Bevan's Run: January 2012

Tuesday, 31 January 2012

College antics and my motion for the Royal College of Radiologists EGM

Saturday, 28 January 2012

1/20 - How the autocrats of the Royal College of Surgeons let down the profession and the NHS

1/20 - How the autocrats of the Royal College of Surgeons let down the profession and the NHS

Tuesday 24^th January 2012 was a momentous day for the NHS. The Academy of Medical Royal Colleges (AoMRC),which is the umbrella organisation that represents the main 20 UK medical Colleges and Faculties, met to discuss the Health and Social Care Bill.

They had produced a joint statement that was leaked to the Guardian, which stated:

"The Medical Royal Colleges and Faculties of the AoMRC continue to have significant concerns over a number of aspects of the health bill and are disappointed that more progress has not been made in directly addressing the issues we have raised......"

"....unless the proposals are modified the academy believes that bill may widen rather than lessen health inequalities and that unnecessary competition will undermine the provision of high quality integrated care to patients.”

"The Academy is deeply concerned that the upheaval caused by the changes in the bill will distract the NHS from the huge task of meeting the current financial challenges."

"The Academy and Medical Royal Colleges are not able to support the bill as it currently stands”

This statement had been agreed by 19/20 of the organisations represented by the AoMRC. Only the Royal College of Surgeons of England (RCSE), led by Professor Norman Williams refused to sign the letter. This was expected to happen because despite having some concerns, Williams has been a longstanding proponent of the reforms, having previously stated that:

“The College largely supports the aims of the reforms to modernise the healthcare system”

Unfortunately, this lack of solidarity with the rest of the profession provided the chink in the armour of a united front of professional opposition to the bill. The 19/20 organisations backing the statement, soon collapsed to 0/20, triggered by the Royal College of Obstetrics and Gynaecology pulling out, and catalysed by a frantic Health Secretary ringing around the College Presidents to apply some hefty political pressure. The statement was never officially released.

This collapse in solidarity was a gift to Mr Lansley, and it was widely reported in the national media including BBC headlines: “Government escapes rebellion by medics over NHS”

This was possibly the moment when the NHS was lost to the English public, in terms described in the Lancet recently (Fulltext reproduced here). I am convinced that a united front of opposition from the Colleges would have been enough to finish off the bill. Many commentators suggest that the reality of the Parliamentary maths would suggest otherwise, but I would them to consider the following situation:

A press conference with the BMA, Royal College of Nursing, Royal College Midwives, and the Academy of Medical Royal Colleges, all sat together signing a letter opposing the Health and Social Care Bill and calling for it to be withdrawn. This would be absolutely devastating for Lansley. Cameron’s pollsters would be calling time on the bill. They are twitched enough about it already.

This is what is so disappointing. The bill had been brought to its knees by sustained campaigning and professional evidence based criticism, and just needed the Royal Colleges to deliver the final blow, as I have explained before. Instead, Norman Williams and his College of Surgeons performed life saving surgery on it. I’m sure Mr Lansley will be very grateful. The extent of this surgery can be seen by the RSCE’s press statement on their current position on the bill:

“The College believes that the Bill should be implemented without unnecessary delays, as otherwise procrastination, without an alternative cogent plan, will lead to further chaos and be to the detriment of patients.”

This position of the College is based the views of the College Officers alone, because they have not surveyed the opinions of their paying members and fellows. This is the autocracy of the surgical establishment in action. Why they would support such a bill is an interesting topic for discussion and I recommend this interesting blog article, which goes into some the issues.

Despite the complete lack of solidarity shown by the Surgeons to the rest of the medical profession, all is not lost. If we can get back to a situation where the majority of the Royal Colleges make individual statements about opposing the bill, this could actually be even more powerful. There is a big opportunity to put the surgeons out in the cold over this. If 19 Colleges signed a joint letter, there is no reason why this cannot happen again on an individual basis. In addition, the Colleges can hardly use the claim of being “apolitical” anymore, especially following the frantic antics of Lansley, and the desire of some College Presidents to meet senior Ministers for more discussions!

The process for this to happen is already in train. The UK Faculty of Public Health have had an Emergency General Meeting and voted overwhelmingly for the bill to be withdrawn. Since the Academy meeting, The College of Emergency Medicine has now stated that:

“The College of Emergency Medicine has significant concerns over a number of aspects of the Bill and is not able to support it in its current form”

The Royal College of Radiologists has now issued this statement, which said:

“Given our widespread concerns over many serious and as yet unresolved issues, The Royal College of Radiologists cannot support, and must continue to oppose, the passage of the Health and Social Care Bill in its current form”

It has also called for an Extra-Ordinary General Meeting of Fellows to debate the bill and form policy.

