THE BMA is now opposed to the whole of the Health and Social Care Bill and is due to launch a public campaign to demand its withdrawal.
The BMA stated yesterday that ‘Doctors right across the medical workforce have been very concerned about major aspects of the Government’s reform agenda for the NHS in England, particularly since publication of the Health and Social Care Bill in January 2011.
‘Following a special meeting of its representative body in March 2011, the BMA took the position that the Bill should be withdrawn or, at the very least, significantly amended, believing that improvements could be made without recourse to primary legislation and wholesale structural change.
‘The BMA continued to engage fully with the Government and others – most notably, the Future Forum – to try to achieve changes to what we believed were the most damaging aspects of the Bill. The BMA sought to ensure that the potentially positive aspects – for example, greater clinical involvement in planning healthcare – could be achieved in the most effective and least disruptive way.
‘The Government has responded with a number of significant amendments to the Bill, such as securing the involvement of other clinicians in commissioning groups, better accountability and transparency of commissioning groups and amending the role of Monitor.
‘However, major areas have either not been addressed at all or have not been adequately answered, including, amongst others:
• a continuing over-reliance on market forces to shape care
• concerns about the future delivery of public health and medical education
• the current plans for use of commissioning incentives (the ‘quality premium’)
• the abolition of the private patient income cap.
‘Doctors’ concerns about the reforms have also continued to grow rather than diminish because of what is actually already happening on the ground. There is a genuine and widespread perception that the positive vision of clinician-led, patient-focused, locally sensitive and accountable commissioning is being lost in the huge amount of often chaotic change taking place right now.
‘On top of this, vast amounts of guidance on how the system will work in detail are being rapidly developed which appear to be constraining clinician-led commissioning within a bureaucratic straightjacket.
‘A recent example is new draft rules on how clinicalcommissioning groups will be able to access commissioning support, which could leave clinical commissioning groups (CCGs) with no choice but to use large, commercial, organisations.
‘In response to this growing sense of unease, BMA Council took the decision at its meeting on 24 November 2011 to move to a position of opposing the whole Health and Social Care Bill.
‘This means the BMA now has a single objective in relation to the Bill – which is for it to be abandoned.’
‘This briefing sets out why doctors have hardened their position on the Bill in the context of the wider NHS reform agenda.’
British Medical Association – Health and Social Care Bill Briefing, December 2011
The NHS reform agenda
‘The BMA strongly believes that NHS reform must flow from a clear vision of what it is intended to achieve.
Access to all for high quality, cost-effective care demands a focus on the values of co-operation, sustainability, evidence-based improvement and equity.
Reform should not risk fragmenting services for patients, destabilising the health service or alienating large sections of dedicated NHS staff.
The process of reform should be evolutionary, not one of damaging and disruptive revolutionary change.
There are a number of problems with the current approach:
Speed of change and implementation
The timetable for reform has been over-ambitious. The result is that major changes are taking place on the ground before the Bill has completed its passage through Parliament.
Assumptions are having to be made about the eventual shape of the health service. Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs) are to be abolished and, in advance of this, PCTs have been formed into clusters and SHAs have done the same. Inevitably, this has led to serious concerns about service stability.
Clinicians have repeatedly raised concerns about the chaos they are already seeing on the ground as more and more change takes place.
We are aware of reports that CCGs are being told that they are too small and must merge to form larger ones to be viable.
The initial message of allowing groups to develop around like-minded practices has been replaced in the authorisation process to one that is linked to groups based on geography.
However, even at this stage, a specific size for CCGs has not been made clear and yet it is implicit in the ‘readyreckoner’ that has been issued by the Department of Health, which made it clear smaller groups would be not be viable.
Groups have already been formed but are increasingly being re-formed with time, energy, money and commitment wasted because of lack of a clear plan from the beginning and not allowing natural development over a longer period.
There is real uncertainty about how primary care will be managed. PCT clusters were created in haste and even now, many wonder whether they will have to merge again to form evenlarger clusters in some areas of the country. It is not certain whether these clusters will transfer to the outposts of the NHS Commissioning Board, to commissioning support groups or possibly CCGs, or whether staff working in these clusters will lose their jobs altogether.
Similarly, there remains a lack of clarity around how and where the many statutory functions and responsibilities of SHAs will be undertaken after they are abolished.
The Government is attempting to create a legislative framework for its NHS reforms whilst pursuing other policies in parallel that are separate from the Bill. This has led to a lack of coherence and has introduced complexities on a number of levels.
There is a continuing lack of a clearly articulated vision and little in the way of tested and coordinated plans for implementation. Instead, there are a number of apparently uncoordinated initiatives, related but not properly linked. For example, the Bill sets out new responsibilities for Monitor, the NHS Commissioning Board and CCGs in relation to promoting and managingpatient choice while a major roll out of the ‘Any Qualified Provider’ policy is already underway without any need for legislation.
Furthermore, the Government’s stated aim of reducing unnecessary bureaucracy is looking increasingly meaningless as new bodies and structures are created with increasingly complex interrelationships. Much of the detail is being left to secondary legislation and guidance which has also meant that the overall picture remains vague and incomplete.
Knock-on effects
Despite the Government’s efforts to clarify its intent on several aspects of the Bill, there are still unanswered questions in many crucial areas such as practical implementation and how individual components within the reforms will work together.
The consequences of change have not been properly thought through in a number of areas. Radical reforms to overhaul the arrangements for public health delivery and the provision of education and training for clinicians are being pursued alongside the Bill. However, much greater thought still needs to be given to how the knock-on effects from the structural changes in the Bill will impact on these other reforms.
Most importantly, an increasingly massive amount of management and clinical time is being taken up with the process of reform, diverting attention from the pressing financial challenges facing the health service.
Mismatch of rhetoric and reality
There has appeared to be a divergence between the Government’s overall stated direction of travel and what has transpired in reality. For example, a key component of the Government’s NHS reforms is to entrust GPs and other healthcare professionals to lead on the commissioning of services for patients to ensure local health needs are met.
However, the powers of the NHS Commissioning Board over CCGs as outlined in the Bill appear overly restrictive and seem to undermine their autonomy.
There are significant concerns that CCGs will not have genuine freedom and sufficient independence to make locally sensitive, locally accountable, patient-focused decisions.
Conclusion
The scope of the Bill is wide-ranging and extremely complex but many of the improvements to the NHS that the Government says it wants – for example, shifting decision-making powers to clinicians and streamlining patient pathways – do not require legislation, and can be achieved without wholesale structural change.
The reform package as a whole must be rethought. It is not too late to think again. The Government’s reform approach is adversely affecting the ability of the health service to deal with the real priority of improving quality in the face of a massive financial challenge. This, rather than unnecessary and unwelcome restructuring, should be the priority.
The BMA believes that the focus on the changes already flowing from the reforms is creating a noticeable distraction from efforts to ensure and improve the quality of patient care.
Continuing with these radical reforms, especially in a period of huge financial constraint, is an enormous risk.’