Open letter to the BMA about the health white paper

Clive Peedell and more than 100 co-signatories ask why the BMA is not representing its membership and has acted as though the proposed health reforms are a done deal

Dear Hamish Meldrum, Laurence Buckman, and all members of the BMA General Practitioners Committee,

After the publication of the health white paper earlier this year, Hamish Meldrum wrote to the profession to explain that the BMA was going to “critically engage with the consultation process” to defend the founding principles of the National Health Service and the principles underpinning the BMA’s Look after our NHS campaign.

The consultation period is now over, and it is clear from the Department of Health’s response to the consultation that the BMA’s policy of “critical engagement” has failed to persuade the government to alter its approach. The BMA responded with a damning press statement: “There is little evidence in this response that the government is genuinely prepared to engage with constructive criticism of its plans for the NHS. Most of the major concerns that doctors and many others have raised about the white paper seem, for the most part, to have been disregarded.”

In fact, Andrew Lansley’s plans are now even more market based. Within the new operational framework for the NHS in England, “price competition” will be introduced, which fundamentally changes the NHS from a “quasi-market” system of fixed prices (tariffs) to a more open market system. Hospitals will be allowed to charge rates lower than the national tariff, which sets prices for thousands of NHS procedures and covers roughly half of hospital income. According to Zack Cooper from the London School of Economics, “Every shred of evidence suggests that price competition in healthcare makes things worse, not better.”

The NHS Confederation shares this view: “Economic theory predicts that price competition is likely to lead to declining quality where (as in healthcare) quality is harder to observe than price. Evidence from price competition in the 1990s internal market and in cost constrained markets in the US [United States] confirms this, with falling prices and reduced quality, particularly in harder to observe measures.”

Moreover, the BMA has stated that it has “concerns over the use of ‘best practice’ or deregulated tariffs in the NHS, because this system brings with it price competition, which can risk basing decisions on price rather than on clinical need.”

The white paper is still awaiting publication as the Health Bill, which will then need to be subjected to the legislative process before being enacted by parliament. We are therefore very concerned that the BMA and more specifically the BMA General Practitioners Committee is treating proposed policy (that is, a white paper) as if it is policy. For example, on 17 December 2010, the chairman of the General Practitioners Committee Laurence Buckman stated in a letter to all general practitioners: “Practices should now be working with other practices to make progress in setting up their embryonic consortia and electing and appointing a transitional leadership.”

In addition, on the topic of general practice consortiums and commissioning, a recent BMA briefing paper stated: “The pace of change in developing commissioning must allow the vanguard to develop swiftly.”

The fact that market based policies have actually been strengthened by Mr Lansley goes against BMA policy from numerous BMA annual representative meetings and the stated principles of the BMA’s Look after our NHS campaign. The BMA should therefore withdraw its policy of “critical engagement” with the government and engage more with its own membership. It is remarkable that despite “the most radical restructuring of the NHS since its inception,” BMA Council recently voted against holding a special representative meeting of the BMA to allow its membership to debate the current proposals. This is in contrast with the BMA’s stance against the other most significant NHS white paper reforms, Working for Patients in 1989, when two special representative meetings were called.

Although the BMA hasn’t formally surveyed the profession about the white paper, surveys conducted by the King’s Fund and the Royal College of General Practitioners have both highlighted the high level of concern among healthcare professionals, with fewer than one in four doctors believing that the proposed reforms will improve the quality of patient care provided by their organisation or practice.

We believe that the BMA has no mandate from the BMA membership to continue with the “critical engagement” policy. Mr Lansley’s reform agenda has been widely criticised across the health policy and political spectrum as moving too fast, yet the current approach from the BMA could actually hasten the pace of reform because the association has effectively sent a message to the profession that the white paper is a done deal.

We have serious concerns that the proposed reforms will fundamentally undermine the founding principles of the NHS by creating a much more expensive and inequitable market based system. However, we also believe that the BMA could play a crucial role in saving the NHS from this fate, because, according to the Health Service Journal, “From an influence point of view the BMA is critical because it could derail the coalition’s white paper reforms, which propose a clinically led system. If the BMA were to say no, then the whole initiative could grind to a halt.”

Thus the NHS really is in your hands. We understand the pressures you are under, but it is now time to mobilise the profession and stop these damaging reforms, which will not only destroy the NHS but also profoundly affect the social fabric of our nation.

This is a great opportunity for the BMA to achieve redemption for its opposition to the inception of the NHS in 1948. We urge you to take it and will support you 100% of the way.