Written evidence by the Medical Practitioners'
Union (CFI 09)
ABOUT THE
MEDICAL PRACTITIONERS'
UNION - UNITE
MPU, founded in 1914, is a small group of doctors
(compared to the BMA) currently mostly GPs in deprived areas.
MPU merged with another trade union that has resulted in becoming
part of Unite. We participate in the representative machinery
of the medical profession through agreements reached with the
BMA in 1950. As part of the Health Section of Unite MPU's policies
are informed by other professional groups, particularly health
visitors, sexual health workers, mental health and school nurses.
It has a track record of influencing national policies such as:
the GPs' Charter, Junior Doctors' hours, and of influencing the
medical profession - exposing racism in the profession, the vulnerable
position of sub-consultant grade doctors, campaigning for a salaried
option for GPs and for better health services for asylum seekers.
Of particular relevance is that MPU produced proposals
for locality commissioning (1991) which became Labour Party policy
in 1992 and the policy of the BMA by the mid 1990s.
STATEMENT OF
CURRENT ATTITUDE
TOWARDS THE
NHS AND SOCIAL
CARE BILL
(References: "Clause
..."' refers to the Bill; "IA ..." refers to the
Combined Impact Assessment. Other references will be supplied
on request)
1. Context: The National Health Service is
not perfect but has improved particularly since its funding was
increased. It had its highest patient satisfaction rating recently.
Its outcome figures do compare well with other health systems
in spite of government assertions to the contrary. The NHS provides
access to health care rated as the best in the developed world.
Whilst it is possible to agree with elements of the
Bill, we oppose the Bill as a whole because of the creation of
competitive markets, the powers of Monitor, the wholesale dismantling
of organisational structures, the privatisation of NHS assets
and the conversion of Directors of Public Health into local government
officials with perceived loss of their important independent voice.
The basic ethos of the NHS may not be directly undermined
by the Bill but indirectly the "free at the point of use"
principal could be undermined by the uncritical adoption of market
principles. As profits become the bench mark of "good health
services"' some services could be seen as not cost efficient
merely because they are complex and expensive rather than inefficient.
Marketisation and commodification of health services
reduce the high ideals of the NHS to that of simple trading. The
ethos of the NHS and of those who working in the Service are crucial
to its success and mirrored by the high value which the population
ascribe to it. Knowing the price of everything and the value of
nothing sums up this concern.
The experience of Independent Sector Treatment Centres
(ISTCs) is that they offered services (often at 11% above NHS
Tariff) to patients with uncomplicated medical histories ('cherry-picking)
leaving the NHS to deal with patients with complex, multiple diagnoses.
The evidence from PFI projects is that they are more
expensive than publicly financed builds, are poor value for money
and distort the funding allocations to PCTs with PFI projects.
The Health Services of Wales, Scotland and Northern
Ireland have not introduced the purchaser-provider split nor competition
as a drivers for cost efficient, quality services.
2. No democratic mandate: the reorganisation
of both the provider and commissioning side was five years in
the planning according to the SoS but barely mentioned in his
Party's Manifesto and specifically ruled out in the Coalition's
Agreement - no top down, major reorganisation of the NHS. There
should be trust between the people and its government - such trust
has been jeopardised with regard to the future of the NHS in England.
3. Commissioning is defined by MPU as: the
process of gathering and analysing the wants and needs of a population,
identifying the services required to meet those needs and of monitoring
those services and their outcomes as they are delivered.
4. There is nothing against and everything for
the involvement of GPs and other professions in the commissioning
of care. There is however no need to abolish PCTs or SHA to
achieve this, nor to establish competition within the provider
setting.
5. Privatising the Commissioning Function:
the abolition of PCTs and SHA to be replaced by GP Consortia opens
the door to private sector involvement in the commissioning process.
This is of course government policy and MPU is totally opposed
to it. There has been confusion as to whether GPCCs will be NHS
Bodies (Clause 6 1E (1)) - they should be.
