Monday, June 30, 2008

BMA position statement

Downloadable pdf.

Also the text of aletter from the BMA's patient involvment group:

Letter from Juliet Dunmur re. Privatisation of GP practices:

Dear Hamish

Privatisation of GP Practices

After comprehensive discussion by the members of the BMA PLG, I am writing to you about our fears as patients, and on behalf of patients, about the changes being implemented in the way General Practice in England is organised, funded and run.

Our concerns are based on the change from self-employed GPs and partner-led practices to market-controlled, profit-driven clinics; on the issues the DH has chosen to prioritise when commissioning and remunerating General Practice services, and in the way it has chosen to address these issues. We are apprehensive that these changes and the new focus of Government will lead to a decline in the quality of patient care for all patients in England.

The PLG has identified a number of major concerns, many of which we believe you will share, and also makes some proposals on what the BMA might do to address them. Our main concerns are:

The voices of older, less able, more ill and less vocal patients and carers are not being heard.

The current Government focus on longer opening hours masks and ignores the needs of many patients who, ironically, are the people who are more likely to be ill, make more use of NHS services and more likely to cost the NHS more if their needs are not addressed early on.

Opening hours is an easy goal to measure, cheap to provide and amenable to private providers. However, this focus gives the appearance that patients’ needs are being addressed while ignoring patients’ other needs and preferences. Evidence from the Picker Institute shows that continuity of care and confidence that your GP will act as your advocate are vital for patients, particularly those with long-term conditions, and elderly and disabled people. We are concerned that government is selectively focusing on objectives that serve their political goals and are pushing forward service redesign based on this, rather than on what patients want and need.

Our proposal is that the BMA should challenge the government to develop policies for providing general practice services that meet the needs of the all patients, using evidence from the Picker Institute.

The unilateral imposition of change, instead of flexibility according to needs in a particular area.

We are concerned that government is increasingly imposing a ‘one-size-fits-all’ pattern of service delivery instead of allowing local variation according to local need. The BMA often quotes the figure that 84% patients are content with practice opening hours. However, this overlooks the needs of some sections of the population for whom current opening hours are inappropriate, and who do not use General Practice as a result, giving the potential for ill health through late diagnosis and intervention. Similarly, the policy to compel every PCT to set up a polyclinic, regardless of what services currently exist in the area and their acceptability by and convenience for the local population, shows a blatant disregard for patients’ needs, and the needs of the general community served by general practices.

Our proposal is that more evidence of how GP practices are already being flexible, meeting the needs of local communities and engaging with their patients should be made more public. We feel there should be more public acceptance of variability of service provision in general practice by the BMA: promote the good practice and be open about the areas where it is not so good.

The new GP arrangements are a step backwards for community health and participation and a psycho-social approach to care.

The consolidation of GPs into large, anonymous clinics, and the move towards private companies running GP services is likely to lead to a significant reduction in the development of initiatives to involve local communities in improving their health. As Sam Everington has demonstrated, GPs who see themselves as much a part of the community as their patients and the other residents are more likely to make a commitment to that community and develop innovative means of improving public health. Those patients less likely to use conventional services, who are also of lower socioeconomic status, non-English speaking and who have long-term conditions are likely to suffer as a result of reduced community commitment from profit-led provider companies.

Moreover, care focused on fulfilling the minimum requirements of a low-cost tender and subsequent contract will almost inevitably lead to a more biomedical model of care rather than a rounded, medico-psycho-social approach that is accepted as necessary to improve health and encourage people to participate fully in their health care, their families, jobs and communities. The issue of increasing health inequalities needs to be made forcefully.

Our proposal is that the BMA should engage with patient and consumer organisations also concerned with health inequalities, offer your support to their efforts to make such needs known and campaign with their support. The voice of the powerful doctors’ organisation along with them would make a real impact.

GPs will lose even more clinical autonomy

We fear that GPs operating in new profit-driven and cost-sensitive private companies that are commissioned to run clinics and practices will have less autonomy to utilise their clinical training and judgement when offering care to their patients. Referrals to secondary and tertiary providers are likely to be even more curtailed than they are now through PCTs.

We also worry that these new healthcare corporations will not want their employees (GPs) to prescribe expensive drugs or treatments, even if the GP feels that it is the best decision in her/his clinical judgement. This scenario is likely to lead to a more widespread postcode lottery when it comes to referrals and treatments, and the gradual decline of clinical freedom as more ‘expensive’, clinically-led GP practices are replaced by profit-driven and cost-dependent corporate medical employees.

