The Chairman of the doctors union, the BMA, wrote a letter to the medical profession on 30th July regarding the new health White Paper (WP).
This letter outlined how the BMA (British Medical Association) was responding to the Coalition Government’s Health White Paper ‘Equity and Excellence: Liberating the NHS’.
The WP was published on 12th July and represents the Tories’ plans to accelerate the commissioning and delivery of NHS care by the private sector. The bill is due to go before parliament in the Autumn.
The BMA’s letter recommends engagement in the consultation process and suggests ways forward for the key new proposal of General Practitioners (GPs) commissioning in consortia.
All outside commentators from left to right of the political spectrum, state that GP commissioning in consortia, will open the door to private companies to come in and commission and provide NHS care.
Many have also pointed out that the proposals in the bill will lead to the ending of the NHS as a publicly provided service.
By agreeing to critically engage with the government’s (very brief) consultation, and already laying out advice on how the GP commissioning should happen, the BMA’s letter adopts a position of conciliation and acceptance. It is, in effect, assisting the government to go ahead with its new legislation.
Every member knows that without the BMA negotiating a change to the GPs’ contract, GP commissioning consortia cannot happen. The BMA has the power to stop these plans going through.
What makes this failure to stand up for the NHS worse, is the fact that, last year, the BMA launched its Look After Our NHS; publicly funded, publicly provided (LAON) campaign, which called for less provision of NHS care by for-profit private companies.
Aware that many BMA members can see that the new health bill is opposed to everything the LAON campaign stood for, the letter impudently suggests that ‘critical engagement’ rather than saying ‘No thanks’, is the best way to keep the private sector out!
The WP was published two weeks after the BMA’s annual conference and was not discussed by the representatives. It is urgent that the membership have a chance to discuss the implications of this bill and be allowed to vote BMA policy.
A recalled Special Representative Meeting of the BMA is urgently needed to discuss the WP and vote on it.
1. No privatisation warning.
The BMA chairman’s letter to the medical profession does not warn of the key privatisation dangers of the WP.
It does not attempt to spell out the following key changes proposed in the WP:
• That the main bulk of NHS resources are given to an entirely appointed NHS commissioning Board, which will allocate most of the funds to around 500 GP commissioning consortia. The Board will no doubt contain representatives of private health corporations.
• That GPs will no longer be working in separate GP surgeries, but must be joined into federations covering populations of up to 100,000. That these federations will not just provide primary care for patients but will also take on the role of commissioning (purchasing) all hospital and community care in their areas and of Out of Hours care.
In order for this to happen, GPs will have to take on two roles, the medical and the commissioning roles and the change in contract will have to be negotiated by the BMA.
The WP specifically states that help with commissioning for GP consortia can be obtained from the private sector.
All commentators agree that private companies will be brought in to do this commissioning and it is already happening in relation to PCT commissioning.
• The end of GP surgery practice boundaries.
• All commissioning will adhere to ‘patients choice’ – meaning the private sector must be given contracts to do NHS work.
• All commissioners must not commission from ‘NHS as preferred provider’. The policy is ‘any willing provider’. Monitor will enforce the end of advantage for NHS monopoly providers and police a ‘social market’ of competing providers according to European competition law, and act as a regulator like OFGEM.
• That NHS trust hospitals be de-authorised and all trusts must become Foundation Trusts (FTs) and have unlimited opportunities for private work, and more financial freedoms to borrow from banks and accumulate surpluses, and for their assets to be removed from state ownership and given over to the employees in the form of a social enterprise or mutual business. This would lead to effective de-nationalisation of the hospitals and reverse the changes of 1948.
• The outsourcing of community care is to be accelerated and completed by April 2011.
• Payments by Results tariffs will be set by Monitor, and reduced to ‘best practice tariffs’ and no longer national average tariffs. This will introduce price competition. The Board will design new pathway tariffs.
• £20bn funding cuts and the prospect of mass staff redundancies.
The BMA letter says that the proposals ‘represent very significant changes to the organisation of health services in England’ and are ‘wide ranging’, and ‘will have a significant impact on you and your patients.’ It advises reading the WP or summaries of it.
It mentions:
• ‘increased responsibilities for doctors’
• ‘phasing out the PCTs and SHAs’
• ‘greater focus on outcomes’
• ‘perceived threats to education and national terms and conditions’
• ‘significant proposals for the future of public health, with closer working with local authorities and ring-fenced budgets intended to ensure the provision of a wider public health agenda’
• ‘one of the key planks of the government’s proposals is to devolve more involvement and financial control in commissioning to GPs’
• that there could be ‘knock on effects’ in the other three devolved nations, such that ‘unwelcome aspects of the market could leak across the English border’.
The only comment the letter gives on the WP is misleading. ‘Many consider the White Paper to be something of a large curate’s egg; good in parts, bad in parts, unclear in parts and even internally inconsistent in parts.’
But the WP is a completely consistent whole, whose content is clearly aimed at ending all three parts of the NHS – primary care, secondary care and community care – as publicly provided services.
2. No analysis and no conclusions drawn
The letter makes no attempt to draw conclusions regarding the aims of the legislation, to explain or even to warn its members that the handing of the commissioning and provision of NHS care to the private sector will be the main result of this legislation.
It declines to point out that the direction of travel is towards the NHS as a public-private partnership, in which the government funds healthcare at a much reduced level, with the provision of care to be by chains of competing private companies, which will have been commissioned by those same private companies ‘helping’ the Board and GP consortia to commission.
The NHS will be nothing more than a brand name. The door will be open to patient charges, health insurance and health maintenance organisations.
As a union, whose members’ futures are completely bound up with the fate of the NHS, this is a failure of duty.
It also represents an abdication of the BMA’s responsibilities to warn the population at large that the Coalition is legislating for the end of the NHS.
