Dr Lansley’s Monster
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d408 (Published 21 January 2011) Cite this as: BMJ 2011;342:d408
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We would like to apologise to Dr Peter H Lansley and any other Dr
Lansleys who have been mistaken for the architect of the government's
latest health reforms. We thought that the editorial entitled "Dr
Lansley's Monster," and a series of articles appearing in the print
journal and on the website, made it clear that we were referring to Mr
Andrew Lansley, England's Secretary of State for Health.
Competing interests: I am a co-author of the offending editorial
If I understand Ms Bray's response correctly, it is that because the
word "mad" has been used to stigmatise people with mental health problems
it should be withdrawn from use, perhaps permanently.
We don't agree. We needed a word to communicate the sense of the
government's proposed reforms as being "mentally disordered or deranged;
insane; resulting from or caused by madness; extremely and recklessly
foolish" - the Chambers dictionary definition of the word "mad."
We were trying to be accurate, not clever.
Competing interests: I am a co-author of the offending editorial
Thank you for a lucid description of the enormous costs and very
uncertain benefits of the governments proposals.The electorate were denied
any opportunity to vote with this issue in mind.The NHS is continually bad
mouthed, when international comparisons repeatedly show we do more, for
less money than many other services. Major changes are happening before
the bill has even been passed though parliament; this should be
unconstitutional.
Massive reorganisation on this scale will waste billions of pounds,
all diverted away from caring for patients, or managing services
effectively.
Furthermore, expertise derived from Primary Care is being diverted to
managing the excessive emphasis on secondary care that mars all developed
health care systems. The potential for dangerous fragmentation of services
, already happening to some extent will become widespread. Having "any
willing provider" means duplication of services ( to enable choice and
competition) and that is inevitably wasteful.
It would be better to abolish the purchaser provider spilt, oblige all
local health economies to reduce secondary care spending by ( say) 30% and
reinvest that money in effective primary care. Experienced GPs should be
innovating in primary care instead of trying to restrain spending on
secondary care. Instead we are "not allowed to commission ourselves" .
Most improvements in General Practice ( the move to group practices, high
standards of training, widespread computerisation,audit, effective chronic
disease management and screening programmes etc etc) were initiated by
enthusiastic GPs. Lets harness that flair for innovation again.
With longer appointment times,rapid access to investigations, more and
better trained frontline staff, and savings redirected back into primary
care real change might be possible.
There are precedents; Changing Childbirth in the 1980s prioritised
collaborative care planning, reducing duplication and waste, but got lost
with the increasing power of secondary care trusts. Primary care personnel
who reduce hospital admissions ( saving money), reduce prescribing (
saving money) and who resist medicalisation do not see those savings
redirected into Primary care. Innovation to do more care outside hospital
is taking place already; we can build on that incrementally without
dismantling the entire structure of the NHS
Competing interests: I am GP , GP tutor/trainer
Congratulations on the most succinct commentary so far on the latest
reforms. The frustration of course is that nobody in Government or the
higher layers of NHS management is listening - why should they! We have
had 13 years of stalinist control of Medicine and the population are cowed
into submission.
However in all the anxiety about the onset of GP commissioning nobody
has made much comment of the amount of clinical time this will bleed away
from general practice. And its likely to be the experienced GPs who will
be seduced into management roles. So the additional risk to the reforms is
that the day job will suffer and those attributes of good general practice
which control demand will weaken. Patients already report difficulty in
making appointments at practices and their frustrations with having to see
different doctors all the time - so expect pressure on A&E and on
referrals to increase.
There is also the incredible notion that GPs are the only group of
clinicians who are deemed competent to control the financial resources of
the NHS. Where on earth did that come from and how on earth are the BMA
accepting it. I respect my consultant colleagues and value their
individual skills, as I hope they do mine. So why are they not included in
the commissioning process?
Competing interests: No competing interests
"Financially sound" ? I cannot agree with you Richard.
Wales took the step of supposedly abolishing the purchaser-provider
split some years ago, and has reversed the management process of decades
by merging lots of trust providers and locally-responsive 'Local Health
Boards' into a handful of great amalgams running everything. Historically
these re-creations were hugely costly, and always overspent.
We in Wales witness a rapid decline in efficiency from a low starting
base, and no clear responsibility as to who to blame for what.
"Real cash and head count savings" ? You might as well argue for the
abolition of money, and everybody can just get on with seeing patients
without regard for cost, being grateful for the odd half-dozen eggs, or a
bottle at Christmas in a pre-capitalist 'gift', or rather, barter economy.
"Clinicians can then move their focus from cost issues to real things
like efficient and effective patient care and quality". Never have I
known a clinician (from the lowly GP on up to tertiary Oncologist), once
released from cost concerns, do anything but spend spend spend on the
"best" (ie- most expensive new drug) available.
There must be a way to optimise acceptably safe effective treatment
somewhere in the UK, but it cannot possibly be achieved by disregarding
cost.
I rest my CASE for a Cheap, Acceptable, Safe and Effective NHS.
