Friday 30 December 2011

Bevan's Run update

The main aim of Bevan’s Run is to protest against the Health and Social Care Bill and raise public awareness of the threats the bill poses to the future of the NHS.
The opponents of the reforms have quite legitimately received criticism for being too negative and not offering any alternative solutions for the NHS. However, many opponents of the reforms do in fact have many ideas to help improve the NHS, which are not based in market ideology. The Scots and the Welsh have abandoned the purchaser-provider split and these are models that the English NHS could adopt. However, an interim position would need to be adopted if the bill is blocked. The chaos created by the reforms even before the bill has been enacted needs to be addressed and NHS stability would be the first priority. This is in keeping with the views of 20 health policy academics
Clearly, a new plan for the NHS cannot be written by an individual. This requires input from health policy experts, economists, DH officials, NHS stakeholders, politicians etc. However, I certainly think a broad outline plan can be put up for debate and that is what I intend to do.
I will therefore post a broad outline of a way forward for the NHS on this blogsite on the last day of Bevan’s Run (Jan 15th).
The BMA has also been asked by Council members to produce a new alternative vision for the NHS. I would hope to update about this too.

In the meantime, my focus is going to be on raising awareness of why this bill is so bad for the NHS and the nation. Over the coming days I will be blogging about market failure, the role of politics and the 3 main political parties in NHS reform, the meaning of privatisation and political lying, and the revolving doors culture of the NHS. There will even be a piece about the need for the medical profession to own up to its own failings on the NHS!

I will also be focusing on preparing for the run, which is taking a lot of organisation, including getting physio for my shinsplints, which are now much better!
We are currently short of a support driver for the first 2 days, so if anyone fancies helping out from Monday evening (Cardiff) to Wednesday afternoon (Tetbury), the please get in touch by email

We are still working out the best route, but the current plan is as follows:

Day 1 (Tuesday 10th Jan): Cardiff to Chepstow (Travel Lodge, off M48. English side of Severn Bridge)

Day 2 (Wednesday 11th Jan): Chepstow to Tetbury

Day 3 (Thursday 12th Jan): Tetbury to Burford

Day 4 (Friday 13th Jan): Burford to Oxford (Wheatley), stopping off at Witney at 11.30am for rally. Meet at Church Green off the High Street. We will then march down the High Street to deliver “Bevan’s Postcard” to Cameron’s Conservative Party constituency office. We then head off to Oxford and aim to get the village of Wheatley. I’m giving talk in Oxford at the Friends meeting House in St Giles, Oxford in the evening at 7.30pm.

Day 5 (Saturday 14th Jan): Oxford (Wheatley) to High Wycombe

Day 6 (Sunday 15th Jan): High Wycombe to London (Richmond House, Whitehall). We aim to get to Richmond House at about 2-3pm. We will publish route soon, but anyone that wants to join in could meet us in Uxbridge. (Details of meeting point to follow). We will post Bevan’s Postcard to Department of Health. Might also have time for speeches.

Tuesday 27 December 2011

Postcard from Bevan's Runners

One of the main reasons for doing Bevan's Run is to raise public and professional awareness about how the Health and Social Care Bill will lead to increasing privatisation and commercialisation of the NHS, thus further undermining the founding principles of the NHS. The bill is close to being enacted (likely to happen at the end of March 2012) and the coalition nature of Government means that the Government has a majority in both Houses of Parliament. It therefore seems inevitable that this bill will become law, and campaigning and protesting may seem like a waste of time to many. However, I strongly believe that this bill is such a threat to the future of the NHS, that it is vital to continue to apply pressure to this Government through the democratic process. Public opposition to this bill from professional bodies and campaigners has already achieved a great deal including an unprecedented "pause" in the passage of the bill, and crucially a historical record that this bill was widely seen as flawed and a threat to the future of the NHS. However, despite some changes to the reform agenda following recommendations from the Future Forum, the key clauses in the bill that will result in further NHS privatisation and marketisation remain intact. The fight to defend the NHS must therefore continue and this must be focused on raising public awareness and public pressure on the Coalition partners. It is clear that any government that messes with the NHS (especially when recent evidence suggests it is more popular than ever and performing very well), will run into trouble and it is well known that David Cameron and Nick Clegg have serious concerns that these reforms will damage their respective parties as well as their personal political legacies.

Anuerin Bevan famously stated that the NHS:
 “will last as long as there are folk left with the faith to fight for it”

That is why Bevan’s Run will be personally delivering a postcard from Bevan’s statute in Cardiff to Mr Cameron’s constituency office in Witney and Mr Lansley at the Department of Health in London, calling for the Bill to be withdrawn.