Travel and access to general practice

One reason why patients like a local GP surgery is that travel to them is short and easy, a particular concern for people with long-term conditions, older people and people with young families. The proposal for universal polyclinics is likely to take away this neighbourhood access and continuity of care. The RCGP’s recent briefing by their PLG sets this out clearly.

Our proposal is to join forces with the RCGP and their PLG on this. The RCGP has sent out some excellent factsheets on Lord Darzi’s review of the NHS which give an overview of the benefits of GP surgeries from both the doctors’ and the patients’ points of view.

In conclusion

We believe that services can be improved by building on the strengths of general practice: on personalised care; healthcare close to home in the heart of the community; co-ordination of care; GP practice teams able to deal with multiple conditions and integrate different types of care; aftercare for patients after discharge from hospital; lifelong care; prevention of illness.

At present patients have free access to their GPs under the NHS. We have seen what happened to NHS dentistry: when top-down measures were imposed on dentists, many abandoned NHS service completely and chose to work privately in order to provide the level of service they valued. This resulted in half a million people losing access to NHS dentistry since the government introduced reforms in April 2006, figures from the Information Centre suggest. Only 50% of all adults in England were seen by an NHS dentist last year; the rest either having to pay for their care, or going without any care. This has resulted not only in a two (three)-tier system but in a consequent build-up of health problems for those denied access to dental services, leading to the development of more serious conditions, and therefore extra distress for the patient and potential extra expense for the NHS. We do not wish to see this happen to access to general practice but fear the potential outcomes highlighted in this letter may leave few other options. This would be a tragedy for the NHS, especially as we celebrate its 60th anniversary.

We look forward to hearing from you, and are happy for you to circulate this letter or to quote from it as seems appropriate to you.

With best wishes,

Juliet Dunmur,
Chair BMA Patient Liaison Group

Darzi links

Not had time to read them yet (obviously, being a full time GP) but here are some links to the various documents.

The Report.

The Proposed Constitution.

A High Quality Workforce.

Friday, June 06, 2008

Louise Boden

An email has come to my attention. It is from Louise Boden, the Chief Nurse at UCLH, and so she is no longer a clinician at all of course, but a manager, paid for out of tax payers money.

The email is full of hyperbole and half-truths, insults and implications about GPs in general. It is really very insulting about GPs. She obviously is very jealous of us.

Here is the text:

-----Original Message-----
From: Boden,Louise=20=20
Sent: 06 June 2008 07:54
To: Divisional & Senior Nurses; Nurse/Midwife Consultants; Clinical Nurse
Cc: Heads of Nursing
Subject:Don't be fooled: this doctors' protest is all about profits, not patients

GPs are fighting the new polyclinics for the same reason they refused to join the NHS 60 years ago: to protect their businessThe British Medical Association has declared war on the government. Nothing new there, as the doctors' trade union sends out several press releases a day crying wolf about anything the government does. Next week is polyclinic protest week, with posters and leaflets in every GP practice encouraging patients to sign a petition doctors are taking to Downing Street.

The ideas of surgeon-turned-minister Lord Darzi mutated through various models - but finally emerged as 152 new clinics (London) or health centres of flexible size (everywhere else), which each primary care trust designs to suit its most needy area. But the BMA says they will "fragment care and destabilise existing services. Some surgeries may have to reduce services for patients while others could be forced to close." Scary warnings abound tha
t the era of the GP is over, bureaucracy will rule and your beloved local surgery will go the way of the post office. The BMA told PR Week it is digging into its war chest for a national poster campaign. The Conservatives have jumped on the Save Your GP campaign - something they may regret. So what's the problem the new clinics seek to solve? Although the nation's 8,500 GP practices do 90% of NHS work, hospitals take 80% of the cash. For decades
Labour and Tory governments have striven to get resources out of hospitals and back into the community, with more early prevention and less emergency repair. The other reason is to get a grip on bad GPs, which is difficult as they are private businesses. Most are good, but up to 15% are seriously inadequate - often single-handed practices in shabby premises in the neediest areas, in stark contrast with some of the most hard-working and idealistic GPs.

