Open letter to the BMA about the health white paperBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d7 (Published 04 January 2011) Cite this as: BMJ 2011;342:d7
- Correspondence to: C Peedell
Dear Hamish Meldrum, Laurence Buckman, and all members of the BMA General Practitioners Committee,
After the publication of the health white paper earlier this year, Hamish Meldrum wrote to the profession to explain that the BMA was going to “critically engage with the consultation process” to defend the founding principles of the National Health Service and the principles underpinning the BMA’s Look after our NHS campaign.1 2
The consultation period is now over, and it is clear from the Department of Health’s response to the consultation3 that the BMA’s policy of “critical engagement” has failed to persuade the government to alter its approach. The BMA responded with a damning press statement: “There is little evidence in this response that the government is genuinely prepared to engage with constructive criticism of its plans for the NHS. Most of the major concerns that doctors and many others have raised about the white paper seem, for the most part, to have been disregarded.”
In fact, Andrew Lansley’s plans are now even more market based. Within the new operational framework for the NHS in England,4 “price competition” will be introduced, which fundamentally changes the NHS from a “quasi-market” system of fixed prices (tariffs) to a more open market system. Hospitals will be allowed to charge rates lower than the national tariff, which sets prices for thousands of NHS procedures and covers roughly half of hospital income. According to Zack Cooper from the London School of Economics, “Every shred of evidence suggests that price competition in healthcare makes things worse, not better.”5
The NHS Confederation shares this view6: “Economic theory predicts that price competition is likely to lead to declining quality where (as in healthcare) quality is harder to observe than price. Evidence from price competition in the 1990s internal market and in cost constrained markets in the US [United States] confirms this, with falling prices and reduced quality, particularly in harder to observe measures.”
Moreover, the BMA has stated that it has “concerns over the use of ‘best practice’ or deregulated tariffs in the NHS, because this system brings with it price competition, which can risk basing decisions on price rather than on clinical need.”7
The white paper is still awaiting publication as the Health Bill, which will then need to be subjected to the legislative process before being enacted by parliament. We are therefore very concerned that the BMA and more specifically the BMA General Practitioners Committee is treating proposed policy (that is, a white paper) as if it is policy. For example, on 17 December 2010, the chairman of the General Practitioners Committee Laurence Buckman stated in a letter to all general practitioners8: “Practices should now be working with other practices to make progress in setting up their embryonic consortia and electing and appointing a transitional leadership.”
In addition, on the topic of general practice consortiums and commissioning, a recent BMA briefing paper stated6: “The pace of change in developing commissioning must allow the vanguard to develop swiftly.”
The fact that market based policies have actually been strengthened by Mr Lansley goes against BMA policy from numerous BMA annual representative meetings and the stated principles of the BMA’s Look after our NHS campaign.2 The BMA should therefore withdraw its policy of “critical engagement” with the government and engage more with its own membership. It is remarkable that despite “the most radical restructuring of the NHS since its inception,”9 BMA Council recently voted against holding a special representative meeting of the BMA to allow its membership to debate the current proposals. This is in contrast with the BMA’s stance against the other most significant NHS white paper reforms, Working for Patients in 1989, when two special representative meetings were called.
Although the BMA hasn’t formally surveyed the profession about the white paper, surveys conducted by the King’s Fund and the Royal College of General Practitioners have both highlighted the high level of concern among healthcare professionals, with fewer than one in four doctors believing that the proposed reforms will improve the quality of patient care provided by their organisation or practice.10
We believe that the BMA has no mandate from the BMA membership to continue with the “critical engagement” policy. Mr Lansley’s reform agenda has been widely criticised across the health policy and political spectrum as moving too fast, yet the current approach from the BMA could actually hasten the pace of reform because the association has effectively sent a message to the profession that the white paper is a done deal.
We have serious concerns that the proposed reforms will fundamentally undermine the founding principles of the NHS by creating a much more expensive and inequitable market based system. However, we also believe that the BMA could play a crucial role in saving the NHS from this fate, because, according to the Health Service Journal,11 “From an influence point of view the BMA is critical because it could derail the coalition’s white paper reforms, which propose a clinically led system. If the BMA were to say no, then the whole initiative could grind to a halt.”
