Policy responses and statements
Background: In this discussion paper 'A rational way forward for the NHS in England ' outlining an alternative approach to health reform, the BMA suggests a system which would separate national politics from the day-to-day running of the health service. Core values and core services: The NHS constitution would contain the core values of the NHS incorporating new ones such as supporting education and research alongside the founding values. It would include a charter explaining what the public can expect as patients and carers and what the NHS expects from them. Crucially, it would also contain arrangements to determine the range of services that are nationally available on the NHS, together with nationally-agreed standards for the quality of those services. The BMA believes that the NHS should provide a comprehensive range of services, available to all on an equal footing. If we are going to retain an equitable, universal approach within limited resources then priority setting is inevitable. Politicians need to acknowledge this, and that it happens already but in a non-transparent and piecemeal fashion. A clear and transparent approach is needed. We need a public debate to decide a process to define a list of core NHS services – it will be a very substantial core – that will be nationally available. We need an ongoing mechanism to review and amend priorities in the NHS which must include an effective way of incorporating the views of patients, public and professionals. The BMA suggests enhanced local groupings, which would include patients and clinicians, to agree and define a process for delivering the national core services and to decide on any additional health services (also funded from central resources) which would be available in that area. An independent Board: Under the BMA’s proposals, parliament would establish and appoint the NHS Board of Governors. The Board would be responsible for ensuring compliance with the NHS Constitution and be accountable to parliament. An executive management board, appointed by the governors, would guide the performance and national operation of the NHS. As the ultimate guardians of the public purse, politicians and parliament should decide the high-order questions around setting priorities and funding. When it comes to the day-to-day running of the NHS, the role of national politics should be significantly reduced. The time has come to look at a much more independent framework for the NHS to allow greater flexibilities for health economies to develop care systems and to find ways of increasing local accountability. Other recommendations in the BMA report include (recommendation numbers in brackets) :
COMMENTS ON The Royal College of Physicians of Edinburgh is pleased to respond to this discussion document from the BMA following considerable feedback from its Regional Advisers throughout England. Although this College is based in Edinburgh, half of our UK Fellows live in England. We share the concerns expressed at last year’s BMA conference and, in particular, continue to champion the founding principles of the NHS. We also agree strongly that it is the doctors who are best placed and trained to drive forward improvements in patient care, and we share the frustration that initiatives which are clearly in the patient’s best interest are consistently blocked. Furthermore, we deplore the current attitude in the NHS that those who dispute or disagree with government objective should be ostracised or ridiculed and excluded from further discussions. The recent fiasco of MTAS provides a perfect illustration of the current problem. Serious concerns were consistently raised by both the Royal Colleges and the BMA, which fell upon deaf ears. Much of the change over the last few years has been ideologically led rather than evidence based. We feel that the most important feature of this document is the recognition that there is a need for public debate on the NHS and for politicians to decide how to approach the next decade. This is a clearly written document and the brief overview is particularly concise and apposite. We agree with the analysis of the problems and the requirement for a more mature approach to future decisions about Health Care Policy. Recurrent general concerns voiced by Fellows follow. Firstly, it was felt that particular problems have arisen in the commissioning process in England with often inexpert PCT’s addressing issues according to their administrative, rather than clinical, significance. The BMA’s concerns in respect of independent treatment centres and their negative impact upon NHS services were also echoed by responding Fellows; it is suggested that an important role for ITC’s could be to provide services which are not the core provision of the NHS. Another concern expressed is that the whole report is quite long and, to encourage wider engagement, extensive circulation of the overview and recommendations should stimulate more discussion. It was also pointed out that, without stability, a clear direction in training and assessment of Junior Doctors (a central role of the College) is extremely difficult. We would hope that the government will view this as a constructive document which puts the needs of the patients first, rather than the interests of the medical profession. We not unnaturally support the favourable allusions to a more collaborative and less market driven Scottish NHS. One area which the BMA paper does not address, and which we feel extremely important, is the current loss of freedom for both patients and doctors. Whilst the government may argue that the patient freedoms have increased (eg choose and book etc), there are other areas in which freedom is much diminished (eg availability of treatments). Likewise, for doctors we have lost important freedoms in the organisation of our own services, for instance, through centralised appointment systems, pooled waiting lists and major restrictions in our ability to follow up patients – even for diseases where long term care is in the patient’s best interest. We feel that too much time is now required for all of us to examine what we do and how we do it, rather than seeing and treating patients. These issues are not addressed in the paper. Some of our Fellows also feel that this paper is insufficiently radical to capture headlines and media interest, although how to achieve this is not spelt out by contributors. It has also been pointed out that there is no mention of the likely requirements in respect of funding these changes – a point that will be rapidly seized upon by government. The paper would have much more impact if it could be shown to be cost neutral so that, for instance, the Independent Boards, elected local health councils and effective clinical information systems can be funded by saving or replacement of other services. All are in agreement that the importance of clinical expertise, leadership and cooperation should take priority over the current emphasis on markets, managers and competition. We would comment upon the specific recommendations as follows:
3. & 4. There is some scepticism about this concept, mainly because of
15. - 17. Involvement of local citizens has often inhibited change and often
22. & 23. Are agreed, and their actual delivery would be welcomed by all.
Whilst doctors in Scotland are more supportive of the Executive, there are still significant problems and, whilst the system may presently be working better than in England, it is not a universal panacea. From a research perspective, the suggestion that SHAs should enable close relationships between health and services and clinical research centres is laudable, but there is less confidence in such an outcome at grass roots level. We feel that we are being saddled with an inordinately complex administrative structure and bureaucracy that is already severely impacting upon clinical research, particularly outwith academic centres. The document also acknowledges the challenge of an ageing population in the linkage of health and social services to provide holistic patient care; clinical networks could develop a system to benefit the elderly. Finally, we feel that the document should be praised for highlighting that the purpose of the NHS is to provide good quality services, particularly to the most vulnerable in society. Some or our contributors felt that the Government’s health service reforms have not achieved their object and have wasted considerable finance, and it is therefore entirely proper that the BMA should put forward its own proposals. Copies of this response are available from: Lesley Lockhart, Tel: 0131 225 7324 ext 608 [5 September 2007]
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