GP Principals are independent contractors to the
NHS under one of three contractual arrangements: General Medical
Services (GMS) a UK wide, national contract; Personal Medical
Services (PMS) a locally held contract with a PCT and; Alternative
Personal Medical Services (APMS) which is a proper commercial
contract with a PCT. GMS and PMS are the norm and GPs and their
staff have access to the NHS Pension scheme and regard themselves
very much as "part of the NHS".
APMS contract holders do not have to be GPs and have
fully commercial contractual arrangements with PCTs. They are
more distant from "the NHS family". The GPs working
in APMS are usually salaried to the company and are usually not
GP Principals.
Two or more APMS practices could form a "private"
Consortium with confused allegiance to either private employer
or NHS, yet with access to NHS funds. As with all Consortia it
can write its own constitution, raising issues of accountability
and conflicts of interest.
6. Price competition within the NHS as indicated
by supplementing national tariff with a "maximum price"
(Clause 103 and 104), has been shown to lower the quality of health
care provided. Improving the quality of health services should
be by sharing good practice and outcome data, thereby using peer
pressure rather than market competition. This method has been
successful in rationalising prescribing by GPs and would work
in a similar way for inappropriate GP referrals.
Recent "clarifications" by the SoS that
competition will be based on quality not price will remain unconvincing
whilst "maximum price" is on the face of the Bill and
whilst Monitor's role is specifically stated as promoting competition
(Clauses 52 (1) (a) and 63 (1) (c)) and enabling easier entrance
to and exit from the "health market" (IA B106 and 112).
We would ask for the evidence that market competition
improves health outcomes. (The Impact Assessment rests its case
for the success of market competition on examples from new car
sales, replica kits, the air travel industry and opticians). We
question the current rhetoric that investment over the last 10
years had not improved health outcomes. There are improving outcomes
for stroke management, surviving heart attacks and for cancer
services which have not been quoted by the Government.
7. If the Any Willing Provider policy (AWP) is
pursued as currently envisaged GP Commissioning Consortia (GPCCs)
will actually do very little commissioning as defined above.
Services are likely to be commissioned as follows:
(a) Special Commissioning by NHS Commissioning
Board
(b) A&E, ITU and so on - no tendering
as they are likely to be located at the local hospital (whether
NHS or privately run). Any reconfiguring will have to be done
at a supra-Consortia, "regional"' level.
(c) Elective Services - AWP will be selected
by the patient with GP support from a national list perhaps trimmed
to more local providers
(d) Long term conditions (eg diabetes,
heart disease) "off the peg" packages of care will be
designed by providers and offered to Consortia. It is likely that
any "tweaking" of the package will only be possible
at the margins since providers will want to minimise different
services for different (neighbouring) consortia. This "provider
dominance" is commissioning the wrong way round and leaves
the tail wagging the commissioning dog. If led by the private
sector and uncoordinated it risks further weakening the comprehensive
nature of current NHS services.
Consortia are the bill payers for most of these services
and will have limited choice over providers. The patient chooses
elective care not the host consortium. The SoS has recently said
that competition rules will not apply if the Consortium can show
their decision is in the best interests of patients. Once the
Bill is law the present or any future SoS could change this interpretation.
How will GPCCs manage demand with such limited control
over service provision?. Demand management of appropriate GP referrals
has historically proven difficult. As noted above, peer pressure
could reduce inappropriate referrals.
8. The AWP policy is likely to be detrimental
to NHS hospitals and to the provision of comprehensive acute services.
Commercial providers have to date provided straight-forward procedures
only - hip replacements, hernias and cataracts. The Impact Assessment
makes explicit that there should be easier entrance to and exit
from NHS provision and that competition between providers should
be stimulated (IA B4). As private providers take more procedures
from NHS hospitals the following may result:
— Acute
hospitals rely on "cross-subsidies" to support over
tariff services from services provided under tariff. Less income
to NHS providers leads to financial instability and pressure to
increase non-NHS income; for example, exploiting the removal of
the cap on earnings from private patients (IA B72) resulting in
longer waiting lists for NHS patients (IA B156).
