Members of the British Society of Rehabilitation Medicine are voting on a proposal to change our Society’s name. The president, John Burn, has visited, virtually or in person, most of the regions of the UK to meet members and discuss the vote. Northern Ireland is the notable exception. I have attended seven of the nine visits, gaining greater insight into the proposal’s genesis. For example, the similarity between the Brexit campaign our debate is close. I do not want to persuade the reader to vote for or against the proposal in this post. The post has two goals. I wish to convince the reader that they must vote. The vote may be to abstain, a meaningful statement about the voter’s opinion, or the vote may be for or against the proposal. Second, I wish to explore the deeper issues affecting the decision. This analysis is essential because, if Brexit taught us anything, it taught us that the real work begins after the vote. Therefore I will explore what we will need to do, whichever way the vote goes. The failure to consider the consequences of the vote and plan what we will do may have serious consequences.

Please note

I am now Deputy Secretary of the BSRM, making me a Trustee of the charity. I wish to make three points very clear.

1. As an officer and trustee, it is my duty to act in the best interests of the Society in all matters where I am acting on behalf of our Society, whatever my personal views may be. I am aware of this and will always act and decide in the best inteests of our Society.
2. Everything written here, and indeed in the whole website, is written by me as an individual. This post does not represent the view of our Society.
3. I am not attempting to change anyone’s mind about their vote. My concern (as a member) is for the future of our Society, and my intention is to ensure that the Society prospers whatever the overcome of the vote.

Preamble.
Discussions held on the BSRM name change vote

The first specialist rehabilitation society in the UK was the British Association of Physical Medicine, founded in 1943. (here) In 1970 it changed its name to the British Association of Physical Medicine and Rheumatology. It then changed its name to the British Association for Rheumatology and Rehabilitation. Then, in 1983, the association split. One half became the British Society for Rheumatology, and the other half became the Medical Disability Society. Then, the name changed to the British Society of Rehabilitation Medicine; I do not know the date, but I suspect it was when the General Medical Council named the speciality in about 1996.

The BSRM is our fifth name in nearly 80 years. Other societies also change their names. Sometimes organisations split into two. Change is normal.

Our president, John Burn, has planned the process of voting on the proposal to change our name carefully. He organised a group to set out a document outlining the reasons for switching to the new name and the reasons not to do so. This document is available here. He also arranged to attend regional meetings of specialist training committees or the BSRM in most regions. I participated in most sessions to discuss the proposal with Julian Harriss and learn how the change to the 2021 curriculum had progressed.

These meetings were initially referred to as debates, but it was impossible to debate on a virtual platform. Debate fosters a confrontation, with a winner and loser; discussion encourages active exploration of ideas with more chance of reaching agreement and consensus. Following the conversation with Jav Haider in Cardiff (here), I think the meetings were more productive in promoting dialogue and discussion.

Indeed. as these meetings progressed, more and different matters were raised by members and were discussed, including some issues not covered in the prepared document. My analysis of the situation and views about the choice changed. It has reinforced my belief that discussion is a better way to arrive at the best decision. Talking in a group and listening to others working through ideas helps clarify the listener’s opinions.

This post will next discuss my analysis.

What is the discussion really about?

The proposal to change the name of our Society has certainly generated strong emotions. This situation is reminiscent of the Brexit debate. In the Brexit argument, the exact question was about membership of the European Union. People could have decided on analysing facts and predictions about economic and commercial issues, possibly with an additional dispassionate analysis of the relative political advantages and disadvantages. However, many people’s votes arose from deep-rooted emotional feelings and the feeling that politicians were ignoring their wishes.

This similarity leads me to review our own much smaller decision. The issue generates emotion far above the simple question, especially as this will be the sixth change, reverting to a name similar to our original name.

The discussion document itself hints at this. One set of arguments is, to an extent, based on considering facts and predictions and putting forward reasons for retaining the name. The other half of the document makes a series of assertions without any apparent links to mechanisms or facts, similar to the Brexit debate.

As the discussions have moved forward, I have considered what factors energise members who want to change the name; it seems that people who want to change the name feel more certain about the need to change than people who would prefer not to change our name.

In the next section, I will show that everyone agrees upon many essential facts and opinions. I will then explore the factors that may drive the desire to change the name but are not made explicit in the discussion document.

Agreed.