The Royal College of Physicians has also been forced to have an Extra-Ordinary General Meeting by it Fellows and will be making a statement next week.

Other ordinary College fellows and members are working on the Colleges too. A College lobbying website for members and fellows has also been set up.

Next week is going to be a big week for the NHS. The damage caused by the Royal College of Surgeons of England can be repaired, but only if the other Colleges wake up the reality that the bill is unamendable. They must realise that they cannot support this bill, especially when the issues surrounding Clause 1 and related Clauses have not been resolved, and the risk register is being held back. I have been campaigning against this bill for a long time and have witnessed Lansley use every trick in the book to force this bill through. The so called “major concessions” on the bill so far are mainly cosmetic and simply do not protect the NHS from increasing commercialisation and privatisation. There is simply too little Parliamentary time to allow for proper scrutiny of more concessions because of the complexity of the bill. The true meaning of any new changes and their knock on effects with other parts of the bill can take weeks to sort out. In addition the potential for unintended consequences is much greater with complex legislation.

So it is now time for the College Presidents to stand up for the public interest, the NHS and patients. They should listen to the majority view of the medical profession, and the views of the academic health policy community, and call for the bill to be withdrawn. It is too dangerous for the NHS to allow this bill to pass into law.

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.”

Academy of Medical Royal Colleges

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 withdrawn”³.

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:

'It is horrific that the NHS's future is threatened'⁵

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 legislation”¹². 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 care”¹³. 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 promise”¹⁵

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 cartels²⁰. 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-market” ²⁹.

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.³²Since 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 excellence ³⁵. 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.

We leave the College presidents to ponder the words of Arnold Relman, Professor Emeritus of Medicine and Social Medicine at Harvard Medical School and former editor of the NEJM, who recently lamented:

“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

http://www.nhsca.org.uk/index.html

References:

1. Available @: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127443 accessed 1/9/11

2. Available @: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf

3. Available @: http://www.bma.org.uk/healthcare_policy/nhs_white_paper/latestnhsreformstatement.jsp accessed 1/9/11

4. “Health bill changes fail to win over GPs, RCGP survey finds”. Pulse. 21st July 2011Available @:

http://www.pulsetoday.co.uk/newsarticle-content/-/article_display_list/12436518/health-bill-changes-fail-to-win-over-gps-rcgp-survey-finds

5. ‘Sir Roger Boyle: “It’s horrific that the NHS’s future is threatened”’. The Independent. Tuesday 26^th July 2011.

6. “A slice of Britain: Lib Dem guerrillas plot their next move”. The Independent . June 19^th 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

8. Shirley Williams’ speech to the NHS Confederation Conference. 8/7/11. Accessed: 1/9/11. http://www.libdems.org.uk/speeches_detail.aspx?title=Shirley_Williams%E2%80%99_speech_to_the_NHS_Confederation_Conference&pPK=fb31954a-12ee-4832-82f5-e61fa65ed5ea

9. http://www.dutytoprovide.net/

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

12. http://www.conservatives.com/pdf/NHSautonomyandaccountability.pdf

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

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/
http://www.bma.org.uk/about_bma/index.jsp
Evidence to Public Bill Committee. Tuesday 28 June 2011. Available@: http://www.publications.parliament.uk/pa/cm201011/cmpublic/health/110628/pm/110628s01.htm
Personal correspondence with NHSCA, dated 17^th August 2011

19. http://www.rcplondon.ac.uk/about/mission

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

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.

Bottery M. Education, policy and ethics. Continuum. New York, 2000
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/

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

32. Available @: http://www.bma.org.uk/healthcare_policy/nhs_white_paper/moripoll2011members.jsp

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/

Cox J. “The Medical Education Standards Board: castrating the Medical Royal Colleges? BJGP 2002. March; 179-180
Department of Health website. Modernising Medical Careers. Available @ http://www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesandtraining/Browsable/DH_5835992
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

Saturday, 21 January 2012

The NHS is in the hands of the Medical Royal Colleges

The recent decision by the Royal College of Nursing (RCN) and the Royal College of Midwives (RCM) to come in line with the policy of the BMA to oppose the Health and Social Care Bill and call for its withdrawal, was a defining moment. Andrew Lansley’s desperate attempts to claim that this was all political and related to the ongoing pensions saga clearly highlighted how serious a blow this was to his plans. This was further emphasised by the offering of further concessions on the bill as reported in the Health Service Journal.

