British medicine's desperate need for leadership

Sir John Tooke and his panel who have been inquiring into Modernising Medical Careers (MMC) are like a team who arrive at the scene of a terrible air crash. ¹ There are bodies, blood, and wreckage everywhere, and the air is filled with rumour, speculation, and blame. How did this awful thing happen and who is at fault? Sir John's panel are doing a thorough job of picking through the wreckage of MMC and the Medical Training Application Service (MTAS), and they are right that this was a ‘deeply damaging episode for British Medicine’. Their search has disclosed not only a catalogue of errors but also fundamental problems like there being ‘no consensus on the role of doctors at various career stages’ and ‘an aspiration to mediocrity’ not excellence. How could we have gone so wrong? One inevitable conclusion of the panel is that British medicine lacks coherent, strategic, high level leadership—exactly as Sir Maurice Shock warned the profession in 1994. ² Instead, we have a plethora of self-interested, ineffective, squabbling bodies. My hope is that out of the wreckage of MMC and MTAS will come the leadership that British medicine desperately needs.

The report quickly dismisses the idea that the disaster was all the fault of the government. It describes the Byzantine advisory structures and makes clear that many medical bodies were involved. Sir John's panel even examined the attendance of representatives of the bodies and shows that they were present when poor decisions were made: ‘The question of selection into specialty training was discussed 17 times between 2004 and 2007 in at least three different MMC bodies’. The royal colleges were not, however, adequately consulted on the critical issue of the nature of the MTAS questions and the scoring system employed. Too often, however, advice from the medical organizations was conflicting. Thus the Junior Doctors Committee of the British Medical Association (BMA) argued for a delay in implementation, but after originally supporting a delay the Trainee Doctors Group of the Academy of Medical Royal Colleges withdrew its support—'raising issues about the consistency of medical professional advice on matters of key importance.’ The report continues:

‘Indeed the advice derived from individual medical professional constituencies frequently reflected the particular interests of that grouping rather than the interests of medicine and medical care as a whole … At a national level the Inquiry acknowledges that the medical profession has frequently failed to proffer coherent advice on key issues of principle, reflecting in part a very complex organizational structure, which owes more to history than necessarily function or purpose. There has been a dearth of medical professional leadership over this period.’

The prescription of the panel is simple: ‘The medical profession should have an organization/mechanism that enables coherent advice to be offered on matters affecting the entire profession, including postgraduate medical education and training’. Sir George Godber, who was Chief Medical Officer from 1960 to 1973 and who no doubt received conflicting, self-interested advice from medical organizations, has been making the same point for nearly half a century—unheeded. And it was more than a decade ago at a gathering of all the medical clans that Sir Maurice Shock, former rector of Lincoln College, Oxford, said: ‘The doctor is different, the patient is different, and the medicine is different. In short, everything is different except the way you organise yourselves’. ² Because doctors lacked a body capable of analysing the environment and setting a strategy for the whole profession, doctors were overwhelmed by a ‘blitzkrieg from the right’ at the end of the 1980s. To regain their influence, doctors needed a top body concerned primarily with strategic and high political matters. Otherwise, warned Sir Maurice, ‘the profession will never be able to punch its weight’.

Sir Maurice also recognized the major barrier to the creation of such a body: ‘It almost goes without saying that to achieve action on such a scale will require the leading professional bodies to surrender some of their independence to a new representative body which in its turn would be guided by a cabinet, serviced by a small but first rate administration’. Medical organizations have been reluctant to surrender power and independence, but none of the existing organizations is up to the task—as the MTAS disaster illustrates.

The BMA is the largest and richest of the medical organizations, but it can never be the high-level, strategic body that is needed because—no matter that it may pretend otherwise—it is a self-interested trade union. Whatever it says is discounted. Plus it lacks academic respectability. The royal colleges and specialist societies are like Italy before the Risorgimento, a gallimaufry of city states with limited interests and clout, many of which are politically naive, poor, and incapable of strategic thought. The Academy of Royal Colleges is dysfunctional, and the GMC rightly belongs to patients not doctors and is regulated by Act of Parliament. The Postgraduate Medical Education and Training Board seems to have been almost stillborn and is recommended by Sir John's panel to be swiftly merged with the GMC. So, as the cliché has it, medicine has lots of leaders but no leadership.

So will the obvious now happen? Will a high level, effective body be formed? Three elements are needed for change: a burning platform (‘we can't go on like this or let this happen again’); a vision of what would be better; and clarity on who will do what tomorrow. We certainly have the burning platform, although complacency can break out at any moment in the medical profession. Sir Maurice provided a hasty sketch of what a better organization might look like, and surely Sir John and his panel can in their subsequent work strengthen the vision and provide next steps. Then, as is so often the case in human affairs, disaster will provide the catalyst to something long overdue and very valuable.