Solidarity Magazine » BMA Fri, 01 Mar 2013 19:29:19 +0000 en-US hourly 1 Doctors to launch public campaign against proposed NHS reforms Fri, 22 Jul 2011 16:52:04 +0000 Continue reading ]]> BMA votes to reject idea that changes to health and social care bill will reduce the risk of privatisation of the health service

Randeep Ramesh, social affairs editor, Guardian Wednesday 20 July 2011

The government faces a summer of discontent over its NHS reforms after doctors voted to launch a public campaign against the health bill, and one of the UK’s internet campaign groups raised £10,000 in three hours after emailing members to pay for expert legal advice over the bill.

The British Medical Association’s council, the executive committee of the union, voted to pass a series of motions critical of the government’s bill – and crucially accepted that doctors “start a public campaign to call for the withdrawal of the health and social care bill”.

Put forward by NHS consultants Clive Peedell and Jacky Davis, the motion will ratchet up the pressure on ministers over the summer break who had hoped that the bill’s third reading in early September would be an easy ride.

The BMA, which represents 140,000 doctors, voted to “reject the idea that the government’s proposed changes to the bill will significantly reduce the risk of further marketisation and privatisation of the NHS” and “agreed that the government is misleading the public by repeatedly stating that there will be ‘no privatisation of the NHS’”.

Dr Hamish Meldrum, chairman of council at the BMA, said: “Whilst the BMA recognises there have been some changes following the listening pause, there is widespread feeling that the proposed legislation is hopelessly complex, and it really would be better if the bill were withdrawn.”

His colleague on the council Dr Peedell said that the health bill was “just a privatisation bill with a third of it devoted to [producing] an economic regulated market”.

To underline that the government’s attempts to dissipate professional and public anger – such as the legislative pause – have had little effect, internet campaigners at 38 Degrees, which has 850,000 members in the UK, claimed to have raised cash at the rate of £56 a minute via an email marketing campaign on Wednesday.

The money will be used to get lawyers to comb through the 180 amendments produced by the government when it re-submitted the bill for its second reading earlier this month.

“38 Degrees members want to cut through the tangled web of amendments which make up Andrew Lansley‘s re-written NHS plans. So we’re chipping in to hire legal experts to go through them with a fine tooth comb,” said the organisation’s executive director, David Babbs. “We’re concerned that real threats to our NHS may still lurk behind Lansley and [David] Cameron’s warm words. Are we on a slippery slope to the NHS being broken up by EU competition laws? Why does Lansley seem to be watering down his legal duty to provide a national health service?”

Labour’s John Healey pounced on the news of opposition to the bill. “Despite David Cameron‘s promises, his health bill changes are a bureaucratic mess, not a proper plan for improving patient care. Now people are realising that despite the ‘pause’, the wasteful and unnecessary reorganisation is going ahead and the long-term Tory plans to break up the NHS remain intact.”

The Department of Health said: “We will never privatise the NHS. The BMA’s position is disappointing because previously the doctors’ union said there was much in our response to the listening exercise that addressed their concerns, and that many of the principles outlined reflected changes they had called for.

The independent NHS Future Forum confirmed there is widespread support for the principles of our plans to modernise the NHS, including handing more control to doctors, nurses and frontline professionals.

Patients will never have to pay for NHS care. The bill has changed substantially since the BMA first voted to oppose government policy. Our plans have been greatly strengthened in order to improve care for patients and safeguard the future of the NHS.”

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Doctors reject revised NHS plans Tue, 28 Jun 2011 16:42:41 +0000 Continue reading ]]> By Nick Triggle Health correspondent, BBC News, in Cardiff

Doctors have rejected the government’s revised NHS plans, urging their union to take a tougher stance.

Delegates at the annual British Medical Association conference voted in favour of calling for the Health and Social Care Bill to be withdrawn by 59%.

The union initially welcomed concessions by ministers this month on competition and patient choice.

But doctors at the Cardiff meeting said it was time to keep pushing the government “further and harder”.

The plans involve opening up the health service to greater competition and giving GPs a lead role in spending the NHS budget.

Amid mounting criticisms the government put the changes on hold in April. Two weeks ago ministers attempted to appease opponents by watering down certain aspects of the plans.

But delegates at the BMA said they were still not satisfied – despite pleas by BMA leader Dr Hamish Meldrum not to vote in favour of a series of critical motions.

One of those was calling for the bill underpinning the changes to be withdrawn.

