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TheBMA on TwitterThis film explores doctors’ concerns about how competition and market forces could threaten the delivery of integrated healthcare, particularly for services that are provided to vulnerable patients or those with rare diseases.
If you share some of the concerns raised in this film, leave a comment below.
You can find out more about our NHS Reform Stories project here.
The government is proposing massive changes to the way public health medicine is organised in England. This film highlights the concerns of a public health trainee.
If you are worried about the future of public health medicine leave a comment below.
You can find out more about our NHS Reform Stories project here.
Many doctors are worried about the impact that health reforms will have on the quality of medical education and training. This film explores some of these concerns.
If you are worried about the impact of the health reforms on education and training leave a comment below.
You can find out more about our NHS Reform Stories project here.
Last week, Professor Malcolm Grant was appointed as the chair of the NHS Commissioning Board. His role will be to take forward the plans to create the Board and provide strategic leadership and vision for NHS commissioning. Following his appointment, he described the Health and Social Care Bill as, “completely unintelligible.”
To anyone that has tried to make sense of the Bill and the battery of amendments that have followed its publication, it is easy to sympathise with Professor Grant. But sometimes you get a better understanding of things by taking a look at the bigger picture. Going through the submissions to the BMA’s NHS Reform Stories project, for example, has highlighted many of the flaws in the legislation.
Integration was a major concern for many. A sexual health consultant was worried that the focus on competition and complexity of commissioning arrangements will lead to fragmented, poorer quality sexual health services in his area. His frustrations were shared by many others who felt their efforts to improve services could be jeopardised by the reforms.
Doctors who work with vulnerable patients were also concerned about the impact of the reforms. A number of psychiatrists told us their fears that the emergence of new providers could fragment services and disrupt the continuity of care that is so important in dealing with patients with mental health problems.
There were also many who had worries about the future of medical education and training. These ranged from concerns that the restructuring would disrupt their training to those who thought that cash strapped NHS trusts should not be given responsibility for training.
There was also a email from a public health doctor who felt that the confusion surrounding the reforms had meant that there were no jobs for new CCT holders. This is a shocking waste of talent, taxpayer’s money and it raises questions about what will happen to our public health services in the future if they are not properly staffed.
Many would agree with Professor Grant assessment that the Health and Social Care Bill is unintelligible. But it is clear, to those that work in the NHS at least, that the current reforms present clear threats to patients and the future of our health service.
Integrated care is something of a holy grail for the NHS. It breaks down the barriers between GP surgeries and hospitals to ensure patients are seen by the best type of clinician at the best time in the best place. It also has the potential to save money by increasing efficiency – an attractive proposition in the current economic climate.
Take diabetes care, for example. When not managed properly it can lead to heart disease, eye problems, kidney disease and even amputation. A project in Manchester has shown how complications can be reduced by bringing secondary care expertise into the community. By giving nurses immediate access to consultants through virtual clinics, and introducing structured patient education programmes, they have shown it possible to reduce the risk of complications and save the NHS money.
There are two main elements of the reforms that make the delivery of integrated care more difficult. The first is the emphasis on strengthening ‘market forces’ to shape health services. Even without the Health and Social Care Bill, the Government’s new policy of ‘any qualified provider’ will encourage the involvement of a much wider number of health care providers, including private sector organisations, creating competition with existing NHS providers for specific services within care pathways. Increased competition for these service areas could easily lead to cherry picking of the easiest and most lucrative contracts, leaving it to the NHS to pick up the more complex service areas, as well as making it harder for providers to co-operate and collaborate across the whole pathway for the benefit of patients.
The second problem with the reforms is their complexity. They were launched on a promise to reduce bureaucracy but now look ridiculously complicated. Integration of healthcare depends on getting all the different parts of the NHS working together. If this was difficult in a world of strategic health authorities and primary care trusts, how much more difficult will it become with an NHS Commissioning Board, clinical senates, clinical networks, Public Health England, Healthwatch England, Health Education England, citizens’ panels, local education and training boards, health and wellbeing boards and clinical commissioning groups?
