Tuesday, 24 January 2012

The Open Letter to the Royal College Presidents

An open letter to the Royal College Presidents regarding the Health and Social Care Bill

This open letter was sent to the Royal College Presidents in September last year. It was signed by these doctors
and was reported in the Guardian, but at that time the Colleges failed to act decisively and come in line with the majority view of the profession.

Now that the Royal College of Nursing and the Royal College of Midwives have joined the BMA in opposing the Health and Social Care Bill and calling for its withdrawal, the Medical Royal Colleges now find themselves in a pivotal position, where their united opposition could result in the bill falling. I have therefore decided to put the open letter on my blog for a wider audience because it explains the key reasons and arguments for why the Medical Royal Colleges should oppose the Health and Social Care Bill and call for its withdrawal.


Dear Presidents,

“The Academy’s role is to promote, facilitate and where appropriate co-ordinate the work of the Medical Royal Colleges and their Faculties for the benefit of patients and healthcare.”


We write to persuade you that the Royal Colleges' current policy of cooperating with the government’s proposed NHS reforms in England as stated in the 2011 Health and Social Care Bill is not in keeping with the wishes of the majority of the medical profession and not in the best long-term interests of either patients, doctors or the Royal Colleges.

Current situation
Following the unprecedented pause in the passage of the Health and Social Care Bill to allow for a “listening exercise”, it has become clear that the Government’s proposed changes to the Bill1 in response to the Future Forum report2, have done little to address the concerns of the medical profession. In fact, the representative body of the BMA reinstated its policy to call for withdrawal of the bill at its Annual Representative Meeting (ARM) in June. The key issues that were highlighted by the ARM were serious concerns regarding:
i)                    the removal of the duty of the Secretary of State for Health to provide a comprehensive health service
ii)                  the role of Monitor in the promotion of competition
iii)                the enforced nature of competition through the promotion of the choice agenda, as a higher priority than tackling fair access and health inequalities
iv)                increasing marketisation and privatisation of the English NHS


Professional support is lacking
In response to the Government’s failure to reassure the medical profession about its proposed changes, BMA Council subsequently voted in favour of starting a public campaign to call for withdrawal of the Health and Social Care Bill. Council also agreed that the Government was “misleading the public by repeatedly stating that there will be no privatisation of the NHS”.  Dr Hamish Meldrum, Chairman of the BMA said that:
there is widespread feeling that the proposed legislation is hopelessly complex, and it really would be better if the Bill were withdrawn3.

The RCGP survey of over 1,000 GPs following the Government response was also highly critical. Dr Clare Gerada, Chair of the RCGP stated:
‘ GPs don't think this bill is going to create a patient-led NHS, they don't think it's going to increase autonomy, they don't think it's going to improve patient care and they don't think it's going to reduce health inequalities.'4

An online BMJ poll of over 1000 doctors showed that 93% wanted the bill to be withdrawn and a smaller online poll by GP magazine showed that 94% thought the bill should be scrapped. The Government’s former Director for heart disease and stroke, Sir Roger Boyle, also spoke out against the bill. He pulled no punches when he stated that:


Dr Evan Harris, the influential Liberal Democrat GP dismissed the NHS Future Forum report as "cliché-ridden, trite nonsense" and held out the prospect of further revolts6.

Parliamentary and other support is lacking
It is not just doctors who remain concerned by the Bill. The Liberal Democrat MP and member of the Health Select Committee, Andrew George said:
“If the Government had been listening it would have scrapped the Bill. Instead it looks as if they've just massaged and tweaked it a bit.”7

The concerns have also spread to highly influential members of the Lords. In her speech to the NHS Confederation, Baroness Williams stated that:
“I would be less than candid if I failed to mention that there are still some unresolved and troubling issues to be addressed”8

