| BMA's challenge to all parties |
| (1) To
promote the health of the nation through action
involving all relevant government departments, local government, health
authorities, and voluntary organisations
(2) To support
doctors and other health professionals in
articulating targets and taking action, for example:
To
help people disadvantaged by physical, mental, or social
problems
To reduce the level of health and environmental hazards of tobacco
To deal with problems affecting the health of young people
To influence the development of environmental, housing, and
transport
policies
(3) To allocate resources on the basis of assessed
need and
the quality of the outcome of care to ensure equity of access and
treatment for all patients
(4) To enunciate a clear evidence
based strategy for the
balanced development of primary and secondary health care, together
with community care
(5) To recognise the need for coherent and
consistent policies
on the development, welfare, and use of the skills of staff in the
service
(6) To fund the NHS unambiguously and explicity from
public
funds with due allowance for service inflation and no assumption of
efficiency savings. |
The contemporary scene is mixed. Progress has been made in raising
immunisation rates, screening for cancer of the breast and uterus,
reducing fatalities from road accidents, and containing the epidemic of
HIV and AIDS. But young people-girls in particular-are smoking more
than ever, suicide rates in young men are a major concern, and obesity
is a growing problem. A more encouraging feature is the commitment by
the government(2) and political parties in general
to the
principles of equity, relevance, and quality in health care. The
development of primary health care is currently the subject of
legislation and must be matched by a coherent strategy for the hospital
service and community care.
Thirdly, I urged the importance of assessing needs rather than
demands,
and outcomes rather than outputs. There was nothing new in this. A
government working paper envisaged "a gradual introduction of a
population approach to health needs assessment." (3)
Sadly, commissioning of care continues to be based largely on
secondhand information of limited relevance to local needs. While the
efficiency index has proved to be flawed, progress has been made in
devising mechanisms to evaluate the outcomes of care, and medical audit
is established, although its potential remains to be exploited. The
imperative of evidence based medicine is now holy writ, 25 years after
Archie Cochrane's assertion that "there is a whole rational health
service to gain." (4) The position of public
health
physicians, who are the key to this work, is critical and in many
places parlous. With few exceptions, they remain trapped within the
purchasing process, unable to fulfil their crucial functions fully.
My fourth point concerned the need for society to determine its
priorities and allocate resources accordingly. Debate about priorities
continues, with tortured issues of rationing generating fitful heat and
little light.
Fifthly, I called for the reform of purchasing to include locality
planning and rolling contracts based on quality, safety, and choice
with a commitment to education, training, and research. Locality
planning is winning support-although it is bedevilled by uncertainty
about the future of fundholding; and the need for longer term contracts
is generally acknowledged. An imaginative research and development
strategy is in place, and the role of postgraduate medical deans has
been enhanced.
The sixth point concerned the corresponding need to reform the
provider
side of the purchaser-provider split. Trusts have been forced to
compete for survival by offering every major service, thereby
duplicating specialist services for a defined population. Indeed, they
were enjoined not to "collude." Sensible rationalisation is
now
beginning to happen, though the public remains to be educated. Local
pay determination has been discredited by its disastrous imposition on
nurses. The medical input to management through clinical and medical
directors has fostered a palpable improvement in relations between
medical and other managers.
My seventh point was a call for purchasers and providers to join
forces
in strategic planning. This is an aspiration whose time has come, and
both authorities and trusts are now beginning to talk of joint
planning.
Given some progress so far, the BMA's new six point challenge
emphasises where we need still more effort. We have thrown down the
gauntlet. Who will pick it up?
A W Macara
Chairman,
BMA Council
BMA,
London WC1H
References
1 British Medical Association. Core values for
the
medical profession in the 21st century: report of a conference held on
3-4 November 1994. London: BMA, 1995.
2 Secretary of State for Health. The National
Health
Service: a service with ambitions. London: Stationery Office,
1996. (Cm 3425.)
3 Department of Health. Working for patients:
developing districts. London: HMSO, 1990:13.
4 Cochrane AL. Effectiveness and efficiency:
random
reflections on health services. London: Nuffield Provincial
Hospitals Trust, 1971:85.