The announcements by the RCN and the RCM were also a defining moment for the Medical Royal Colleges, who are represented by the umbrella organisation, Academy of Medical Royal Colleges (AoMRC), chaired by Professor Sir Neil Douglas.

Suddenly, the Medical Royal Colleges find themselves in a position where they are the key players in the future passage of this bill and the future of the NHS. They are the last remaining big players representing frontline NHS professionals who remain on the fence regarding the bill. They represent the frayed fibres of a damaged rope rubbing against a rock, which Lansley is desperately clinging to for survival, as he hangs over a cliff edge. If the Colleges came out against the bill, then those final fibres would finally be severed and Lansley and his bill would fall. Even though the Government has a majority in both Houses, their public credibility would be shot to pieces if they went against a united professional coalition of the BMA, RCN, RCM, Unison, Unite and the AoMRC. It is inconceivable that the coalition would try to enact such a flawed bill against such powerful professional opposition, whilst simultaneously holding back the Risk Register. It would be a PR disaster of the highest order.

In addition, one of Lansley’s three key stated principles underpinning his reforms is “empowering frontline health professionals”. United opposition from the medical and nursing professions would make a mockery of this claim, sending a clear public message of distrust in Mr Lansely and his bill.

So the future of the NHS really does lie in the hands of the Medical Royal Colleges – and they know it. Following the RCN and RCM announcement, my own College (the Royal College of Radiologists) sent out an unprecedented urgent e-bulletin about the Health and Social Care Bill. In the bulletin, the RCR President, Dr Jane Barrett, stated:

“Next week could be a defining period for the Colleges’ views on the Health and Social Care Bill”

This refers to a number of meetings that will be going on behind the scenes next week.

The Colleges must act during this crucial week, and they must act in the interests of their members and fellows, which means calling for the withdrawal of this highly unpopular, ideological and flawed bill. They have not acted in this way to date, and they cannot continue to use the excuse that they are apolitical to remain on the fence. After all, the President of the Royal College of Paediatrics and Child Health, Professor Terence Stephenson, is a member of the Government appointed Future Forum. Furthermore, the Chairman of the AoMRC, Prof Sir Neil Douglas has already given evidence to the Bill scrutiny committee and stated that:

And Norman Williams of the Royal College of Surgeons has stated (without a mandate from his fellows) that the:

“College largely supports the aims of the reforms to modernise the healthcare system.”

In addition, the Government’s response to the Future Forum report secures a number of important roles for the Colleges in delivering and leading the reforms. 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, there is a solid argument that they have a clear mandate to oppose the bill, because the majority of members and fellows of Colleges are also members of the BMA, which has been mandated to oppose the bill and call for its withdrawal by its members. It is also unacceptable that the Colleges (with the notable exceptions of the RCGP and RCPsych) have not even surveyed the opinions of their members/fellows on such an important issue.

The Colleges had already been warned about the bill in an open letter from myself and well over 100 high profile co-signatories. They failed to act decisively at that point. They have another chance and they must take it. Otherwise they could end up sharing the same legacy as the Liberal Democrats in colluding with a bill that will see the demise of the NHS.

All doctors who belong to Colleges and want this bill withdrawn must now write to their Presidents ASAP. They must be made to feel the strength of opinion that is out there on the frontline.

The other fundamentally important point is that the organisations calling for withdrawal of the bill should not back down, even if Lansley offers “significant” concessions. He is simply not to be trusted. He is after all a man who has said there would be “no top down reorganisations” and “no NHS privatisation”. The bill is far too complex and there is too little time to properly assess the impact of any new concessions. For example, the independent legal opinion on the Secretary of State’s duties and powers took weeks to put together. At this late stage, the only safe option for the NHS is for the bill to be withdrawn.

We can will this battle, but we must stand firm.

If you are a doctor, please lobby your college here

Tuesday, 17 January 2012

"Let's be 'avin' you!"

Bevan’s Runners message to NHS and health leaders - “Let’s be ‘avin you”

The last day of Bevan’s Run started just after 8am on a frosty morning in Beaconsfield, with the aim of doing a 6 hour marathon to get into Whitehall by about 2pm.

