Pinch of Salt


Michael White - a commentator for the Guardian - had some thoughtful things to say the other day about health reforms in England and Wales. 

Over the years the BMA has been extremely resistant to change - and has opposed just about every government including the one that set up the NHS in 1946.

So I would take what they have to say with a huge pinch of salt - because like many a trade union - the BMA is trying to have its cake and eat it all at the same time.  

Is the huffing and puffing over health reforms just hot air?

Andrew Lansley will get his NHS bill passed and the results will not be as good as he predicts – or as bad as many critics say

The British Medical Association famously opposed the 1946 NHS Act of Aneurin Bevan.

So the British Medical Association has again ratcheted up its rhetoric to warn that Andrew Lansley's health and social care bill is so complex and incoherent that it will cause "irreparable damage" to the NHS if it becomes law in the weeks ahead – as it will do. How impressed should us mere laymen and patients be? Not too impressed, I'd say.

Let's first agree on a couple of basic points. The bill is over-large and as incomprehensible in many ways as critics like the BMA say, perhaps as good an example of what is sometimes called "creative destruction" as we are likely to see from the legislative sausage factory at Westminster.

So no one can confidently predict how Lansley's Cameron-backed attempt to make primary healthcare and the many professions that run it – as distinct from hospitals – become the driving force within the NHS will work out in practice, especially at a time when the service is under intense financial pressure. It's not just the cuts, it's that some of us are getting older, but refusing to die as soon as our parents did, others are getting fatter and acquiring chronic conditions that would have killed their parents. Modern medicine is brilliant – but it costs.

Second. It is perfectly rational for the BMA, as the professional association for around 140,000 UK doctors, to oppose the bill in its capacity as the docs' trade union, which is the sweatier part of its function. Why so? For better or worse, Lansley wants GPs (and the other specialists in primary care) to take control of the bulk of England's healthcare budget, to shape policy and priorities, to direct funds and tell hospitals what they want from them.

Quite a revolution. I heard the health secretary say the other day that in the new dialogues now opening up between clinical commissioning groups (CCGs) – the doctor-led successors to primary care trusts (PCTs) – and the all-powerful hospital sector, the hospital docs have been heard to say "why didn't you tell us that's what you wanted?" Indeed.

The trouble for GPs – the 42,000-strong Royal College of GPs is also militantly against the bill, as are most royal colleges – is that this may mean (it's certainly meant to) that they will get the credit, but also the blame, for local decision-making about health priorities. Can't get that hip operation? Can't get fertility treatment or that cancer wonder drug the Daily Mail is cynically banging on about? Let's get out there and key the doc's BMW!

Nasty things like that may happen and the doctors may get the blame instead of the politicians. It's one of the incalculables I mentioned above. The test is "who goes on Radio 4's Today programme to defend the policy?", whether it's a cancer drug denial (not worth the cost) or a rational but unpopular local hospital closure. Doctors are often happy to let elected officials – local as well as national – take the heat while they engage in what is unkindly called "shroud waving".

That may – may – all change. Some doctors with entrepreneurial flair and medical ambition are already providing such services in parts of the country, innovating and saving money at the same time, as the Labour-set target for £20bn of savings over five years required the NHS to do long before Lansley took over. Others show no such zeal and who can blame them? As their current ballot (imprudent in the present economic climate, I'd say) over "industrial action" (sic) over their pensions shows, the BMA leadership is not always financially acute.

We're all in favour of local medical decision-making, at least in theory. We know best, not Westminster or Whitehall, don't we? But we're all against the local "postcode lottery" too – in schools and transport services as well as the NHS. It's an inherent tension in society and the tireless Polly Toynbee wrote a brilliant piece only the other day about the National Institute for Clinical Excellence (Nice), a Labour success story, and how it holds the ring.

In trying to reform Nice, Lansley made another blooper. I know the health secretary moderately well and doubt if there are any more decent or conscientious MPs on either front bench. It's just that he's got his cunning plan to make the NHS fairer and more efficient – yes, he believes this – and is stubbornly determined to stick to it. Criticism makes him more inflexible, to the likely private despair of his old lieutenant, David Cameron, who (after one unintelligible briefing by Lansley aides) was quoted the other day as telling Steve Hilton, his pixie policy guru: "We're fucked."

Fucked or not, Lansley is going to get his bill through the Lords and Commons with enough amendments (cosmetic or real, only time will tell) to square the eminently square-able Shirley Williams. The task is made harder by the fact that he's not a very crafty or persuasive politician: he couldn't give away bottled water to travellers dying of thirst in the Sahara. But he knows a lot – a great details man, is Lansley – and we should not doubt his sincerity, though I realise that you may.

Back to the BMA and the warning letter sent to GPs on Thursday by Dr Laurence Buckman, chairman of the association's GP committee (GPC). It's a good letter, albeit long and complicated, but read it if you have the time.

What it argues is that the BMA favours clinical-led commissioning, has done for years as successive Tory and Labour health secretaries have tried – with real but varying success – to make the NHS behemoth more responsive and efficient by putting primary care (which is both cheaper, nicer and often safer for patients than being in hospital) in the driving seat.

Some innovative GPs are already proving it can work, but it hasn't worked well enough or widely enough, which is why Lansley decided to abolish the primary care trusts and force the pace. Instead of doing it organically he's using legislation, breaking Cameron's famous "no top-down reorganisation" pledge, though he's probably trying to claim it's bottom-up.

Buckman's serious worry contains a paradox. For all the talk of localism he fears that the national NHS commissioning board, which the bill is setting up, will dictate terms to GP commissioners, forcing them to merge into larger, more "efficient" bodies and – critically – to hand over many functions to back-office "commissioning support services", which could end up running the show.

This is where the fear of backdoor privatisation lurks, that McKinsey, KPMG and other foreign – not all American – healthcare providers will move in – they are certainly trying to – and screw the taxpayer and the patient. It's all too rushed and too risky, says Buckman's letter.

The paradox is that we are warned against chaos and privatisation at the same time as we know – should know – that the commissioning board is in the hands of the NHS CEO, Sir David Nicholson, a brilliant Whitehall warrior with a past in, yes, the Communist party. Unlike many, I doubt if he is keen to feed McKinsey's bloated profits, but unlike others he thinks (so do I) that the NHS's near-monopoly could probably benefit from a bit more invigorating competition from private and voluntary sectors, the sectors routed by Aneurin Bevan in 1948.

I can follow both lines of argument, but I also know that the BMA famously opposed Bevan's 1946 NHS act and opposed – also in lurid terms – Tony Blair and Alan Milburn's efforts to give hospitals more autonomy by becoming foundation trusts (FTs) just a few years ago when Gordon Brown was playing politics with the issue behind the scenes. Few oppose FT status now, though there have been failures as well as successes (of course).

All of which is to say that we should listen carefully to the BMA, but also to Lansley, who is neither a fool nor a crook. He will get his bill through and the results will not be as good as he predicts and hopes – nor as bad as his many critics say. "But the health professionals are near unanimous in their opposition," I hear you murmur.

Up to a point, Lady Copper. Lansley gets a lot of stick, for instance by heckler June Hautot, 75, outside No 10 the other day, a Unison militant who has been shroud waving against hospital closures for decades. As an ally of Arthur Scargill she might instead have pondered the fate of deep coal mining, but never mind.

And, amid all the Guardian's copious and brilliant coverage of the controversy on its health websites I am grateful for this cautionary tale on the Guardian Professional site. For all the huffing and puffing, BMA-style, of the Royal College of GPs only 7% of its members actually voted on its plan to keep PCTs in place. Bear that in mind too as the drama unfolds.

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