Open letter to the BMA about the health white paper

It has been a real pleasure to read the many comments in the rapid
responses to Clive Peedell's and co-signatories' "Call to mobilise the
profession and stop these reforms", including his and others' excellent
replies to Stephen Black, who thinks markets in health provision are a
good thing.

As others pointed out the gradual dismantling of the NHS has been a
development over many years. 23 years ago I wrote a Personal View in the
BMJ pointing out my impressions of the differences in healthcare provision
in my home country, Germany, where I have studied Medicine, and my host
country, Scotland, where I had worked at that time for 7 years as a
doctor. (1)

I have since continued to work as GP in Edinburgh and my observations
from that time have been again and again confirmed. Let me describe some
aspects, just to give you a flavour.

Germany has an insurance based system. On the surface all German
hospitals and doctor's practices look nice and flashy. But prevailing in
every aspect of interaction is an unpleasant sense of competition: between
insurance companies, hospitals, specialists, GPs, all wanting the
"business" of the client/patient, which will be funded by the insurance
company. This results in reduced co-operation between all health
professionals. For instance, it reduces sharing of equipment, like
exercise tolerance machines, CT and ultrasound scanners or mini labs,
which each specialist would have to have on their own premises. The usage
of those instruments, of course, attracts a fee from the insurance. And
this leads to effects which distort the real medical need: a doctor finds
himself having to use the equipment frequently, irrespective of need, in
order to make the investment of that equipment worthwhile. This leads to
over investigation. In addition interpretation of results is less
valuable, as it is just done by one doctor or a small group of clinicians.

In the NHS such equipment is located in a local hospital accessible
to all those in the surrounding GP practices, led by sensible demand from
consultants and GPs who have mostly no other consideration to think about
than the patients health. A specialist
radiologist/haematologist/cardiologist, respectively, evaluates all
results. Local guidelines ranging from prescribing issues to stroke
management, from bedburo to geriatric day hospitals are distributed and
regularly updated, along with a wealth of other info (a bit too much at
times), reliably not influenced by drug companies.
There is an overwhelming sense of co-operation and sharing of resources .
It is an enjoyable atmosphere to work in, seeing that decisions made for
patients are purely led by need. Unlike Germany, healthcare costs are
lower in the UK.

A change to a market driven system will create a significant culture
change in this big section of society, with knock-on effects to other
parts. Whether we like it or not it will create behaviour changes amongst
physicians and results in reduced trust.

I really hope that the NHS can be kept, will receive much more
generous funding- and can be improved along the lines of the proposals
Peter Hayes suggested in his rapid response.

If a majority of BMA members wants these reforms stopped then our
colleagues at the BMA have to represent us and they have to "turn their
backs on the reform process"

Please add my signature to the signatories of the letter.

(1) Helga Rhein, Personal View. Br Med J (Clin Res Ed) 1988;296:1063
doi:10.1136/bmj.296.6628.1063 (Published 9 April 1988)

Please add my name to the growing list of supporters of this letter.
I had hoped that the consultation period was a real consultation period
but clearly it was not.
I feel alarmed and cheated that the proposed changes are already being
rapidly enacted when nobody has voted for them either in a general
election or in parliament. If anything we all voted for no major change.
This is shows contempt for the electorate and those who participated in
the 'consultation'.
The BMA now needs to recognise this groundswell of opinion in its members
and reflect our views robustly.

Like Mr.Black I am not a doctor but I was the chairman of an NHS
Trust for over 10 years so I understand how it functions. Previously I had
managed private and public companies and later I merged large charities
and I was a local authority councillor but there is a differnce with the
NHS so management consultancy norms do not readily apply.
Nevertheless Mr.Black has a point about consultants and their private
practices.

He is also right about the BMA. In its trade union role it has no
equal in defending its members even when they do not have a foot never
mind a leg on which to stand and it is this reputation which makes it hard
for some of us to take it seriously when it purports to speak for the
patient.

The fault with markets and the NHS is that providing medical care should
not be seen as a business. It is a service and although one can see acute
illnesses in episodical terms and so cost and provide for them it is much
more difficult for those chronically ill where continuity is a major
requirement. Nowhere is this more important than in childrens services and
in caring for the elderly because of the fraility of the latter and the
impact on the parents of the former who need the security of one supplier
of several different medical inputs over a long period of time, perhaps
even a lifetime.

The NHS has suffered since inception by splitting primary from secondary
care. Bringing both together with GPs and hospital consultants sitting on
the same
NHS Trust boards with a CEO answerable to them not the other way around
plus a representative of the local authority offers a much better model of
care than GPs contracting out their consortium duties to private concerns
intent only on making money.

The White Paper is a car crash so far as I am concerned with GPs cast as
the fallguys for the cost cutting required because of the enormous cost of
commissioning .. discarding this, centralising the purchase of
consumerables and manufacturing its own generic drugs is the right way
forward otherwise the NHS, as I know it, will just be the training ground
for the private sector.

I would like to add my support the authors of this timely message to
the BMA leadership.

It is vital that the profession is robustly represented in this
dangerous experiment which the coalition government seem intent on pushing
through. It is clear that it is ideology rather than evidence behind it,
and it is time that the BMA shows some leadership.