The Government made a significant concession on the issue of integration in response to the BMA’s lobbying – changing the primary role of Monitor from promoting competition to requiring the regulator to support the delivery of integrated care. But, of course, this isn’t always going to sit easily with other requirements on commissioners, for example to extend patient choice of provider across a much greater range of services. Whatever happens on the Bill, clinicians must take the opportunity to make sure that better integration of care does become the primary driver for change in local health economies, not the enforcement of an ideological obsession with increasing competition.
As the Health and Social Care Bill moves into the House of Lords, the debates will continue. We have little time left for persuasion. If we are going to win the integration debate, we must illustrate our arguments with examples about how patients will be affected by the reforms. If you are working on a project involving integrated care that you think will be jeopardised by the reforms, email us at nhsreformstories@bma.org.uk or leave a comment below.
The latest figures on waiting times make for grim reading. The number of people forced to wait six months for treatment has leapt by 61% in a year. This will not come as a surprise to anyone working in the NHS. The pressure to save money is all pervasive and putting off today what you can do tomorrow is an easy way of saving money (in the short term at least).
But it is not only the financial squeeze that threatens to increase waiting times – the Health and Social Care Bill also has the potential to make patients wait longer. Clause 168, which proposes the removal of the limit on the amount of income a hospital can make from private patients, remains. This clause could lead to a fundamental change in the character of Foundation Trusts from NHS organisations that provide some private healthcare into NHS branded providers that prioritise profitable private patients at the expense of NHS patients.
The cap on the income generated from private patients was introduced at the inception of Foundation Trusts to ensure they focus on NHS work. It varies from trust to trust with the amount of money that can be earned from private patients pegged to the proportion of private patient income earned by Foundation Trusts in 2002-03.
The current situation where some Foundation Trusts, like the Royal Marsden, are allowed to generate almost a third of their income from private patients whilst others are not allowed to make any money is based on an incoherent policy and is not acceptable to many health workers or patients. The cap should remain but be consistently applied across all trusts. Doctors remain concerned that any Foundation Trust in difficulty will be tempted to get its limit (cash or numbers treated) to rise and this will distort priorities. Trusts should also have to make concrete assurances that NHS services will not suffer, whatever the level of the cap.
There is clear evidence that when waiting times go up more people seek private healthcare. The combination of increased waiting times and Foundation Trust being given free rein to profit from private patients is a toxic combination that could lead to a two-tier health service where those who can afford to pay are treated promptly, whilst everyone else is made to play the waiting game.
Closing failing hospitals is never popular, especially around the time of an election, just ask David Lock the Labour MP who in 2001 was unseated by Dr Richard Taylor’s single-issue stance to protect Kidderminster Hospital.
For all the tentative talk about NHS service reconfiguration, governments tend to back down in the face of public opposition – which means a threat to local MPs. Historically, failing NHS services tend to be propped up by hidden bailouts. How can the NHS achieve the efficiency savings asked of it whilst some services are soaking up resources in this way? What if it might actually be “the right thing” to let these facilities go?
The Health and Social Care Bill ‘solution’ was to do away with the financial protection offered to trusts. The basic plan was to create a level playing field with the private sector, so that insolvency rules would apply to hospitals in a way that could have seen hospitals going into administration and ultimately being wound up to meet the demands of creditors (which would presumably include NHS staff).
There was a caveat – some designated services could be protected from insolvency by a special administration regime, the idea being that some services could not be allowed to fail because of the impact it would have on patients. What does that mean? All NHS services are vital to someone somewhere.
Understandably the BMA had huge concerns about the lack of support for healthcare providers that found themselves in financial difficulties. There are after all many reasons that hospitals can find themselves with financial problems such as historic debt (often linked to expensive PFI deals), patient choice fluctuations, changes to tariffs, and competition from private providers able to cherry pick the most lucrative contracts.