Dr Meldrum said he would continue to ask for more.

But he added: “If you push too far you may lose some of the ground you have taken.”

But delegates were not convinced with 59% voting in favour of the motion.

Dr Jacqueline Applebee, a GP from London, said the overhaul would result in one of the “biggest ever social injustices” as it would lead to charges for services and backdoor privatisation.

We have a duty to past, present and future generations,” she said.

Paddy Glackin, who is also based in London, added: “This is a slippery government that we cannot give any wriggle room to. This is not the time to back off, this is the time to push further and harder.”

Vote ‘disappointing’

It is the second time the BMA has called for the bill to be withdrawn. In an emergency meeting in March doctors voted in favour of it being withdrawn, but their attitude softened when the concessions were published, with the union’s leaders indicating they were willing to work with ministers to get the bill right.

That stance will now harden following the conference vote. In fact, Dr Meldrum is likely to convey the message on Tuesday afternoon when he gives evidence to the House of Common’s bill committee about the reform programme.

A Department of Health spokesman said: “This vote is disappointing because only a few weeks ago the doctors’ union said there was much in our response to the listening exercise that addressed their concerns, and that many of the principles outlined reflected changes they had called for.

“The bill has changed substantially since the BMA first voted to oppose government policy. Our plans have been greatly strengthened in order to improve care for patients and safeguard the future of the NHS.”

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Open letter to the medical profession: Now is the time to get tough on NHS reform Sun, 26 Jun 2011 15:42:09 +0000 Continue reading ]]> We are writing as a group of concerned doctors and we are also members of UK BMA Council.

Next week the representatives of UK doctors meet in Cardiff for the annual BMA meeting. The meeting occurs at a time when the NHS is at a crossroads. ??The 60-page Government response to the Future Forum does nothing to reassure us about the Health and Social Care Bill and its underlying aim to impose a fully-fledged market on the NHS, which will result in increasing fragmentation and privatisation of the English NHS.

It has become very clear that on close inspection of the Government’s response to the NHS Future Forum report, the key changes that the BMA and other organisations like the RCGP have asked for have not been met:

1. That the Secretary of State should retain responsibility for ensuring provision of a comprehensive health service.

A technical briefing note on the Government response by the Public Interest lawyer Peter Roderick and Dr Evan Harris concluded that “it appears that the new Bill will continue to propose abolition of the Secretary of State’s duty to provide health services in accordance with the Act, and of his or her duty to provide the key listed NHS services, and will not propose to give this duty to any other body”

2. That Monitor’s primary role to promote competition should be removed.

Although the regulator, Monitor, will no longer “promote” competition “as an end in itself”, the government says that it “will maintain the existing competition rules for the NHS” and give it a “clearer statutory underpinning” which implies that there will be at least the same, or more competition, and not less. The government will do this by making the Department of Health‘s Co-operation and Competition Panel (CCP) a statutory body within Monitor “retaining its distinct identity”.

In addition, “the NHS Commissioning Board in consultation with Monitor will set out guidance on how choice and competition should be applied to particular services, guided by the mandate set by Ministers”. The NHSCB will also set clear expectations about offering patients choice through a “choice mandate”. Dr Evan Harris has stated that “this is simply reintroducing the marketisation of the NHS – rejected by (the LibDem) conference – by the back door of the NHSCB.”

To make matters worse there remains lack of clarity on EU competition Law, which could irreversibly open up the NHS to overseas providers competing for NHS contracts paid for by UK taxpayers.

3. Reducing the role of ‘Any Willing/Qualified Provider

According to the Government response, the revised bill will outlaw the Government now, or in the future, from naming the NHS as ‘preferred provider’. This clearly opens up the NHS to an “Any Willing/Qualified Provider” rather than reducing it. In addition, the staff “right to provide” policy will enable groups of clinical staff to set up their own social enterprises or “mutuals” and sell their services back to the NHS.

These are just a few examples of the ways the Government has crossed the “red lines in the sand” of the BMA and RCGP in order to stay on course with its original plans. It does not surprise us that the Lib Dem MP, Andrew George, who sits on the Health Select Committee, said: “If the Government had been listening it would have scrapped the Bill. Instead it looks as if they’ve just massaged and tweaked it a bit.”

