Views And Reviews

BMA wants to reform the reforms

BMJ 1994; 308 doi: (Published 02 April 1994) Cite this as: BMJ 1994;308:922
  1. L Beecham

    “We need to reform the reforms,” the chairman of the BMA council, Dr Sandy Macara, told a press conference last week to mark the third anniversary of the NHS reforms. The association had predicted that there would be a lack of direction about the introduction of the internal market and took no pleasure in saying “we told you so.” There had to be a return to equity in the provision of health care with decisions being made on clinical grounds, Dr Macara said. The internal market would not go away and doctors had to make it work in the best interest of patients. The association is calling for a period of tranquility and for the government to listen to the people working in the service.

    Mr John Chawner, chairman of the Central Consultants and Specialists Committee, doubted whether patients were better off. Every day there were new examples of fast tracking for patients of fundholding general practitioners and waiting lists were going up for people with serious illnesses. “It is obvious to everyone except ministers that there is huge dissatisfaction in the health service,” Mr Chawner said. Managers were interfering in clinical decisions and many senior staff were frightened to speak out on behalf of patients. He believed that the reforms had destroyed the brotherhood in the service and reported that there was a motion at the annual conference of senior hospital staffs in June calling for consultants to resign from the NHS and sell their services back to hospitals. A similar proposal last year was defeated but Mr Chawner said that the CCSC would be examining possible schemes.

    General practitioners have also had to grapple with a new contract, which was introduced in 1990. Many general practitioners were snowed under with bureaucracy, according to Dr Ian Bogle, who chairs the General Medical Services Committee. Their workload had increased and morale was low. The contract had “destabilised British general practice.” The internal market had not been thought through and district health authorities were not ready for their purchasing role on behalf of non-fundholding doctors. The way forward was for locality purchasing schemes with advice coming from providers.

    GPs support voluntary generic prescribing

    Representatives of Britain's general practitioners support the idea of pharmacists substituting a generic drug for a branded product when a prescription is dispensed, provided that the doctor has not indicated otherwise on the prescription form.

    The decision, which the General Medical Services Committee took last month, reverses the committee's previous policy that doctors should tick a box on the form if they did not object to a generic drug being dispensed. The 1982 Greenfield report recommended that doctors should tick a box if they did not wish the pharmacist to dispense a generic drug.

    There will now be discussions between the profession's representatives and the Department of Health on how doctors could indicate on the FP10 form that they wanted a proprietary brand to be dispensed. The form may have to be redesigned.

    Originally opposed to generic prescribing, Dr Jane Richards, who chairs the GMSC's prescribing subcommittee, said that nearly half of all prescriptions were not written generically. There was a danger that manufacturers of proprietary brands might invest less money in research and development in future, but Dr Richards believed that doctors had to make substitution work.

    “No change is not an option,” according to Dr Ken Harden. Automatic generic prescribing would lead to large savings and would reduce the need for the government to extend the limited list of drugs that could be prescribed on the NHS. In a paper he presented to the committee Dr Harden said that it had been estimated that the potential savings in England by generic substitution of an identical dose and form of preparation in prescribing costs between 1992 and 1993 would be pounds sterling 76.5m if the top 30 drugs were prescribed generically. Most generic products were products were produced by four well established drug firms and generic products were subject to just as rigorous quality checking as were branded products. If doctors could still choose to prescribe a proprietary brand their clinical freedom would not be affected.

    Speaking against the proposal Dr Richard Tiner suggested that there was sufficient pressure towards voluntary generic prescribing without the committee changing its policy. Target drug budgets and incentive schemes encouraged a wide use of generic prescribing. Dr Tiner thought that bioavailability and product liability were potential problems.

    Consultants call Labour's health plan “bland”

    Senior hospital doctors say that they are disappointed with the Labour party's consultation document Health 2000. The health and wealth of the nation in the 21st century (19 February, p 492). Speakers at the last meeting of the Central Consultants and Specialists Committee called the paper “bland.” But they emphasised the importance of a dialogue to try to influence the final document, and the chairman of the CCSC, Mr John Chawner, and other representatives are meeting the Labour party's health spokes people regularly.

    “The document is superficial and vague and deals only with reversing what the Tories have done,” Miss Connie Fozzard, a consultant obstetrician in Truro, told the meeting. The document put a lot of trust in preventive measures to save money. Yet some screening programmes, for instance, had not been proved to be cost effective.

    Referring to the statement that the Labour party was examining ways “to facilitate the transfer of suitably experienced clinicians into full consultant status,” Dr William Ryder, consultant anaesthetist in Newcastle upon Tyne, feared that this heralded a subconsultant grade.

    The Labour party wants to ensure that the true cost of private practice is identified and reimbursed to the NHS. This would include the cost to the NHS of training staff who then use their skills in the private sector. Dr Michael Goodman, consultant in general medicine in Manchester, suggested that the BMA's health policy and economic research unit should examine this aspect.

    Mr Bill Heald, a consultant surgeon in Basingstoke, pointed out that if the Labour party was proposing to eliminate many of the aspects of the NHS reforms which the profession had been asking for, doctors should be supporting the consultation document rather than criticising it. He hoped that the profession would clarify its thoughts before the next general election.

    Partial shifts for junior doctors are the way forward

    The Junior Doctors Committee's survey on hours of work showed that despite the publicity and encouragement for moving to a shift system 76% of respondents worked on call rotas. About 11% said that they worked a full shift system, although nearly 75% of doctors who worked in accident and emergency departments said that they worked this pattern. Nearly 5% of respondents said that they worked a partial shift and nearly 4% a combination of a full and partial shift.

    The JDC believes that many doctors still do not understand the advantages of a shift system, and a paper prepared by Dr Alex Freeman, a senior house officer in Southampton and a member of the executive committee, was approved and will be circulated to regional task forces and local implementation groups. She concludes that partial shifts are the way forward for doctors in the onerous specialties but they require communication and commitment and flexibility from all affected staff.

    The terms of service say that a partial shift is appropriate where there is a significant routine workload during the day and where doctors working a standard working week are required to work for a substantial proportion of their contracted additional duty hours.

    In her paper Dr Freeman says that a good rota is better than a partial shift and that shifts will be unworkable if they do not have the consultants' support. She counters some of the misconceptions about partial shifts. They do not always involve a week of nights; they do not mean doing more nights on call; and they do not ruin weekends off. Protected handover periods can improve continuity of care, and if supervised the handover periods provide educational opportunities.

    It is not true, Dr Freeman says, that partial shifts are suitable only for doctors in the training grades. Consultants and other career grade staff can take part - for example, in intensive care units and labour wards. Partial shifts do not mean less hands on experience.

    Partial shifts do not mean fewer hours and less pay. Partial shift additional duty hours are paid at 70% of standard rate and junior doctors moving from on call rotas will not lose financially.

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