Medicine and Labour Chapter 14 The British Medical Association as a Trade Union

The British Medical Association has always been a trade union. Its objective has always been to raise the status, and hence the power and income, of the medical profession. In recognising that power, income and status are interrelated it acknowledges a principle that would be second nature to many officials in TUC-affiliated unions, especially white-collar unions.

The activities of the BMA in the nineteenth century included the winning for the profession of control over entry to the profession, the attempt to unite doctors in a common approach to the exploitative behaviour of the friendly societies, and the pursuit of a re-grading claim for doctors in the armed forces. No trade union would have done otherwise.

Despite the fact that it was obviously engaged in trade union activity, including the pursuit of pay negotiations ever since the introduction of National Health Insurance, it continued to deny that it was a trade union until the mid-1970s. Under the Heath government’s Industrial Relations Act the BMA was entered on the Special Register, which listed organisations that were not trade unions but were authorised to act as such. The Register was invented largely to cater for the BMA. After the repeal of the Act, the Special Register was abolished and organisations listed on it were transformed into registered trade unions.

The BMA thus became in law a trade union, although retaining also its status as a learned society and a company limited by guarantee. It would be difficult, if not impossible, to set up today a body which had all three of these legal statuses.

The BMA may have acquired the legal status of a trade union, but it had done so reluctantly. The accession of John Havard to the secretaryship changed that. Havard set out,with considerable success, to reorganise the BMA as an efficient trade union and there was no nonsense about denying that status.

Why did the BMA deny for so long that it was a trade union, why does it still stay out of the TUC and why did it undergo the change from denial to acknowledgement?

John Havard explains the BMA’s non-affiliation to the TUC as due to four factors – the TUC’s political alignment with the Labour Party, the question of industrial action, the fact that the TUC may enter into deals with government on behalf of its member unions as a collective interest of the realm, and the fact that various TUG policies incline against the interests of doctors.

We have already seen that the last of these points is not one that is exclusively a BMA concern. It was also shared by the MPU throughout the whole of its existence until its merger with ASTMS, to the point that the MPU probably only stayed in the TUC throughout that period because of a desire to identify with the trade union movement even though it judged the TUC to be an organisation it did not want to be part of. For the BMA, which does not share that need for an emotional bond to organised labour, the arguments which led the MPU repeatedly to debate disaffiliation must be compelling.

I doubt, however, whether these arguments really are a question of specific anti-doctor policies, because it is not easy to find such policies within the TUC and those issues which the BMA is likely to mention, such as salaried service, health centres and nationalisation of the pharmaceutical industry are not issues which would ever have had a repelling effect on the MPU. The issues which the MPU used to debate as disaffiliation issues were even more trivial, such as TUC policies on sickness certification, which triggered off a major disaffiliation Debate in the 1930s, or some derogatory comment about doctors by a General Council member, which triggered off the almost successful disaffiliation proposal of 1967.

Organisations which threaten to take their ball home if they are criticised or defeated invite the suggestion that their ball is not essential. The trivia which the BMA gives as its reasons for non-affiliation and which the MPU used to debate as reasons for disaffiliation must be pretexts and excuses rather than real reasons, or we would have to dismiss the whole leadership of the medical profession as petulantly irrational. The other three reasons are more significant.

Medicine as an Estate of the Realm

At the time of Lloyd George’s conflicts with the House of Lords we find an interesting exchange between the peers and the BMA. The suggestion had been put forward that various professions and interest groups should be allowed access to the House of Lords through an indirect mechanism. For each such interest group the House of Lords would allocate a group of peers who would take it upon themselves to maintain regular contact with the organisation representing the interest group so that its views could be conveyed to the House of Lords. The move was an attempt by the House of Lords to find itself a constituency which could protect it at a time of conflict, and it came to nothing because peers lost interest when the conflict receded.

The response of the BMA was interesting. It rejected the idea on the grounds that the only form of representation in the House of Lords which would be acceptable would be medical peers. The ambition of the BMA was to be more than just an interest group, for medicine to be seen as an estate of the realm.

To some extent medicine has achieved that status. The BMA has direct access to the Prime Minister. Its pronouncements on health matters command a significance akin to that of the CBI’s pronouncements on industry. It is more than just a question of expertise, for the engineering institutions or the Royal Society do not command the same unchallenged status, although possessed of as much expertise. Nor is it just the question of doctors being an important interest group in an important industry, for comments by the NUT on behalf of teachers or by the TGWU on behalf of lorry drivers do not command the same authority.