It is also increasingly apparent that these widespread concerns are entirely justified.  Most notably, the public interest lawyer, Peter Roderick, has stated that:
“The fundamental legal basis for the NHS, which was put in place in 1946, will be removed by the Government’s Health and Social Care Bill.”9
He goes on to state that:
 a direct line of logic can now be traced in the Bill, which leads to the unavoidable conclusion that if the Bill was to be enacted, the legal stage would be set for private companies to be entitled to run much of the NHS and for market forces to determine the way many health services are provided.9
This is in entirely keeping with evidence recently published in the BMJ that the reforms will inevitably lead to further NHS privatisation and NHS asset stripping in England.10,11

Democratic legitimacy?
Also of major concern is the lack of democratic legitimacy for this bill. The 2010 Conservative Election Manifesto stated:
“More than three years ago, David Cameron spelled out his priorities in three letters – NHS”
This refers to the 2007 Conservative Party White Paper, NHS Autonomy and Accountability. Proposals for legislation12. The introduction was written by David Cameron and Lansley, which stated:
Improving the NHS is the Conservative Party’s number one priority....this requires an end to the pointless upheavals, politically-motivated cuts, increased bureaucracy and greater centralisation that have taken place under Labour..”
The document also states:
As part of our commitment to avoid organisational upheaval, we will retain England’s ten SHAs, which will report to the NHS Board (para 4.28)”, and “PCTs will remain local commissioning bodies.”

Professor Kieran Walshe also highlighted the fact that the Coalition agreement had specifically pledged to “stop the top-down reorganisations of the NHS that have got in the way of patient care13. He estimated costs of reorganisation between £1.8billion and £3 billion14.
The Liberal Democrat MP, Andrew George said that Lansley had "Torn up the agreement to resist imposing a top-down re-organisation" and Zack Cooper from the London School of Economics said: “The new health secretary campaigned on a pledge to eliminate top-down shake ups of the health service.  This white paper contradicts his campaign promise15

Colleges responsibilities
In light of the above evidence, we believe that the Royal Colleges should be taking a much more active role in opposing this bill and should publicly back the BMA’s call for the bill to be withdrawn. In fact, since the BMA represents over two thirds of all practising doctors in all branches of medicine16, is it not incumbent upon the Royal Colleges to support the BMA’s position?

Unfortunately, far from backing the BMA’s call for withdrawal of the bill, the AoMRC President, Sir Neil Douglas told the bill scrutiny committee that:
 “...there are so many disadvantages in delaying that we have to get on with it to the best of our ability now. We will not be able to give you definitive answers on detailed questions because our members have not had a chance to respond, but we will do our best and we believe that we should be going forward at the moment.”17

However, surely any perceived need to avoid delay, as expressed by Sir Neil Douglas, is entirely due to the insistence by both Department of Health and the government on beginning implementation of the reforms before parliament has given its approval. This is at best undemocratic and quite possibly unconstitutional. As in athletics, jumping the gun should result in disqualification!
In addition, the President of the Royal College of Surgeons, Professor Norman Williams has recently stated that the “College largely supports the aims of the reforms to modernise the healthcare system.”18

Considering the continued widespread professional opposition to the bill, these are worrying statements that could be interpreted as showing that the Colleges are out of touch with the views and concerns of the majority of grassroots doctors. The question must therefore be asked as to why the Colleges, with the exception of the RCGP, have taken this position.
One explanation may be found in the Government’s response to the Future Forum report, which secures a number of important roles for the Colleges in delivering and leading the reforms2. These roles include the establishment of close links with the NHS Commissioning Board (para 3.55), involvement in identifying the procedures most at risk of cherry picking (para 5.42) and prioritising work on Payment by Results (para 5.42)

Just as the Government has no mandate from the electorate to push through this bill, the Royal Colleges have no mandate from their Members and Fellows to help deliver and lead the reforms. In fact, it is unacceptable that the Colleges (with the notable exception of the RCGP) have not even surveyed the opinions of their members/fellows on such an important issue.