Thus the NHS really is in your hands. We understand the pressures you are under, but it is now time to mobilise the profession and stop these damaging reforms, which will not only destroy the NHS but also profoundly affect the social fabric of our nation.
This is a great opportunity for the BMA to achieve redemption for its opposition to the inception of the NHS in 1948. We urge you to take it and will support you 100% of the way.
Cite this as: BMJ 2011;342:d7
The following 118 doctors are co-signatories to the open letter: Charlotte Abson, consultant oncologist, Maidstone; J Mark Aitken, consultant physician (retired), Leavenheath, Suffolk; Amina Aitsi-Selmi, Wellcome Trust PhD Research Fellow, London; Ian Banks, president of the European Men’s Health Forum, London; Christopher Bem, consultant surgeon (ear, nose, and throat, and neck), Bradford; Morris Bernadt, consultant psychiatrist, London; Crispin Best, Chair, BMA Scottish Local Negotiating Committee Forum; John Beynon, consultant gynaecologist, Chichester; Kambiz Boomla, chair, City and East London Local Medical Committee, London; David Bramble, consultant child and adolescent psychiatrist, Shrewsbury; David Broughton, clinical director (older people), Middlesbrough; Peter Bruggen, retired consultant psychiatrist, London; Christopher Burns Cox, consultant physician, Bristol; Nicholas Burns-Cox, consultant urologist, Taunton; Penelope Burton, general practitioner (retired), Hampshire; Ruth Caudwell, consultant community paediatrician, London; Iain Chalmers, editor, James Lind Library, Oxford; Anne Chamberlain, consultant in rehabilitation medicine (retired), Leeds; Peter Crome, consultant geriatrician, Keele; Robert Cumming, retired consultant haematologist, Glasgow; David Cundall, consultant in community paediatrics, Leeds; S Dar, specialty registrar, Essex; Jonathan Dare, emeritus consultant in child psychiatry, London; Jacky Davis, co-chair of the NHS Consultants Association and founding member of Keep Our NHS Public; Nicholas Dennis, consultant in clinical genetics, Southampton; John Dickinson, general physician (retired), Sheffield; Paola Domizio, histopathologist, London; Joanna Downton, consultant in rehabilitation medicine, Stockport; Christopher Dowrick, professor of primary medical care, Liverpool; Gary Drybala, consultant psychiatrist, Leicester; Robert Elkeles, professor of diabetic medicine and consultant physician, London; David Elliman, consultant paediatrician, London; Nina Essex, consultant physician (retired), London; Barry Fairbrother, consultant surgeon, Sutton, Ashfield; Henry Fell, consultant microbiologist (retired), Bury St Edmunds; Jacqueline Ferguson, consultant in psychotherapy, Oxford; Peter Fisher, president of the NHS Consultants Association and consultant physician (retired), Banbury; Peter Fleming, paediatrician, Bristol; Andrea Franks, consultant dermatologist, Chester; Roger Franks, consultant cardiothoracic surgeon, Liverpool; Robert Galloway, specialty registrar in emergency medicine, Tunbridge Wells; Zahid Ghufoor, general practitioner, London; John Gibbs, consultant paediatrician, Chester; Geoffrey Gill, consultant physician, Liverpool; Colin Godber, consultant in old age psychiatry (retired), Winchester; Niru Goenka, consultant physician in diabetes and endocrinology, Chester; Steve Goodacre, accident and emergency clinician, Sheffield; Paul Goulden, consultant anaesthetist, Dewsbury; Hilary Graver, general practitioner (retired), London; Richard Grunewald, consultant neurologist, Sheffield; Mary Harrington, consultant physician, Keighley; Evan Harris, former Liberal Democrat MP for Oxford West and Abingdon and Liberal Democrat science spokesman; David Hawkins, consultant physician in HIV and genitourinary medicine, London; Roger Hayter, consultant physician, Machynlleth; Graham Hitman, consultant physician and