Health and Social Care Bill

Memorandum submitted by Dr Franz Schembri Wismayer (HS 137)


This submission considers changes to the role of GPs in allocating resources to individual patients as a result of proposals in the Health and Social Care bill in the context of changes in health policy since 1990. It draws on research into clinicians perceptions of their roles in resource allocation decisions at the time of the introduction of the internal market to the NHS in 1990. It concludes that the proposed changes in policy are likely to undermine the trust that has enabled the public to see their GP as acting largely in their interest resulting in pressures which together with the extension of the role of the market is likely to lead to an inequitable provision of healthcare, which is unlikely to be politically acceptable, and an increase in overall costs. It argues for the rejection of the restructuring proposed in the Bill and for the considered development of health policy building on gains made in the last decade and seeking public approval as well as genuine consultation with professional groups.

1)I am a member of the Royal College of Psychiatrists and have 18 years of experience

as a doctor in the NHS, 16 in the field of Mental Health. I studied for a BSc in Medical Sociology in 1989/90, taking a first, when I researched philosophical, ethicist’s and clinician’s, and health policy perspectives on the microallocation of resources (the allocation or prioritization of particular patients to particular therapeutic or diagnostic interventions) in the NHS in the context of the white paper "Working for Patients" introducing the internal market. I interviewed consultants from a broad range of specialties in a London teaching hospital including a number of local GPs regarding their perception of and responses to problems raised by microallocation in their practice, and how these might be affected by changes in health policy.

2) I found that the problems presented by microallocation decisions extended across all

specialties including General Practice in addition to life saving specialties such as ITU bed allocation and selection for organ transplantation in which they had previously been studied. Most doctors interviewed perceived substantial tension between their roles as advocates for the patient and as societal allocators. Nearly all felt non-medical factors entered into their allocation decisions, frequently feeling the decisions were not legitimated by "medical judgement". Most felt the dual role of advocate and allocator was becoming more difficult and was not maintainable. Responses suggested that doctors were willing to sacrifice a degree of clinical autonomy, being in favour of external input into allocation decisions. Views regarding the impact of the white paper included concerns regarding "buck passing" by the government and identified a challenge to clinical autonomy.

3) The NHS has historically provided a nominally comprehensive service for a relatively

low cost in terms of GDP. The "deal" has been that the government put in a limited pot of funding "at the top" while clinicians have rationed healthcare covertly on the basis of "clinical need". In return for not complaining too loudly about the size of the pot, they enjoyed largely unchallenged clinical autonomy. In this implicit rationing system doctors were often not explicitly aware of their role perceiving themselves primarily as patient advocates. In the late 1980s in the context of increasing developments in medical technology, increasing public expectations of healthcare, and some real limitations in resources, healthcare professionals precipitated the perception of a healthcare system in crisis, often going public with examples of cases vividly illustrating the consequences of resource limitations. Pushed to act the Conservative government proposed the purchaser-provider split and the introduction of the internal market.

4)The impact of The NHS and Community Care Act, 1990, was limited by strict central

control of competition preventing politically embarrassing consequences of efficiency gains such as hospital closures or inequalities in access to services. The balance of power however between managers and healthcare professionals did shift, managers gaining greater influence over clinical work. Under New Labour individual GP fundholding was abolished and PCTs took control of budgets, maintaining the purchaser-provider split. Greater third party control of allocation decisions became a reality and the creation of NICE enabled a relatively transparent assessment of the effectiveness and cost-effectiveness of new treatments and technologies facilitating a public debate over decisions whether to fund them and reducing geographical inequalities in provision. There followed a period of unprecedented investment in the NHS coupled to targets, rewards and sanctions, as well as the development of the market with the creation of foundation trusts and the introduction of a wider diversity of providers as well as payment by results. There has been considerable debate about the impact of these changes.

5)The circumstances of the 2011 Health and Social Care bill are different. The NHS has

enjoyed favourable international comparisons, public approval ratings are high and both the role of GPs in providing an integrated approach to healthcare and in gatekeeping access to secondary services, and the role of NICE in evaluating and controlling the introduction of new treatments and technologies are much admired internationally. The major challenges facing the NHS are maintaining and improving services during a period of severe restraint in public spending and adapting to an increasing frequency of restructuring. The Conservative government has sought to create a perception of an NHS failing in relation to European healthcare systems in order to justify plans for a radical restructuring largely concealed from the electorate in 2010. There is a legitimate debate about whether developing the role of the market in healthcare can improve quality and efficiency, the consensus among health policy analysts being that appropriate regulation is necessary. The NHS bill does not represent this. Initially attracted by the promise of increased power, the Royal College of General Practitioners under Clare Gerada has been clearer sighted about it’s implications and has begun to recognise a "poisoned chalice". The BMA’s response has followed a similar pattern.

6) Much of the comment on the Bill has focussed on the consequences of price

competition and "any willing provider" as well as whether structural change can be delivered during a real terms fall in health spending. The point I would like to highlight is the potential consequence of making GPs explicitly responsible for the budget and hence for rationing. Rather than "freeing GPs to chose the best treatment for their patients" as Andrew Lansley has disingenuously claimed, tensions between their role as both advocate and allocator will increase. The explicit nature of this is likely to undermine the trust that has enabled the public to continue to see their GP as acting largely in their interest and potentially has a number of consequences. Patients will be more likely to challenge clinical decisions and the demand for diagnostic procedures, referral to secondary care and interventions will increase. Together with the extension of the market these pressures are likely to drive the development of co-payments, the expansion of private health insurance and the development of a multi-tiered service. Soon we will find ourselves having moved from a system that has limited overall costs while delivering provision perceived as largely acceptable and equitable by the public, to a system similar to that in the United States, widely recognised as the most expensive, least efficient and least equitable in the developed world. The British public have a strong sense of fairness particularly with regard to healthcare provision, these changes together with the geographical inequalities likely to result from different priorities set by GP consortia as well as the removal of NICE’s role in approving funding for new treatments are likely to be politically unacceptable.

7) Rather than a precipitate and uncertain restructuring, I believe policymakers should

seek considered development in health policy that seeks to build on the real gains made under Labour and seeks public approval as well as genuine consultation with professional groups. The goal of the current government seems to be to push through ideologically driven reform which once enacted will be near impossible to reverse seemingly with little thought for the political consequences. I strongly believe that rather than negotiating minor adjustments to the Health and Social Care bill, it should be opposed in it’s entirety and health policy rethought from an early stage. I strongly urge the committee to consider the national rather than party political interests when scrutinising this bill.

March 2011