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

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