Other examples in the Government’s response, which confirm its original direction of travel include: (i) the outsourcing of the function of commissioning to private companies, exposing the system to a whole new raft of even less identifiable conflicts of interest; (ii) the extension of personal health budgets; (iii) promotion of the choice agenda (which promotes competition); (iv) no mention of a reversal in the policy of allowing the NHS CB and commissioning groups to introduce additional charges for services they decide are not part of the NHS (Clause 22, para 14s of the bill); (v) retention of all the mutually reinforcing levers of a healthcare market (patient choice, competition between a plurality of providers, Payment by Results, and freedom for Foundation Trusts).

Thus, it is clear that the NHS will be subjected to increasing market competition and private provision and commissioning of services, which will undermine the founding principles of the NHS and drive it towards a mixed system of funding. In addition, the work of Lucy Reynolds from the London School of Hygiene and Tropical Medicine published in the BMJ last week also described how the bill could allow private companies to strip NHS assets “leading to more a expensive system that will deliver worse quality of care”. We therefore totally reject the repeated claims of the Coalition leaders that their reforms will deliver greater NHS efficiency and that there will be “no NHS privatisation”.

If all of this is not bad enough then even the supporters of clinically led commissioning must be highly concerned with a return of central control in the NHS via a strengthened NHS Commissioning Board and clinical senates. Thus, even the potentially “good part” of Dr Meldrum’s “Curate’s egg” has now gone rotten.

In conclusion, the simple fact is that the Government’s proposed changes to the bill are mainly cosmetic in nature. There are no ‘significant’ policy changes that will alter the general direction of travel of the reforms and we believe the proposals will actually create even more problems for the NHS by increasing the tiers of bureaucracy. It is at this point that we would remind Mr Clegg that “no bill is better than a bad bill”. He would also do well to listen to views of his fellow liberal Democrat colleague, Dr Evan Harris, who dismissed the NHS Future Forum’s paper on Choice and Competition as “cliché-ridden, trite nonsense” at the Social Liberal Forum last weekend.

It is incumbent on us as doctors to ensure our patients will always have access to a health service that does not differ across the country, a health service that is there when you need it and does not require an insurance policy or self funding if you need some extra care that your personal budget won’t fund. ?The NHS is facing the biggest threat in its history and as its founder, Anuerin Bevan famously said: ‘It will last as long as there are folk left with the faith to fight for it.’

We therefore urge members of the medical profession to take up the fight for the NHS by continuing to oppose this damaging bill and call for its withdrawal. We urge them to lobby their MPs, members of the House of Lords, and BMA representatives by highlighting what this bill means for the NHS, the profession and our patients.

Dr David Wrigley, GP, Carnforth, Lancashire

Dr Clive Peedell, Consultant clinical oncologist, James Cook University Hospital, Middlesbrough

Dr Jacky Davis, Consultant Radiologist, Whittington Hospital

Professor Ian Banks, President of European Mens Health Forum and Professor of Men’s Health, Leeds Metropolitan University

Mrs Anna Athow, Consultant Surgeon, North Middlesex Hospital

Written in personal capacities and all are members of BMA UK Council

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GPs not fooled by David Cameron’s pledges – doctors vote overwhelmingly to prevent destruction of NHS Thu, 09 Jun 2011 17:02:16 +0000 Continue reading ]]> 9 June 2011

GPs have voted overwhelmingly to continue to oppose the Health and Social Care bill.

The GPs, including members of the Medical Practitioners Union (part of Unite) were among 250 GPs present at the British Medical Association’s annual GP conference in London today (Thursday).

The vote reflects that doctors are also not convinced that the prime minister’s pledges will safeguard the service.

Ron Singer of the Medical Practitioners Union said:

“GPs were not fooled by the warm words of the prime minister. Today GPs have signalled to the government that their health bill is not acceptable in any aspect. The general consensus is that this bill must go.

It poses the greatest threat to the NHS since its inception. Far from improving the nation’s health, such is the scale of the change the government is seeking to impose, they will compromise the health of the nation and endanger patients.

Whatever the prime minister may promise, the medical experts are telling him this bill will fragment the NHS. Our parliamentarians must now listen.”

Ron Singer added:

“GPs are those charged with putting the government’s plans into action so we need to be convinced by them, but we have been warning for months that they simply will not work.

The government would not listen then, it has shown not to be listening during the pause and we are extremely sceptical that the prime minister’s pledges, however well-intentioned, will make these plans any more acceptable.

GPs are warning again today – this bill is a serious threat to patients’ lives and the future existence of the NHS itself. It must go.”

