Health Matters | Paul Corrigan's blog

Before Christmas I wrote a post that called into question the depth of the BMA’s love for current PCT staff. I pointed out that in their latest guidance they were extolling the virtues of current PCT staff to BMA members leading clinical commissioning groups as being the best experts in commissioning. I suggested that they were doing this because in the last couple of years they have become fearful of new private sector firms selling their services to GP led commission groups. Read the rest of this entry »

A. When they might chose to do something with which the BMA disagrees.

Over the years the BMA, like any effective trade union, has always stood up for its member’s right to make their own choices. All trades unions do this and the BMA is assisted in this role by the professional autonomy training that all doctors receive.

Whilst this is true of all doctors, it is even truer for GPs because GPs have also traditionally run their own businesses. Therefore, as small business people, it has been up to them where they get their accountancy or legal advice from. Similarly it has been up to GPs to decide whom they might employ as receptionists or nurses. Read the rest of this entry »

Last week’s BMA briefing on the Health and Social Care Bill not only argued their continuing opposition to the Government reform, but demonstrated how much they wanted to move the NHS away from modern society.

In June readers will remember that the Government’s reform of its reforms argued that they would amend their Bill to make it clear that they would outlaw any Health Minister that argued for a change in the proportion of NHS services that were provided by the public sector, the private sector or the voluntary sector. They did this because they had been stung by the accusation that they had a policy of increasing the share of NHS services to be provided by the private sector.

So, true to their principles, they reversed the policy from being one in favour of increasing the size of the private sector to one where you were not legally allowed to have a view on it at all.

This new law would outlaw a policy where a Minister, or Monitor, argued – for example – for a higher proportion of third sector organisation hospices providing services for end of life care.  The outlawing of this statement was meant to prevent the accusation that the Government was in some way against NHS public service provision.

If the current state of provision was, say, 30% private, 30% third sector, and 40% public sector then freezing proportions may in some way make sense. But given that for most parts the NHS provides well over 90% of provision, this policy freezes provision in very unequal proportions.

The aim of this new law was to argue that Government could not have a policy of increasing the proportion of care from a sector. However the Government was NOT saying that they would stop individual patients from choosing whatever provision they wanted. So if a large number of patients chose, for example, to move their end of life care from an NHS hospital to a voluntary sector hospice, the government would say this was up to them and not caused by Government policy.

It was not having a policy which would tell patients what to do that has made them fall foul of the BMA. .

At the time I suggested that whilst the BMA and other public sector trades unions would welcome the fact that the Government no longer wanted to have a policy of increasing competition in the NHS, the policy of Government neutrality would not appease them.

They would not rest until the Government had a policy of outlawing the private sector from providing any more services for NHS patients.

Last week’s BMA briefing made it clear that this was now their position.

“ In relation to the increased use of the private sector in providing care, the changes in the Bill put a duty on the Secretary of State, Monitor and the NHSCB not to ‘exercise  <their> functions for the purpose of causing a variation in the proportion of services provided  by any sector. This does not prevent such a variation taking place as a result of market forces < e.g. patients choosing more providers from a particular sector through AQP- any qualified provider>

The BMA believes that

• Although the Government has attempted to address concerns about the increased use of the private sector, there is still too much emphasis on using ‘market forces’ to shape health services. The Bill still allows for there to be an increase in the use of private sector providers”

BMA briefing page 2

This is a really important explanation of the BMA’s position and it gives us a view of the kind of society that they want to create. It demonstrates how far they are prepared to change the nature of an open society in order to appease their own fear of the private sector.

Since they argue that the Bill is flawed because it “allows for there to be an increase in the use of private sector providers”, presumably a good Bill would in some way outlaw any such increase.

Since the Bill does not ‘prevent such a variation taking place as a result of market forces – for example patients choosing more providers for a particular sector’  presumably a good Bill would in some way outlaw patient choice if that choice was to result in a higher proportion of NHS care being provided by the private sector.

In an open society this is extreme stuff. It is worth a moment’s quiet thought about the sort of society these restrictions would create.

The BMA want a bill that would make it illegal for private sector organisations to provide a higher proportion of NHS health care than they do at the moment. Even more shocking is the fact that the BMA would be satisfied with a Bill that would make it illegal for patients to choose to have their operation carried out by a private sector provider if that movement increased the proportion of provision for NHS patients from the private sector.

In the past there has been much talk by the BMA about their concern that patients are individually not really up to making these choices.

But here it is clear that they are not frightened of the individual capability of patients to make these choices but they are really worried that the overall outcome of making these choices might increase the proportion of private sector providers for NHS patients.

They want to restrict patient choice for directly political reasons.

But what sort of society do they want to create?

Last week the BMA wrote to all MPs outlining their continued hostility to the Health and Social Care Bill. Their briefing behind that letter makes really interesting reading. Two main political themes emerge. The second of these I will post about tomorrow.

The first is that despite (but I think really because of) the Government’s June reform of its own reforms, the BMA still thinks the Bill needs to either be withdrawn or substantially amended.

 “The BMA acknowledges the efforts of Government to listen to and address some of the concerns that have been expressed about the Bill to date. Despite some improvements to the Bill over the summer and , despite there being some positive aspects to the reforms, such as getting clinicians more involved in planning health care, real problems remain. This BMA still believes that the Government reform plans pose an unacceptably high risk to the NHS in England, threatening its ability to operate effectively and equitably, now and in the future. This is why the BMA continues to call for the Bill to be withdrawn, or at the very least, to be subject to further, significant amendment.”