3. The fraud of ‘engagement’
But there is a larger purpose in this avoidance of study and analysis and drawing of considered conclusions about the WP, by the BMA leadership.
How could it be that the Daily Telegraph, the Guardian, Pulse magazine, Health Service Journal, Tribalgroup, Professor Chris Ham and the Kings Fund, many of them friendly to the government, can all see that the WP represents the reversal of the gains of 1948, but the BMA leadership, who have been working and negotiating in the NHS for years, apparently cannot?
By not drawing out the real meaning of this proposed legislation, and pretending to be confused by the ‘unclear in parts and internally inconsistent parts’ of the WP, the BMA leadership justifies its policy of avoiding opposition to the bill.
How can you oppose something that you don’t understand or is “ good in parts” ?
So this apparent incomprehension serves to pull the wool over BMA members’ eyes and avoids coming out clearly in line with the BMA’s Look After Our NHS campaign and saying ‘No thank you’ to the WP proposals.
4. Acceptance of the White Paper’s plans
But the BMA’s position is worse than that. It’s not just one of let’s talk, let’s have ‘critical engagement’ with the consultation. It is a position of collaboration, acceptance and endorsement of the plans.
In paragraph eight, the letter says: ‘One of the key planks of the government’s proposals is to devolve more involvement and financial control in commissioning to GPs. The BMA has made it abundantly clear that for commissioning (i.e GP consortia commissioning) to be successful, there must be the fullest engagement with secondary care colleagues, and indeed with the public. There is an opportunity here for doctors to take more control over their working lives and design services for their patients, but only by working together, in partnership, will doctors be able to maintain or even improve services in these financially constrained times.
‘Commissioning will also require high-quality management support and we fully expect that consortia will wish to engage with experienced NHS managers to work with them, both in developing their plans but also in the longer term.’
Four things are clear from this.
(i) The BMA agrees with GP commissioning consortia provided certain conditions are are fulfilled.
It says GP commissioning consortia will be ‘successful’ provided there is engagement with consultants and the public. No doubt the government will deliver these assurances in words. By proposing this ‘successful’ mode of operating, the BMA is agreeing to it.
(ii) the BMA is actually promoting GP commissioning consortia, by suggesting that doctors will have more control over their working lives. The reverse will be the case as the Board and the consortia will decide every aspect of commissioning.
(iii) the BMA concedes that GPs in consortia will not be able to commission on their own and will need help, but suggest that ‘experienced NHS managers’ will work with them.
However, the WP is quite specific in proposing that the private sector can be invited to help GP consortia with commissioning. Moreover many primary care health centres are already being run by private companies and it will be impossible to keep them out of commissioning as their surgeries will be part of the consortia and will have a say.
The BMA is spreading the illusion that commissioning by GP consortia can be kept in public hands. This is gross irresponsibility.
(iv) the BMA is spreading the illusion that GPs will have genuine powers to design services for their patients in their areas, in a way that might improve services, in a time of massive cuts in funding.
This last message is re-iterated in the final paragraph of the letter
‘. . . it is vital that we rise to the challenge, and together, try to ensure that we mould these proposals into a set of solutions that can benefit our patients and the working lives of doctors.’
The illusion is being peddled that this Tory privatisation legislation can be ‘moulded’ to benefit patients and doctors by an obedient and cooperative trade union leadership critically engaging in consultation talks. This is absolute nonsense.
The more the trade union leadership grovel and chat, the more they will be trodden underfoot. Once the GPs’ contract is renegotiated by the BMA and in the bag, the government will steam ahead with full privatisation of commissioning. These private companies will then be designing and reconfiguring ‘NHS’ services to suit themselves, not patients or doctors.
5. Selling appeasement to the membership
The BMA leadership is embarrassed by its own apostasy and its own supine posture in front of the government, so it seeks to cover this up by pretending to its membership that its new line of ‘critical engagement’ with the consultation, and support for GP commissioning consortia, is consistent with its Look After Our NHS campaign.
Points three and four of that campaign state ‘The BMA calls for an NHS which significantly reduces commercial involvement in the NHS’, and ‘uses public money for quality healthcare, not profits for shareholders’.
They even have the cheek to say they are ‘not deserting’ this campaign. They must think we are mad or have very short memories.
The new legislation builds on many of the privatisation reforms of the last government and promotes them; PFI hospitals, Foundation Trust businesses, the outsourcing of community care in Transforming Community Services (TCS), the commodification of care through PbR, the extension of the market to a true market.
The government has chosen to end the purchaser- provider split for primary care, (as is the case in the US where the Health Maintenance Organisations owned by health insurance corporations commission and provide care).
This is not because the government loves integration, but because it recognises that primary care is the gatekeeper to secondary care and it is determined to REDUCE SECONDARY CARE ON A MASSIVE SCALE. Commissioners given rationed budgets will have to close hospitals as never before. The GPs in name and the private commissioners in practise, will be closing the hospitals.
Every one of the WP proposals leads to the commercialisation and marketisation of healthcare in England combined with massive cuts.
To argue, as the BMA letter does, that ‘critical engagement’ in these consultations will help ‘defend the founding principle of the NHS and the principles underlining our campaign’ is cynical in the extreme and designed to confuse the gullible or ignorant.
6. Refusal to call a Special Representative Meeting
The letter asks members to put forward their views on the White Paper via BMA News or the weekly newsletter. It promises to seek ‘more structured assessments of members’ opinions through various avenues’ and, meanwhile, to email the special WP pages on: .
The one thing the leadership is not allowing is the right of its membership to discuss and vote on the WP. It is not recalling its representative conference.
The BMA should be calling a special representative meeting of its membership as there was no chance to discuss the WP proposals at the Annual Representative Meeting in June.