The postcard and text are below:

Dear Mr Cameron and Mr Lansley,

We write to ask that you withdraw the Health and Social Care Bill on the following grounds:
1. If enacted the bill will inevitably lead to increasing NHS privatisation and commercialisation, which will further undermine Bevan’s founding principles of the NHS.
2. The reforms lack democratic legitimacy. This is clearly a major top down reorganisation, with abolition of PCTs and SHAs and the creation of a regulated competitive external market, which will see an end to the NHS as a publicly funded and publicly provided healthcare system. This was not in your election manifesto, not in the coalition agreement, and not what the public voted for at the last General election.
3. The bill lacks professional support. The BMA and RCGP have both publicly called for the bill to be withdrawn, despite the fact that one of the key principles underpinning the reforms was supposed to be clinician empowerment, with GPs at the heart of the reforms. The message from the medical profession could not be clearer in that these reforms are seriously flawed and will be detrimental to the future of the NHS and patient care. Since there is strong evidence that clinical leadership and followership are fundamentally important to successful healthcare reform, this raises serious questions about your decision to plough on with the reforms in the face of such medical opposition.
4. The NHS is under unprecedented financial pressure and coupled with the £20billion QIPP efficiency savings agenda, massive reorganisation of the NHS at this time carries a high risk of service fragmentation and failure. There is evidence that some of the major changes that have already taken place on the ground are threatening service stability, even before the legislation has been enacted. The reforms will also drive up costs due to the increased bureaucracy and administration of the new healthcare market and the drive to turn patients into “consumers” of healthcare through the choice agenda.
5. Market driven healthcare systems erode professional values and the public service ethos, which is the glue that sticks the NHS together.
6. The NHS is one of the greatest achievements in modern British political history. Public satisfaction with the NHS is at an all time high according to the latest British Social Attitudes survey. The NHS is also one of the most highly performing and cost effective healthcare systems in the world, especially when it comes to equity and access to healthcare. The NHS logo has become one of the most powerful brands in the UK, carrying over 95% recognition among the general public, and very strong levels of credibility, authority and trust.
We accept the NHS is not perfect and also accept the need for continued evolutionary improvement and reform due to the changing healthcare needs of the aging population and advances in medical technology. However, the case for such massive change and reorganisation of the NHS as legislated by the Health and Social Care Bill has not been made. The bill is seriously flawed and should be withdrawn. In the words of the deputy Prime Minister, Nick Clegg: “No bill is better than a bad bill”.

We are certain that Anuerin Bevan, the founder of the NHS, would be appalled by this bill and we wanted to show our strength of opinion by personally delivering these postcards from his statue in Cardiff. 

Yours sincerely,
“Bevan’s runners”
Dr Clive Peedell
Co-chair NHS Consultants’ Association
BMA Council and Political Board
Consultant Clinical Oncologist
Dr David Wilson
Consultant Clinical Oncologist

Monday 19 December 2011

Why Lansley’s market driven reforms are doomed to fail - the problem of Clincial Leadership and Followership

Without doctors, attempts at radical large-scale change were doomed to fail.”

“The essence of clinical leadership is to motivate, to inspire, to promote the values of the NHS, to empower and to create a consistent focus on the needs of the patients being served”
Department of Health, 2007

Over the last several years it has become widely accepted that clinical leadership and clinical followership are essential to successful healthcare reform. Under the previous Government, the Darzi Next Stage review stated that:
Clinical leadership is a topic central to the success of the health service.”
A recent report by the NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges (AoMRC), Engaging Doctors, highlighted a review of the Clinical Leadership literature by Ham and Dickinson and concluded that:
Without doctors, attempts at radical large-scale change were doomed to fail.”
This review also concluded that effective leaders require followers to implement change. The development of ‘followership’ is therefore just as important as the development of leadership.

Clinical leadership is arguably now even more important considering the current reforms have supposedly put clinicians at the heart of the reforms. The NHS leadership website states:
“Effective clinical leadership is critical if we are to achieve an NHS that genuinely has the quality of care at its heart.......With the economic challenges facing the NHS, it is imperative that frontline clinicians have the leadership skills to drive through radical service reform”

The development of effective clinical leadership is dependent on clinical engagement, which in turn requires trust, shared values, and a shared vision of the direction of NHS reform. However, the last 20+ years of NHS reform has seen all 3 main political parties in England support a market based vision for public service delivery.  The Labour MP and former cabinet minister, John Denham summed this up well :
"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""
Yet this pro-market vision is the antithesis of what medical professionalism is about. Eliot Friedson stated that medical professionalism was underpinned by an ideology that assigns a higher priority to needs based work rather than to economic rewards. It focuses on the quality and social benefits of work rather than its profitability. Thus medical work is totally unsuited for control by the market or by government or business. [1]

Medical professionalism also presents an obstacle to market reforms because "medical sovereignty" exerts control over the market through a combination of cultural authority on patients and political influence over policy making [2]. Doctors control access the healthcare system and allocate resources. The recent BMA MORI poll confirmed that most doctors want to work collaboratively rather than in competition, and most GPs and patients want to use their local incumbent providers as long as they provide good care.
I therefore subscribe to the view of Professor David Marquand, who stated that public service professionals “are in a profound sense not just non-market, but anti-market”[3]

This all poses a huge problem for Mr Lansley’s pro-market reforms, because his first guiding principle is to “maximise competition.....competition is the primary objective”.
This is why the proposed legislation has aimed to enforce the market on doctors through the powers of Monitor and compulsory membership of GP Consortia for all GPs.