The Royal Society, the engineering institutions, the NUT and the TGWU command authority as powerful interest groups. The CBI commands authority of a different order of magnitude, as an estate of the realm, and the BMA is also in this category; until the Thatcher government was elected in 1979, the TUC was in a similar position.

This would explain why the BMA was so reluctant to describe itself as a trade union and why it is now inconceivable that it should affiliate to the TUC. One estate of the realm does not affiliate to another, let alone one which has temporarily lost that status. Would the BMA ever give up the right to sit alongside the TUC for the opportunity to influence the TUC?

This attitude, moreover, must wash over onto the MPU. It has always been in its interests to be a medical organisation first and a trade union second. As a trade union it is small with limited penetration into its potential membership and little direct power in the negotiating machinery in which it participates. As such it is insignificant. But as a medical organisation it represents a strand of opinion within an estate of the realm and as such it is a powerful interest group in its own right. Moreover as the medical organisation of the labour movement it operates in two spheres, representing each within the other, so that within medicine it speaks with all the authority of Labour and within the labour movement it speaks with all the authority of Medicine. The BMA has always been prepared to regard the MPU as the medical organisation of the labour movement, and to accept it as such, but it has felt compelled  to  attack   the  MPU  because   the   latter   has   seen   itself, unrealistically, as a rival to the BMA. The idea of the MPU representing Labour within Medicine and Medicine within Labour led several BMA leaders to protest when the TUC terminated its separate affiliation of the MPU, protests which surprised the TUC which had assumed that the BMA would regard the MPU as a despised tiny rival.

The medical profession’s faith in itself as an estate of the realm was shaken during the period of the social contract. Here the BMA found itself bound by agreements reached between the TUC and the government. This was the only time that the BMA ever seriously debated joining the TUC. It was also the time that it began to describe itself as a trade union. But TUC affiliation was rejected and the BMA was careful to say that it was a trade union as well as a professional association, so as to cover all its options.

It acquired its new rhetoric cautiously, at first, ready to retreat if necessary. It soon discovered, however, that the world at large had regarded it as a trade union for many years and that its role as an estate of the realm was not thereby threatened.

What would have threatened it would be for the BMA to be seen merely as a trade union, or primarily as a trade union. Affiliation to the TUC would have carried that implication, at any rate whilst the TUC itself was an estate of the realm.

The affiliation of the BMA to the TUC will occur when, and only when, it is in the interests of the BMA to affiliate to the TUC and that would require substantial changes in the relative status of medicine and labour, or alternatively substantial changes in the relationship of medicine to other estates of the realm which gave it the chance of affiliating to more than one of them.

Let us suppose, for example, that the trend towards abolishing the distinctions between service industries and production industries continues to the point at which general medical services are acknowledged to be a major service industry and the GMSC, as the representative of general practitioners, is invited to join the CBI. The BMA could not accept affiliation to the CBI for the same reason that it could not affiliate to the TUC. But it could affiliate to two or three such organisations. For it may forfeit one’s status as an estate of the realm to affiliate to one other estate of the realm, but to affiliate to two or three of them would be so breathtaking an act that it would enhance one’s status.

Alternatively changes in the relative status of the BMA and the TUC, so that the BMA was clearly subordinate to the TUG and lost no status by affiliating, or clearly superior so that it would patronise the TUC by joining, would also make affiliation possible. If, for example, the BMA lost its special status and its right of access to the Prime Minister and medicine became just an occupation like any other, the BMA would join the TUC. If the TUC declined in influence so that the labour market was seen as no more special than any other economic market, the BMA could then join the TUC just as easily as it could now, as publisher of the British Medical Journal, join a publishers’ association. If the TUC became the premier estate of the realm, with investment controlled by workers’ pension funds under union management, and industry under workers’ control it would be possible for the BMA to affiliate to the TUC without losing its status as an estate of the realm by doing so. If the medical profession became the premier estate of the realm, through society putting health above all other social values and turning to doctors to provide it with advice on everything that impinged on that value, the BMA could then patronise the TUC just as it could now join a publishers’ association, for everybody would know that its role as a trade union, like its role as a publisher, was secondary to its new role of running the country.

I do not expect any of the social changes which would make BMA affiliation to the TUC possible to occur within the next 20 years.

Industrial Action

The BMA refused to describe itself as a trade union for many years and still explains its non-affiliation to the TUC in terms of its opposition to industrial action. It is, of course, unthinkable that doctors would ever take industrial action. Their very service ethic makes it inconceivable. They may have the right to break their contract with their employer but they could never break their obligation to their patients.

