‘THIS response details the BMA’s position on the specific areas for reform contained in the consultation Liberating the NHS: Greater choice and control, building on the views set out in our previous consultation responses. We trust our comments will be considered and used to develop the proposals in a way that ensures the maximum benefit for patients and the NHS.
The BMA supports meaningful choices for patients. However, we are concerned that the emphasis on patient choice could result in increased health inequalities, as well as confusion and inaction due to uncertainty. Choice must be extended in a manner which is fair, avoids duplication of services and is affordable.
We do not support the policy of choice of any willing provider in the context of price competition and the market. We strongly believe that the any willing provider policy risks undermining local health economies, intensifying the market approach in the NHS and that it conflicts with the stated aim to encourage integrated services. We are, therefore, very disappointed that the Government appears to be determined to pursue this policy despite the risks, and we urge it to reconsider its position on competition in the NHS.
We remain deeply concerned about the speed which with the Government is pressing ahead with implementing its proposals, seemingly without listening to warnings about the risks of this rushed approach. Whilst we agree with some of the proposals for extending choice outlined in this consultation document, we also believe that any changes should be introduced in a measured way. Unfortunately, we do not believe that the Government is exercising sufficient restraint in relation to the pace of change, despite some concessions, or that it is being truly responsive to the concerns being put forward by the medical profession and others.
The BMA agrees in principle with some of the choice offers proposed in this document, including for some mental health services; diagnostic testing; and choice of named consultant-led team in elective care. However, choice will not be appropriate in all cases, and doctors must continue to act as advocates for patients, providing them with information and guiding them through the system. We are also supportive of the commitment to giving patients more information on research studies and more scope to join if they wish, and we believe that patients should have choice about end-of-life care and which GP practice is best for them. We do, however, have a number of concerns in relation to the removal of practice boundaries.
The BMA does not support the mandatory use of Choose and Book, nor do we support the rolling out of the personal health budgets programme before robust analysis of the pilots has taken place.
Furthermore, the BMA would urge caution with respect to putting choice on a legislative footing. We agree that offering patients choice is desirable where this is clinically appropriate and where resources allow this. However, extending entitlements to choice in legislation risks giving choice primacy over other considerations, and this may not always be appropriate.
We believe that patient safety must be paramount, both when choices are first made and further along the care pathway, and that expectations around choice must be carefully managed to avoid giving rise to an unrealistic expectations and rising demand beyond the capacity of the already over-stretched NHS resources.
1. Introduction
1.1 The BMA is an independent trade union and voluntary professional association, which represents doctors and medical students from all branches of medicine all over the UK. We have a membership of over 140,000 worldwide. We promote the medical and allied sciences, seek to maintain the honour and interests of the medical profession and promote the achievement of high quality healthcare.
2. Greater choice and control
How should people have greater choice and control over their care? How can we make this as personalised as possible?
2.1 The BMA supports meaningful patient choice. However, we do not believe the patient choice agenda of recent years has improved clinical outcomes or offers patients the choices they actually want.
Neither do we believe that it should be assumed that all patients necessarily want to make a ‘choice’. Our views on patient choice are set out at Appendix A.
2.2 The patient choice agenda pursued under these proposals risks placing choice ahead of fairness, thereby increasing inequalities in health. This could ultimately restrict many people’s choices as services decrease or favour those who can negotiate more effectively and whose needs can be met most easily and profitably. There is evidence to suggest that everyone benefits from a more equal society, not just the least well-off.
Any Willing Provider: the basic assumption
Which healthcare services should be our priorities for introducing choice of any willing provider?
2.3 The BMA strongly opposes the introduction of choice of any willing provider in the context of price competition.
2.4 We remain profoundly critical of increased involvement of commercial interests and the active promotion of a market approach in the NHS, which is intensified by the any willing provider policy. We believe that multiple routes to obtain a single service may lead to confusion among patients, and risks fragmentation of the service that will increase costs and complexity and could impact upon patient safety. Evidence shows that increased commercialisation has not been beneficial for the NHS or patients.
