Caring for the NHS: the BMA’s way forward


October 2007
The principles and proposals contained in this policy framework demonstrate the desire of the medical profession to play a leading part in recasting reform and reflect an enduring commitment to the National Health Service. The BMA therefore urges the Government to engage in meaningful dialogue with the medical profession and work with the BMA in achieving a way forward that ensures the NHS is fit for the 21st century.

1. An NHS constitution
The BMA will campaign for a constitution for the NHS.
  • The core values of the NHS
In summary, these will include its founding principles concerning equity and access – healthcare, free at the point of delivery, based on need not ability to pay – enduring principles – healthcare funded from general taxation – and new values reflecting the modern NHS – a focus on good health, a commitment to support world-class research and education and an ethos of professionalism.
  • A new Patient’s Charter
In summary, the charter will establish the duties and obligations the NHS has to its patients, setting out the standard of service patients can expect to receive. Moreover, the charter will determine a compact in which the public and patients will have a range of expectations made of them with regard to their relationship with, and obligations to, the NHS.
  • The operational framework of the NHS
In summary, the framework will detail the accountabilities relating to decisions concerning the range of services available in the NHS and their evaluation; decisions on standard-setting and achieving those standards in relation to the quality of services in the NHS; and arrangements for local accountability to patients and communities in the NHS.

2. Governance and accountability
The BMA will campaign for changes to the governance of the NHS and for a new framework of accountability and responsiveness.
A new framework is required in order to foster more transparent and robust relationships concerning the development and implementation of national health policy, the setting of priorities in respect of NHS operational management and to ensure arrangements are in place to progress the local accountability of services. The design of the framework will require genuine consultation involving patients, clinicians, politicians, and key regulatory bodies and other agencies.

Principally, the proposed independent framework will:
  • Accept that national politics does have a role to play in determining priorities and budgets for the NHS but will stress that such decisions must be informed at the earliest stage by clinical insight and that the role of politicians in the day-to-day running of the NHS should be markedly reduced.
  • Advocate a shift of power so that the NHS is managed under the direction of health professionals with local accountability and within national standards set by Parliament.
  • Recommend that a board of governors is created and charged with the management of the NHS, ensuring it fulfils the aims and responsibilities as set out in the NHS constitution, including the requirements of professional leadership, adherence to the standards set by Parliament and local accountability
  • Recommend that an executive management board, appointed by and accountable to the governors, is established and charged with responsibility for guiding the performance and national operations of the NHS within the foregoing principles .
  • Recommend that, in the context of the new framework and NHS constitution, the Department of Health’s new role is to support the delivery of the NHS constitution with a primary focus on public health and tackling health inequalities.
  • Recommend greater flexibility for local health economies to develop a range of mechanisms to increase local accountability and responsiveness.
3. Comprehensiveness, universality and resource allocation
The BMA will campaign for an honest and open public debate on the range and extent of services to be available in the future NHS.

Unquestionably, there are already demonstrable variations in access to particular services in the NHS across localities; waiting lists remain for certain treatments; the NHS’s responsibility for providing or funding long-term care is being scaled back; and the cost of a range of procedures and treatments have been identified as prohibitive by some purchasers in the context of financial constraints within the system. Moreover, with the continued emergence of new technologies, expensive pharmaceuticals, an aging population and consumerist behaviour, health care costs are being driven upwards.

Inevitably the problem of resource constraints in the NHS will become more acute without continued sizeable increases in resources being made available. As the NHS develops in the 21st century the government, medical profession, patients and the public must therefore openly explore the challenges these pressures present and how they might best be confronted.

Principally, the public debate will comprise:
  • A new dialogue, sponsored by the government, that will allow all parties – the public and patients, their politicians, clinicians and NHS managers – to consider the values that underpin the NHS and to honestly discuss what can be expected from the health care system that results.
  • An informed recognition that developing a responsible approach to the issue of resource allocation is integral to meeting the challenges facing the NHS in the 21st century
  • A commitment to meet the challenge of making informed, transparent and reasoned decisions about treatment priorities and the availability of treatments at both a national and a local level, in the event that there are insufficient resources to meet all the demands on the NHS
  • A commitment to ensuring that the debate will not subjugate the NHS’s key priority of the treatment of the sick and the continued good health of the well.
  • A thorough exploration of how a continued commitment to free, comprehensive health care, available to all, can be most pragmatically met in England.

4. Clinical engagement
The BMA will campaign to highlight, and ensure a renewed focus on, the central importance of the meaningful involvement of clinicians in the planning and delivery of reform.

The BMA has long contended that the continued marginalisation of the professional view is a key reason that the recent NHS reform programme has often proven incoherent, has not gained support and has failed to secure the long-term and sustainable improvements that NHS staff, the public, and most importantly patients, wish to see.

It is crucial that the professionalism and independence of doctors is reaffirmed and that the tradition of medicine as a knowledge-based, research-driven field of practice is respected. The meaningful involvement of clinicians and the deployment of evidence-based decision making at every stage of service design and development is central to achieving successful change in the health service and to the delivery of high-quality care to patients.

Principally, the renewed focus on clinical engagement will:
  • Seek a fundamental change in manager-doctor relationships, moving away from what is often an antagonistic interaction, towards a constructive partnership that enables health professionals to provide direction and leadership in the planning of health reform and in delivering patient care.
  • Seek to ensure that NHS managers are granted greater freedom from satisfying political demands made by the centre and are encouraged to use their skills to support their clinical colleagues in diagnosing problems and identifying solutions to improve clinical quality and service development.
  • Require a renewed commitment by the NHS to make protected time available for clinicians to plan service development.
  • Foster an environment in which doctors are encouraged to assume greater management responsibilities and regard this as a positive, constituent part of a rewarding career structure, not a hindrance to developing a clinical career.
5. Public and patient engagement
The BMA will campaign to highlight, and ensure a renewed focus on, the central importance of meaningful and transparent public and patient involvement in the development, planning and delivery of reform.