Competing interests: i am a GP in Wales
I am deeply unimpressed by your Editorial, and indeed by its magazine cover, (BMJ 2011;342:d408 ).
I think you should now give equal prominence to an apology, - making it clear that there are current BMA doctors who happen to bear the name of the current Health Secretary, yet with considerable nobility and pride, - indeed armigerously.
However much satisfaction you may derive from your (trivial) ad hominem epithets, you must acknowledge this to be a particularly ungodly error.
Yours faithfully
Dr Peter Lansley
Competing interests: No competing interests
Delamothe and Godlee glossed over the most obvious and financially
sound concept: the complete removal of the provider / purchaser split.
Ridding the NHS of the huge contracting and financial management tail in
hospitals, PCTs and SHAs would make real cash and head count savings.
Instead of the constant round of management meetings, clinicians can then
move their focus from cost issues to real things like efficient and
effective patient care and quality.
Competing interests: No competing interests
The British Medical Journal ought to eschew prejudicial language
against people with mental health problems.
Instead in this issue of bmj.com both Tony Delamothe, deputy editor
and Fiona Godlee, editor in chief, embrace the language of bigotry as they
join forces to attack on Andrew Lansley.
We all know the phrase "politically correct gone mad" is in common
currency. That does not make it clever or appropriate, especially when the
phrase comes from the mouths of leaders in medicine.
This blunder in taste is made still worse by the use of the phrase
"Dr Lansley's monster". It sounds as though Tony Delamothe and Fiona
Godlee routinely see people with mental health problems as monsters.
Tony Delamothe and Fiona Godlee are both fully within their rights to
discuss and criticise Mr Lansley's proposals but if they belong to the
medical community they ought to be able to do so without using
stigmatising language about a marginalised group of people.
Competing interests: No competing interests
There is no mandate for these sweeping changes, which were not in the Coalition agreement, and Lansley's defence of GP commissioning is that on p46 of the Tory party manifesto it was menioned. In thecontext that Practice Based commissioning was being piloted in PCTs this gave no clue that PCTs would be abolished and GPs given responsibility for ?80 billion of NHS money.
All three parties said they favoured any willing provider although Labour had before the election said that the NHS was their preferred provider. Missing from the media coverage including the time given to him last week on the PM programme is any discussion of the cost of the market-which the Department of Health seem unwilling to reeal if they have costed this.This market was set up by Labour ( who should admit that it was a mistake which did not achive their aims and cost at least ?10 billion a year to run).
On Friday 21st when asked by a listener he denied that introducing competition with any 'willing provider' (including US health corporations) would mean EU competition law would apply. Experts in the field disagree and if he gets his way our NHS would be ruled by the vagaries of the market - which is in any case an unsuitable model for health care-as Julian LeGrand taught me when doing my MSc in Public Health in 1998.
I hope your editorial will wake doctors from their passive apathy and get them to let their MPs know this week before the second reading on Monday 31.1.11 that this is lunacy. I hope it will also stiffen the resolve of BMA Council to fight this pernicious legislation which does not need to be introduced so fast. Kill the Bill. Thank you for you forthright analysis
Competing interests: Co-cbair of Keep Our NHS Public
Financial risk in GP commissioning and Dr Lansley's monster
As someone who has had a long standing interest in quantifying the
financial risk associated with health care provision and purchasing it
amazes me that this issue has not received greater prominence in the
discussion of why PCT's appear to have so recently fallen into deficit and
the implications to GP commissioning (1-7).
Any purchaser of health care on behalf of a defined population will
be subject to poorly understood long-term oscillations/cycles/undulations
in the costs associated with that population (8-17).
While GP commissioners may be better able to reduce costs than PCT's
such cost reduction will not alter the natural tendency of costs to behave
in a cycle of surplus and deficit. Only in this case, GP commissioners
will be expected to achieve this feat in the absence of any growth in
funding.
Alas the eventual outcome is assured, and untill then we must comfort
ourselves with Shakespeare's profound words, "Once more unto the breach,
dear friends, once more ....."
References
1. Jones R (2004) Financial risk in healthcare provision and
contracts. Proceedings of the 2004 Crystal Ball User Conference, June 16-
18th, 2004. Denver, Colarado, USA. Available from: www.hcaf.biz
2. Jones R (2008) Financial risk in practice based commissioning.
British Journal of Healthcare Management 14(5), 199-204.
3. Jones R (2008) Financial risk in health purchasing Risk pools.
British Journal of Healthcare Management 14(6), 240-245.
4. Jones R (2008) Financial risk at the PCT/PBC Interface. British
Journal of Healthcare Management 14(7), 288-293.
5. Jones R (2009) The actuarial basis for financial risk in practice-
based commissioning and implications to managing budgets.
Primary Health Care Research & Development 10(3), 245-253.
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8. Jones R (2009) Trends in emergency admissions. British Journal of
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13. Jones R (2010) Do NHS cost pressures follow long-term patterns?
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14. Jones R (2010) Nature of health care costs and financial risk in
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15. Jones R (2010) Nature of health care costs and the HRG tariff.
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Competing interests: The author provides actuarial and forecasting services to health care organisations