The BMA has, of course, taken industrial action or used it as a threat to back up negotiations on several occasions throughout the period in which it has been unthinkable. It advocated in the nineteenth century that doctors should combine to withhold their services from friendly societies unless their terms were met, and the doctors of Cork did so. Against both Lloyd George and Bevan it organised concerted withholding of labour as a sanction, although it was never implemented because a settlement was reached. Several times in the succeeding years it has collected from its members undated resignations from the NHS, although it has never needed to present them to the government. However in 1970 it implemented sanctions against the Wilson government for rejecting the Review Body recommendations, although the sanctions were confined to disruption of administration and did not affect patient care. In 1975, in two separate disputes which overlapped in time, consultants and junior doctors carried out an overtime ban which did affect patient care, and junior doctors did this again in 1976.

The BMA’s attitude to industrial action is therefore that it is unthinkable, inconceivable and unethical except, of course, when it is necessary. The exception is usually forgotten until it becomes relevant and then it is remembered and the industrial action is implemented. When it is over previous attitudes can be resumed.(The BMA’s approach may be catching on. Eric Hammond of the EETPU has recently denied that his ‘no strike” agreements with certain companies really limit the right to strike, since nobody can actually stop people taking strike action. I doubt, however, if this double-think can be successful unless practised by members of the establishment.)

In fairness to the BMA it must be said that the industrial action of 1970 did not harm patients and that the previous threats of industrial action had included proposals for the continuation of medical care other than by the NHS system that was being disrupted. It is however doubtful if those alternatives would have worked, and there is no doubt that patients were harmed in 1975 and 1976.

Political Alignment

The relationship between the TUG and the Labour Party is one of the reasons given by the BMA for not affiliating to the TUG. As we have seen, depoliticisation is central to the identity of the profession and so it would be expected that the medical profession would draw back from participation in a politically-aligned trade union movement.

I doubt, however, if that is the main reason for non-affiliation, which is adequately explained by the perception of medicine as an estate of the realm as influential as organised labour.

At that comment the discussion might end were it not for a startling passage in the second volume of the official History of the British Medical Association.

Elston Grey-Turner writes:

After a lapse of a third of a century, we may wonder why a National Health Service scheme which incorporated much of what had been advocated by the BMA itself in ‘A General Medical Service for the Nation’ (1938) and the report of the Medical Planning Commission (1942) should have aroused such determined hostility from the Association in 1948. This hostility was not so illogical as it might seem. The planning reports had not been deeply studied by the rank and file of the profession. But when Mr Aneurin Sevan’s Bill appeared, they did not like the feel of it. Most doctors sensed that it presented a threat to their independence of action in the practice of their profession. This did not mean that they had withdrawn their support for a general medical service for the nation only that they did not approve of the sort of service that Bevan intended to impose on them. When he promised to amend his Act, enough doctors agreed to co-operate to make it work.

(Grey-Turner, op. cit., p.75. Grey Turner repeats Stark Murray’s error of dating ‘A General Medical Service for the Nation’ from its reissue in 1938 rather than from its original adoption in 1930, thereby making the BMA a latecomer to a field in which it was actually a pioneer. It is easy to see why Stark Murray should have taken this line, but odd that Grey-Turner should repeat the mistake.)

So far there is little in Grey-Turner’s analysis to which one can take exception. But he continues:

Many people at the time were puzzled by the sudden volte-face in the BMA’s attitude. The fact is that there was an emotional, even political, undercurrent to the dispute. In July 1945, when the great war-leader Churchill was (in his own words) ‘immediately dismissed by the British electorate from all further conduct of their affairs’, many in the middle classes were uneasy. Their misgivings were increased by the utterances of some of the Labour leaders. The Attorney-General (Sir Hartley Shawcross) was reported to have declared ‘We are the masters now’. The Secretary of State for War (Mr Emanuel Shinwell) said that he did not care a ‘tinker’s cuss’ for the middle classes. And Mr Bevan himself (albeit at a later date) said that as far as he was concerned the Tory party were ‘lower than vermin’. This kind of attitude provoked resentment and belligerence in professional people. So long as the Minister of Health exhibited a high-handed, truculent attitude towards the medical profession the doctors were united against him. The pretexts of the dispute were technical and were not understood by the. general public, who were not much interested in an abstract concept of ‘professional freedom’ and could not fathom why general practitioners should object so strongly to receiving a salary. The second plebiscite forced Mr Bevan to make important concessions to the BMA. As soon as he showed that he had learnt that he could not ride roughshod over the BMA and the medical profession, the attitude of the doctors changed … The BMA had won its spurs as the standard bearer of the middle classes.

