WITH the general election in mind, the British Medical Association (BMA) has published a ‘doctor’s manifesto’, A vote to improve health.

What becomes clear in the BMA’s appeals to the ‘new government’ is the medical profession is deeply disturbed by threats to the NHS posed by Labour’s privatisation ‘reforms’ at the centre of which is the Thatcherite competitive market in health.
The BMA introduces its document stressing that doctors ‘are committed to a health service that is properly resourced, comprehensive, free at the point of delivery and provides equal access for all.’

But, it says, a number of challenges need to be faced if these aims are to be made a reality and visibly improve the NHS. The new government must improve public health, helping people to lead healthier lives’

The document stresses that ‘Public health policy must be more coherent and have a clearer national policy. Government should provide support so people can make informed choices.’

The BMA calls for a nationwide smoking ban in public places, more resources for sexual health services, action to cut alcohol problems and on hospital infections it says: ‘Tackling MRSA is everyone’s responsibility. Resources must be in place to ensure that doctors and nurses can clean their hands before and after contact with patients.

‘Hospitals should give health professionals with expertise in infection control a greater say in management issues, and cleaning staff should be valued properly. NHS Trusts should be assessed on the effectiveness of their infection control measures.’ The new government must make patient choice meaningful and relevant to patients’

Here the BMA manifesto says: ‘Evidence shows that most patients would choose good quality services close to their home.’ It adds: ‘Doctors worry that patient choice will favour the more articulate and informed. If information – and therefore choice – about healthcare is only available to these people, the patients who most need to be empowered will be disadvantaged. The most vulnerable people within our society also need access to choices.’

The manifesto warns: ‘Patient choice should not be dependent on a market or competition, neither should it be skewed by spurious targets relating to the level of private-provider use. It does, however, depend on spare capacity, which currently does not exist. The UK is still very short of the doctors, nurses and health professionals needed to run a high quality 21st century health service. Until the first internal market was introduced, GPs could refer patients to any hospital in the country if this is what they and the patient agreed.’

The document continues: ‘Doctors worry that choice appears to be little more than a euphemism for increased private involvement in healthcare and competition between institutions that provide care. Doctors fear that patient choice is becoming a hollow phrase more centred on creating incentives for hospitals to compete, rather than offering patients genuine options. The new government must recognise limits to the role the private sector can play, and strengthen the NHS’

'It is clear that there is a fundamental shift in the balance between public and private provision in the health service,’ says the manifesto. It adds: ‘The private sector should be employed in pursuit of NHS aims and not the other way round.’

It goes on to warn that private treatment centres ‘should not be allowed to destabilise NHS hospitals’ economies. Treatment centres must add to NHS capacity and not replace, or even worse, undermine it.’

The BMA reveals: ‘Current policy in England is predicated on a new financial system called payment-by-results. The aim is that each treatment has a cost (tariff) associated with it and a whole range of providers, both public and private, will compete for patients and the money that goes with them.

‘Unfortunately, this new competitive market, as currently configured, works against the NHS. While NHS institutions have to compete for patients (and income) the contracts for independent treatment centres offer a guaranteed flow of income and they do not have to compete. At a time when many NHS Trusts are experiencing significant financial difficulties, primary care trusts in England have been ordered to spend up to 15 per cent of their elective budget with private providers to build capacity for competition. This does not take into account patient choice and whether local patients want this or will benefit from it.

‘It is right that money should follow patients, but financing healthcare through payment-by-results can only work equitably if all parties are treated equally and if the system is not skewed in favour of private sector providers. Payment should cover a whole pathway of care whereas at the moment it is predicated on secondary care. Tariffs must be fair and accurate and not incentivise unnecessary investigations or treatment.

‘The loss of even a small part of Trusts’ income to the private sector could have very serious consequences on patient services because of the high fixed costs of most NHS healthcare. The payment-by-results regime needs to be robust to prevent financial distortion and ‘cherry picking’ of services by private sector providers.

‘Already, the guaranteed volume for independent sector treatment centres is leading to pressures on certain NHS services to close, thereby threatening the other, less commercially attractive services these providers offer. There is a serious threat to training and the future medical workforce if certain treatments are moved outside the NHS. No department or hospital should close without a strategic review of its role in the local health economy. The new government must involve doctors, patients and the public in the formulation of policy and reform initiatives’

This section warns: ‘Too often, policies are developed without the involvement of doctors’ representatives, patients and the public with the result that they are sometimes impractical to implement, miss out some vital aspect of patients’ interests or are not supported by doctors. A good example of this failure lies within the National Programme for IT.

Patients must be treated according to their clinical need with an effective new standards regime replacing the current targets that distort clinical decisions.’

Again the BMA issues a stark warning: ‘There is a danger that uncontrolled competition, plurality and payment-by-results will result in a greater fragmentation of care. The incoming government must invest in doctors to enable them to lead improvement across the NHS’

The manifesto urges: ‘The steady haemorrhage of qualified doctors from the NHS should be a matter for national concern and every effort made to improve conditions of service so they are made sufficiently attractive to keep qualified doctors in post and attract new recruits. The developed world should be working towards achieving self-sufficiency in doctors and nurses over the next decade.

‘The NHS owes an enormous debt to its internationally qualified staff and the government should ensure that they are made welcome and their contribution valued. While doctors have the right to choose to migrate for training and development purposes, it seems iniquitous that wealthy, developed, English-speaking nations like the UK and the USA should be draining poorer countries of scarce medical manpower.’

The document calls for ‘investment in academic medicine’, warning ‘at a time when medical student numbers are increasing, there has been a decline in the numbers of medical teaching staff because of some universally acknowledged disincentives to this career, including a heavy workload, lack of career stability, insufficient recognition of the value of teaching by universities, and an under-valuing of medical research by the Research Assessment Exercise.’

It calls for ‘improving the working conditions of staff and associate specialist doctors’, saying: ‘This group of doctors has direct contact with patients in hospitals and provides crucial services to those patients. Morale is very low because their contribution to the NHS has gone unrecognised for too long. Their skills, experience and hard work must be properly rewarded.’

The document concludes with the warning: ‘The NHS Pension Schemes should not be reduced in value. They should be funded properly and designed to encourage the recruitment and retention of doctors to the workforce, rewarding those who wish and are able to stay in the NHS. It is unacceptable to renege on contractual expectations for those already in NHS employment. Penalties should not be imposed if doctors are unable or unwilling to continue beyond the normal pension age of 60 (55 for mental health officers).’