Another key issue surrounding market based reforms and medical professionalism is a concept in market theory called Public Choice Theory. This theory uses methods in economics to analyse the behavior of public officials/servants, who are viewed as "utility maximisers" or "rent-seekers" driven by self interest rather than the public interest. Public Choice Theory rejects the idea of public service professionalism and the public service ethos, and views market competition with increasing use of provide providers as necessarily the route to greater efficiency in public service delivery.  Julian Le Grand's work in this area using the "Knights, Knaves, Pawns and Queens" metaphor has been particularly influential favoring this approach in policy making [4]. Public Choice Theory was also major factor in the rise of New Public Management (NPM), which favors narrow economic priorities and micro-management practices (e.g audit, inspection, performance indicators, league tables, monitoring and centrally imposed targets) over professional judgment [5].

Yet another key point about markets is that they undermine the social contract between doctors and patients and damage the doctor patient relationship, because decision making becomes increasingly based on financial concerns rather than patient needs. This was well summed up by David Coates from The Work Foundation in 2006:
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 depend
It should therefore come as no surprise that the American medical profession lost public support faster than any other profession during the rapid commercialisation of the US healthcare system in the 1970/80s [6]. This was also recognized by Professor Kenneth Arrow in a recent interview with the Atlantic:
One problem we have now, is an erosion of professional standards

Thus, the chair of the BMA General Practitioners Committee, Dr Laurence Buckman, quite rightly rejected the idea of performance related bonuses ("Quality Premiums") for GP Consortia. He stated at the recent BMA Local Medical Committees conference that:
"We will not agree to anything that gives patients the slightest perception that we might be making money out of reducing care to patients. This is utterly unethical"

It is absolutely clear that market based reforms and the medical profession do not sit well together, and therefore it’s not surprising that there has been a sustained political attack on the medical profession associated with the pro-market reforms of the last 20-30 years. This has included exclusion from the policy making process, the rise of New Public Management, loss of self regulation, and control over training and education through the Modernising Medical Careers debacle. No wonder why the BMA keep saying “No”!

So this brings me back to the crucial issue of clinical leadership and its importance in the success of healthcare reform. There is clear evidence that a shared vision is vital to the effective clinical leadership:
“Leadership is ineffective if doctors are not in agreement around a vision for the organisation, and physicians’ expectations of their practice life are incompatible with what change requires of them.” [7]
Since market based reforms undermine medical professionalism and the very essence of what it means to be a doctor, how on earth can doctors share the same pro-market vision as Lansley and the other pro-marketeers of the past 20+ years?
This quote from Professor Arnold Relman, former editor of the New England Journal Medicine, sums up the situation nicely:
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.”

I believe that deprofessionalisation and worries about the corrosive effects of privatisation are one of the main reasons why Lansley’s reforms are so unpopular and why there is so much medical opposition. This is why he will never get the medical profession on board and behind him. A few GP enthusiasts will not be enough to deliver the clinical leadership and followership required for successful reform. The reforms are therefore “doomed to fail”. The sooner he realises this and withdraws the bill, the better. In fact, the sooner policy makers from across the political spectrum realise that delivering medical care is incompatible with markets, the better. There will never be effective NHS clinical leadership/followership and successful NHS reform, until the failed market based policies of the last 20+ years are abandoned.

[1] Eliot Friedson Professionalism Reborn: Theory, Prophecy and Policy, 1994.
[2] Starr P. The social transformation of American medicine. Basic Books, New York.1982
[3] Professor David Marquand. Decline of the Public. Polity Press 2004
[4]. Le Grand J. Motivation, Agency, and Public Policy. Of Knights, Knaves, Pawns and Queens. OUP 2006
[5] Bottery M. Education, policy and ethics. Continuum. New York, 2000
 [6] Blendon R. "The public's view of the future of medical care" JAMA
1988 259: 3587-3593
[7] Silversin, J. and Kornacki, M.J. (2000) Leading Physicians Through Change, American College of Physician Executives: Florida

Saturday 17 December 2011

United professional opposition can stop the bill through “Toxification” of the Tories and LibDems

It’s clear that as things currently stand, the Health and Social Care Bill will be enacted in the spring of 2012 because the coalition Government has a Parliamentary majority in both Chambers. Ironically, if the Conservative party had won an outright majority at the last election, the bill would have almost certainly been blocked or very significantly amended, because the Liberal Democrats would have been in opposition and that would have meant that LibDem Peers in the House Lords would have been much more likely to vote against the bill. As Michael White, assistant editor of the Guardian, recently explained in an excellent article on House of Lords reform:
“David Cameron's rose garden pact with Nick Clegg has changed the maths. With 170 Tory and 88 Lib Dem peers (the 153 crossbenchers often split 50/50) the coalition partners usually have a de facto majority over Labour's 238. No one party was supposed to have one in the half-reformed system bequeathed by Tony Blair, but no one planned for coalition. Government defeats are down to around 15%.”