At Uxbridge we were joined by “Dave the Ambulance Man”, who had come all the way from Bognor to do the last 18 miles with us. He is a member of the GMB union and you’ve guessed it - an Ambulance driver! He was very concerned about the bill and its negative effects on the NHS and local services. He said he was frustrated by the unions and was looking for leadership so he could do more to fight the bill. I shared those frustrations when thinking of the medical leaders from the Royal Colleges (with the exception of Clare Gerada from the Royal College of GPs). We felt that the unions and colleges had failed to show the leadership that grassroots members were yearning for to help fight against the bill. There had been too much focus on a “staying in the tent” approach with an associated complicity, which becomes counter-productive when dealing with such ideologically driven proposed legislation. Any form of support for such an unpopular bill is seized upon by the politicians and their media machine, to drive the agenda forward.

I told “Dave the Ambulance Man” about my recent open letter to the Royal College Presidents (co-signed by over 100 doctors ) calling for the Colleges to act in a united front against the bill. They did make a response, but it was a weak response and fell well short of agreeing with BMA policy, which is to call for withdrawal of the bill and to oppose it in its entirety. This is particularly frustrating because the BMA represents about 70% of all doctors, so will also represent the majority of College members and fellows too. I believe that it is disgraceful that the Colleges, (bar a couple of exceptions like the RCGP and RCPsych) have failed to survey the opinions and views of their paying members/fellows on such an important issue – an issue that resulted in the BMA calling for its first emergency Special Representative Meeting (SRM) to debate the bill in 20 years.

Not only did “Dave the Ambulance Man” help me through “the wall” with a very well timed bag of “Skittles”, he also gave me the impetus to once again challenge the Colleges to come out much more actively against the bill. In addition, it also became clear that the leaders of other health unions, like the Royal College of Nursing (RCN), Unite and Unison, also need to show greater leadership to their members and show a lot more fight to defend the NHS. Their campaigns and public statements have not been big or bold enough thus far.

“Bevan’s Run” may now be over, but our fight to defend the NHS and try and stop the Health and Social Care Bill must go on. The NHS is too important to be destroyed by such a flawed, undemocratic and ideologically driven bill.

So the Bevan’s Runners message to Professor Neil Douglas, President of the Academy of Medical Royal Colleges; Dave Prentis and Karen Jennings of Unison; Len McClusky of Unite; and Peter Carter of the RCN is:

“Cahm on. Let’s be ‘avin’ you”

Dave the Ambulance man, a million NHS workers and many millions more members of the public, need you to stand with the NHS Consultants’ Association, BMA and the Royal College of GPs to call for withdrawal of the bill and organise a huge public rally in defence of the NHS. It is in the national interest for you to do this.

So do it together and do it now.

Saturday, 14 January 2012

Final day Details for Bevan's Run

We have now completed 5 days of Bevan's Run after a tough 25 mile slog from Wheatley to Beaconsfield. The initial plan was to stop at High Wycombe, but we took a decision 2 days ago to push onto to Beaconsfield in order to make the last day more manageable in terms of timings of arrivals at the Department of Health.

On the final day of Bevan’s run on Sunday 15^th January, we will be setting out from the Travelodge hotel in Beaconsfield at 7.30am.

Anyone that wants to join us should meet in hotel lobby at 7.20am at latest.

We will be running to Central London via Uxbridge and will follow the A4020 Uxbridge Road to Shepherd’s Bush and the join the A402 Baywater Road, running to Hyde Park on the northern side. We would welcome Hyde Park runners to join us anywhere along Bayswater road by Hyde Park (ETA approx 2pm, but subject to variation! Speakers Corner would be good place). We can also meet people in Uxbridge, who are keen to run a bit further. A good meeting place would be on Hillingdon Road next to the Cemetry, adjacent to Brunel University).

I will be tweeting all day regarding our location.

We will then head towards Whitehall via Park Lane, Constitution Hill, Birdcage Walk, Great George Street, and finally onto Parliament Street and Richmond House.

Dr David Wilson and I will then deliver “Bevan’s Postcard” to the Department Health.

This will be followed by short speeches from myself, Professor Ian Banks (President of European Men’s Health Forum, BMA Council), Dr David Wrigley (GP from Lancashire, BMA Council), Dr Jacky Davis (co-chair NHS Consultants’ Association, BMA Council), Dr Lucy Reynolds (Research fellow LSHTM) and Professor Allyson Pollock (Queen Mary, University of London). I hope to also have an important mystery guest speaker (TBC)

Finally, David and I will run the short distance to Downing Street, to deliver another “Bevan’s postcard” to No 10. (Permission requested)

Hopefully, the following Monday morning Mr Lansley and Mr Cameron will then withdraw the Health and Social Care Bill!