All members of our Society agree on many matters:

1. We want to improve the quality of rehabilitation available to the population
2. We want to increase the availability of expert rehabilitation services
3. The number of doctors trained in rehabilitation is too low
   1. Specifically, the membership of our Society is too low
4. More doctors trained in rehabilitation are needed
5. Rehabilitation’s priority in the NHS is low
6. The understanding of rehabilitation is low everywhere, including in the NHS
7. The scope of the 2021 curriculum is comparable to other curricula throughout the world

We also agree that changing the name of our Society will have a minimal effect upon any of these issues and that a decision to change our name might:

• offer an opportunity for rebranding our Society
• lead to a loss of enthusiasm among members to remain engaged in our Society’s affairs, believing that ‘name change is done’
• lead to people who voted against change feeling over-ruled and therefore beoming unwilling to be engaged.

Last, we agree that we have much work to do for our Society.

What are the emotional drivers?

I start from the premise that the intense feelings and views expressed by many people, primarily people who want the name to change, cannot be explained by the change of name itself. The desire to change must be symbolic of some powerful other reasons. The desire not to change must also arise from some other reasons, although resistance to change is an inbuilt natural human response to any change.

In this section, I am speculating and suggesting. I will give the evidence and reasoning, as far as there is any. I am not judging the reasons, nor am I judging the people who are basing their decisions on the factors I mention. As will become evident, I think it is vital to understand these factors so that we can plan what to do after the vote.

My first speculative factor concerns status. Proponents of the new name often refer to the fact that no one in the UK has heard of Rehabilitation Medicine or knows it. They refer to rehabilitation “being confused with drug rehabilitation” as if that was a bad thing. They contrast it with Physical Medicine and Rehabilitation status in most other countries, where the speciality is popular, over-subscribed and well known and understood.

This concern with status is extended by some people to our staus internationally. There is a concern that doctors in the countries with Physical Medicine and Rehabilitation (the majority) or Physical and Rehabilitation Medicine (the minority) do not consider UK consultants involved in rehabilitation.

My second factor is closely associated with this. It concerns others taking on our role. There are two aspects. The first is that other specialities are undertaking ‘our role’ in rehabilitation. For example, Sports and Exercise Medicine doctors are undertaking musculoskeletal rehabilitation; it is one of their specialist capabilities in practice. (see here) Similarly, stroke physicians undertake stroke rehabilitation. Some people refer to work being stolen, implying that only consultants in Rehabilitation Medicine should undertake it.

The second aspect is that other professions are undertaking ‘our role’, which is usually in musculoskeletal rehabilitation. Again the words used are not very collegiate or respectful.

The third factor is the feeling that “they ignore us“, where they refers to the Executive committee and us refers to all other members. In discussions, members report their perception of not being listened to or communicated with. Specific examples to back up the disquiet are rare, but it is a strong underlying theme.

The last factor may cause upset, but I feel that I must raise it. It concerns discriminatory attitudes and practices within our Society structures and a feeling that the older, senior members make decisions in ways that discriminate. This concern certainly encompasses racial discrimination, which still occurs in the NHS (here), but it extends well beyond racism to feel that the executive acts like an exclusive club.

This suggestion arises from messages seen in the PRM WhatsApp group and emails.

I wish to make some crucial points about this suggestion.

The BSRM does not have an Equality and Diversity policy or, if it has, it is not known, and it is not on our website. To the best of my knowledge, we do not collect any data relevant to Equality and Diversity. Five out of our Society’s six Officers and Trustees are White British as far as I can give an opinion. In contrast, I guess only 50% of members are White British.

Next, no one should say, “But where is the evidence?”. Much racial discrimination is slight, challenging to pinpoint, but very corrosive. Very little of it is likely to be obvious or overtly intentional. Furthermore, discrimination occurs on many other grounds in precisely the same way. I am personally aware of comments made about me that I could interpret as ageist. The statements made about drug and alcohol rehabilitation not being rehabilitation are arguably discriminatory against certain types of disability.

This feeling that our Society discriminates against some people, not only on the grounds of race, may well arise from a lack of accessible information. How are members of committees chosen? How and when do you put yourself forward for election to the executive? How is the chair of a subcommittee chosen? How can a member know about and join a working party? What was discussed at the last executive committee? I do not know how to find out and, if I did not know someone on the executive committee, I would not feel confident to ask.

