperation of the GMC itself which could impede the implementation of the directives. Lest it be thought that we are the only country in dispute with government in health matters, I would draw your attention to the current dispute between the doctors and the government in Belgium, where at the moment the doctors are engaged in an administrative strike and where, unless there is a rapid change of position, a repetition of the doctors' strike of 1964 seems inevitable. This dispute arises from the proposed increased controls by the social security organisations (and indirectly by the government) over the medical services provided by doctors.
Chairman, Standing Committee of the Conference of Postgraduate Deans and Directors of Postgraduate Medical Education of the Universities of the United Kingdom Ninewells Hospital and Medical School,
Dundee
Devolution SIR,-Scrutator's view (23 October, p 1022) that "on issues like devolution the BMA is particularly well suited to represent doctors" ignores the fact that the BMA has ruled that devolution will be a disaster, and has stopped further discussion. Yet big political decisions, like the financial powers for the Assembly and proportional representation for its elections, are at present undecided and will seriously affect the kind of devolved Health Service we will have. The outcome of these questions rests on a knife-edge and if the BMA could only follow, say, the Church of Scotland or the Scots lawyers in their support of a strong Assembly a favourable outcome may result. Having opposed devolution, the BMA instead regard themselves as disqualified from taking any further interest. A possible defence of this neglect is to say that once the Bill is passed in mid-1977 serious study can begin and the Scottish (and Welsh) BMA can get to work on deciding, for instance, how much autonomy they should have, the nomenclature of the new Scottish bodies, and the effects of having to negotiate salaries with the devolved Assemblies. This attitude is a dangerous one, since elections to the Assembly are due in early 1978 and two events may use up the valuable time between the Devolution Bill's assent and the elections. The first is that after the Bill goes through the Royal Commission will probably decide that, since health care is to be devolved, then constitutionally they have no alternative but to make a separate report to the Assemblies. The Scottish BMA may be asked at short notice to produce a substantial, separate submission on the future of the Health Service in Scotland, taking into account its separate character. The second distraction is that the Annual Representative Meeting will be held in Glasgow in mid-1977 just when their Scottish hosts should be holding a special tartan ARM. Instead they will be distracted and exhausted by the national ARM. Now all these events may not combine to give the doctors a disastrous start to devolution, but they might. Those of us who reluctantly respond to the BMA's annual call to continue as members can insist that the BMA shows intelligent anticipation of events. Our representatives make great play of being pawns in a political game, but in Scotland there is to be a new chess game. If the doctors arrive after it has started then there is no hope
Department of Surgery, University of Glasgow
EEC medical directives
A J ROWE Bury St Edmunds, Suffolk
***We apologise for the fact that owing to an editorial error we wrongly attributed the comment made in Council to Dr Rowe.-ED, BM3. National Insurance deductions
SIR,-As a result of negotiations carried out by the BMA with the DHSS last year doctors are now able to avoid having excess contributions deducted where they have more than one employing authority. The procedure to follow in such cases, which is very simple, can be found, together with much other information about National Insurance contributions, in the notes on the subject which the BMA prepares each year for the benefit of its members. The fact that these notes can be obtained by sending a stamped, addressed envelope to the Secretary of the Association was given wide publicity in the BMJ and in BMA News Review earlier this year and large numbers of
13 NOVEMBER 1976
hoped that nothing would happen to endanger patients in any way. Nevertheless, their action was solely in their own interests, to try to force amelioration of their own remuneration and terms of service and to diminish their work load. It is now evident that industrial action by doctors has had effects far beyond the ordinary withdrawal of labour. In industry arrangements are made to try to deal with potential emergencies during a strike-for example, in aiming to ensure essential services and supplies to hospitals and patients. Similarly, doctors' industrial action would be expected to include such emergency plans and, indeed, has done so. But there are experienced trade union leaders outside the medical profession who would prefer doctors not to take industrial action and deplore it in the interests of humanity. They do not expect doctors to "fight" industrially any more than doctors would do so in war. Some doctors have declined to join in any industrial action: many have done so reluctantly. Their justification was belief in the strength of unity and dislike of "blacklegs." But the argument most commonly used was that the DHSS (aware that it was dealing with a profession unwilling to expose patients to risks) had pressed its advantage beyond the reasonable limit and had provoked the doctors to act. Whether the DHSS recognised its own responsibility to patients was a matter of opinion. In the end the doctors blamed the Department, which in turn blamed the doctors. The feeling that the Department was going beyond the decent limit was aptly expressed by a French colleague in saying, "Ils abusent de votre naivete." Whatever the reason, patients had to suffer the consequences of doctors and the DHSS wrangling over them. This must not happen again.
I offer the following suggestions to the Royal Commission: (1) Doctors must agree that in view of their vocation they will not take industrial action and the DHSS must respect this. (2) A new "civil" (Geneva type) convention should be set up to prevent patients being harmed in disputes between doctors and the Government. (3) The General Medical Council should state that the privileges of registration will be endangered by industrial action and that disciplinary action could result. (4) An independent (probably lay) arbitrator should be appointed to decide whether action by the DHSS has been unreasonable towards a profession pledged not to take industrial action. The arbitrator would also decide whether professional action was contrary to the new convention. Both parties-the DHSS and the profession-must abide by the decisions of the independent arbitrator. I have discussed my views with many doctors of all ages and experience, as well as with lay people. All have encouraged me to express my opinions to the Royal Commission and this letter seems one of the best ways to do so.