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Regional members pile pressure on BMA with vote to oppose health bill Fri, 18 Feb 2011 15:02:18 +0000 Continue reading ]]> 18 Feb 11

By Ian Quinn Pulse Magazine

Exclusive: The momentum in favour of a vote of outright opposition against the Government NHS reforms gathered pace last night after a fractious meeting called by BMA London voted to stop the health bill in its tracks.

An overwhelming majority of the estimated 250 people at the meeting backed a motion calling for the BMA to scrap its policy of critical engagement and instead introduce a policy of total opposition to the bill.

Up to 100 protestors carried out a noisy demonstration against the reforms outside the regional meeting and inside the hall at BMA House, health minister Simon Burns faced catcalls from some of the audience and saw the Government’s plans come under fire from BMA leader, Dr Hamish Meldrum.

The BMA London move is the latest in a series of motions by BMA divisions and council members calling for a policy change, which looks set to be debated at a BMA Special Representative Meeting next month.

Dr Meldrum, who has come under increasing pressure to drop the BMA’s engagement policy, set out the association’s strong objections to the bill at the meeting, especially plans to ramp up competition from the private sector.

Also speaking at the meeting, shadow health minister Diane Abbott attacked the Government’s plans and afterwards declared the meeting was a sign of ‘all-out opposition to Tory health reforms.’

Mr Burns faced a string of questions from angry members of the audience, who demanded to know why the Government had not trialed its plans and also why many of the key elements of the health bill were not included in the coalition’s manifesto.

Outside the meeting, Dr Ron Singer, president of the Medical Practitioners’ Union and one of its GPC members, explained why they were protesting.

We think the changes proposed in the bill are so massive that nothing but outright opposition to, so that it never sees the light of day, it is the only course. A lot of people turning up tonight will tell the London division of the BMA that they must take a stronger line. What is being offered to GPs – to run the NHS and have control over the budget – is just simply not true.’

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The BMA Council has called a Special Representative Meeting to debate the government's NHS reforms Fri, 28 Jan 2011 17:24:31 +0000 Continue reading ]]> The BMA has also published a second reading briefing, which demands amendments to the Health Bill.

The council’s chief concerns are that the stability of local hospitals is considered when setting rules on economic regulation; that GP consortia are not forced to make providers compete and can instead work collaboratively; and that national oversight of medical education is maintained.

The BMA had so far resisted calls to hold a Special Representative Meeting, where members meet to debate an important issue that cannot wait until the Annual Meeting but has now schedule one for the 15th of March.

The BMA revealed this week that it is to survey its members to help understand which aspects of the Health Bill it should lobby parliament on.

An article for The Guardian by GPC chairman Dr Laurence Buckman, suggests the BMA is stepping up its opposition to the reforms, with a warning that patients will become ‘internal medical tourists’, with the wealthy shopping round for consortia that offer expensive or rare treatments.

In a letter to GPs this week, Dr Buckman warned that the reforms have ‘real potential to destabilise health economies’ and urged doctors to involve all their staff and colleagues to help shape the reform.

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The BMA Council has called a Special Representative Meeting to debate the government’s NHS reforms Fri, 28 Jan 2011 16:24:31 +0000 Continue reading ]]> The BMA has also published a second reading briefing, which demands amendments to the Health Bill.

The council’s chief concerns are that the stability of local hospitals is considered when setting rules on economic regulation; that GP consortia are not forced to make providers compete and can instead work collaboratively; and that national oversight of medical education is maintained.

The BMA had so far resisted calls to hold a Special Representative Meeting, where members meet to debate an important issue that cannot wait until the Annual Meeting but has now schedule one for the 15th of March.

The BMA revealed this week that it is to survey its members to help understand which aspects of the Health Bill it should lobby parliament on.

An article for The Guardian by GPC chairman Dr Laurence Buckman, suggests the BMA is stepping up its opposition to the reforms, with a warning that patients will become ‘internal medical tourists’, with the wealthy shopping round for consortia that offer expensive or rare treatments.

In a letter to GPs this week, Dr Buckman warned that the reforms have ‘real potential to destabilise health economies’ and urged doctors to involve all their staff and colleagues to help shape the reform.

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Open letter to the BMA about the health white paper Sun, 09 Jan 2011 18:39:04 +0000 Continue reading ]]> 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.