By taking this stance, not only are the Colleges failing to represent their members and fellows, we believe they also failing to safeguard their very own principles
One of the key roles of the Colleges is to “promote the underlying principles of medical professionalism and leadership”19
However, the last 20 years of NHS reform has seen medical professionalism and the public service ethos increasingly undermined and eroded by market based policies and ideology.  This is because neoliberal market theories, such as public choice theory, reject the idea of the public service ethos and view public service professionals as self interested “rent seekers” whose real purpose is to make money and legitimise monopolistic cartels 20. Professor Julian Le Grand (former health policy advisor to Tony Blair) noted how public choice theory had become influential under the Thatcher government from 1980’s onwards, and used the metaphorical model of  “Knights, Knaves, Pawns  and Queens” to describe how this had changed attitudes towards the motivations and behaviours of public service professionals. Public servants were increasingly viewed as essentially self-interested “knaves” rather than public-spirited altruists or “knights”, whereas service users were regarded as consumer “queens” rather than passive “pawns”. He argued that “Public policy should be designed so as to empower individuals: turn pawns into queens” with the ensuing logic that public services should be delivered through competition and consumer choice 21.
This is precisely what has happened at a policy level as evidenced by the following statements by former Cabinet Minister John Denham MP;  
“All public services have to be based on a diversity of independent providers who compete for business in a market governed by Consumer choice. All across Whitehall, any policy option now has to be dressed up as “choice”, “diversity”, and “contestablity”. These are the hallmarks of the “new model public service”22
and former Prime Minister, Tony Blair in his speech to the Public Services summit in 2004:
“It is only by transferring power to the public through choice, through personalising services, that we can create the drivers for continuous improvement in all our services.”23
             
The influence of public choice theory was a major factor in the rise of New Public Management (NPM) in the NHS (e.g the Griffiths Report, 1983), which favours narrow economic priorities and micro-management practices (e.g performance indicators, league tables, monitoring and centrally imposed targets) over professional judgment24.  Furthermore, relationships between medical professionals and patients depend on trust rather than contractual obligations and attempting to reduce the provision of healthcare to economic transactions erodes the intrinsic motivations on which the doctor-patient relationships depend25.
This strikes right at the heart of the social contract, which is fundamental to medical practice and professionalism. As Professor Kenneth Arrow recently stated about markets in healthcare “one problem we have now, is an erosion of professional standards” 26
It is therefore no coincidence that the American medical profession lost public support faster than any other profession during the rapid marketisation of the US healthcare system in the 1970/80s. 27

Another reason why medical professionalism is under threat is because it actually presents an obstacle to market reforms because doctors, especially GPs as the “gatekeepers”, control access to the healthcare system and exert control over the market through a combination of cultural authority on patients and political influence over policy making28. Doctors generally refer their patients to local services and prefer to work collaboratively to ensure the health needs of the local community are met. This form of collaboration is fundamentally anti-competitive in nature, and Professor David Marquand was therefore correct when he stated that public service professionals “are in a profound sense not just non-market, but anti-market29.
This clearly leaves Mr Lansley with a huge problem with his reform agenda because as he stated in a speech to the NHS confederation: “the first guiding principle is this: maximise competition…... which is the primary objective” 30
He also made it clear in the same speech that the way to maximise competition is to maximise the numbers of purchasers and providers in the system. This explains the thinking behind the policies of Any Qualified Provider and patient held budgets, and also explains why GPs are being given £60 billion of the NHS budget:
“The statutory formula should make clear that choice should be exercised by patients, or as close to the patient as possible, thereby maximising the number of purchasers and enhancing the prospects of competition, innovation and responsiveness to patients.” 30