2.5 We are, therefore, deeply concerned that the Government has chosen to disregard the criticism that we, and many others, have levelled at this policy. The Government’s refusal to engage on this issue is disappointing, and seems to be symptomatic of a wider reluctance to heed the voices of those who are concerned that the current direction of travel, and particularly the increased emphasis on competition and the market, is putting at risk the values upon which the NHS was built.
2.6 Our concerns about the potential impact of the any willing provider policy are set out in more detail at Appendix A.
How can we offer greater choice of provider in unplanned care?
2.7 Choice of unplanned care provision is already in place in the form of walk-in centres, which have been used by many patients at early stages in what is often a self limiting illness. The BMA is concerned that this adds to costs by duplicating services, without offering any clear health gain. We believe that any increased choice in unplanned care should be cost effective and that efforts should be made to avoid duplication of services.
2.8 In addition, research into Independent Sector Treatment Centres (ISTCs) shows that even in elective care, multiple providers are ineffective (our views on ISTCs are set out at Appendix A). We would therefore question extending choice further into unplanned care given that it is not always effective in planned care.
Making choices about maternity services
Which choices would you like to see in maternity services and which are the most important? . . .
2.11 The BMA cautiously welcomes the introduction of choice of treatment and provider in some mental health services. Our views on choices in mental health services are set out in our response to Equity and Excellence. . .
Making choices after a diagnosis
Would you like the opportunity to choose your healthcare provider and named consultant-led team after you have been diagnosed with an illness or other condition?
2.19 The BMA supports the choice of named consultant-led team for elective care, but has concerns that it would not be appropriate for all services. Our comments on this choice offer are set out in full in our response to Equity and Excellence.
2.20 In addition to this, we are concerned that this choice offer appears to be based on the assumption that GPs refer either for a specific procedure or for a consultant to make a diagnosis, rather than for a specialist opinion on the most appropriate management. We believe that offering patient choice of another provider at this stage could undermine the professionalism of the first consultant and increase GP workload if the patient is re-referred elsewhere. There are also issues around patient safety, due to increased fragmentation of care, as choice may introduce more steps, people and organisations into the process.
2.21 We are also concerned that the proposal to offer patients a choice to transfer between teams and/or organisations after being diagnosed could lead to increased costs at a time of financial austerity.
Making choices as part of personalised care planning
What else needs to happen so that personalised care planning can best help people living with long term conditions have more choice and control over their healthcare?
2.22 We welcome a stronger focus on joint working between health and social care, and we note the emphasis on joined up working to facilitate personalised care planning, as well as the recognition that effective care planning is already being delivered by many health and social care professionals. . .
Choosing a GP practice
2.26 It is right that patients should be able to choose which GP practice is best for them?
However, removing practice boundaries entirely may have a large number of unintended and unwanted consequences. It will increase the cost of providing care, complicate resource allocation, make home visiting, currently a contractual obligation for GPs and a vital service for many chronically sick, immobile and elderly patients, impractical, and will damage continuity of care. It may widen health inequalities and will make commissioning care difficult for patients who do not live locally. . .
4.9 We note the reference to the development of tariffs for community services. We would seek more information on whether this will allow practices to provide these services on a case by case basis and receive payment for them, even if currently deemed part of essential services by some PCTs. Tariffs must encourage high quality care and value for money and not produce the unintended consequence of destabilising existing providers. . .
4.10 The BMA does not support the any willing provider policy. That there is a need to produce additional tools to negotiate the range of providers brought about by the any willing provider model reinforces the BMA’s concern that the policy risks introducing additional costs and complexity to the system.
Personal health budgets
The White Paper indicates that the Government will explore the potential for introducing a right to a personal health budget in discrete areas.
Which conditions or services should be included in this right?
4.11 We would not support the rolling out of the personal health budgets programme before robust analysis of the personal health budgets pilots has taken place. The BMA’s views on personal health budgets are set out in our response to Equity and Excellence. . .’