BMA Briefing on the Bill

The Prime Minister’s belief that following the amendments he forced on the Secretary of State in June, the profession would support the Bill, has not really worked.

This I am afraid comes back to the same problem as of a year ago. Then the Government had no narrative for its reforms. It did not offer an explanation of what the big problem with the NHS was, and could never therefore explain how the detail of their reforms would solve it. What was the question to which GP commissioning was the answer? Not having told us what the problem was they had to be hazy about how their reforms would tackle it.

There was a very big hole where the Government’s narrative should have been and since everyone assumed they must have some sort of reason for doing it people began to find their own explanations for why the biggest health bill ever was being pushed through Parliament.

A range of explanations surfaced, all of which seem to add up to an overarching narrative that the Government had a “”secret plan to privatise the NHS”. Indeed by the time the Government called for a pause in their reform programme in April/May last year nearly 60% of the population believed that the Conservatives had such a plan.

This is a very difficult place for a Government to be. How do you counter the idea of a ‘secret plan’? Every time you deny it the point is reinforced, because you are not going to tell us – because it is ‘secret’.

So anxiety about this public belief led to the sound of the screeching of brakes being applied – and a dramatic U turn. This was the attempt to create the narrative that they had changed their changes, and for a few weeks this was good, if very temporary, politics. Many people recognised that the Government had indeed changed their changes.

But the problem for the reform of the reforms – from June onwards – is that there is still no simple explanation of the problem that this new set of Government reforms is going to solve. If the Government could not explain to us what problem GP led commissioning consortia was going to solve, how would “clinical commissioning groups in close relationship with clinical senates” solve anything? The new explanation of the big picture was even more elusive.

The last three months have been very similar to the previous six.  Where was the narrative for which Conservative MPs could argue as they went out into the country? “This is the problem with the NHS and this is how our reforms will solve it.”

At best Tory MPs can say that these new reforms are better than the previous ones. But that’s not a confident narrative that they can take out and argue for.

So over the summer the BMA found itself still in the same position that it had been since December 2010 when the Bill was published. They had no Government narrative to compete with. They have never had to disprove what the Government was saying, they only had to create their own story about what the government were planning to do and people would give it credibility.

On the streets of many towns in England last weekend people were being asked to sign a petition to ‘save the NHS’ (which many people would of course sign). The Government have failed to force those people, and others such as the BMA, to engage in a powerful debate about what they are doing.

The best that any believer in the reforms could do when confronted with the petition is say that “honestly, we don’t want to privatise the NHS”. They could not say “we are doing it for these clear reasons”.

This was clearly demonstrated by the statement from the Secretary of State in the papers earlier this week that said simply that it was ‘scaremongering to say that his plans were aiming to privatise the NHS’.

So at the precise moment when the public is looking for a lead from the Government as to why the Bill as back in the House of Commons what it came up with was still not an explanation of why they are doing it. The best guidance the public have been offered is an argument that says that other people’s explanations are in some way scary.

In terms of the politics of the reform programme September is a lot like March. The Prime Minister successfully got his Secretary of State to change his policy, but the problem had not been with the policy, it had been with the lack of explanation of the policy. So the PM solved the wrong problem. He changed the policy and made it even more difficult to construct an explanation. And he left as his Secretary of State someone who is really very, very interested in the detail of policy.

But given that the Secretary of State couldn’t really explain the big picture of why a reform policy that he had spent 6 years creating mattered, he is not likely to be able to explain the big picture of a policy that has been cobbled together in a few weeks by a range of people he doesn’t know.

Today the Health and Social Care Bill goes back to the House of Commons for its report stage. Even after such a long discussion there are still a number of vital arguments that are still undeveloped. Part of the reason for this situation is that not only had the Government failed to develop a narrative for its original reforms – up to June of this year – but it has failed to do so for its reformed reforms since. Read the rest of this entry »

Last week I posted about a piece of research that examined public thinking about the issue of private sector health companies using staff trained within the NHS at public expense. The majority believed that doctors who made money in private practice should make some contribution to the public purse from their earnings if their training had been paid for by the public. Read the rest of this entry »

One of the constant conversations that the current Secretary of State had with the leadership of doctors’ organisations over the six years of his apprenticeship as shadow secretary of state concerned how much they hated waiting times targets.

From 2001 onwards they had railed ineffectually against a Government that won the 2001 and 2005 elections partially on the promise to reduce maximum waiting times for NHS patients. The capability and capacity of the NHS to reduce maximum waiting times was one of the core public reform narratives that brought about change in the NHS over that period. Read the rest of this entry »

This post continues my interest in the role that leading organisations in the medical profession have in trying to persuade the Government to come out against competition and especially the introduction of new entrants into the NHS.

If the BMA really believed in their position of being both against the private sector providing services and competition, there seem to me to be a number of powerful things they could do. The first would be to ban their members from taking part in private medicine. By this single action they would greatly restrict the impact of the private sector on British health provision, thereby advancing a policy they favour. Read the rest of this entry »

I spent some of Tuesday afternoon watching a webcast from the BMA special representative meeting and I must say I am really glad that they didn’t have webcams in the trades unions and political congresses and conferences when I was engaged from the late 60s to more recent times. Read the rest of this entry »

Over recent years we have heard a great deal (and quite right too) about the importance of clinical leadership. It’s true that the NHS needs much more at every level.

But we have not heard so much about the equally important experience of clinical “followership”. Whilst it’s true we need hundreds of very good clinical leaders, it’s also the case that we need thousands of very good clinical followers. If you have the former without the later you don’t really get much leadership. Read the rest of this entry »