Whether it was intentional or not, the Tories also played a political ace card by putting through the legislation on student fees right at the beginning of the coalition. This was a fatal blow to the Liberal Democrats, because they lost public support and credibility from the off, as well as losing grassroots members. The Liberal Democrats are now utterly dependent on remaining in coalition to keep their political power and influence alive, because they will be wiped out if the coalition splits and a general election is called. This means playing second fiddle to their Tory masters, who are showing increasing confidence to push forward their own agenda without fear of reprisal. David Cameron’s recent EU veto is the latest example of the Conservative party increasingly exerting its power in the coalition. In fact, the longer it goes on, the weaker the Liberal Democrats become and the less able they are to break free. The Liberal Democrats are like a patient on intensive care being kept alive by a Conservative party ventilator.

Thus, a coalition Consevative-LibDem Government couldn’t have been a worse outcome for supporters of the NHS. We have already seen how, firstly, Liberal Democrat MPs and then LibDem Peers have towed the party line in the Commons and the Lords to support the coalition Government. Even Baroness Williams, a supposed defender of the NHS, has voted for the Government, abstained, or gone “AWOL” from the House of Lords on important Health bill debates and votes.

As for Labour party opposition, they lack the numbers and they lack credibility on the NHS. Many of Lansley’s polices are simply an extension of Blairite New Labour pro-market, pro-privatisation policies. Make no mistake, though, Lansley wants to go much further and much faster than New Labour intended. Unfortunately, Labour’s credibility gap has not helped in the Parliamentary debating.

For those that oppose the bill and stand for a NHS that is publicly funded, publicly provided, and publicly accountable, this is all very worrying and depressing as there doesn’t seem to be a way to defeat the bill through the traditional political processes. However, there is still a possibility that the bill can be defeated and the key to achieving this is through a united front of opposition from the key medical professional representative organisations. This is because one of the three key stated principles of Lansley’s reforms is “empowering frontline health professionals”. Thus, if the medical profession rejects the bill, it would send a clear public message that Lansley’s key principles are not credible, effectively signalling a vote of no confidence in the bill and the Government’s handling of the NHS. Public confidence in this Government on the NHS, which is already at a low ebb, would collapse. The NHS is already running in to huge problems because of the current financial situation and the £20 billion QIPP efficiency saving programme.

If the bill goes through and the NHS fails, the Conservatives would not get back in to power for a generation, and it would be much worse for the Liberal Democrats! So the Government would ignore a united professional front at their peril. 
The key alliance that could scupper the bill is the BMA and the Royal College of General Practitioners (RCGP). The BMA already has a policy position of calling for the bill to be withdrawn and opposing the bill in its entirety. The RCGP holds a very critical position of the bill, but has stopped short of officially calling for the bill to be withdrawn. This may be surprising considering the fact that the RCGP survey showed that 75% of RCGP members supported the BMA position for the bill to be withdrawn. It is interesting to note that a motion to call for the bill to be withdrawn was actually put to RCGP Council recently, but the motion was blocked from being voted on because of a technicality (which a prominent GP member of the Future Forum was responsible for pointing out). However, despite this setback, I believe the RCGP has still got a clear mandate from its members to call for the bill to be withdrawn based on its own surveys, and also the fact that the majority of RCGP members are also BMA members.

The RCGP is the absolute key to all of this because Lansley has stated that GPs are central to the bill, and General Practice is where most of the NHS budget will go. GP “buy in” is therefore fundamental to the bill’s success. So if GP’s aren’t on board, the bill is not viable.
Although the majority of GPs are BMA members, opposition from the BMA alone is not enough. Whenever the BMA disagrees with the Government, it is labelled as a self interested Trades Union organisation, which supports the vested interests of its members rather the interests of patients and patient care. However, if the RCGP with its 40,000 GP members, came out shoulder to shoulder with the BMA to call for the bill to be withdrawn, this would be the killer blow.  Royal Colleges usually try and stay out of politics and the RCGP couldn’t be accused of having vested interests in the same way as the BMA. Such united professional opposition from such key organisations would raise alarm bells in the public perception of the bill and the criticisms of the bill being flawed, chaotic, ideological and driving NHS privatisation, would start to hit home.

Unlike the 2010 election, the NHS will be a key battleground in the 2015 election and being seen to be “toxic” on the NHS by the public is precisely what the coalition will fear most. They will need to back down or face the consequences. It is quite conceivable that the bill could be held up in the Lords and effectively stopped from going through. This would provide the coalition with a “respectable” way out from this mess. It is therefore vital for opponents of the bill to call for united professional opposition to the bill. The more healthcare professional organisations that join in the better, but in reality the RCGP and the BMA would be enough, simply because of the pivotal role of GPs.

