Medicopolitical Digest

The BMA annual representative meetingDoctors oppose resiting of juniors' contractsPrivate hospital given kiss of lifeFrom the local medical committee conferenceThere should be an alternative to target net remunerationCore element of general medical services must be definedGMSC will have triennial elections

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.6997.130 (Published 08 July 1995) Cite this as: BMJ 1995;311:130
  1. Linda Beecham

    The BMA annual representative meeting

    BMA chairman issues three challenges

    Unless three issues are resolved urgently the profession's vision for the future of medicine will not be achieved, Dr Sandy Macara told the BMA's annual representative meeting this week. In his opening address the chairman of the BMA council said that, firstly, there must be a planned, phased increase in the consultant establishment in order to implement the Calman report on specialist medical training. Secondly, the increasing bureaucratic pressure on general practitioners must be relieved and an acceptable alleviation of their out of hours commitment secured. Thirdly, more consultant posts must be provided in public health medicine and means found to enable its skills to be deployed across the NHS.

    In 1994 Dr Macara had talked about healing in a wounded NHS. That remained true in 1995. There remained a famine of positive policies in the government--a failure to acknowledge reality as it force feeds the public on a diet of indigestible statistics. What could the profession do? Its duty was clear--those who understood health care had to continue to prescribe the remedies. Two myths had to be laid to rest. Firstly, that the profession was against change. “We revel in it, when it is for the better, when it provides new weapons in the conflict against disease, weapons tested and proven in clinical trials.” The second myth was that the profession was against competition. Doctors opposed competition for business in health care but “we relish competing with the forces of death and disease in the battle for life and death.”

    PLUNGING MORALE AND RECRUITMENT

    During the session the persistence of the consultants' negotiators had averted the threat of the imposition of local pay and delivered a more equitable arrangement for discretionary payments, which involved management but depended on peer review. Unfortunately, the persistence of the general practitioners had not been so rewarded and they were still facing an obdurate administration over the out of hours crisis. “The result is plunging morale and recruitment and a level of militant determination for change among general practitioners unprecedented in my experience in the NHS.” Pressure was slowly being applied to those trusts which still did not comply with the terms of the new deal on junior doctors' hours but it had been a provocative decision to place junior doctors' contracts with trusts against the advice of the whole profession.

    Looking at the background against which the BMA was working the chairman of council reminded the meeting that British medicine and British doctors remained at the forefront of scientific and technological progress. He cited the advances in molecular biology and genetics, in intensive care, and in therapeutic interventions; the eradication of historically lethal diseases through the success of immunisation programmes; and the promise of on line networking of information and communication.

    But why was Britain slipping back in the league tables of mortality and morbidity? Why did so many of the ablest doctors take early retirement or go abroad? Why did so many young doctors abandon medicine? Because “we are labouring under an alien regime. Not so much an internal market as an infernal bazaar in which considerations of cost reign supreme, while concerns for value and values are relegated to second place.”

    Where stands equity, Dr Macara asked, when the cash lottery dictated priority to patients with lesser need? Where stands integrity when doctors were instructed to inform the patients of fundholders why they had to have their treatment deferred? Where stands the theory of money following patients when patients had to follow the contract? Where stands patient choice when bulk contracts dictated place, time, and person providing the care? Where stands management when the government's policy was to cap resources centrally and delegate blame locally for inability to meet the heightened demands incited by the patient's charter.

    How could the profession reform the reforms to change the situation for the better, to restore competition for relevance and quality of care? The chairman believed that the BMA's seven point plan was as relevant today as it was when he had first propounded it in 1994. Firstly, realism must replace wishful thinking; secondly, a fresh consensus about aims was a political and practical imperative; thirdly, research had to be put into practice; fourthly, the determination of priorities nationally and locally required full, informed public involvement; fifthly, purchasing or resource allocation had to be led by the local assessment of current needs and trends; sixthly, providers must provide the evidence of the outcomes of their care; and finally, purchasers and providers should be encouraged to cooperate in developing long term local strategies.

    Doctors oppose resiting of juniors' contracts

    The medical profession has joined forces to oppose the government's decision that contracts of those junior doctors currently held by regional health authorities will be moved to trusts (24 June, p 1642). The chairmen of the Junior Doctors Committee, the Central Consultants and Specialists Committee, the Joint Consultants Committee, and the conference of royal colleges and faculties have written to the health secretary asking for a meeting to discuss the issue.

