The chairman of the British Medical Association usually just 'emerges'; the system helps avoid unseemly public squabbles. The BMA, with an annual income of pounds 40m, places a high premium on unity and loyalty. Since 1990, the chairman has been Dr Jeremy Lee- Potter, a consultant haematologist. But Dr Alexander ('Sandy') Macara, a public-health doctor from Bristol, will challenge the unwritten codes of leadership at the BMA's annual conference in Torquay this week.
The chairman has to offer himself for re-election after three years in office, and Dr Macara is seizing the opportunity to force a contest in an attempt to revive the bristling, high- profile stand against the Government's policies that characterised the BMA in the late Eighties. Under Dr John Marks, chairman for six years until 1990, the BMA was routinely at loggerheads with the Government over plans to inject business methods into the centrally controlled National Health Service monolith.
The BMA leadership crackled with outrage and dire warnings of chaos that the NHS 'reforms' would bring in their wake. The campaign failed, but the bitterness lingered.
In 1990, Dr Marks's term of office expired. In came the smooth, diplomatic style of Dr Lee-Potter, sole candidate for chairman.
As his distaste for public confrontation with government ministers became evident, discontent mounted among doctors struggling with inadequate budgets and growing waiting lists. In 1991, he narrowly avoided a 'no confidence' vote by the BMA's ruling council meeting in Inverness.
Chairman and challenger are both aged about 60, both members of The Athenaeum club, off Pall Mall in London, and both veterans of BMA committees. But in background and temperament they are poles apart.
Dr Macara, son of a Scottish Presbyterian minister, saw poverty and deprivation in his Glasgow youth. He feels deeply alienated from Conservative thinking and the business ethos now underpinning the NHS.
'Doctors feel the style, if not the substance, of BMA leadership lacks credibility,' he says. 'We need to make it crystal clear that the NHS reorganisation has proved a farce. We must demonstrate to all those NHS professionals feeling demoralised and denigrated by government policies that doctors are not management lackeys, servants of the state.'
Supporters of Dr Lee-Potter expect him to win fairly comfortably in Thursday's vote by the BMA council, if only because of the profession's conservative instincts. Dr Lee-Potter points out that under his leadership, junior doctors' hours have been cut; national conditions of service have been guaranteed by NHS trusts; and GPs have received a bigger say in the purchasing of hospital services.
'If you go out knocking the Government in public the whole time, the relationship between the BMA and ministers breaks down. That is what happened in the late Eighties. Kenneth Clarke (then Secretary of State for Health) did not take the slightest notice of our concerns.
'I was put in this job to remedy that problem. Now we are talking with ministers again. If we returned to the days of confrontation, we would lose everything we have gained,' he said.