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Leading medics challenge GPs to fight Andrew Lansley over NHS reforms Fri, 07 Jan 2011 18:45:39 +0000 Continue reading ]]> More than 100 doctors, including 20 professors, sign open letter criticising British Medical Association leaders

Doctors‘ leaders are facing a challenge from senior medics who claim they have been too quick to accept the government’s NHS shakeup and should instead “mobilise” to thwart it.

More than 100 doctors, including 20 professors, have signed an open letter in the British Medical Journal, criticising the leadership of the British Medical Association, the doctors’ union.

They claim the BMA should abandon its “failed” policy of “critical engagement” with ministers over plans that will “destroy” the NHS, and instead withdraw from discussions with health secretary Andrew Lansley to fight his reforms.

They write: “The NHS really is in your hands. We understand the pressures you are under, but now is the 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.”

Fighting the changes is “a great opportunity for the BMA to achieve redemption for its opposition to the inception of the NHS in 1948,” they add. The letter is addressed to BMA chairman Dr Hamish Meldrum, a GP; Dr Laurence Buckman, who heads its influential GPs’ committee; and the other members of it.

Among the signatories are three members of the BMA council, its 33-strong ruling body, and leading doctors in fields such as cancer, children’s health and emergency medicine. They also include GPs, whom Lansley insists will benefit from his plan to hand £80bn of NHS funding to family doctors in England so that they can commission services on their patients’ behalf.

The letter was organised by Dr Clive Peedell, a consultant clinical oncologist at the James Cook university hospital in Middlesbrough, who is on the BMA council, as are co-signatories Jacky Davis, co-chair of the NHS consultants’ association, and men’s health expert Professor Ian Banks.

The doctors add that it is “remarkable” that the BMA had decided not to hold a special meeting to allow its full membership to air their views, despite Lansley’s proposals being what the King’s Fund health thinktank has called “the most radical restructuring of the NHS since its inception”.

As a result, they say: “The BMA has no mandate from the wider membership to continue with the ‘critical engagement’ policy … The association has effectively sent a message to the profession that the [government's NHS reform] white paper is a done deal.”

Meldrum rejected the criticisms, saying that the BMA, after several debates in its council, had welcomed some key aspects of Lansley’s plans but had “real concerns” about others, “including the speed at which the changes are being rushed through and the dangers of market-based competition in the NHS”.

The BMA plans to increase its lobbying ahead of the publication of the health bill, expected later this month, and will “continue to forcefully represent members’ concerns as the government’s proposals move to the next stage”.

John Healey, the shadow health secretary, said the letter was “evidence of the pressure mounting on Lansley, and the growing criticism of his plans for a high-risk internal reorganisation of the NHS”.

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BMA’s historic mistake on White Paper Wed, 11 Aug 2010 14:54:54 +0000 Continue reading ]]> An Open letter from John Lister of Health Emergency to Dr Hamish Meldrum, Chair of the BMA Council, in response to his letter to BMA members, available at:

Dear Hamish Meldrum

As a campaigner who recently had the pleasure of working as a researcher supporting the BMA’s Look After Your NHS campaign, it was with great sadness that I read your letter to BMA members explaining your organisation’s decision not to join the widespread and growing opposition to the government’s White Paper on the NHS, but instead to “critically engage with the consultation process”.

This decision will certainly delight the Health Secretary, and those who share his declared objective of turning the NHS from a public service, largely publicly provided, into a “social market” in which ’in most sectors of care, any willing provider can provide services“ (White Paper page 37).

By contrast it will dismay the many BMA members, members of the public and other health workers who, like me, were pleased to support the BMA’s Look After Our NHS campaign, and the eight principles it endorsed, and who will see the decision to go along with the White Paper in this way as a retreat from these principles.

It is surely also quite extraordinary that your discussion of the issues which concern the BMA in what you describe as a “curate’s egg” of a White Paper makes no mention at all of the colossal and quite unprecedented £20 billion spending cuts (“efficiency savings”) which are quite explicitly written into the proposals, to be achieved by 2014 (Page 5). To discuss the White Paper without mentioning this crucial factor is rather like discussing a zoo as a space for empowering animals — without mentioning the existence of cages.

It is clear that, far from being empowered to improve services for patients as they might wish, if the White Paper is implemented GPs will, for the next few years at least, find themselves being used repeatedly to wield the axe on a range of popular services, take public responsibility for the closure of local hospitals and facilities and the rationing of care on financial grounds, and be blamed for large scale job losses — including consultants and other medical staff.

