'And there will be more points of conflict to come, such as the issue of where doctors work as opposed to where they are needed.'

The vote of no confidence in the British Medical Association leadership at its annual conference this week shows the gulf that still separates much of the medical profession from the reform agenda . Despite all the gains that the profession have made in the last few years, many doctors remain vigorously unhappy.

Even their leaders' protest about a trust's proposals that just two doctors should be made redundant are not taken as evidence of a robust defence of the profession.

It is certain that there will be real redundancies among clinical staff numbering in the high hundreds during the next six months. Not all of them will be doctors, of course, but some will be; headlines are assured.

And there will be more points of conflict to come, such as the issue of where doctors work as opposed to where they are needed. Over and under-supply will be increasingly exposed as trusts restructure their services in the light of payment by results.

BMA chair James Johnson is right to argue that the apparently permanent and 'active opposition' the conference motion demanded is a cul-de-sac.

But he is in a difficult place with little room for manoeuvre. The vote shows that engaging with the arguments locally should become an urgent priority for trust managers.

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