United opposition will result in the “retoxification” of the Tory brand on the NHS. The LibDems, who are equally guilty, will be equally “toxified”.
The “toxification” of political brands is the key to saving the NHS. So one of the key aims of Bevan’s Run is to call for and campaign for united opposition to the Bill, in order make the coalition government’s NHS policies as publicly “toxic” possible. This is how the NHS can be saved from this bill

Tuesday 13 December 2011

Campaigning against unpopular NHS reforms: Debunking the “Kenneth Clarke” myth

As co-chair of the NHS Consultants’ Association and a member of BMA Council it is clear that the vast majority of medical politicians that I meet share the same concerns about the coalition Government’s plans for increasing privatisation and marketisation of the NHS. However, there is also a clear divide in opinion of how best to address these concerns and counter the damaging effects of these unpopular reforms. The key argument for taking the more conservative approach of “critical engagement” rather than the more militant “outright opposition”, is that it is crucial to stay in the “tent” to retain influence and remain at the negotiating table in order to achieve positive changes and minimise the most damaging aspects of the reforms. Withdrawing from the tent will simply leave room for other less savoury organisations to dictate, whilst organisations like the BMA will simply be sidelined.
I have been struck by the number of times that this argument is also accompanied by discussion of the BMA’s 1989 “Kenneth Clarke” campaign. The story goes that the BMA lost influence because of it’s campaign against the Working for Patients White Paper, which introduced the internal market and purchaser provider-split. There were two BMA Special Representative Meetings (SRMs) during this period that called for a campaign against the NHS reforms, which resulted in the infamous slogan:
What do you call a man who ignores medical advice? Mr Clarke”.
(A fascinating account of this campaign can be read in Dr John Marks' (BMA Chairman at the time) book chapter here, which includes pictures of some of the campaign leaflets!)

Despite the campaign, the bill was still enacted, and it is said that this campaign was the main reason why the BMA has been excluded from policy making ever since. This campaign “failure” has become the mantra of those who think that aggressive campaigning will only damage the BMA. However, it is important to set the record straight on the Ken Clarke episode because it has been misrepresented and misunderstood. It is a total myth that the "Ken Clarke poster" froze out the BMA from future involvement in contributing to health policy. The actual historical facts can be found in this article by Professor Rudolph Klein - "State and Profession: Politics of the double bed"  BMJ 1990), which is a must read

Klein wrote that the 1989 White paper:
was the first time in the history of the NHS that the medical profession was systematically excluded from the decision making process leading up to the review; an exclusion which may perhaps explain the subsequent bitterness rather more than actual policy content.”

The exclusion of the BMA therefore came before any campaign, and the exclusion was in fact a major reason for the “Ken Clarke” campaign. Klein describes this well:
“Indeed, the BMA's subsequent advertising campaign served largely to advertise the fact of the profession's exclusion. It drew attention to the profession's loss of privilege: in happier, corporatist days the profession had its own direct and private links with civil servants and ministers -an iron triangle of consultation that turned out to be made of cardboard in the 1980s.”

Klein’s analysis is in keeping with Nigel Lawson’s autobiographical account in “The View From No 11”. (Lawson was of course Chancellor of the Exchequer at the time). On page 614 of his book he described how a new review group to develop the NHS reforms would:
need to be small and entirely internal. The professionals, once they knew it was going on, would not be backward in giving us the benefit of their advice – and, more fruitfully, we could always get the opinions of politically well-disposed practitioners informally”

There were only seven people on this review group, which included Thatcher, Lawson, John Major and Roy Griffiths (the former Sainsbury’s chairman and author of 1983 Griffith’s report). They met for a year before Kenneth Clarke published the outcome in the January 1989 White Paper, Working for Patients.

So it is clear that the BMA was excluded right from the beginning and it’s exclusion from the policy making process had nothing to do with the “vitriolic” Ken Clarke campaign. However, this myth has persisted and I believe that it has actually contributed to a lack of similar action from the BMA ever since. Lawson states in his diaries that “The opposition from the BMA, once so strident and vituperative, is now little more than a wimper”
This year’s emergency BMA Special Representative Meeting about the current reforms was actually the first one since the Ken Clarke era.

I also think it is important to understand that the profession was left out because a key plank of the Working For Patients reforms was about diminishing the power and autonomy of doctors. This is important for market based reforms, because markets cannot function well in the framework of a powerful professional bureaucracy (more of this in a future blog). Since market reforms have dominated the last 20 years of policy making, I believe that this is actually the most important reason why the BMA and other healthcare professional groups have been largely excluded from the policy making process.