diabetologist, London; Allan House, director of Leeds Institute of Health Sciences and professor of liaison psychiatry, Leeds; William Irving, consultant virologist, Nottingham; Alex James, registrar in anaesthesia; John Jarrett, emeritus professor of clinical epidemiology (retired), London; David Jobson, general practitioner (retired); Frank Joseph, consultant physician in diabetes and endocrinology, Chester; Harry Keen, professor and consultant physician emeritus, London; Jessica Kirker, psychoanalyst and consultant psychiatrist in psychotherapy, London; Sebastian Kraemer, consultant child psychiatrist, London; David Lawrence, consultant in public health and honorary senior lecturer, London; Andrew Leach, consultant anaesthetist, Hastings; Dianne LeFevre, consultant psychotherapist, Basildon; D G Lewis, consultant anaesthetist emeritus, Leicester; Karen Leyden, consultant anaesthetist, Northampton; Graeme Little, general practitioner, Stockton-on-Tees; Anna Eleri Livingstone, general practice principal and trainer, London; Catherine McGrother, consultant in public health medicine, Leicester; Robert MacGibbon, retired general practitioner, London; Anthony Macklon, consultant physician, Durham; Krishnaswamy Madhavan, consultant oncologist, Southend; Alasdair Miller, clinical teaching fellow, Lincoln; Stephen Moore, consultant in emergency medicine, Chester; Patrick Mullen, consultant in anaesthesia, Chester; Patricia Munday, consultant in genitourinary medicine, Watford; Brendan O’Reilly, general practitioner (retired), South Wales; Ragnar O’Reilly, general practice partner, Colchester; David Paintin, consultant gynaecologist (retired), Great Missenden; Janet Porter, consultant in accident and emergency medicine (retired), Southend; John Puntis, consultant paediatrician, Leeds; Paul Revell, consultant haematologist, Stafford; Alexander Robertson, consultant psychiatrist (retired), Ludlow; Trefor Roscoe, general practitioner, Sheffield; Wendy Savage, obstetrician and gynaecologist, London; Brian Scott, consultant physician, Lincoln; Robert Scott-Jupp, consultant paediatrician, Salisbury; Alex Scott-Samuel, consultant in public health medicine, Liverpool; A G Shaper, emeritus professor, London; Francis Sheehy-Skeffington, consultant paediatrician (retired), Cambridge; Brian Silk, retired consultant paediatrician; Alan Smyth, senior lecturer in paediatric respiratory medicine, Nottingham; Gabriel Steer, general practice principal, Kingston; Fiona Subotsky, consultant child and adolescent psychiatrist, London; John Sweeney, consultant in genitourinary medicine, Blackpool; C Mark Taylor, consultant in paediatric nephrology, Birmingham; David Taylor-Robinson, Medical Research Council population health scientist, Liverpool; Katherine Teale, consultant anaesthetist, Salford; Kathrin Thomas, consultant in public health, general practitioner, and honorary lecturer, Cardiff; Jonathan Tomlinson, general practitioner, London; Gill Turner, consultant in community paediatrics, Hexham; Helen Venning, consultant paediatrician, Nottingham; John Ward, general medicine physician (retired), Sheffield; Anthony Waterston, consultant in community paediatrics (retired), Newcastle; Eric Watts, consultant haematologist, Basildon; Malcolm Weller, emeritus consultant psychiatrist, London; Diane Wellesley, associate specialist in clinical genetics, Southampton; Catharine White, consultant in paediatric neurology, Swansea; Steven White, consultant in clinical neurophysiology, London; Chris Williams, locum staff and specialty grade doctor (haematology), Bangor; Michael Williams, consultant in haematology, Birmingham; Barrie Woodcock, consultant haematologist, Liverpool; Robert Wood-Walker, consultant paediatrician (retired), Colchester; Luke Zander, senior lecturer (retired), London; and Patrick Zentler-Munro, consultant physician, Inverness.