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The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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BMA positioning and NHS reform

Filed Under (BMA, GP Commissioning, Health Policy, Reform of the NHS, White Paper) by Paul on 29-09-2010

One of the oddest experiences for any Secretary of State for Health is the reception that they get from the BMA. Of course you’d expect the BMA to protect its member’s interests by negotiating hard for terms and conditions. That is after all what all trades unions are meant to do. But the much odder experience for a Secretary of State is how the BMA starts to act when you develop a policy which their members have asked for.

The current Secretary of State is experiencing this at the moment – and will for quite a while longer. After all he has quite a lot of evidence from his pre-election discussions with GPs that they would quite like to have more power over commissioning and in particular they would like to be out from under the PCTs.

So come the White Paper and the gift to GPs of £60-70 billion of NHS commissioning money, he had expected some resistance from “NHS bosses” to their abolition, but had expected some enthusiasm from the medical profession. Whilst he may have thought that renaming of BMA HQ to “Liberator Lansley House” might be a step too far, he would have least expected happy smiling faces when he next met the BMA.

But he has not been paying attention to how the BMA carries out its negotiation. It thinks that it has a monopoly position over what doctors will and will not do and therefore treats the introduction of any new policy that involves doctors as a major opportunity for demanding more money. The publication of a Government White Paper is an opportunity for the BMA to model itself on the plumber or the car mechanic. Once the white paper is published, the experience is a lot like lifting the bonnet on the car engine or opening up the airing cupboard for a look at the boiler. The immediate response to whatever is in the White Paper (under the bonnet, in the airing cupboard) is a very audible and sharp intake of breath followed by the comment, “If that’s what you want to do, it ‘s going to be expensive”

As I say that can be puzzling when the policy is something that the profession has been asking for. But this is more than just a momentary misunderstanding. It is a whole negotiating ploy. The BMA knows that, for every GP that has over the summer ethusiastically welcomed the policy of GP commissioning its bargaining power is diminished. For every report the Secretary of State gets that GPs are “between anxious and terrified” (I believe is the line) the better the BMA’s bargaining position is. That is why the BMA publications are all desperately trying to deaden any enthusiasm from their members.

So the BMA stance about the whole policy is an important bargaining ploy.

But of course their attempts to get their members into a long-term bargaining position go much further than this. Whilst their GP members may have told the current Secretary of State that they longed to be rid of PCTs, the BMA is recommending that GP Commissioning Consortia, when they look to take on staff with managerial and commissioning skills, only employ PCT staff who have worked for PCTs. Given so many doctors’ relationship to the private sector, this is puzzling unless you understand the long term aims of the BMA They want to ensure that there are no new private sector health organisations in the UK. Because the moment that happens they lose their monopoly position.

The best example of this was their reaction to the policy of Independent Sector Treatment Centres from 2002 onwards. In order to raise the price of the policy they said that of course extra work would need extra pay and in any case there weren’t enough doctors to work in these new private sector organisations. So the Government introduced the additionality rule which said that the new private sector health care providers would have to bring their own doctors and staff with them.

This broke the BMA monopoly and changed the its overall bargaining position. It is not a change that the BMA enjoyed. So they are now against the introduction of new private sector organisations because they will change the terms of trade of their overall position. That’s why they have ended up being more anti private sector than any of the Labour Party leadership candidates.

A further odd thing that has happened is the population size that they are recommending for GP commissioning consortia – 500,000. I am sure that there will be some consortia of that size but saying that is the right size for GP organisations runs completely counter to their argument about size of GP practices. In 2008 they ran a campaign against polyclinics – that had an optimum population size of 50,000 – because they were too big!

Those of us advocating polyclinics were accused of herding GPs into them away from their nice small business that are the cornerstone of GP relationships with their patients.

Commissioning now needs herds that are 10 times bigger than ones that were previously much too big.

The last political point concerns their comments about using commissioning to improve value for money. They believe it would be wrong to use GP commissioning to save money because it would undermine the BMA’s overall position of needing more money for the NHS. This puts them in the lonely political position of saying that value for money cannot be improved. This argument – that any improvement in value for money undermines the overall position that we need more money – is the classic ultra left position. This leads them to having a go at those of their members who successfully improve value for money for their patients, because they are undermining the unions overall position of needing more money.

If any other trades union were to operate this way, sections of the media would uncover this use of politics to protect their member’s interests and attack them.

Let’s see what happens


4 Responses to “BMA positioning and NHS reform”

  1. An insightful piece. Enoch Powell said something very similar 45 years ago.

    The BMA has always got a much better press than it deserves because the media are confused about whether it’s a trade union or not and because the BMA is very helpful to the media–no other health organisation will explain meningitis at 3 am and give you a quote on anything vaguely health related. And every year at the BMA’s annual meeting there’s a splendid piss up for all journalists.