    Dr Andrew Carney, chairman of the JDC, says that his committee is appalled at the decision, which will come into operation next April when regional health authorities are abolished under the Health Authorities Act. The JDC believes that the change will be detrimental to postgraduate education and to patient care. Dr Carney points out that contracts at trust level would make it impossible to protect high quality training rotations, and because of the conflict of interests in trusts there would be an overemphasis on service commitments rather than on education.

    When the health minister, Mr Gerald Malone, announced the decision he referred to a core of national terms of service. The JDC fears that this could be a further step towards local terms and conditions of service. Dr Carney says that it was misleading of the minister to say that the decision was the result of a broad consensus when all the major groups representing the medical profession had opposed any change.

    The JDC chairman has written to junior hospital doctors urging them to write to their members of parliament telling them of their concerns about the future of doctors' contracts and terms of service.

    The profession has asked for an assurance that national terms and conditions of service will continue. Sir Norman Browse, chairman of the JCC, has told Mrs Virginia Bottomley that terms and conditions of service that might vary from trust to trust could cause major practical difficulties for trainees who are moving every six months as part of a rotational training scheme.

    SPECIAL HEALTH AUTHORITY NEEDED

    Sir Norman says that trainees should be given a contract at the beginning of their training programme and this should be the responsibility of deans. He has told the health secretary that the profession would favour a national special health authority for postgraduate medical education. This would employ the deans for the majority of their sessions in deanery outposts. The deans' remaining sessions would be with the regional executive. Juniors' contracts would be held within each deanery, the funds coming from the regional executive, and the deans would be accountable for these funds to the executive.

    The JCC chairman says, “We cannot accept proposals that totally disregard the considered opinion of the medical profession on the way it believes training of its members should be managed.”

    Private hospital given kiss of life

    A phoenix like revival of the failed private Health Care International hospital, built with British government assistance at Clydebank, was reported to the House of Commons public accounts committee last month. Having been rescued by the Abu Dhabi Investment Company, HCI is taking on a further 70 staff, bringing the total to over 400 towards a five year target of 1800 jobs. The £180m 260 bed hospital expects an annual spend of over £30m, and to raise most of its revenue from overseas patients.

    At a committee hearing, Mr Peter Mackay, a senior Scottish Office official, rejected suggestions from MPs that the private hospital was a white elephant. “It has not flopped,” he said. “If it was producing computers people would say it was a great success.”

    He also said that British taxpayers had lost £7.4m in equity and interest when HCI went into receivership last November within three months of its opening after failing to meet its initial occupancy targets of 3000 to 5000 patients in the first year. In its 36 weeks of trading it treated only 761 patients. Mr Mackay said that the banks had lost an equity stake of £35m and a large proportion of money they had loaned.

    A report by the National Audit Office said that the Scottish Office, the company and its financial backers had underestimated the risk that the original project would fail. The aim was to run HCI on the model of a United States high tech hospital and to develop close links with Glasgow University, similar to Harvard medical school's association with Boston hospitals.

    Public assistance totalling £27.6m was provided despite 75% of those consulted by the Scottish Office having expressed concern about the project, mainly about its impact on the NHS. Apart from the loss of four anaesthetists, Mr Mackay said that the impact of HCI on NHS staff had been negligible. It would complement, not compete with health boards and trusts. The NHS has bought about £250m of patient treatment from HCI though the company expected that by far the bulk of its revenue would be from the overseas private sector in the Middle East and Africa.

    'Mr Mackay said the new operators were prepared to back the hospital--arguably the finest and best equipped in Europe--for some years before it became profitable. The National Audit Office quoted estimates that the GCI facility was likely to produce a net benefit to the UK economy in five years.

    From the local medical committee conference

    Violent patients should no longer have legal right to care

    “My chest was bruised, my face was bruised, and my glasses were smashed,” Dr Gillian Beck (Buckinghamshire) told the conference. The meeting unanimously endorsed the motion she proposed that “patients known to be repeatedly violent to health care professionals should no longer have the legal right to general practitioner care, and that alternative arrangements should be made for those persons to receive appropriate medical care.”

