The white paper Equity and Excellence: Liberating the NHS, recently launched by the coalition government, proposes a significant and controversial shake up of primary care.
There are proposals to increase commissioning responsibilities for GPs, phase out PCTs and SHAs and put a greater focus on outcomes. Local authorities will have a greater role in public health, and there are perceived threats to national terms and conditions of service.
The BMA has said it will critically engage with the government over the white paper. The union has just released its full response. It says: “There are elements we broadly support, elements we support in part, elements we are unable to support and elements about which we require more detail before we can develop a fully considered position.”
The following is a summary of the BMA’s white paper response:
Commercialisation of the NHS
The BMA states that it hasn’t supported the direction taken in the NHS in England in recent years towards commercialisation, which is continued, and indeed accelerated, by the proposals set out in the white paper, despite evidence showing that it hasn’t been beneficial for the NHS or patients.
There are aspects of the white paper’s proposals which have the potential to undermine the stability and long-term future of the NHS. The ‘any willing provider’ policy has the capacity to undermine local health economies by replacing existing multi-service natural monopolies with a plethora of smaller units providing more limited ranges of services. This would radically affect both the efficiency and value for money of the NHS.
If the tariff system is to remain, the BMA is anxious that tariffs should encourage high-quality care and value for money and not produce the unintended consequence of destabilising existing providers.
Changing the status of existing NHS providers to foundation trust status has already threatened the character and ethos of NHS provision. Further moves towards the development of corporate entities would threaten the stability of the NHS and the security of its employees and their terms and conditions of service.
Financial climate
The BMA notes that a large amount of money is being spent to make the changes proposed in the white paper, whilst at the same time attempts are being made to release £15-20bn of efficiency savings over the next four years. This is a very difficult climate in which to make substantial service changes and reconfigurations. The BMA questions the value for money of such changes and whether a less disruptive, more cost-effective process could have been proposed to achieve similar aims of reducing bureaucracy and empowering clinicians.
It urges the government and NHS organisations to focus on those areas where they can truly eliminate waste. Robust evidence must be gathered and proper processes put in place.
Transition period
The winding down of PCTs and SHAs must be managed carefully to avoid any confusion and inefficiency. Both should remain in place until the new structures are ready to operate. Steps must be taken to prevent the loss of significant numbers of skilled staff within both types of organisation, something which may already be occurring.
PCTs currently have many statutory functions and responsibilities that will still need to be undertaken after they are abolished.
Training and education
The BMA believes that effective national oversight of medical education and training is absolutely essential. It strongly opposes any moves that will increase reliance on local planning and management of education and training. As local employers unavoidably lack a broad overview of workforce requirements, we believe that the management and planning of the medical workforce can only be done at a national level, and more properly at a UK level.
The BMA believes cohesion and consistency, which enables medical graduates to move between national boundaries, is essential to ensuring that the same high standard of patient care is maintained throughout the UK. Without a uniform approach to training in terms of career progression and standards of qualification, there could be further instability to patient care, as it would become more difficult for the medical workforce to move around the UK.
Public health
The Public Health Service will not be effective unless it can fully support the delivery of public health functions at a local level. There is a danger that the centralisation of skills and expertise into the service might be at the expense of the capacity and capability within local departments.
Patient choice and control
The BMA supports meaningful choices for patients, free from political targets, but we do not believe that the patient choice agenda of recent years, which is continued in the white paper, has improved clinical outcomes or offers patients the choices they actually want. The BMA says that patients want high-quality providers close to where they live and to receive timely, competent diagnosis and treatment and ongoing support when necessary.
NHS Outcomes Framework
While the BMA recognises that some waiting-time targets have helped to reduce headline waiting times in the NHS, the reduction in the number of top-down targets is a positive step. However, the BMA doesn’t support the wholesale replacement of process targets and indicators with clinical and patient reported outcomes measures.
There is clear evidence that the use of process measures is an effective management tool for judging and rewarding quality provided the process measures are valid, have professional support and are able to influence the process of care without having total control over the outcome of that care.
GP-led commissioning
The BMA is interested in exploring with the government the proposals for GP-led commissioning consortia, which see GPs as an intrinsic part of the commissioning machinery within the NHS. Successful commissioning will only be achieved with GPs, secondary and tertiary care consultants and other clinical colleagues, working together. Public Health consultants will also have a significant role to play, as will clinical academics.
Foundation trusts
The BMA is concerned by the government’s determination for all NHS trusts to become foundation trusts, given the notably bad outcomes that have been seen in a number of cases and despite the fact that foundation trust status is supposed to be a mark of quality. We are concerned that intensifying the pressure on NHS trusts to achieve foundation trust status within the next three years will drive more of them to place the achievement of this target above all others, including safe patient care. The BMA would like NHS hospitals to be part of a collaborative publicly owned system of the provision of care for clinical need.
Social enterprise
The BMA is not aware of any evidence that could support the view that significant numbers of NHS staff wish to work in social enterprises and would question whether the benefits of the approach set out in the white paper will be achieved. Attempts to force NHS staff into accepting a move to a social enterprise model without proper consultation or engagement will not produce successful social enterprises.
Economic regulation
The BMA does not support Monitor’s role as promoter of competition in healthcare and believes its focus should be on ensuring quality. If Monitor does take on this role, it should seek the views of professionals and patients before making decisions about anti-competitive behaviour, to find out which services they want in the area and if there are established pathways of care and existing collaboration, rather than force competition when it is inappropriate.
NHS pay
The BMA supports a comprehensive and universal NHS with national contracts and conditions. It is essential that national terms and conditions are protected, to ensure an equitable spread of doctors across the UK irrespective of local differences in geography or economic wealth, and to safeguard against poor working conditions.
Multiple instances of local pay negotiation and bargaining would be time wasting and inefficient. The BMA does not support the proposal to encourage individual employers to determine pay and local terms and conditions for their staff.
NHS pensions
The BMA believes that the NHS pension scheme is sustainable and represents value for money for the public. The scheme for NHS staff in England and Wales has already been subject to a recent major review and, contrary to common misconception, is financed by employees and employers, providing a surplus to the Treasury in recent years.
Cutting bureaucracy
Effective management is essential to the future of the NHS. Whilst the BMA supports measures to reduce unnecessary bureaucracy and administrative costs, some NHS management functions are necessary to ensure the smooth running of services and the NHS as a whole.
Arm’s-length bodies
The government’s proposals to downscale or close a number of arm’s-length bodies have far-reaching implications. The BMA is particularly concerned about the impact of proposals on the Health Protection Agency and the Human Fertilisation and Embryology Authority.
Read the full BMA response.
Tags: BMA, Health policy