  2. […] It’s gonna cost yer, guv! Posted on 29 September, 2010 by Rick An excellent piece from Paul Corrigan on the imminent showdown between the health secretary and Britain’s most powerful trade […]

  3. Paul,
    There is a massive lack of trust between the medical profession and the political class. This is hugely damaging for the NHS and ultimately patient care. Thatcher’s market based reforms brought to an end the corporatist approach to policy making, which Rudolph Klein described as the “end of the double bed”. The relationship has never recovered.
    Judging by your misinformed comments about the BMA and the fact you were health policy advisor to Blair, it is of no surprise that things didn’t improve under New Labour. It is a tragic that the huge sums of money New Labour injected in the NHS have been wasted (despite some significant improvements). Your obsession with market based neoliberal policies, despite all the evidence about market failure in healthcare, has caused an even greater rift with the profession and paved the way for the Coalition to push through even more pro-market policies. These changes signal an end to the founding principles of the NHS.

    Anyway, let’s get to the facts and dissect your article:
    1. “But the much odder experience for a Secretary of State is how the BMA starts to act when you develop a policy which their members have asked for”.
    This statement is false. Successive BMA ARM meetings have called for an end to market based healthcare and abolition of the PP split. In fact the Look After Our NHS Campaign is an anti-market campaign. The White Paper is a blueprint for building on the market-based healthcare system that you helped to design
    2. In terms of demanding more money, the BMA has already accepted pay restraints and understands the current problems associated with the global financial crisis (caused by neoliberal Anglo-American economic policy, which New Labour supported).
    3. GPs also don’t want to risk being left with financial deficits that they may be liable to. This not only includes financial risk, but also reputational risk caused by rationing of care
    4. The reason why the BMA doesn’t want new providers is because this is a classic example of market failure in healthcare. Excess capacity in a single payer system is a nonsense. The start up costs of new healthcare providers are prohibitive – hence the need for the famously generous ISTC contracts. This led to huge waste.
    5. The additionality rule was relaxed because they couldn’t attract enough overseas doctors, and the ones they did attract were either poor quality or struggled with the different systems and equipment in the UK. New providers are now able to poach NHS staff form NHS hospitals. This is bad news when we are trying to deliver a universal service.
    6. GPs and Consultants want to work collaboratively, which means building local services through co-operation, not competition. This is why most doctors are ideologically opposed to a market within an NHS single payer system.
    7. The GPC has suggested a Consortia size of 500,000 because this would allow economies of scale and allow pooling of risk when purchasing costly healthcare treatments
    8. Polyclinics are a completely different kettle of fish. They were opposed because they were excess to requirements in most places (remember that every PCT was told they should build one, whether it was needed or not!). Some current polyclinics still have tiny list sizes because the pre-existing GP practices are delivering such a good local service. They are too big to provide the personal care that local people need. However, they may be more appropriate to develop in larger cities. It was the heavy handed one size fits all approach that offended so many doctors.
    9. When it comes to value for money, you have no clue how to measure it. The same goes for productivity.

    Paul, it’s about you understood the difference between a separate private sector system outside of the single payer NHS system (which doctors can practice in addition to their NHS work) and a market system using the private sector within a single payer healthcare system (which is what you dreamt up and what we have now). The first system allows doctors to take the pressure of the NHS system by treating PPs outside of the NHS. The second system is a disastrous waste of money because patients are encouraged to consume healthcare within a limited budget system (i.e single payer), which requires excess capacity though a plurality of providers, a PbR payment system, national IT to supply information to consumers, complex and multiple contractual processes between PCTs and FTs, and New Public Management to run it. Only a policy wonk could dream up such a ridiculous system. Worse still, a Labour wonk promoting neoliberal policies.

    If we really want an efficient NHS, we need to abolish the market and the claptrap mathematically based ideas of Public Choice Theory (which reject the public service ethios) and return to the trust model of delivering healthcare ie listen to the professions. In turn the professions must be held accountable and we must never see a return of the disgraceful waiting lists of the past. This can be done through external peer review. This has worked really well in Cancer Services.

    Kind Regards,

    Dr Clive Peedell
    Consultant Clinical Oncologist
    James Cook University Hospital

    BMA Council
    BMA Political Board

    I do a clinic in Bishop Auckland. Would love to meet up with you or your wife for a discussion on how to heal the wounds between the medical profession and the political class.

  4. Maybe part of the BMAs lack of enthusiasm towards the White Paper is partly related to the possibility of the current ConLib coalition collapsing before any policy change can be implemented?

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