The British Medical Association (BMA) has always been a trade union with elements of
professionalism on the edges. Its report this week on the NHS reforms was the work of unadulterated, self-serving trade unionism. Our modern
trade union leaders would have been embarrassed to publish it, even Bob Crow.
It tries to portray competition as the opposite of co-operation, when competition is the opposite of monopoly, in this case a public sector medical monopoly. Competition describes an arrangement under which teams of people co-operate with each other to find better ways of serving customers than rival teams of collaborators. The co-operation of which the BMA speaks is a weasel word for producer domination.
The BMA says it wants integration, which it also contrasts with co-operation. And here its argument is more subtle. There is a case for integration when the term refers to co-ordinated rather than episodic management of treatment. Doctors don’t always agree about either the diagnosis or the treatment and patients will often find it useful to rely on a single trusted adviser. But even so, integration is not the opposite of competition. When health care works well, the two go hand in hand.
The most familiar examples of integrated care, under which the work of GPs, hospitals, diagnostic services and long-term care are under unified management, are provided by American health maintenance organisations such as Kaiser Permanente. A now famous study in the British Medical Journal in 2002 found that Kaiser Permanente cared for a cross-section of the population similar to that of the NHS and that it provided services of a higher standard, while making efficient use of available funds. But Kaiser’s heartland is in California, where it faces intense competition from rivals who are trying to provide even better care within the insurance premiums that customers are prepared to pay. In other words, integrated care works best when there is competition.
The BMA is also hostile to ‘cherry picking’. The private sector, says the BMA, will only carry out routine operations that can be performed profitably and will leave the complex more costly operations to the NHS. Again there is a subtlety in this argument because the selection of easy cases is an obvious temptation. The problem arises when fixed payments are made for all procedures of a similar type. Most hernia repairs, for example, can be carried out within the fixed price available under the NHS Tariff, but some will cost more. The BMA assumes that private hospitals will be able to choose which hernia repairs they carry out and discard any patient who will cost more than the fixed price. But the NHS is in control of allocating patients and it is the simplest of tasks to stipulate in contracts with private hospitals that they must accept a fair spread of risks. David Bennett, head of Monitor, the body that will regulate contracts, has already said that he will prevent any self-serving selection of patients.
Moreover, under the 2011-12 NHS Tariff there is provision for price adjustments to be made for complexity and there is further provision for discounts to be negotiated for volume. A private hospital that took all the routine case, for example, could be expected to offer a significant discount. Any saving would stay within the NHS.
However, there is a lot to be said for giving only the routine procedures to private hospitals, above all because it avoids one of the great scourges of the NHS over the years, namely its habit of cancelling operations on the day, perhaps only a few minutes before they are due to take place. Often it’s because the surgeon has been called to deal with an emergency admission, but patients may have planned time off work, arranged for their children to be looked after, starved themselves for 24 hours only to find that their treatment has been put back by weeks. Well-run hospitals arrange for operations booked in advance to be carried out by doctors who are not on call to handle emergencies, precisely so that patients can be given reliable dates.
The BMA says that it is profoundly critical of the direction of travel being taken by the government, especially the ‘increased involvement of commercial interests and the active promotion of a market approach’. It strongly objects to foundation hospitals carrying out more private work. Any profits ‘generated from private practice should be reinvested into care of NHS patients’, says the BMA.
But hang on a minute, the BMA represents GPs who are mainly private sub-contractors to the NHS. The majority of GPs are self-employed and they take fees from the NHS. When their new pay deal was implemented in 2004 they increased their average income by about 30 per cent. In many cases they stopped providing an out-of-hours service because the government put a price on the service and many GPs decided that it was not worth getting up in the middle of the night for the fee being offered. They handed the service over to commercial companies that held contracts with primary care trusts. They were not squeamish about offloading the all-night service to private profit-making providers. And I can’t find any reference to the BMA calling for the 30 per cent increase in pay received by GPs to be reinvested in the NHS so that patients would not suffer.
Professionalism should not be used as a smokescreen for monopoly power. At its best, professionalism is compatible with competition. It is a kind of commercial brand based on a promise to patients that doctors have a code of ethics that requires them to hold each other to high standards. If it means anything at all, professionalism is a promise of accountability, but the BMA’s current strategy is to avoid accountability at all costs by preventing patients from having any alternatives.
David Green is Director of Civitas
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