WALTER HEDGCOCK Saxlingham, Hlolt, Norfolk
Postgraduate education and the junior doctors' contract SIR,-As it is now generally accepted that medical education should be a continuous process from entry to medical school until retirement from practice, it follows that the quality of patient care is largely determined by the quality of the education. In the past those charged with the responsibility for postgraduate medical education have been scrupulously careful in their efforts to distinguish between what seemed to be purely educational matters and those concerned with terms and conditions of service.
1199
Recent changes in the terms and conditions of service for junior doctors cause grave concern because it is no longer possible to make such a distinction. The forces released by these changes will further seriously disturb the already precarious balance between specialties. Furthermore, if left unchecked they will not only adversely affect continuing education but, by jeopardising the recruitment of staff to centres of excellence, will undermine the very foundations upon which the standards of health care in Britain depend.
of being other than a pawn. But if planning started now our representatives could turn into knights, queens, or bishops (if these are allowed in Scotland). What a chance for the BMA to get things right in one part of the kingdom! D N H HAMILTON
HAMISH WATSON
SIR,-In your account (23 October, p 1023) of the meeting of Council on 6 October, you attribute to me the suggestion that the profession, in order to achieve certain aims, should not co-operate in the implementation of the EEC directives. This statement came from someone else in the Council and not from me. The co-operation or non-cooperation of the profession is irrelevant to the implementation of the directives. The latter are legal provisions governing the mutual recognition of degrees and diplomas and co-ordinating regulations relating to the conditions for the practice of medicine. The carrying out of the necessary administrative duties is a function of the General Medical Council and it is our aim that the GMC carrying out this function should be the reformed GMC. In our observations on the Government's proposals for implementing the EEC directives we have consistently made this clear. In the event, however, if the Government makes the necessary legislative changes without reforming the GMC it would only be the non-cooperation of the GMC itself which could impede the implementation of the directives. Lest it be thought that we are the only country in dispute with government in health matters, I would draw your attention to the current dispute between the doctors and the government in Belgium, where at the moment the doctors are engaged in an administrative strike and where, unless there is a rapid change of position, a repetition of the doctors' strike of 1964 seems inevitable. This dispute arises from the proposed increased controls by the social security organisations (and indirectly by the government) over the medical services provided by doctors.
Chairman, Standing Committee of the Conference of Postgraduate Deans and Directors of Postgraduate Medical Education of the Universities of the United Kingdom Ninewells Hospital and Medical School,
Dundee
Devolution SIR,-Scrutator's view (23 October, p 1022) that "on issues like devolution the BMA is particularly well suited to represent doctors" ignores the fact that the BMA has ruled that devolution will be a disaster, and has stopped further discussion. Yet big political decisions, like the financial powers for the Assembly and proportional representation for its elections, are at present undecided and will seriously affect the kind of devolved Health Service we will have. The outcome of these questions rests on a knife-edge and if the BMA could only follow, say, the Church of Scotland or the Scots lawyers in their support of a strong Assembly a favourable outcome may result. Having opposed devolution, the BMA instead regard themselves as disqualified from taking any further interest. A possible defence of this neglect is to say that once the Bill is passed in mid-1977 serious study can begin and the Scottish (and Welsh) BMA can get to work on deciding, for instance, how much autonomy they should have, the nomenclature of the new Scottish bodies, and the effects of having to negotiate salaries with the devolved Assemblies. This attitude is a dangerous one, since elections to the Assembly are due in early 1978 and two events may use up the valuable time between the Devolution Bill's assent and the elections. The first is that after the Bill goes through the Royal Commission will probably decide that, since health care is to be devolved, then constitutionally they have no alternative but to make a separate report to the Assemblies. The Scottish BMA may be asked at short notice to produce a substantial, separate submission on the future of the Health Service in Scotland, taking into account its separate character. The second distraction is that the Annual Representative Meeting will be held in Glasgow in mid-1977 just when their Scottish hosts should be holding a special tartan ARM. Instead they will be distracted and exhausted by the national ARM. Now all these events may not combine to give the doctors a disastrous start to devolution, but they might. Those of us who reluctantly respond to the BMA's annual call to continue as members can insist that the BMA shows intelligent anticipation of events. Our representatives make great play of being pawns in a political game, but in Scotland there is to be a new chess game. If the doctors arrive after it has started then there is no hope
Department of Surgery, University of Glasgow
EEC medical directives
A J ROWE Bury St Edmunds, Suffolk
***We apologise for the fact that owing to an editorial error we wrongly attributed the comment made in Council to Dr Rowe.-ED, BM3. National Insurance deductions
SIR,-As a result of negotiations carried out by the BMA with the DHSS last year doctors are now able to avoid having excess contributions deducted where they have more than one employing authority. The procedure to follow in such cases, which is very simple, can be found, together with much other information about National Insurance contributions, in the notes on the subject which the BMA prepares each year for the benefit of its members. The fact that these notes can be obtained by sending a stamped, addressed envelope to the Secretary of the Association was given wide publicity in the BMJ and in BMA News Review earlier this year and large numbers of