Polyclinics are only destined for London: elsewhere there will be health centres grouping several GP practices with new facilities. Lord Darzi's London model will be a hub around which are grouped existing local GP practices, often in the same premises - or new ones that fill in gaps. The hub will offer diagnostics and specialist clinics of all kinds; patients can walk in and see a GP, or be referred by their own GP. These clinics come with new
money from the centre and just two universal rules: they must be open from 8am to 8pm, and must see any patient who walks in. Does this sound like a threat or a promise? That may depend on whether you are a patient or a GP. It's hard to see a downside for patients. They will have access to a host of services nearby instead of in a distant hospital - and, joy of joys, at any time from 8am to 8pm. Where new health centres have opened recently - I
saw a beautiful one in Crewe - there has been a stampede of patients to join.

In one of their few firm policy commitments, the Conservatives seem to be making a bad error. They say they will stop the polyclinic and health centre programme - and, even more surprising, they won't make GPs open their doors outside office hours. Andrew Lansley, the shadow health spokesman, told Pulse magazine they would restore GPs' control over what hours they open, which oddly puts the Tories on the side of the union against patients' interests.However, the BMA draws its power from the trust people put in doctors but not in politicians, which may be why Cameron reckons he should hang on to their coat-tails as they march on Downing Street, pretending that "patient care will be damaged" whenever anything threatens their own terms of service. Cameron should ask Kenneth Clarke for his unfond memories of BMA tactics. Many decent doctors blench at the crude and dishonest shroud-waving
carried out in their name. The BMA fought tooth and nail against opening GPs' doors at hours to suit working people: the government won only a meagre three extra hours one evening a week, and no weekends. This is despite a 58% increase in pay when their brilliant negotiators pulled the wool over the eyes of John Reid and Alan Milburn - whose 2004 contract let GPs off all weekend and evening work for a puny =A36,000. (BMA negotiators could hardly believe it: they were expecting to lose =A315,000). The contract paid them if they hit 75% of their targets: they pretended that was tough but when they easily reached 92% they hit the jackpot. The National Audit Office said it cost =A31.78bn. Unsurprisingly, GPs have had no pay rise in the four years since, and that's part of the grumbling grievance behind this current campaign.

The BMA's petition to Downing Street will be shaped as a giant birthday card for the 60th anniversary of the NHS, so let's remember what happened back then. Aneurin Bevan failed to get GPs to the join the NHS, so they remain to this day private businesses. They have life-long contracts that can't be removed, with a guaranteed income, and large increments for doing things that should be part of their job. They own their businesses - and usually
their premises - and sell them on when they retire. As a result the NHS hasn't been able to ensure GP practices are spread to where they are needed most. The fact GPs are not direct NHS employees has always worsened inequalities in health provision as they congregate in richer, leafier spots. This BMA protest has nothing to do with patient care - and everything to do with jealously protecting what they see as a threat to their business model. So
it's hard to keep a straight face when the BMA scaremongers about "the threat to your surgery" from "commercial providers" who "will be more interested in their shareholders than patients". The BMA expresses indignation that more GPs might become directly employed by the NHS - but forgets to mention that a growing 35% of GPs are now directly employed by other GPs who meanly refuse to make them full partners in their businesses. Some contracts may
go to private providers - but the first has gone to a group of local GPs, and that is expected to be the model, except in rare cases. The new clinics will be built with various financial partnerships between the NHS, private funds and GPs' own investments. In the London borough of Camden and Derby, whole GP services have been contracted out to a private health company, causing consternation about creeping NHS privatisation - but these will remain the exception. In Camden the practices were already being run by the loca
l primary care trust and now open long hours, attracting more patients. But anti-privatisation campaigners are right to be wary: it is typical Gordon Brown triangulation that a mention of using the private sector has to be injected into everything to show he's a Blairite reformer at heart - as with this week's announcement that, as a last resort, failing hospitals could bring in private managers - though few expect it to happen: it was tried at Birmingham's Good Hope - and failed.

Of course polyclinics could go wrong. They could be underfunded and badly run. PCTs are not always good commissioners and could choose the wrong models in the wrong places. Clinics attracting patients may destabilise other practices - but frankly, that's the point. GPs who can't be bothered to join something offering new services for their patients are the very ones who may need a bit of destabilising. For all the fuss, London's 152 new clinics
will cover only 3% of GP services. But if they are half as good as promised, they may blaze a trail so that soon every patient will want one.

I will be passing this to the BMA as I suspect that a robust defence will be forthcoming (who am I kidding?!). There are many statements in this email which I suspect are not evidence based, for example that 15% of GP surgeries are seriously inadequate.

With colleagues like these, eh?

  • I have just discovered that this is a cut and paste job from Polly "I love Labour" Toynbee in today's Guardian.