In its submission to the PLPHC's inquiry into the progress of NHS reform and the role of private sector providers, the BMA raises the following concerns:
- - Insufficient public consultation on the implications of reform for the NHS
- - Inadequate engagement with the profession in shaping the direction of reform
- - Lack of data on quality and cost efficiency of the independent sector's provision of NHS care
- - Risk to continuity of patient care and lack of integration of new providers into the NHS
- - Threat to training for junior doctors as services are transferred from NHS hospitals to the independent sector
- - Failure to create a level playing field between the independent sector and conventional NHS providers
Dr Paul Miller, chairman of the BMA's consultants' committee said:
?This Government has invested impressive amounts of new money into the NHS and the extra capacity provided by the independent sector has the potential to help reduce waiting times even further for patients. But sadly, the programme of reform, as is currently being implemented, threatens to destroy what already works well in the NHS.
?Pushing forward an agenda with a mix of independent sector and conventional NHS providers, without properly assessing where the extra capacity is needed and how it is to be integrated with existing structures, risks fragmenting NHS services and losing continuity of care for patients.
?Local clinicians and the public are often excluded from discussions to introduce the independent sector into local NHS services and the lack of data on outcomes means that they are unable to assess the quality of patient care or ensure new providers offer value for money.
?Consultants are keen to develop more innovative ways of working. We urge the Government to properly engage clinicians, and the public, to ensure the new NHS complements rather than threatens existing services and high quality care for patients is maintained.?
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The BMA's submission to the Parliamentary Labour Party Health Committee follows:
British Medical Association Submission to the Parliamentary Labour Party Health Committee (PLPHC)
The BMA has previously commended the current Government for its unprecedented investment in the NHS and recognises that spending has increased by 70% compared to that in 1997. Furthermore, it is likely by 2007-08 the Labour Party's pledge to lift health spending in Britain to the European Union average will have been fulfilled. We have welcomed both the rise in the numbers of doctors and nurses working in the NHS during this period and the fact that waiting lists for many treatments have fallen and continue to do so in line with the challenging targets that are now so often the focus of managers and doctors in the health service. Accordingly, we acknowledge these aspects as the ?progress of the NHS' under Labour. However, in contributing to this review we wish to highlight areas where we believe that the programme of reform accompanying the record investment may threaten the ability of the NHS to function effectively; where the quality of patient-care delivered in the NHS may be compromised; and how maintaining the standards expected of the UK medical profession is becoming increasingly problematical as the structure of the NHS changes.
Key Points: ? Insufficient public consultation on the implications of reform for the NHS.
? Insufficient engagement of the profession in shaping the direction of reform.
? Insufficient data with regard to the quality and cost efficiency of the independent sector's provision of NHS care.
? The threat to the continuity of care and services from the lack of integration of new providers into the NHS.
? The threat to training for junior doctors as services are transferred to the independent sector.
? The lack of a level playing field between the independent sector and conventional NHS in respect of financial cost pressures.
1. We are concerned at the general lack of information that is made available, and that is held centrally, with regard to the independent sector's (IS) provision of NHS care and services. Most generally, both the public and local clinicians (in secondary and primary care) are typically excluded from discussions around the introduction of the IS into local health economies and are therefore unsure as to the nature of the contracts between the DoH and IS providers. Moreover, the current paucity of data means that external, reliable monitoring of the performance of IS providers is not possible and thus the public and profession cannot be entirely confident that the increasing role of the IS is contributing toward the maintenance and development of a safe, high-quality health service.
2. Nor is it clear what clinical governance arrangements exist in the IS centres or how they link with arrangements in the conventional NHS centres with whom they work. We would like to stress that in seeking more robust audit and clinical outcome data these are, of course, retrospective measures. It is therefore essential that greater transparency is encouraged to ensure that IS providers operate to the conventional quality standards and protocols currently in use in the UK for the procedures that they undertake. We are concerned that IS providers may use different protocols that have not been developed on the precautionary principle that is the norm in the NHS. It is unreasonable for patients to unknowingly form part of the learning curve for some IS providers.
3. The lack of data also precludes a useful analysis of the value for money (VfM) of the new providers. We believe that at present there is little robust evidence to suggest that VfM is being achieved, most notably in ISTCs. What evidence does exist demonstrates that the NHS and the taxpayer is often paying a premium for IS involvement. Certainly, the Government has stated that in 2003-04 the ?procedures purchased under the ISTC programme cost on average 9% more than the NHS equivalent cost? (Hansard, Official Report, 16 March; vol.432, c.273w). Moreover, there have been instances of ISTC contracts being paid in full despite a failure to deliver the number of procedures set out in those contracts. We are also concerned that the costs of administering the commissioning of services from multiple providers, including costs associated with invoicing and debt recovery, will consume resources which would be better spent on providing care.
4. An independent review of the ISTC programme's productivity and its impact on the wider NHS is therefore much needed. Claims that the programme is more cost-effective and efficient must be reliably tested. Whilst it is true that the the rapid introduction of ISTCs has made a contribution to the reduction of waiting lists we would suggest that traditional NHS organisations, in response to targets and by developing new ways of working, have made a bigger impact. For example, the ophthalmic ISTC scheme is responsible for only 3% of the total number of cataract procedures undertaken in the NHS, while the conventional NHS provides 300,000 per year. Moreover, in presenting these figures we must also consider the significant clinical concerns that have been raised with regard to the services provided in a number of these ISTCs.