— A&E
and ITU unable to call on a complete range of services 24 hours
a day if some departments have "failed" and closed (IA
B149).
— NHS
left with more complex (IA B54) and expensive case mix due to
"cherry-picking".
"Designated Services" as laid out in the
Bill (chapter 3) will attract a premium payment (Part 3 chapter
7) from the provider and so there will a disincentive to designate
services. Again A&E may not have a full range of services
to call on 24 hours a day unless all relevant services are "designated",
the direct opposite of the Government's intention to apply the
rigour of the market.
9. Postcode lottery of services: Consortia
are to have autonomy, can construct their own constitution and
decide which services will and will not be provided for their
patients. Patients in neighbouring Consortia could therefore receive
a different menu of services provided to different service specifications.
Whilst adapting services to local need is acceptable this policy
tends to remove "National" from the NHS and puts at
risk the equitable provision of services for the English population
as a whole.
10. Fragmentation of Community and Primary Care
Services: The NHS delivers care in teams - obvious in the
hospital setting but less so in the community. During the 1980's
primary health care teams (PHCT) were common - health visitors,
midwives, district nurses, GPs, practice managers and often social
workers. The move away from practice alignment of community staff
and increasing work load as more services are provided in the
community, has led to the decline of PHCTs and poorer coordination
and integration of services (IA B44). The best primary care relies
upon good systems, good relationships between colleagues and,
crucially, trusting and long-term relationships with patients.
Any attempt to re-introduced PHCTs to promote integration of services
will be hampered by multiple, community providers competing for
business rather than cooperating for care.
Multiple providers in competition with each other
has already proven problematic for primary care as residential
care services have been privatised - one company employing the
staff, another providing care packages to residents and community
staff who now have little contact with the practices serving the
residents.
11. Conflicts of Interest:
— GPs
and/or private companies as both commissioners and providers
— GPs
having to consider the Consortium's budget versus the needs of
the individual patient coupled with rewarding practices for referring
less (Clause 23 223L). This fundamentally distorts the trust embedded
in the doctor-patient relationship and the GP's role as patient
advocate.
12. MPU also has concerns similar to
those raised by other groups and organisations:
— the
haemorrhage of talent from PCTs and SHAs at a time of massive
reorganisation;
— resources
diverted to reorganisation rather than patient care;
— costs
of redundancy pay, the reorganisation itself and rising transactional
costs;
— risk
of organisational dysfunction or collapse;
— lack
of evidence that the new system will benefit patient care;
— weak
accountability and democratic structures proposed; and
— knock
on effect on teaching and training as private sector absorbs more
trained staff.
13. RELEVANT
CV OF DR
SINGER, PRESIDENT
| 1981 to 2009 | GP Principal in Edmonton, North London.
|
| 1982 to Date | Member Enfield and Haringey (now Enfield) Local Medical Committee
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| 1982 to 2004 | Member of various NHS Bodies representing Enfield Local Medical Committee or Edmonton GPs: Enfield and Haringey DHA, Enfield DHA, Edmonton Primary Care Group, Enfield PCT's Professional Executive Committee
|
| 1992 to 2003 | Founding and Executive member of National Association of Commissioning GPs (which later became the NHS Alliance)
|
| 1996 to Date | Member of General Practitioners' Committee of BMA (representing MPU)
|
| 1996 | Author/editor: GP Commissioning: an inevitable evolution (Radcliffe)
|
| 2003 to Date | President, Medical Practitioners' Union - Unite
|
Dr Singer is not a member of a Political Party but contributes
indirectly to the Labour Party via Unite's political levy.
February 2011
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