Another serious problem for Mr Lansley is that it is now widely accepted that clinical leadership and clinical followership is crucial to successful healthcare reform31, but this clearly requires “buy in” from the profession, which relies on trust and a shared vision. However, a recent MORI poll of BMA members commissioned by the BMA clearly showed that doctors overwhelmingly think that pro-competition market reforms will be detrimental to patient care and will fragment services.32 Since markets also undermine  medical professionalism and the doctor patient relationship, Mr Lansley is hardly likely to gain much professional support for his reforms, which is precisely what we have been witnessing since the White Paper was published last year. In fact, New Labour’s market based reforms were also deeply unpopular and opposed by the BMA’s “Look After Our NHS campaign.” 33

The Colleges should also be very concerned about the effect of market reforms on medical training and standards. The profession has already suffered the Modernising Medical Careers (MMC) debacle, which can in part be explained by the influence of market based policies. MMC utilised a competency based tick box approach to training and it is important to note that Competency Based Training (CBT) originated in the 1980s and was a politically driven movement with the aim of making national workforces more competitive in the global markets by focusing on discrete technical skills with an emphasis on outputs, performance assessment, and value for money34.
Sir John Tooke’s report of MMC, Aspiring to Excellence, clearly highlighted MMC’s emphasis on achieving minimal standards rather than excellence35. A prescient editorial in the British Journal of General Practice described how the proposals for the establishment of PMETB:
“… are clearly intended to enable the Secretary of State of the day to direct that standards can be lowered to meet the manpower demands of the NHS” 36
MMC was clearly designed to produce a “fit for purpose” medical workforce in the new healthcare market. For example, the Department of Health website stated that MMC:
Focuses on the development of a flexible medical workforce....and....most importantly, will deliver a modern training scheme and career structure that will allow clinical professionals to support real patient choice” 37

Conclusion
The Health and Social Care Bill builds on the market based policies of previous Governments, and poses an enormous threat to the NHS, medical professionalism, the doctor patient relationship, and ultimately patient care.  It will put an end to the English NHS as a publicly funded, publicly provided, publicly accountable health service, which has served us so well for over 60 years and continues to do so38. These reforms are not just another episodic tinkering with the NHS, because independent expert legal opinion indicates that they will increase the likelihood of EU competition law being applied, which will effectively result in irreversible market based changes to the NHS.

So it is now more crucial than ever for the leaders of the Royal Colleges to join in with the chorus of opposition to the reforms to prevent the further marketisation and privatisation of the English NHS, which will be inevitable if the bill is enacted.  The bill cannot pass without the support of the medical profession. The Colleges have a rare opportunity to make a stand for the NHS, the medical profession, and patients. We therefore call upon the Academy of Medical Royal Colleges to act in the public interest by publicly calling for the withdrawal of the Health and Social Care Bill.

Finally, we would like to state that we acknowledge that the NHS is not perfect and that we favour its vigorous evolutionary development. The NHS has undergone constant change since its inception and this will clearly need to continue in order for the NHS to face up to the serious challenges of the future. However, this must involve meaningful discussion and consultation with all those who will be responsible for providing the service. It must involve full consideration of all options, not least the benefits of following the rest of the UK in abandoning the purchaser provider split and other market based policies, and pursuing a professionally led, collaborative approach to healthcare delivery based on trust, accountability, and the highest professional and ethical standards.

Medical professionalism cannot survive in the current commercialized health care market. The continued privatization of health care and the continued prevalence and intrusion of market forces in the practice of medicine will not only bankrupt the health care system, but also will inevitably undermine the ethical foundations of medical practice and dissolve the moral precepts that have historically defined the medical profession.” 39