Following the listening exercise, the government has reconsidered its position. It has recognised the problems of the past and said, publicly, that they would look again at failure regime and introduce new amendments.
Perhaps it is not surprising that there has been a change in direction on failure regimes given the fate of David Lock back in 2001. But the government will need to get to grips with the F word. We await the final details of the government’s revised plans for failing NHS services. Let’s hope they have learned that letting hospitals go bust is no way to run a comprehensive National Health Service.
Following the high drama of the listening exercise and the government’s acceptance that its original proposals to reform the NHS were flawed, the media has moved on to other things like the phone hacking scandal and the financial woes of the Eurozone. You could be forgiven for thinking that the Health and Social Care Bill has gone away. Sadly, this is not the case.
During July, the Health and Social Care Bill returned to be discussed in the Public Bill Committee. Some of the issues raised by the BMA and others have been addressed. But the amendments have not produced a positive consensus, with Unison recently describing the amended Bill as Frankenstein’s bill and others, including the RCN and the RCGP, still unhappy with aspects of the reforms.
Whilst pressure from organisations like the BMA has forced the changes, for example, the removal of the primary role of Monitor to promote competition and the over ambitious deadline to convert all NHS Trusts into Foundation trusts, the Bill is still unclear on serious issues such as what will happen when health care providers fail. Concerns also remain about the introduction of a quality premium which could threaten the doctor-patient relationship. And now there are new issues becoming clear as the new Bill is scrutinised in detail.
At the BMA’s recent Annual Representative Meeting doctors voted to continue to push for the Bill to be withdrawn. The conference stopped short of opposing the Bill outright, adopting the more pragmatic approach of continuing to engage with the government to get further improvements. This was endorsed at a meeting of BMA Council last week.
BMA Council also passed a motion calling for a public campaign to get the Bill to be withdrawn. So the battle to protect the NHS from poorly thought-out legislation continues. The BMA will also be producing an updated briefing shortly setting out further changes that it believes are needed on the Bill if it is to be kept. Let us know what you think by leaving a comment on the blog or by emailing info.healthbill@bma.org.uk
In the aftermath of the waves of coverage, comment and commotion that followed the end of the listening exercise on NHS reform and the government’s swift response, there was one piece of good news that went somewhat unnoticed; a positive, if tentative step forward in the field of medical research.
The original draft of the Health and Social Care Bill had a worrying gap when it came to this area, with little mention or reference to the impact of the reforms on a sector that produces an array of positive contributions to our society. Patients obviously benefit, daily in some cases, from the medical innovations that are produced from the labours of clinical academics and their consultant colleagues in the NHS. Just as importantly are the financial dividends that new research delivers to the UK economy and the Treasury – which runs into billions each year.
The Bill’s original cold shoulder to research was frankly unacceptable to the BMA’s Medical Academic Staff Committee (MASC), who began pressing for a response from the off. This we got last week – to an extent. The government now explicitly recognises the importance of a continued major role for research, and, more importantly, obliges clinical commissioning groups and the NHS Commissioning Board to take it into account when making their decisions.
So far, so good, but unfortunately that gap has not been completely filled. While the commissioner side have clear continuing responsibilities, it is less clear what the requirements are for providers when it comes to clinical research, especially how they are supposed to support and maintain existing research facilities.
There is also a worrying vagueness when it comes to who supports staff costs in the NHS arising from research work.
These are issues that need to be clarified as the government embarks on the redrafting of the Bill. The BMA will be keeping a very close eye on these developments, pushing ministers to make sure that we don’t end up with a solution that is well intentioned but incomplete. We will also be making it clear that it is important we retain and build on the workforce we have – as MASC Co-Chair Michael Rees told the recent COMAR conference – so that we have the right backbone with which to fulfil our national potential in the field of research.