Grey-Turner, a former secretary of the BMA writing its official history, comes extremely close to attributing an overt party-political motivation to the BMA. Actually the analysis is nonsense. The BMA attitudes to Bevan were the same as its attitudes to his Tory predecessor Willink and the BMA was preparing for a fight long before the 1945 election. If there was any difference in their attitude to Willink and to Bevan it was only that Willink surrendered and Bevan fought.

The significance of Grey-Turner’s analysis is not that it is either correct or credible, but that it raises the question of whether that approach was present in BMA House in senior levels at the time that Grey-Turner was a senior official of the BMA. Was Grey-Turner interpreting the past in the light of the present as he experienced it?

The period between the introduction of the Review Body in 1962 and the extension of the Review Body system to other health service staff in 1984 is one in which the medical profession’s pay was dealt with by a procedure which to some extent insulated it from the general pay bargaining of the NHS. That may be viewed as an era distinct from the periods before it and after it.

In that period of 22 years the country was governed by the Labour Party for almost exactly half the time and by the Conservative Party for the other half. During the time in which Labour has been in office the BMA has carried out four industrial disputes. In the other half of the time it has carried out none. Against that background we find a leading official of the Association attributing party-political motivations to it in its official history. There is a case to answer. (Indeed if we substitute the NUM for the BMA, reverse the parties and substitute Scargill for Grey-Turner we find that another union in a similar situation has been convicted by the press under the principle of res ipsa loquitur.)

I don’t actually believe, on my personal experience, that party-political motivations play a major part in the thinking of BMA House today. However I am not sure that that was true ten years ago. Certainly in the 1975 junior doctors’ dispute, although the majority of those who took part and the majority of the grass-roots leaders that the dispute threw up did so because of the issue of principle involved, there were certainly people who sought to link the dispute to the concurrent consultants’ dispute and spoke openly of bringing down the government. Although they did not succeed the two disputes certainly shattered the Castle/Owen health ministry.

Substantial changes have taken place over the last decade in the BMA’s perception of itself politically, as a trade union, and as a part of the NHS. To understand those changes we need to understand the medical politics of the 1970s.

The 1970s – Crisis in the BMA

The success of the BMA in establishing itself as the focus of unity of the medical profession has been obtained very largely by its sensitivity as an organisation to the pressures that grow up in the pluralism of the profession. It is through this pluralism and the interplay of competing interests, mediated through the sophisticated political machinery of the profession, that the terms are negotiated on which the unity of the profession can be maintained.

Sometime during the 1950s this process began to fail. I do not claim to know the reason for that failure, but its effects were obvious during the 1960s. The BMA failed to read the danger signs of GP discontent until the MPU had rammed them down its throat, and by that delay it forfeited the opportunity to control events and found itself forced to accept the MPU programme, in the form of the Family Doctor Charter.

The same insensitivity manifested itself over the discontent of the junior hospital doctors which allowed the JHDA to become the dominant organisation of junior doctor politics. This dominance persisted until the JHDA’s disastrous error in adjourning the HJSGC sine die and leaving an open field for the BMA to find new leaders loyal to the traditional image of the profession.

It is also symbolic of the political arrogance of the BMA at the time that it assumed that the resignation of the JHDA officers of the HJSGC and their replacement by others was the solution to all the problems of junior hospital doctors, and that the issues which had led to the formation of the JHDA could be ignored.

In the early 1970s the BMA found itself faced with three external threats. The MPU, after its merger with ASTMS, was for the first time in its history a credible alternative to the BMA, in the sense that it actually possessed the resources that would allow it to be the representative organisation of the medical profession if the profession so wished. It is true that the profession did not so wish, and that the MPU was still deeply scarred by the schism of 1965. Nonetheless the BMA faced a real threat. The JHDA was riding high after its outstanding successes of the late 1960s and most junior doctors saw the JHDA as their representative organisation to at least as great an extent as they saw the BMA.

If the JHDA had merged with the MPU, and if it had also held on to office in the HJSGC to stop a new leadership arising, whilst at the same time trying to break the HJSGC away from the BM& in protest at the refusal of autonomy, it is likely that the BMA would have been split and the JHDA/ASTMS would have gained dominant negotiating rights for junior hospital doctors. The BMA was saved from this outcome only by the hubris of the JHDA leadership, which neglected both the significance of its lack of resources and the possibility that the HJSGC could, after all, function without it.