Public consultation is a statutory duty in respect of service reform but it is too often shallow and merely placatory. Decisions concerning the provision of services – what is to be delivered and how, quality setting, and the monitoring and maintenance of standards must appropriately involve the public and patients. A service can only be responsive to users if users are involved, and providers fully understand the needs of the public.

Principally, the renewed focus on public and patient engagement will:
  • Recommend that at a local level, the needs of communities, including different ethnic groups, disabled people, people of different ages and hard to reach groups, are discovered and understood.
  • Seek to ensure that when difficult decisions need to be made, particularly in the context of limited resources, open and transparent public engagement is undertaken to both encourage informed debate on such issues and identify the services the public wish to have provided.
  • Seek to ensure that when such decisions are made, the public is given a clear and transparent explanation as to how a decision was reached and the manner in which their views have or have not influenced the decision–making process.
6. Funding and structure
The BMA’s commitment to equity and local accountability requires a funding mechanism which delivers resources to local health economies on the basis of equal access to those in equal need and which below this level is flexible enough to fund local models of service

The present system of allocating available resources to local health economies by means of a needs-based funding formula is the most effective means of ensuring equity.

At the local level, the structure for funding and provision may differ across health economies. Such models as have been developed to date have suffered from trying to impose a national model on local circumstances. Local funding arrangements will need to address inter alia:
  • The perceived deficiencies of the PbR arrangements. In particular their relevance to different care pathways and their tendency to destabilise providers with high fixed costs.
  • The funding arrangements needed to provide access to out-of area facilities (see below). These must be fair to both commissioner and provider.
  • The appropriate mechanism for jointly developed services. Where innovative programmes are being introduced across health sectors and/or between health and social services the funding streams are often unclear, non-recurrent or both.
The BMA believes that the precise way in which health services are delivered to local populations must remain a matter for local determination.

Populations with differing needs and varying geographical settings will require different configurations of services and local health economies must be prepared to develop these. This will inevitably mean that a different mix of health services is available to local populations but patients will rightly expect that the generality of services will be available regardless of locality and that all services will be provided to the same quality regardless of the manner in which they are delivered.

The BMA believes that the relationship between the body charged with identifying and meeting local health needs and the organisations providing services should be as close as possible to facilitate integration and cooperation.

It is generally accepted that the most efficient and effective means of delivering primary medical services is via independently contracted general practices which are able to design facilities to suit local circumstances and their patient populations.

As far as secondary care is concerned, a closer relationship between provider and funding body could take the form of directly funding providers for their catchment populations, although for many if not most providers, complex commissioning arrangements or cross-boundary referrals could make this difficult. For those health economies where such a direct relationship is not feasible (e.g. multiple providers across administrative boundaries) the split between commissioner and provider will need to remain and contractual and funding arrangements be designed to accommodate this in a way which encourages cooperation.

The BMA is committed to an approach which is based on cooperation rather than competition and in this context, envisages a peripheral role for private sector provision. It should only be introduced where it satisfied these three criteria:
  • It should be complementary to existing capacity
  • It should only be introduced where existing providers are unable or unwilling to meet demonstrable demand
  • It should not undermine the comprehensive delivery of healthcare
Whilst recognising the need for wider debate about actual structures and financial flows, and recognising also the scope for local variation the BMA, will produce a potential model for operation of a local health economy as an illustration of how its proposals could work.

7. Education, training and research
The BMA will campaign to ensure that the provision of high quality undergraduate and postgraduate medical education and training is central to the future operation of the NHS.

The BMA will campaign to ensure that future NHS reforms embrace and nurture academic medicine as a means of safeguarding the future of the profession through education and translating research into new, affordable therapies which in turn have a direct impact on the quality of NHS care.

The future competence of the medical profession, the excellence of NHS services and quality of NHS patient care is dependent on the provision of world-class medical education, training and research. In this context, academic medicine has an important role to play in maintaining and improving the high quality of doctors produced, the quality of healthcare provided and the quality of the environment in which healthcare is delivered.

Principally, the campaign for medical training, education and research will:
  • Stress the vital need for access to patients for education and research purposes in order to ensure the continuing development of the NHS as an institution with world class medical research and a health service built on evidence-based medicine.
  • Advise that undergraduate and postgraduate education and training is meaningfully integrated within, and is a fundamental part of, local health economies. In particular, it must not be seen as secondary to service provision, especially as the hours available for training continue to be reduced, but essential for the continuation of high quality patient care.
  • Seek the removal of the structural impediments and pecuniary disincentives for doctors to take on the task of teaching and mentoring the next generation of doctors.
  • Encourage greater recognition of the synergy between research, education and clinical practice and the need to ensure that this synergy is maintained through quality assured education and research that is incorporated into the delivery of patient services through the practise of evidence based medicine.
  • Seek to combat the trend of the NHS being seen as an unattractive place for innovation and encourage a new focus on transparency of research funding and on the funding of translational research.
  • Encourage the development of hospitals that focus on excellence and innovation in health research, as well as providing patient care.
  • Demand that the contribution of academic medicine to the NHS is supported through meaningful consultation with medical academics, the provision of adequate funding and the best use of new configurations of academic-bioscience hospitals.
8. Public health
The BMA will outline the changes in the functioning of Government that it believes to be necessary both nationally and locally to ensure a higher priority to the health of the people as a social value.

Principally, the new approach will focus on developing a more central role for public health:

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