'Clinical engagement has to be approached critically. It cannot be pursued as an end in its own right'

With Wimbledon a washout, those in search of an alternative spectator sport needed look no further than last month's British Medical Association annual conference. Held in the congenial seaside setting of the English Riviera (that's Torquay to you and me), the conference offered some interesting insights into the question of the moment: in our new, touchy-feely mode, what would an NHS look like if it were run by the workers?

A bit confused is the answer.

For example, BMA activists in the Midlands 'deplore unreasonable charges' but Rotherham BMA argues that 'charging the patient is the way forward to keep the NHS viable'. Brighton BMA goes further, demanding GPs be allowed to charge patients via private health insurance for consultations.

Edgware BMA believes offering patients a choice of hospital is 'patronising and demeaning', but Tameside BMA says it should be 'strongly supported as long as it is genuine and meaningful'.

Oxford BMA 'demands the abolition of the purchaser-provider split', whereas Brent BMA wants to 'promote effective practice-based commissioning'.

BMA accident and emergency consultants believe 'clinically led reconfiguration is important to improve patient care', whereas BMA activists in London 'call on the BMA to completely oppose these reconfigurations'.

North and Mid-Staffordshire BMA asserts that reforms including 'a time-sensitive consultant contract and the expansion of medical undergraduate numbers constitute an assault on the medical profession' (uh?), and argue that private providers will help recreate 'Soviet Russia 40 years ago' (did Leonid Brezhnev really introduce independent treatment centres?).

And juxtaposed with an Observer story emanating from Number 10 and stating: 'A drive to slash the rates of MRSA and other hospital infections is being masterminded by Gordon Brown' (!), we have Rotherham BMA's contribution to the subject: 'To reduce infection, hospital doctors should wear no clothing on the wards.'

In short, the usual blend of overstatement, opposition and contradiction, mixed with more conventional demands - for higher pay, for monopoly negotiating rights over doctors' terms and conditions and, yes, for better car parking.

So where does that leave a new prime minister and new health secretary looking to 'engage' more with the clinical professions?

One starting point is an important new book. Public Matters: the renewal of the public realm takes a critical look at how government has sought to reform public services over the past decade and then analyses how best to balance the need for improvements in education, criminal justice, health and welfare with the desirability of winning the hearts and minds of public sector workers.

In a chapter on professionals, former home secretary Charles Clarke puts his finger on the conundrum by pointing out: 'Over the last decade, one of the most potent rallying cries against [government] reforms throughout the public service has been 'trust the professionals'. The government has been rebuked for telling teachers how to teach, downgrading doctors' professional judgement and undermining the integrity of professions.

'At the same time, some of the professional associations and trade unions have made themselves pretty obdurate opponents of change. They appear focused upon defence of their own short-term interests despite obvious consumer concerns and there have been some classic formalised stand-offs, the overall consequence of which has been demoralisation.'

He goes on to demonstrate that this professional alienation is not just about the personalities of the politicians they have butted up against, or the nature of the reforms, but stems from more profound social changes entailing greater transparency about performance variation between professionals, taxpayer challenge to unresponsive monopolies, and new technologies that change the demarcation between skilled and less-skilled workers. Even in terms of workload, US academic David Mechanic has shown that 'in almost every era doctors have perceived themselves as 'running faster' but there is little evidence to support this'.

So the point is not that clinical engagement isn't important, it just has to be approached critically. And it cannot be pursued as an end in its own right, in lieu of wider changes.

For a new administration interested in this topic, here are five initial thoughts.

First, don't let talk of engagement deflect you from challenging the status quo. Reach for the moral high ground: explain that the NHS must embody the attributes of timeliness, reliability, compassion and respect in all it does. It is then obvious that the NHS has to continue changing.

Second, it follows that you won't succeed in improving the NHS if you interpret 'clinical engagement' as meaning any staff group has a veto on change. For although the interests of staff and patients overlap, they are not identical. Work with the progressives; don't be derailed by the headbangers.

Third, while you should dispense with unnecessary reorganisations of primary care trusts and strategic health authorities, you cannot afford to put reform on hold for a year while the excellent Professor Sir Ara Darzi produces his report. Ride a bike too slowly and you just fall off.

Fourth, remember we're not at year zero when it comes to clinical engagement. Remind people the NHS is two decades into a model of hospital organisation that already has consultants holding budgets and running most departments.

And here's a fifth one. Remember that no matter how well things are going, this was (I'm not joking) the closing resolution at this year's Torquay conference: 'The BMA deplores this, condemns that, and calls for a return to the good old days'. So there you have it.

Simon Stevens is chair of UnitedHealth Europe and a trustee of the King's Fund. Simon_L_Stevens@uhc.com