A third rival arose in the form of the HCSA, a consultants’ breakaway group.

BMA membership fell rapidly through the first half of the 1970s to a trough of around 50 per cent. For probably the only time in the history of the profession the question of alternative organisations and joint negotiating rights became a topic of serious discussion.

The response of the BMA to this unprecedented threat to its status was not to acknowledge its failure, but to seek coercion as the solution to its problems. The idea of abolishing the universal franchise of the craft committees and integrating them into the machinery of the BMA as pure BMA committees elected only by BMA members came to prominence and, indeed, the BMA voted for this one year, only to reverse it the next year when it realised that neither the profession nor the government would accept it and that the only consequence would be the setting up of joint negotiating structures in which other organisations would have seats. Even after this debacle the idea of coercion arose. An exchange between a questioner from the floor and the platform at an ARM revealed that the idea was around of affiliating to the TUG in order to freeze ASTMS recruitment under the Bridlington agreement, and was abandoned mainly because it was thought it wouldn’t work and the TUG wouldn’t play along. As membership slid ominously towards 50 per cent the idea of a closed shop was seriously debated.

In the midst of this squalid period came the 1975 junior doctors’ dispute. The facts of this dispute are really quite simple. Barbara Castle had agreed with the HJSC a new contract for junior doctors which would increase their earnings by increasing overtime payments as a result of the shortening of the working week from 80 to 40 hours. When the time came to implement the contract a pay policy was in force as part of the social contract, and so overtime rates were cut to keep the pay bill unaltered. The situation was complicated slightly because a new system of paying overtime rates was being introduced at the same time, and so the cut in overtime rates was not as direct as the above description implies. The HJSC did not call for industrial action, nor did the JHDA or MPU, but spontaneous industrial action broke out all over the country, which ASTMS rapidly made official so far as its own   members were concerned, whilst the BMA and JHDA still held back. New grass-roots leaders were thrown up by the dispute and eventually were voted into office as the leaders of the HJSC. The dispute was finally settled by a redefinition of the difference between ‘A’ units of overtime (immediately availability) and ‘B’ units (stand-by) which allowed more people to claim ‘A’ units. As a result the pay policy was broken, but by a formula so complicated that nobody noticed. The new contract for junior doctors was open to local interpretations and this highlighted a defect of BMA organisation – the lack of any effective mechanism for local negotiation. ASTMS exploited the advantage which this gave it and built up its membership in those areas where it had a reasonable base to start from. The height of its success was the Wigan dispute described earlier.

Renewal of the BMA

The successes of the MPU in taking up local issues at this time has been described in Chapter Four. As described there, the BMA was able to hold off the challenge largely by the hard work of the HJSC office in Birmingham and the ability and loyalty of two members of staff who were later made redundant.

Renewal, however, was now at hand. Politically it can be attributed to the work of the HJSC leaders. Organisationally it can be attributed to John Havard, who undertook a major reorganisation of the BMA when he took over the secretaryship. This included a new emphasis on services to the individual member, including the new industrial relations service by which full time officials were recruited to handle members’ grievances, allowing the BMA to combat the ASTMS threat. Communications were improved and attitudes wjjre altered. Trade unionism was no longer a dirty word. Political sensitivity returned. Stirrings of discontent were identified and dealt with and the MPU developed the distinct feeling that its best political initiatives were stolen before it could make much ground with them. Later an insurance brokerage was established to provide further benefits of membership.

BMA membership responded by increasing steadily back towards the kind of percentages that it had achieved in the past. The JHDA and HCSA declined and the MPU challenge also disappeared.

The renewal of the BMA led to changes in the way it viewed itself. Those changes, however, were a process of reinterpreting the long-standing identity of the profession in the light of changed circumstances. It was the 1960s and 70s which were atypical in their rigidity and lack of dynamism. By failing to adapt to changing circumstances, by failing to respond to changed patterns of thought, both within society at large and within the profession, and by allowing certain essentially political ideas about the NHS and about party politics to replace the profession’s traditional eclectic paranoia, the BMA’s role as the focus of unity for the profession had declined to the verge of collapse, to be saved once by mistakes by the JHDA leadership and once by the dedication of staff members whom the BMA later sacked. It would seem, however, that that atypical period has now been overcome.