This list is not exhaustive!
1. The profession and the public were lied to.
Cameron’s speech at 2006 Conservative party conference:
“No more pointless and disruptive reorganisations”. Instead, he said that change would be “Driven by the wishes and needs of NHS professionals and patients”
Liberal Democrat MP, Andrew George, of the Health Select Committee, said that Lansley had
"Torn up the agreement to resist imposing a top-down re-organisation"
Thus, trust was destroyed from the off, and it got worse.......
2. Much of the reform was implemented before the bill was even enacted and then used to justify support for the reforms! Cameron and Lansley repeatedly claimed that the uptake of pathfinder GP Consortia was evidence of widespread support, despite the fact that GPs were desperately trying to fill the hole left behind by the disintegration of PCTs. This was perfectly summed up by Dr Laurence Buckman, chair of the BMA GPC who said that:
“Getting into the lifeboats is not the same as supporting the sinking of the Titanic.”
3. The case for radical change to the NHS was not made. The Government’s arguments were consistently demolished by the evidence.
Doctors accept the NHS is far from perfect, but it is still a highly performing and highly cost effective healthcare system in comparison to other countries. It has recently enjoyed its highest ever public satisfaction rates
A good summary of Government myths about the need for change can be found here
There is also good evidence that large reorganisations of the NHS have failed to improve the service and are not cost effective
The bill seems to fulfil the conclusion that “reorganisation often seems to be pursued in the absence of good evidence”
4. The legislation will result in increasing marketisation and privatisation of the NHS
This has been made clear in this explanation by Richard Blogger and also via papers in the BMJ:
BMA policy, which is decided by members at the Annual Representative Meeting (ARM) has shown consistent opposition to NHS privatisation and marketisation
5. Doctors believe that competition within the new healthcare market will fragment services, increase inequalities and damage patient care. A MORI poll conducted for the BMA clearly showed this (Full report)
Since Lansley’s first guiding principle was to “Maximise competition”, this was clearly at odds with the profession’s view!
Various Royal Colleges and Medical Societies also made clear statements about the potential for harm to patient care by these reforms eg the Faculty of Public Health stated that:
“the Health and Social Care Bill, if passed, would damage the NHS and the health of people in England......we are now calling on the government to withdraw the bill in its entirety because it would be in the best interests of everyone's health”
6. The massive reorganisation of the NHS at a time of NHS austerity (ie £20 billion QIPP “savings”) was considered to be an irresponsible act. This was well put by Dr Graham Winyard, who resigned from the Liberal Democrats health team because of their support for the reforms:
"It is just not sensible to impose this top-down reorganisation on an NHS struggling to meet the biggest financial challenge in its history. To continue to do so in the face of near unanimous opposition from patient, staff and professional organisations simply invites slow-motion disaster both for the NHS and for the party."
7. Market driven medicine leads to deprofessionalisation. In fact, market theory in the form of public choice theory rejects professionalism and the public service ethos. Public servants are viewed as rent seeking knaves. Professor James Buchanan of the Virginia School of public choice theory is on record as saying that the public service ethos does not exist. This ideology formed the basis of Julian Le Grand’s influential Knights, Knaves, Pawns and Queens analogy, which led to the rejection of the “Trust” or professional model of healthcare delivery, in favour of the citizen-consumer choice market model. Paradoxically, this view of medical professionals as “rent seeking, knavish” self-interested agents of business, feeds on itself. In the United States, where the commercialisation of medicine exists in its most extreme form, the American medical profession has lost public support faster than any other professional group. (Blendon R. JAMA 1989).
Public choice theory and marketisation of healthcare are key reasons why the medical profession has been under attack for the last 30 years. Doctors are clearly a problem to the proper functioning of the market and must be disempowered. The market clearly cannot function if doctors focus on collaboration rather than competition and build local services through local referral patterns. Professor David Marquand was correct when he stated that public service professionals are “in a profound sense, not just non-market, they are anti-market”. Hence the need to control doctors, which is precisely what the reforms do. Hence GPs were forced into consortia, and the rules of the system mandate that patient choice is paramount. So the idea that clinicians will be empowered is pure folly.
8. Education and Training wasn’t even part of the Bill. In the context of the discussion of public choice theory and markets above, it is not difficult to see why. Medical education and training has been under attack for a long time. New Labour’s introduction of Modernising Medical Careers (MMC) was one of the biggest scandals in medical history. It was clearly designed to produce a “fit for purpose” medical workforce to suit the needs of employers in the new healthcare market. MMC utilised a competency based tick box approach to training. 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 money. Sir John Tooke’s report of MMC, Aspiring to Excellence, clearly highlighted MMC’s emphasis on achieving minimal standards rather than excellence.
A prescient editorial in the British Journal of General Practice described how the proposals for MMC:
“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”
9. The idea that illnesses, diseases and their treatments should be traded as commodities in a market is abhorrent to most doctors in the UK. Most doctors see medicine and the delivery of frontline healthcare as a vocation and a public good, not a hard-nosed business. The idea of profiteering out of a public service is rejected by doctors because it undermines the doctor-patient relationship. This is why the BMA GPC rejected the idea of the Quality Premium, which would result in payments to GPs who hit financial targets.
10. The bill was driven by ideology, not evidence. This speech by Andrew Lansley is compulsory reading for all those who want to understand his motivations and ideas. This reform was about replacing the collectivist structure of the NHS with an external market, which will inevitably lead to a mixed funding system. We will see increasing out of pocket costs to patients and increased uptake of healthcare insurance. The legal basis of the founding principles of the NHS has been removed by the Act. The profession did not want this and the public did not vote for it.
Oops! I forgot number 11 (Just like Lansley, Milburn, Clarke and many others over last 20 years) :
The representative groups of all the major healthcare professions (eg BMA, RCN, RCM) have been excluded from the health policy making process. The exclusion of the BMA is well described in this excellent BMJ piece by Professor Rudolph Klein. Politicians prefer to trust the opinions of managment consultants from the likes of McKinsey and KPMG rather than frontline clinical professionals. This is because they share a belief in market driven healthcare. However, this has only served to alienate the health professions from the political class, which has been a disaster for the NHS, because research has clearly shown that clinical leadership and followership is crucial to any successful healthcare reform. How can this be possible when ideologies are poles apart and trust has completely broken down?
It is crucial that policy makers and politicians re-engage with the professional representative groups, but this will only be possible if they abandon their unevidenced pro-market ideology. We need to return the NHS to a publicly funded, provided and accountable health system. Anyone who says this is unaffordable should look at the evidence. It is a matter of choice, not affordability. It's time to listen to the NHS consultants, not the management consultants.
Finally, a quote from Arnold Relman, Emeritus Professor of Medicine, Harvard Medical School. (Former editor of the New England Journal of Medicine).
This nicely sums up why doctors rejected Lansley’s reforms:
“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”.