5. In addition, claims of simple efficiency ignore the fragmentary effect on NHS services that introducing the IS into local heath economies is having. We are concerned that in pushing forward the plurality agenda there has been both a failure to examine existing NHS capacity and sufficiently integrate new IS capacity with local services. We would wish to question the logic behind a scheme which sees patients having to travel from Durham to Middlesborough for an MRI Scan provided by the IS while an MRI scanner in Durham is idle. Similarly, should it be the case that patients in Southampton are expected to travel to an orthopeadics ISTC provider in Salisbury while Southampton's own conventional orthopaedics centre has excess capacity and is now in fact having to close capacity due to the loss of work to the IS?
6. We are also concerned with the increasing trend of transferring NHS work to the IS and plans to offer private companies an opportunity to take over publicly financed NHS buildings and equipment such as state-of-the-art operating theatres at a new NHS treatment centre in Birmingham, part of the New Forest Lymington hospital in Hampshire (a PFI scheme) and surgical units at Ravenscourt Park hospital in Hammersmith. This transfer of work and facilities does not see the IS providing extra capacity. Rather, money and NHS resources are being redistributed to the IS often to the detriment of existing high quality services.
7. Current policy will see traditional NHS centres experiencing severe financial pressures that will extend beyond the services directly affected by ?competition' from the IS but also to the additional services such as non-elective, small specialty or support services, that the conventional NHS is responsible for (and that the IS does not wish to provide). This pressure is exacerbated by the fact that the IS favours a simple case-mix, leaving the conventional NHS with complex, co-morbid patients, as well as the IS's post-operative complications and those requiring intensive care and high dependency facilities not available in ISTCs. This highlights another financial advantage given to the IS and a further barrier to the conventional NHS's ability to compete with these new providers. We are therefore particularly concerned that, with the introduction of Payment by Results in its present form, traditional NHS institutions will find themselves under increasing and unfair financial pressure whilst IS providers benefit from the high volume of simple case-mix, guaranteed referrals and improved tariffs available to them.
8. We have grave concerns in respect of the threat to the provision of training for junior doctors that is occurring as procedures most suited to training purposes are transferred to the IS. Phase one of the ISTC programme excludes the providers from training responsibilities completely and there is ongoing uncertainty with regard to proposals for the provision of training in phase two. If the IS continues to be exempt from contributing to training, and particularly the cost of training, then we are concerned that the standard and quality of the medical workforce will suffer. There is already evidence that Southampton's orthopaedic centre is at risk of losing training recognition due to the loss of capacity to the ISTC in Salisbury where no training will be carried out. This clearly also raises concerns over the future recruitment and retention of staff in the conventional NHS as opportunities for training, education and research are likely to deteriorate.
9. We are concerned that little work has been undertaken to explore the potential outcome of the complex interaction of current reforms. This is particularly true of the push for greater involvement of the IS in healthcare delivery at the same time as a new payment system is being rolled-out (PbR) and new commissioning models are in their infancy, such as Practice Based commissioning (PBC) and proposals contained in Commissioning a Patient-led NHS (CPLNHS). What planning has been undertaken centrally to ensure the continuity of services at the end of the contracts currently held, or being negotiated, by the IS care and to assess the impact of the likely over-capacity that will exist in the NHS in 2008? We believe there is an inherent tension between certain reforms, particularly PBC, PbR and Patient Choice, that have not been adequately addressed. We are concerned that primary care commissioners will face difficulties in designing high quality, cost-effective integrated care pathways whilst PbR acts to encourage secondary care providers to maintain their volumes and whilst patients are able to exercise unfettered choice in deciding where to receive their services. We would therefore like clarification as to how this combination of reforms is intended to be managed.
10. We accept that the current IS programme is intended to support the shift to primary care that is central to many of the current policy reforms and will form the focus of the forthcoming health White Paper. However, we would be concerned if proposals to introduce more opportunities for the IS to provide services outside hospitals were implemented without further consultation with the profession. These concerned are also held by the public as shown by the results of the consultation program run on the white paper in Birmingham. In particular, any changes in primary care must build on the many successes of general practice rather than undermine them. Certainly, for chronic care, which accounts for 70% of NHS spending, cooperation, not competition, between units is needed.
11. The BMA and the profession is willing to engage with the Government in developing new innovative models of delivery but clearly does not want to see current services that work well being threatened. We are concerned that the recent public consultation to inform the forthcoming White Paper relied heavily on questions about choice, convenience and access, and therefore implied an increased market of primary care providers, without providing an understanding of the context of the reality of finite resources, where increasing choice and access may mean less continuity and personal care. Paradoxically, the opportunity for patients to exercise choice may in fact diminish as local centres are downsized or closed in the face of competition from the IS and consequently the continuity of care that patients both demand and benefit from will be threatened. For example, emergency services may be lost to a geographical area if the local NHS provider fails, with detriment to all living in that region but especially to the least well off, who will find it hardest to travel in order to receive emergency care.
12. In conclusion, we do not feel that the public has been fully informed about what recent changes to the structure of the health service will mean for the NHS in the long-term and suggest that the continued expansion of the role of the IS requires further public consultation. Moreover, we do not believe that the financial arrangements currently in operation are sufficiently transparent and we are concerned that they are unduly favorable to new providers at the expense of conventional NHS providers.
13. We therefore ask that a level playing field is established for all providers in respect of the financial cost of providing a high quality national health service and maintaining a skilled workforce across and that the same quality measures, regulation and clinical governance processes are used to assess and assure the effectiveness and safety of services provided by both the public and independent sector. We wish to see stronger measures established to ensure that current IS provision complements traditional NHS institutions and promotes the development of high quality care pathways, and a highly skilled workforce, rather than compromising them. To enable this there needs to be a much greater involvement of the profession in these changes to utilise the knowledge and skills available and build on the trust doctors have from the public.
BRITISH MEDICAL ASSOCIATION