    Dr Beck said that she had been attacked by a patient while doing a home visit. It had taken four policemen to detain the man and a psychiatrist commented later that one day he would kill someone. “Sadly,” she said, “there are some patients who are too violent to be cared for by a general practitioner.”

    Dr Abu Hossain (Lambeth, Southwark, and Lewisham) described how he had been the subject of two assaults in the past two months, during which £10000 worth of damage had been done to his premises.

    Although the regulations have been changed to allow general practitioners to remove patients from their list “with immediate effect,” they may have to provide immediate necessary treatment. The conference endorsed a motion, which declared that this was unsatisfactory and urged the General Medical Services Committee to make it explicit that it is for the doctor to decide whether a consultation was necessary and that it was appropriate for the doctor to wait until a police presence could be assured unless the patient's life was in danger.

    There should be an alternative to target net remuneration

    Dr Stephen Earwicker (Nottingham) persuaded the conference that the system of target net remuneration was hampering the future development of general practice and that alternatives should be negotiated. The present system was outdated, he said, and was hindering primary health care. It was not a question of money but about the quality of service that could be provided. Why was the system so wrong? “It rewards sloth and stifles innovation. It removes incentives.” Target net remuneration did not recognise increased workload and was unfair.

    Dr Ken Harden (Glasgow) agreed with him. The system had served general practice well in the past but it was now time to look at a new concept and negotiate on the basis of contractual activity.

    One of the GMSC's negotiators, Dr Judy Gilley, sympathised with the motion but pointed out the necessity of trying to reconcile the interests of different sorts of practices. It was not easy to devise a system of remuneration. She understood that the profession did not want more targets; it wanted a work sensitive contract with more money for more work.

    Core element of general medical services must be defined

    General practitioners have called for the core element of general medical services to be defined based on the principles set out in the GMSC's document Core General Medical Services and the Classification of General Practitioner Activity, which has been sent to all general practitioners in the annual report. They want the core element remunerated through a nationally negotiated contract and amended only by agreement with the GMSC. Last month's conference also agreed that once the core element had been defined it would pave the way for certain non-core, non-general medical services to be remunerated through either local or national negotiations from funds outwith target net remuneration.

    The motion could be reduced to “GPs must learn to say no,” Dr Ian Cathcart (Forth Valley) told the meeting. For too long general practice had been the safety net and the dumping ground. Doctors had to say no until the work was properly funded.

    The matter was urgent, according to Dr Adam Jenkins (Ealing, Hammersmith, and Hounslow), and he opposed the suggestion that progress should be presented to the 1996 conference. The shift from secondary to primary care was the single most important threat to general practice. A mechanism was needed to stop this before 1996. A colleague from the same constituency, Dr Stuart Drage, emphasised the importance of ensuring that the 95% of primary care was not smothered by the 5% of secondary care which was being imposed on general practice.

    Figure2

    Three of the GMSC's negotiators: from the left, Dr Simon Fradd, Dr Brian Goss, and Dr Judy Gilley

    The conference carried as a reference a proposal that the GMSC should also define traditional secondary care services as guidance for general practitioners.

    GMSC will have triennial elections

    The conference has decided that in the interests of continuity the election of regional representatives to the GMSC will be on a triennial basis with one third of members being elected each year. Doctors will be able to make more satisfactory practice arrangements if they know that they will be on the committee for three years. Proposals will be presented to the 1996 conference and the new system could be in place for the 1996-7 session.

    A suggestion that the representatives should be elected by all general practitioners who contribute to the defence fund was defeated. Dr David Roberts (Northamptonshire), who has been campaigning for the electorate to be widened and not confined to members of local medical committees, had supported this part of the motion but he did not want it restricted to those doctors who had paid into the defence fund. “I have difficulty with partial democracy,” he said. People were not asked if they contributed now; Dr Roberts did not think that they should be in the future. But Dr Fay Wilson (Birmingham) did not want representation without taxation. The franchise should not be extended to people who were not prepared to pay up.

    Dr Gareth Emrys-Jones (Cornwall), who has chaired a task force looking at election options, reported the interim results of a sample poll of general practitioners. Of those responding 71% favoured an election every three years; 91% said that a third of the GMSC should be elected each year; and 70% wanted all general practitioners to vote.

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