With no PCT bureaucrats or SHAs to carry the can for unpopular decisions, GPs will find themselves exposed time and again to hostile public opinion and even tabloid press coverage: their very motives in undertaking this role will also be widely called into question, especially when it is such a reversal from the previous, popular BMA stance.

Perhaps you may be concerned that if the BMA did not get involved, the private sector might simply step in and take charge. But this is clearly not the case: Mr Lansley desperately needs the fig-leaf of BMA (and especially GP) involvement to lend any degree of credibility to his highly controversial proposals.

As private consultancy Tribal have pointed out:

The success or failure of this initiative depends on whether GP support for the proposals can be secured. The first test is whether GPs will be willing to form consortia without excessive financial incentives, given the significant responsibilities associated with managing tax-payers money.”

Again, later in the full document, Tribal note that:

This problem will become acute if the GPs fail to respond with enthusiasm to Mr Lansley’s invitation. Even with the power to direct, achieving both the timetable and the desired impact requires the positive engagement of a majority of GPs. There will doubtless be enthusiasts but will they constitute a majority, will they provide sufficient apostles to lead 500 consortia?”

(Tribal 2010: ’Liberating the NHS’ – The next turn in the corkscrew?, page 10)

It is also important to recognise that as a formula for a new, competitive health market, ALL of the White Paper proposals fit together as an interconnected whole, and ALL are therefore important to the government. This makes it almost impossible to imagine that ministers will be willing to make any serious concessions, let alone the level of compromises which might, as your letter suggests, enable the BMA to “mould these proposals into a set of solutions that can benefit our patients and the working lives of doctors”.

Your letter gives no idea of what the BMA might do if it fails to achieve any of its (as yet undefined] objectives in “moulding” the White Paper, and finds the end result unacceptable. What credibility will it have with other health unions or the wider public if it is forced to make yet another abrupt U-turn after it has so seriously undermined the opposition at the outset?

And where in the White Paper does it give any grounds for the BMA to believe that the government might agree with you that “for commissioning to be successful, there must be the fullest engagement with secondary care colleagues. . .”? In fact the strengthened powers for Monitor and repeated reference to the Competition Commission in the White Paper make it clear that any such engagement is to be ruled out in the new, even tougher competitive market framework, which would pit GPs as commissioners on one side of the divide, and their professional colleagues in provider organisations on the other.

It is not at all clear how if the BMA had taken a hard line of opposition through the brief consultation period it would, as you claim,“greatly increase the risk of bringing about the adverse outcomes that many of you fear”.

There is no sign so far of compromise from Mr Lansley. On the contrary the prospect of pulling the BMA in behind the proposals and splitting the ranks of health workers has strengthened the government’s hand, giving ministers confidence to stand firm, making it more likely that they will discount other opposition from health unions as ’self-interested’.

In fact it is far from clear that a majority even of GPs are convinced that the White Paper offers them any positive way forward. The wafer thin vote in favour of commissioning at the LMC conference, and the 68% poll against it on DNUK suggest that a firm lead from the BMA, explaining the issues and reaffirming its principles, could easily carry a majority for demanding Mr Lansley think again.

And this kind of solid front could make it very difficult for ministers to press through with reforms that only a few right wing think tanks, neoliberal academics and self-interested private sector employers can be seen to endorse2.

There are signs that you and your colleagues are aware of the contradictory position you have now put yourselves in, by “engaging” with policies that only months ago you were correctly campaigning against. BMA News reports that the same BMA National Council which took this unfortunate decision also reaffirmed its support for the Look After Our NHS campaign. You, too, insist in your letter that you are not deserting these values:

Quite the reverse. We believe it is only by responding critically to the challenges and the potential consequences of the government’s proposals that we can defend the founding principles of the NHS and the principles underpinning our campaign.”

I am sure you and others are sincere in believing that it is possible both to “engage critically” with Mr Lansley and uphold your principles. But this is simply not the case: even a passing glance at the eight principles3 shows immediately that they are all quite incompatible with Mr Lansley’s vision for the NHS.

Principle 1 argues correctly that “Comprehensive and universal services can only be ensured by public sector services delivering treatment on the basis of clinical need, not ability to pay”: yet the White Paper makes clear that existing NHS Trusts will be compelled to become Foundation Trusts, while Foundation Trusts (together with their assets currently valued at £15. 8 billion) will in turn, if Mr Lansley has his way, be removed from the NHS balance sheet – ceasing to be public sector organisations.