When one cannot discover how or why a decision was made, one feels powerless and, if the decision is contrary to the person’s expectation, one also feels suspicious.

I will summarise. I think that many other factors may well influence people’s voting intention. These factors may not influence everyone, and they will be in different proportions in different people. They include:

• concerns about our status within the UK healthcare system, publicly, and internationally
• a feeling that other medical specialities and other professions are usurping work that we should be undertaking
• a perception that the concerns of members are not considered by the executive
• a belief that some members with power and influence are discriminating again other members unfairly.

While I cannot substantiate any of these suggestions with solid evidence, I think they are sufficiently likely and sufficiently concerning to require action.

Society work already under discussion

Before reaching my conclusions and recommendations, I want to remind readers of the work already planned, if not started.

Constitution.
The constitution is to be reviewed and revised. Charity law has changed and, although not required legally, we should bring our constitution into line with modern practice. At the same time, items within the constitution need changing, with some new ones possibly being added and older ones removed.

Strategy.
We have been discussing strategy for some time – I recall meetings before the pandemic, so it must be at least 2-3 years. The executive committee needs a clear strategy to structure its activity and guide priorities. We also need to finalise the strategy before the constitution is revised, as it may alter our objects.

Communication.
The need for a comprehensive and integrated communication strategy and structure is evident and must be another stream of work to start and carry forward as fast as possible. Poor communication underlies many of our problems. The lack of a good website may contribute to our failure to attract members from other specialities who undertake rehabilitation, such as geriatricians, psychiatrists, and stroke physicians. Jav Haider, Damon Hoad, Marlene Worrell and I are actively taking this forward now. Although we hope to have a new site in one to three months, it will take much more work to achieve better communication.

Regional groups.
The weakness of our regional structures has also been made evident by COVID, which has disrupted national systems and meetings. There has not been an excellent regional structure to fall back on. This lack of regional BSRM networks has made the education of trainees much more difficult.

Our Society has about 375 members. One might think that should be enough to undertake this work. However, the clinical demands on members are high, Trusts do not support work for specialist societies with job plans, and the number of people volunteering is low. Over the last 2-3 years, one real positive change has been the number of trainees becoming actively involved. Maybe the trainee FaceBook group has been a help.

Conclusions – what now?

The proposal to change our Society’s name has spotlighted that our Society’s management and administration and, in my view, our structures and processes need urgent attention. I will enlarge upon this and set out some actions required.

Governance.
Although my suggestion that feelings of discrimination and unfairness within our Society’s process are the least well-evidenced suggestion, I think it is the most critical area to act on. We have already recognised a need to review committee structures and processes. We need to extend the review to all aspects of our Society. For example, we need to develop, agree upon, write down, and act on policies. They need to be easily found. We specifically need a policy on Equality and Diversity and handling any complaints or concerns raised by members.

Communication.
Failures in communication have already been highlighted. We need to improve this dramatically and as quickly as possible. It should include making all committee documentation available – purpose, terms of reference, how to apply to join, agendas and minutes etc. All policies need to be publicly available.

Collaborative, cooperative relationships.
The third area of concern is our relationship with other medical specialities and with other professions. It upsets me that we, who work collaboratively in multiprofessional teams, speak about different professions and specialities as competitors. Many individuals, teams, and specialities within the health service undertake rehabilitation, and we must see them as colleagues and collaborators and welcome them into our Society. There should be no mention of others as competitors in texts, WhatsApp messages, emails or conversations.

Planning.
We should have had a plan outlining our response to the potential outcomes of the ballot. We do not. We should develop a plan as soon as possible. The program will be based on the actual result, so it will not need to consider alternatives, but it must still be a plan to consider all members, not simply those who supported the actual outcome. When planning, we will need to consider the number voting for each choice, including those who abstain. The closer the vote, the more care we must take to handle further change, with widespread consultation and engagement.

Involvement of all members.
Last, all members need to participate actively and constructively in this work. Small groups of members, even just one or two, will need to undertake much of the hard work. However, it is essential that everyone looks at, thinks about, and comments on documents produced. This method effectively develops good documents provided people read and respond, if only to say that they agree.

Postscript.

I hope this has given you food for thought. Now, if you are a member, please vote. Every vote counts, especially those who abstain. We must know that everyone received the ballot invitation and also thought about it, and this is only possible if you vote:

• in favour, or
• against, or
• abstain