Although Thatcher’s conservative party got their reforms through, it is important to note that the opposition from the BMA did actually have some lasting impact on the Tories, who were rendered "toxic" on the NHS. The last White Paper of the Tory administration, A Service with Ambitions (1996), was remarkable for its lack of mentions for markets and its promotion of partnerships instead. (See Ian Greener’s book: Healthcare in the UK, p 103). However, Greener goes onto to say:
"Clarke still created an important principle that policy makers almost routinely follow today - that it is not necessary to consult organised doctor groups when planning NHS reform" (ibid, p108)

What we are seeing at present is in keeping with Greener’s analysis. There is no chance that the corporatist days are going to come back, whilst we have a marketisation/privatisation agenda on the table. The BMA has been ignored right from the start and the Government has recruited it’s own medical professional advice from smaller unrepresentative organisations like the National Association of Primary care (NAPC), which I’m sure Nigel Lawson would label as today’s “politically well-disposed practitioners”.

Now that the Ken Clarke myth has been put to the “double bed”, and it is clear that the BMA has so little influence on policy making, I believe there is every reason for the BMA to fight a hard and aggressive campaign against Lansley’s NHS privatisation bill. There is nothing to lose and everything to gain. Moreover, the BMA has been given the mandate to oppose and campaign against the bill by its ruling Council, and this is what it must do if there is any chance that we are going to save the NHS.
The BMA should also note that it gained an extra 2,000 members during the Ken Clarke campaign (and only lost 20!)

Friday 9 December 2011

How Lansley duped the professions into “supporting” his reforms.

The Health and Social Care Bill has been hugely controversial and has faced significant criticism from across the health sector. There was even an unprecedented “pause” of the reforms. Despite this, the bill continues on its course through the Parliamentary process largely unchanged (in terms of it’s key purpose to increasingly privatise and marketise the NHS), and its architect, Andrew Lansley remains in post. A key reason that the bill has got this far is that although there has been a lot of criticism, there has not been a united front from the health professions calling for the bill to be withdrawn. The British Medical Association is the only major organisation that has called for withdrawal of the bill, and now opposes the bill in its entirety. So how has Lansley managed to avoid total opposition from other NHS stakeholders?

A key reason is that Mr Lansley was very careful to make sure that the White Paper, Equity and Excellence: Liberating the NHS, (which preceded publication of the Health and Social Care Bill) contained key Motherhood and Apple Pie principles to gain and claim support, and deflect criticism from the main NHS stakeholders.

These crucial Motherhood and Apple Pie principles of the reforms can be found in the Foreword of the White Paper, which was co-signed Lansley, David Cameron and Nick Clegg.
There are 3 main principles of the reforms:

First, patients will be at the heart of everything we do. So they will have more choice and control, helped by easy access to the information they need about the best GPs and hospitals. Patients will be in charge of making decisions about their care.”

Second, there will be a relentless focus on clinical outcomes. Success will be measured, not through bureaucratic process targets, but against results that really matter to patients – such as improving cancer and stroke survival rates.”

Third, we will empower health professionals. Doctors and nurses must to be able to use their professional judgement about what is right for patients. We will support this by giving front-line staff more control. Healthcare will be run from the bottom up, with ownership and decision-making in the hands of professionals and patients.”

Who could possibly disagree with “putting patients first”, a “focus on clinical outcomes” and “empowering health professionals”. And that is the key point. These principles are designed to be very powerful rhetorical devices that state one thing (which is hard to argue against) but can actually mean something completely different. In the case of “putting patients first” and having “more choice”, this is a mechanism designed to increase competition in the new healthcare market. A market cannot work without choice and competition. In the case of measuring “clinical outcomes”, this is also key to the functioning of the market, because in order to choose services between different providers of services, patients need the information to do so. It’s a way of countering the problem of information asymmetry in healthcare markets. Finally, the idea of “empowering health professionals” is just as much about devolving power and responsibilities away from the Secretary of State. The reforms will lead to healthcare rationing and eventually a mixed funding system, so it will be clinicians (GPs) that will be held accountable, not the Secretary of State. This is why Clause 1 of the bill (and its associated clauses) on the duties and powers of the Secretary of State for health are so crucial.

The powerful political rhetoric of these 3 principles certainly registered with the Medical Royal Colleges and the Royal College of Nursing, who made the following press statements following publication of the White Paper to support these key principles:

The Academy of Medical Royal Colleges stated:
The Academy shares the Government’s vision for the NHS, as set out in the White Paper. In particular we welcome:  

The clear commitment to putting the needs of patients and the public first
The use of improved health outcomes as the driver and measure of success
The empowerment and engagement of clinical healthcare professionals.”

The RCN stated :
“The principles on which the proposed reforms are based – placing patients at the heart of the NHS, focusing on clinical outcomes and empowering health professionals – are both welcome and supported by the RCN.”