The White Paper states clearly that in future Foundation Trusts “will be regulated in the same way as any other providers, whether from the private or voluntary sector” (page 36). The removal of Foundation Trusts from the NHS has

Criticism has spread well beyond the ’usual suspects“ of opposition parties, the left and the TUC health unions. Both the Lancet and the BMJ have carried major and convincing critiques of the proposals: Sir David Nicholson has made it clear that he doubts the timescale and the viability of the proposals, although he is now committed to driving them through.

The NHS Confederation has published a general critique of such sweeping reforms in the last ten years, pointing to the swift succession of organisational changes and the flimsy evidence of success; Civitas and others have been critical and warned of the likely implementation costs of the White paper proposals.

Even Chris Ham of the King’s Fund has been reluctant to lend more than minimal support to the Lansley plan.

The principles are expanded in more detail in the BMA pamphlet NHS Reforms are damaging our health service, available at: http://lookafterournhs. org. uk/wp-content/uploads/doctor-final- 270110. pdf potentially serious consequences for their staff, including consultants and hospital doctors, who would no longer be NHS employees, and new members of staff who would as a consequence be outside NHS pay scales and review bodies, pensions and other important terms and conditions.

But privatisation of health care on this scale has never occurred in any health service anywhere in the world, so nobody knows the possible consequences for the future of patient care. It is most surprising that the BMA should vote in favour of participating in an experimental change that has so little evidence to support it, and which poses such a long-term threat to a large section of its own members.

Principle 2 of the BMA’s campaign for a public NHS argues for an NHS which is “publicly funded through central taxes, publicly provided and publicly accountable”: but of course the White Paper does not even guarantee the first of these. It conspicuously avoids the issue of tax funding, while it also makes clear that few, if any NHS services will remain publicly provided after 2013, when NHS Trusts will be officially wound up. And it gives no clear mechanism by which the service will be publicly accountable.

The early signs on accountability are not promising: none of the sweeping changes being brought forward now by Mr Lansley and the ConDem coalition government have been subject to any prior public debate, let alone put forward clearly to the electorate: and if previous governments are any indication, the extent to which the public will be given any opportunity to shape the changes in advance of far-reaching top-down legislation is likely to be minimal.

The best opportunity to force ministers to take note of public opinion and that of health care professionals and others would have been for the BMA to work with those who are challenging the proposals, rather than to allow itself to be tied in — however “critically” – with the plans themselves.

Principle 3 of the BMA’s campaign calls for a significant reduction in commercial involvement in the provision of health care, and principle 4 looks for public money to be used for “quality healthcare, not profits for shareholders”. However that is not the position of the White Paper, which explicitly rolls back the (belated, but welcome) commitment by Andy Burnham last autumn that the NHS should be the “preferred provider” of services.

Lansley’s White Paper repeatedly argues instead for the use of “any willing provider” – an open invitation to for-profit private providers to bid for services. We have already seen (and campaigned against) the negative consequences of such bids, in the money wasted on Independent Sector Treatment Centres, primary care, and other sectors of the NHS. In each case, the costs are higher or quality of service lower than NHS provision.

To make matters even worse, the White Paper’s organisational changes will effectively close off the option of NHS providers continuing in England after 2013, in what Kingsley Manning of Tribal has called a “revolutionary” denationalisation. To make the direction of travel quite clear, the White Paper also explicitly proposes to abolish the “arbitrary cap on the amount of income Foundation Trusts may earn from other sources” – i. e. private, commercial medicine. Especially in the context of the frozen or declining revenue budgets for NHS and Foundation Trusts over the next five years, this too opens the way for a downsizing of public sector activity and an increase in “commercial involvement”.

BMA Principle 5 restates the value of “co-operation, not competition”, emphasising the risks to patient care, and calling for greater integration and collaboration. Again, no objective reading of the White Paper can find anything in it which is consistent with this approach.

The key principles embraced by Mr Lansley centre from start to finish on the creation of a competitive market, in which the power is put in the hands of commissioners, and providers are obliged to compete with each other. Principle 6 calls for the NHS to be “led by medical professionals working in partnership with patients and the public”. But it’s clear that the scope within the White Paper for such partnerships will be extremely limited: GPs will have restricted managerial resources to assist and advise them in the allocation of large commissioning budgets 4, and limited time and capacity to conduct their own interaction with any wider public alongside their own clinical work.

