The British Medical Association is both a trade union and a professional organisation. Professional activities such as its successful campaigns around seatbelt legislation and smoking have added weight to its standing as a union. It is not noted for drama and histrionics.
So there was significant surprise when its governing body, the BMA council, recently voted to reject the recommendations of the Cass review, an independent review commissioned to look at NHS gender identity services in England, which was accepted in full by the last government and its successor.
BMA members were genuinely outraged. Letters to the BMJ accused the council of bringing “the BMA and the medical profession into disrepute”. One correspondent said they were “more shocked than anything I can think of in 40 years of practising medicine”. Some members, aghast at the BMA adopting such an irrational policy, resigned after decades of union membership. A letter accusing the BMA of being secretive and opaque, and of going against the principles of evidence-based medicine and ethical practice, quickly attracted 1,500 signatures, 1,000 of whom are BMA members. The signatories include many high-profile names in the profession, people not normally inclined to sign protest letters.
Opposition to the review is difficult to understand because Dr Hilary Cass, who chaired the review, is clear that what she wants is to improve the evidence base for the treatment of patients with gender dysphoria, which she judged to be seriously lacking. She and her team spent four years looking at evidence from around the world, and talking to more than 1,000 people including children and their families, clinicians and those with lived experience. Her conclusions, supported by seven peer-reviewed systematic reviews, were greeted with relief by doctors and their professional organisations, who felt that for too long children and adolescents had been subjected to potentially life-altering treatment without enough evidence.
How did the BMA end up so completely out of touch with its members? In brief, the union is the victim of entryism, a political strategy whereby members of an organisation join a larger organisation in order to influence and change its policies. Resident (previously known as junior) doctors were angry about the sharp fall in their pay since 2008 and organised a group called DoctorsVote to campaign for full pay restoration. Part of the group’s strategy was to get its members on to the BMA council, which they did with great success, taking almost half the voting seats in 2022.
So far, so reasonable: the BMA is a trade union and its core role is to improve the working conditions of doctors.
But having a large and well-organised pressure group on its council brought predictable problems. DoctorsVote is disciplined when it comes to pursuing its agenda (which turned out to go beyond full pay restoration to include entrenched opinions on the transgender debate), and in voting group members on to BMA committees.
A toxic atmosphere developed in the council chamber, and a climate of fear and intolerance of genuinely held beliefs meant that some people were reluctant to express opinions that were out of step with DoctorsVote. Thus was the scene set for the debacle over the Cass review.
A motion to council calling for the disavowal of the review was altered – after a leak to the press – to one that called for a public critique and for the BMA to block the implementation of the review’s recommendations.
The motion was passed, although the vote was not unanimous, with further leaked figures showing that more council members abstained or voted against the critical part of the motion than voted for it. The leaks – of material that should never have been secret in the first place – led to an unpleasant witch-hunt for the leakers, when the BMA would have been much better advised to ask itself where it had gone wrong with the whole process. The ensuing fracture between council and the membership was inevitable, and was compounded by a leadership in denial, more concerned about whistleblowing than facilitating open debate.
So why did the BMA, which is not a scientific body such as Nice, feel it could criticise and undermine Cass’s work? The BMA has allowed itself to get into a position whereby a vocal minority of council members with an anti-Cass agenda have engineered policy that the membership have not been consulted on and do not agree with. While they are sincere in their beliefs, these council members have no hard evidence for their opposition, and good intentions aren’t enough to guide medical practice. It must be underpinned by evidence.
The BMA now finds itself isolated in its opposition to Cass, and with its reputation and integrity damaged. The prognosis for the union is not terminal, but it needs to acknowledge the mess that it is in and then to pull itself back from the brink of what one critic has called “its descent into madness”.
It should start by realising that it is unacceptable for a membership organisation to shroud its debates about key issues in secrecy and cover-ups. Members who elect their representatives on to council are entitled to know who backed the motion and who voted for it. The abuse that unfortunately accompanies any debate around trans issues is not an excuse for a lack of transparency. If you aren’t prepared to be accountable to the membership who elect you then you shouldn’t stand for public office.
The BMA needs to embrace democracy and consult its members, as it has done in the past over sensitive and contentious issues such as assisted dying. If it fails to do this, one would be forced to conclude that it is afraid of the views of its wider membership. The BMA set up a “task and finish” group to evaluate the Cass review; its assessment will go ahead, but in the interim the union should be neutral on the review and undertake to consult its members when the results are available. Only in that way can it start to restore the trust of the profession and ultimately our patients.
A union that doesn’t represent its members’ interests is a union in trouble. A union leadership that ignores its members’ concerns will eventually pay the price. And when the BMA acts in a way that damages its own reputation, then the reputation of all UK doctors is threatened. That is why the medical profession is in an uproar over what has happened.
• Dr Jacky Davis is a consultant radiologist and a member of the BMA council