Furthermore, as late as 6th of September 2011, despite being critical of the reforms, even the BMA stated public support for these 3 principles in a joint letter to the Times with Peter Carter (RCN), Clare Gerada (RCGP), Professor Cathy Warwick (Royal College of Midwives), Professor Sue Baliey (Royal College of Psychiatrists), Phil Gray (Chartered Society of Physiotherapy) and Peggy Frost (British Association of Occupational Therapists):  
"We support a vision of healthcare that is patient focused, clinically-led and based on outcomes."

The following day, in Prime Minister’s Questions, David Cameron took full advantage when he told the Commons:
"now you've got the Royal College of GPs, the physicians, the nurses, people working in the health service supporting the changes we're making"
This was disputed, but the damage was already done.

Furthermore, Andrew Lansley then used this in defence of his no confidence vote at the RCN conference.

So, these 3 core principles which were made clear in the foreword of the White Paper have served Mr Lansley and the coalition very well. It is imperative that leaders of the professional health organisations take more care in understanding political rhetoric. Once again the political class has run rings around a politically naive medical and nursing establishment. They need to wake up now and defend the NHS, before it’s too late.
The RCN, RCGP, Royal College of Midwives, and other professional organisations should sign a joint statement with the BMA as soon as possible to get this bill withdrawn.

Wednesday 7 December 2011

BMA Inside Story: NHS privatisation is the main reason why BMA are opposing the Health and Social Care Bill

The BMA has just released a briefing about why it has decided to abandon the bill. The key statement is the following:
"The BMA has a single objective in relation to the Bill - which is for it to be abandoned"

The proposers of the motion that lead to this change in BMA policy were Dr Jacky Davis and Dr David Wrigley. They are crystal clear in their reasons for proposing such a motion and have stated that it was because "the bill will clearly lead to increasing NHS privatisation and marketisation, and the Govermment will not compromise on these aims"
This is a particularly important motion, because as I have explained in my previous blogpost, the government have repeatedly denied that there will be NHS privatisation. This motion shows that the BMA does not believe the misleading claims of Government.
It is time the public were informed that this bill is a NHS privatisation bill and that is one of the key purposes of Bevan's Run.
Dr Lucy Reynolds, a former accountant and now a research fellow in health policy at the London School of Hygiene and Tropical Medicine, couldn't have put it more clearly, when she stated:
“I used to work as a City accountant in the 1980s. I know a privatisation Bill when I see one. This is a privatisation Bill”.

The Health and Social Care Bill is a complicated, incoherent mess in terms of health policy. However, it actually makes perfect sense in terms of the Government's supply side economic policy, where the aim is to replace large swathes of the public sector with the private sector. It is a very clever piece of legislation. The key policies that will deliver this are the mutually reinforcing policies of choice and competition, Any Qualified Provider (AQP), payment by results (PbR), patient held budgets, Foundation Trust freedom and abolition of private patient cap, and crucially the "abdication" of the Secretary of State's duties and powers to provide a comprehensive service. This is why the bill is unamendable. These key policies are the red lines on both sides, but the Coalition Government has the majority in the Commons and the Lords. There can be only one winner and this is why the NHS is in such grave danger.

So those who care about the NHS as a publicly funded, publicly provided and publicly accountable healthcare service must continue the fight against this bill and apply as much pressure to the political class as possible. The key is to inform the public that the Government is privatising the NHS. This is what the Tories and Lib Dems fear most. NHS campaigners need to call for a united front from the key NHS stakeholders, who need to show the courage to back the BMA on this issue. This united professional front is the only possible way to inform and help the public understand what is happening to their NHS. If we continue along the line of “trying to make the best of it”, the NHS will be destroyed by Lansley's market.

Bevan's Run is about uniting professional opposition to the bill and raising public awareness about this anti-NHS bill.
Please support Bevan's Run
Please sign the epetition and please donate to Keep Our NHS Public

Monday 5 December 2011

Why Friday the 13th January will be a nightmare for David Cameron

Bevan’s Run will pass through Witney on Friday 13th of Jan 2012. This is an ideal opportunity to pile the pressure on David Cameron, who is ultimately responsible for the Health and Social Care Bill. Despite all the controversy over the reforms, he has publicly backed Mr Lansley.
The Health and Social Care Bill has become the new poll tax for the Conservative Party. They have re-toxified themselves on the NHS and are terrified that the public will find out about their privatisation agenda. They have handled this situation by taking a position of repeated denials of NHS privatisation on the premise that if you say something enough times, people will acually start to believe you. These denials have come from Andrew LansleyNick Clegg and of course Mr Cameron.
In fact, Mr Cameron recently stated on BBC News that “there is no privatisation taking place”
Please note in the clip that he also used term “customers” instead of “patients”!
Furthermore, in his recent speech on exporting and growth on November 10th, he went off message and stated “From the Health Secretary, I don’t just want to know about waiting times. I want to know how we drive the NHS to be a fantastic business for Britain.”