If rumours that there will be around 500 consortia in England are correct, the average size for a consortium will be around 80 GPs, or 3-4 per existing PCT area: this leaves ample scope for widely different local pressures and issues between different GP practices in different areas within consortia. Nor is it clear how GPs can really be accountable to their own patients, when they will also be under pressure from GP colleagues to press through decisions that balance the books for the whole consortium, in the context of £20 billion of cuts.

To add to the potential confusion, the White Paper makes no reference to neighbouring consortia having any obligation to cooperate with each other — for instance over the resourcing of services from a shared local hospital — after the mechanisms for wider planning of services (SHAs and PCTs are to be abolished. There is a real danger of a new parochialism, and a new postcode lottery on availability of treatment, with widening inequalities even within PCT areas — and contradictory decisions on the future of local provider services. Do GPs really want to carry responsibility for the unpredictable consequences of this potentially anarchic situation?

Principle 7 seeks value for money,“but puts the care of patients before financial targets”. With the overriding obligation on GPs as commissioners to carry (the Health Service Journal suggests that the consortia management budgets could be as little as one third of the present management spend by PCTs (Ju1y22:7) through £20 billion of cuts by 2014, the White Paper makes it difficult to ensure that this principle could be consistently upheld in any area.

Principle 8 sounds an important warning over the need to commit to “training future generations of medical professionals”. But the SHAs which currently plan medical and professional training are to be abolished. Thousands of training places are already set to disappear for both doctors and for nursing staff, with University staff posts also at risk.

The fragmentation of the NHS, especially once Foundations are “off balance sheet” and obliged to run as businesses outside of any guaranteed framework of funding or government support, also throws the long term future of training and education of professionals into serious doubt.

By 2013 the NHS Commissioning Board would be the only, drastically reduced, surviving element of today’s NHS: can we be certain that this will be able to ensure that self-managing Foundation Trusts concerned with their own balance sheets and financial pressures — let alone the panoply of “any willing providers” — will invest sufficiently in training and development of staff? Conclusion

In summary, it is clear that the BMA decision represents a very serious mistake, and is clearly incompatible with the previously declared principles and campaigning profile of the BMA. It runs the risk of putting GP members as commissioners into conflict with members working in hospitals and other providers, dividing the organisation itself, while also splitting the BMA from the broad body of opinion of health trade unions and professionals.

It is most unlikely that this stance will be viewed with much respect by health ministers, who will simply regard it as a strengthening of their position — and an indication that if they keep the pressure on they can get their way with the BMA.

And it seems that there is no fall-back position to be adopted if the gamble of “critical engagement” falls flat, and the government presses on with those aspects of the White Paper that the BMA regards as unacceptable. It is also worrying that you have not identified any “red line” issues where you are determined changes must be made as a condition of involvement, or bottom line objectives to enable the BMA to determine the success or failure of your “critical engagement”. This vague approach seems more likely to lock the BMA into the process regardless of the outcome of its engagement with ministers.

The BMA is to be applauded for having taken a firm and principled position for the last few years in challenging New Labour’s market-style policies and upholding the principles of the NHS. It is unfortunate that the change of government appears to have brought a retreat from this position, and concessions to policies which are far more extreme in their scale and implications that any previous NHS reforms.

I’m sure I don’t need to remind you that in 1946 the BMA chose badly and wound up on the wrong side of the debate in opposing the launch of the NHS in 1948.

The last to come round at that time – long after consultants and hospital staff had been persuaded of the advantages of a national career structure, training and standards – were the GPs, many of whom did not change their position until after the NHS had been formed and almost the entire population had immediately signed up for it. You will be aware that for many decades this error haunted the BMA’s links with other organisations. But it seemed that this had finally been overcome with the BMA’s vigorous defence of NHS values against New Labour’s proposals. Indeed it was remarkable that earlier this year the BMA contingent on the national demonstration in defence of public services, in which you took part, was bigger and more vigorous than some of the TUC health unions with larger membership.

Sadly it seems that the current stance of the BMA could result in the GPs again lining up on the wrong side of the debate, as the current government contemplates the definitive reversal of Bevan’s nationalisation of the hospital network, which laid the groundwork for the NHS.

I very much hope that the BMA will take immediate steps to strengthen the very limited critique which seems to inform the current policy, and will soon recognise the need for a shift of direction. If not, the organisation will again be discredited – for effectively abandoning its key principles in the vain hope of future influence over a government that does not share them, and is firmly set on an opposite course, to the detriment of doctors, health workers and patients.

John Lister PhD
London Health Emergency
August 3 2010

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