Yours sincerely,

Dr Clive Peedell MRCP FRCR
Consultant Clinical Oncologist
Co-chair of the NHSCA

Dr Jacky Davis FRCR
Consultant Radiologist
Co-chair of the NHSCA

Dr Peter Fisher FRCP
President of the NHSCA


References:
4.      “Health bill changes fail to win over GPs, RCGP survey finds”. Pulse. 21st July 2011Available @:
5.      ‘Sir Roger Boyle: “It’s horrific that the NHS’s future is threatened”’. The Independent. Tuesday 26th July 2011.
6.      “A slice of Britain: Lib Dem guerrillas plot their next move”. The Independent . June 19th 2011. Available @: http://www.independent.co.uk/news/uk/politics/a-slice-of-britain-lib-dem-guerrillas-plot-their-next-move-2299731.html  accessed 1/9/11
7.      “Taxpayers will no longer 'bail out' failing NHS hospitals”. The Telegraph. 20/6/11. Available@: http://www.telegraph.co.uk/journalists/martin-beckford/8587176/Taxpayers-will-no-longer-bail-out-failing-NHS-hospitals.html accessed 1/9/11
10.  Peedell C. Further privatisation is inevitable under the proposed NHS reforms. BMJ 2011; 342:d2996
11.  Reynolds L. For-profit companies will strip NHS assets under proposed reforms BMJ 2011; 342:d3760
  1. HM Government. The coalition: our programme for government. Cabinet Office, 2010. www.cabinetoffice.gov.uk/media/409088/pfg_coalition.pdf
14.  Walshe K. Reorganisation of the NHS in England. Editorial. BMJ 2010; 341:c3843
  1. Lansley’s GP lottery. Public Finance.16/11/10 Available @ http://opinion.publicfinance.co.uk/2010/07/lansleys-gp-lottery-by-zack-cooper-and-john-van-reenen/
  2. http://www.bma.org.uk/about_bma/index.jsp
  3. Evidence to Public Bill CommitteeTuesday 28 June 2011.  Available@: http://www.publications.parliament.uk/pa/cm201011/cmpublic/health/110628/pm/110628s01.htm
  4. Personal correspondence with NHSCA, dated 17th August 2011
20.  Lowe R. The Welfare State in Britain since 1945. Macmillan, Houndmills. 1993
21.  Le Grand J. Knights, knaves or pawns? Human behaviour and social policy. J Soc Policy 1997;26:149–69
  1. Available @: http://www.chartist.org.uk/articles/labourmove/march06denham.htm
23.  Blair T. We should not shy away from radical reform. Speech to Guardian Public Services Summit, 29 January 2004.
  1. Bottery M. Education, policy and ethics. Continuum. New York, 2000
  2. Coates D. Reviving the Public: A New Governance and Management Model for Public Services. The Work Foundation. 2006}
26.  Interview with Kenneth Arrow: The Atlantic Jul 28 2009. Available @: http://www.theatlantic.com/politics/archive/2009/07/an-interview-with-kenneth-arrow-part-two/22279/
  1. Blendon R. “The public’s view of the future of medical care” JAMA 1988 259: 3587-3593
28.  Starr P. The social transformation of American medicine. Basic Books, New York.1982
29.  Marquand D. Decline of the Public. Polity Press 2004
30.  Lansley A. Extract from “The future of health and public service regulation” speech. 2005. Available @: www.andrewlansley.co.uk/newsevent.php?newseventid=21.
31.  Ham C. Engaging Doctors in Leadership. A review of the literature. Available @ http://www.hsmc.bham.ac.uk/work/pdfs/Engaging_Doctors_Review.pdf
  1. http://www.lookafterournhs.org.uk/
34.  Department of Education. Working together: education and training. London: HMSO, 1986
35.  Tooke J. and others. Aspiring to Excellence.  Findings and final recommendations of the independent enquiry into modernising medical careers. 2008.  HMSO (The Tooke Report) Available @: http://www.mmcinquiry.org.uk/
  1. Cox J. “The Medical Education Standards Board: castrating the Medical Royal Colleges? BJGP 2002. March; 179-180
  2. Department of Health website. Modernising Medical Careers. Available @ http://www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesandtraining/Browsable/DH_5835992
  3. http://www.bbc.co.uk/news/10375877
39.  Relman A S. Medical professionalism in a commercialized health care market Cleveland Clinic Journal of Medicine November 2008 vol. 75 Suppl 6 S33-S36

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