The Department of Health website also states that “Health Minsters have said they will never privatise the NHS”. Moreover, the Government response to the Future Forum report, states it will rule out “any question of privatisation” and on page 43 there is a subheading entitled “Ruling out privatisation”

As I have recently explained in a BMJ article, Mr Cameron and the Government are misleading the public because privatisation is an inevitable consequence of the reforms. Independent legal opinion also supports this notion. There is also solid evidence that the reforms will lead to NHS asset stripping.  This is all in keeping with Government supplyside policy to replace large swathes of the public sector with the private sector. Dr Max Pemberton, columnist from the Telegraph, gives another good example here.

The Bill may be completely incoherent from a health policy perspective, but it makes perfect sense if privatisation is a key priority. This is a key reason why Mr Lansley wants to "abdicate" his repsonsibilites as Secretary of State for Health, because public provision and commissioning of services will be increasing taken over by the private sector and it will be the economic regulator (ie Monitor) that oversees this.  

The evidence that Mr Cameron and the coailtion government are misleading the public about NHS privatization is overwhelming and they need to be exposed on this issue.
So on Friday the 13th of January 2012 when Bevan's Run (hopefully) reaches Witney, I will stop off to give a public speech to the local people to explain how their MP is privatising the NHS. I hope this event can be turned into a demonstration with the help of NHS campaigners joining in to fill Witney town centre.
I will be also be delivering a postcard from Bevan’s statue to David Cameron’s constituency office explaining how the bill will increasingly privatise the NHS and that therefore the bill must be withdrawn because there is no democratic mandate for such action.

I therefore call on NHS workers and members of the public to help make Friday the 13th a nightmare for Mr Cameron and the Coalition government by exposing their misleading denials about NHS privatisation. 

Saturday 3 December 2011

Training going well, but doesn't make up for fact I'm a marathon virgin!

I have a confession to make. I've never run a marathon before!
However, I've been running regularly for a couple of years and doing much longer distances over the last few months. The furthest I've run is 18miles, but I'm building up stamina nicely.
Over the last 3 days I've done 3 half marathons (14miles, 16miles and 14 miles). Apart from feeling achy, my 39 year old body is holding up well.

I'm under no illusions how tough this run is going to be and I'm training hard for it. There is a long way to go to get fit enough for this run, but if I stay fit and healthy and take the correct advice, I will give it my best shot.
Thanks for all the very supportive comments and e-mails so far.

I'll post some political stuff soon, but the key political blogs will come during the run itself fro maximum impact.
I'll also share some campaigning ideas that I'm finalising at the moment. 

Thursday 1 December 2011

Welcome to the Bevan's Run blogsite!

Welcome to the Bevan's Run blogsite!

My name is Clive Peedell and I am Consultant Clinical Oncologist working for the NHS in the North East of England.
I am co-chair of the NHS Consultants' Association and a member of BMA Council and BMA political board. I have been an active campaigner against NHS privatisation and market based reforms.
I believe that a publicly funded, publicly provided and publicly accountable NHS is the most cost effective and equitable way to deliver healthcare to our nation's population.
This aim of "Bevan's Run" and the associated Bevan's Run blogsite is to raise public awareness about the serious threats that the coalition Government's Health and Social Care Bill poses to the English NHS. These threats were well summarised in a recent article in the Lancet: 

“The proposals are ideological with little evidential foundation. They represent a decisive step towards privatisation that risks undermining the fundamental equity and efficiency objectives of the NHS. Rather than “liberating the NHS”, these proposals seem to be an exercise in liberating the NHS’s £100 billion budget to commercial enterprises”
Professor Margaret Whitehead et al, Dept of Health Inequalities and Social Determinants of Health, University of Liverpool.  The Lancet, Volume 376, Issue 9750

All the key NHS stakeholders have expressed serious concerns about the proposed NHS reforms. The BMA has a policy of calling for the bill to be withdrawn and opposes the whole bill. A recent survey of GPs by the Royal College of General Practitioners showed that three quarters want the bill to be withdrawn.
In addition, a group of over 400 public health doctors recently wrote an open letter to the House of Lords arguing that the bill will cause “irreparable harm to the NHS, to individual patients, and to society as a whole,” that it will “erode the NHS’s ethical and cooperative foundations,” and that it will “not deliver efficiency, quality, fairness, or choice.”

Despite this widespread opposition to the proposed reforms, the bill is continuing its passage through Parliamentary process and is likely to be enacted in the Springtime of 2012. It is therefore imperative that the public are informed about what is happening to the NHS, so they can apply pressure to Members of the House of Lords and the House of Commons to stop the passage of the bill.

Anuerin Bevan, who spearheaded the establishment of the NHS in 1948, famously stated that the NHS "will last a long as there are folk left with the faith to fight for it"
In recognition of Bevan’s words, I will be running the 160 miles from Bevan's Statue in Cardiff to the Department of Health, Richmond House, in London over 6 days in protest against the Health and Social Care Bill.
I am very grateful to Dr David Wilson (a fellow Consultant Clinical Oncologist) who as an accomplished long distance runner, will be accompanying me on the journey.