We had been warned, but that starkness of the BMA's response to Health Secretary Andrew Lansley's White Paper remains surprising.

The BMA's restated opposition to growing NHS commercialisation comes as scant surprise. Their repsonse states, "aspects of the White Paper’s proposals ... have the potential to undermine the stability and long-term future of the NHS. The ‘any willing provider’ policy has the capacity to undermine local health economies by replacing existing multi-service natural monopolies with a plethora of smaller units providing more limited ranges of services. This would radically affect both the efficiency and value for money of the NHS".

They mention the development of FTs, but then (with irritating vagueness) add, "further moves towards the development of corporate entities would threaten the stability of the NHS and the security of its employees and their terms and conditions of service".

Eh? One-two, give-us-a-clue?

The statement reads, "aspects of the White Paper’s proposals ... have the potential to undermine the stability and long-term future of the NHS. The ‘any willing provider’ policy has the capacity to undermine local health economies by replacing existing multi-service natural monopolies with a plethora of smaller units providing more limited ranges of services. This would radically affect both the efficiency and value for money of the NHS.

"Changing the status of existing NHS providers to foundation trust status has already threatened the character and ethos of NHS provision. Further moves towards the development of corporate entities would threaten the stability of the NHS and the security of its employees and their terms and conditions of service.

"We remain opposed to the commercialisation and active promotion of a market approach in the NHS, and to the very significant threats to national terms and conditions of service and education and training for doctors contained in the White Paper. Moreover, the wish, expressed frequently in the White Paper, to improve the patient experience and provide more seamless, integrated care, seems at odds with many of the policies which will, inevitably, widen the purchaser provider split".

This has gone a little bit further than a negotiating position prior to the start of talks about the new GP contract.

Austerity tomorrow
Of the planned efficiency savings of £15-20 billion over the coming three financial years, the BMA comment "This is a very difficult climate in which to make substantial service changes and reconfigurations. We would question the value for money of such changes. The logic behind this point about efficiency savings representing questionable value for money is not immediately apparent.

The document is on stronger intellectual ground over the winding-up of PCTs, rightly stating that the "complete list of both statutory and non-statutory roles has been drawn up and sent to PCTs ... should now be made publicly available. Functions that will no longer be required should be clearly identified so that consortia are able to operate effectively with their reduced budgets. We would like further details on where responsibility for the many non-commissioning functions of PCTs and SHAs will lie during the transition period and following abolition, and what will happen to PCT debts. These debts should not be passed on to consortia, as we believe this will prevent them from functioning to their full potential and will also discourage GPs from becoming involved in consortia".

It is also on reasonable ground where it clarifies the intent to "strongly oppose any moves that will increase reliance on local planning and management of education and training", citing issues around quality and pan-UK workforce mobility. The quality point is a little disingenuous - medical training is not a perfectly-made souffle of excellence at the moment - but the workforce mobility issue is an excellent one.

Unsurprisingly, the BMA still doesn't like patient choice and thinks it's good for nothing, citing the old crap "people just want a good local hospital" argument. Wrong on this one, chaps. Wrong and paternalistic. There's also some rhetorical guff about GPs having a big input into public health, which raises a laugh that is not so much hollow as eviscerated.

Conflict of interest in GP commissioner-provision: raised, but not resolved
The document notes that "some patients may view GP-led commissioning with suspicion, particularly when their GP refers them for treatment from another GP provider. It will be essential to develop and implement a system that maintains patient trust and protects professional values. This system should be as transparent as possible and assure patients that their doctor is referring them to a particular provider purely because it will provide the best clinical outcome".

This is a good point, but is going to require some serious thinking. It would be helpful if the BMA did some modelling of how this might work.

A farewell to economic regulation
A particularly evident collission course arises with the BMA's response over the plans for Monitor to become the all-powerful economic regulator: "The BMA does not support Monitor’s role as promoter of competition in healthcare and believes its focus should be on ensuring quality. If Monitor does take on this role, it should seek the views of professionals and patients before making decisions about anti-competitive behaviour, to find out which services they want in the area and if there are established pathways of care and existing collaboration, rather than force competition when it is inappropriate.

"Competition between hospitals can be wasteful and inefficient and so these powers should only be used when it can be demonstrated that introducing competition will benefit patient care.".

'Consideration will need to be given to the rules surrounding risk-pooling, stop-loss insurance and reconciling this with the position of ‘no bail outs’. Clarification will also be needed on which organisations will be required to participate, whether un-used pooled funds can be carried forward to future years and whether a deficit can be offset by the subsequent year’s funds. Clear rules also need to be set out to specify what will happen if risk-pooling fails, or if Monitor assesses that a provider is not financially viable'

The full-length document goes into better detail on bail-outs: "The White Paper states that ‘there will be no bail-outs for organisations that overspend public budgets’. Whilst we agree that organisations should manage resources wisely, there can be genuine reasons why organisations that have tried and failed should be supported. An advantage of a coordinated NHS is the risk pooling and risk sharing that is possible, which has enabled Primary Care Organisations to survive previous financial challenges. This should continue, as a rigid ‘no bail out’ approach would be harmful to local commissioning.

"Consideration will need to be given to the rules surrounding risk-pooling, stop-loss insurance and reconciling this with the position of ‘no bail outs’. Clarification will also be needed on which organisations will be required to participate, whether un-used pooled funds can be carried forward to future years and whether a deficit can be offset by the subsequent year’s funds. Clear rules also need to be set out to specify what will happen if risk-pooling fails, or if Monitor assesses that a provider is not financially viable".

Shaky foundations
Neatly ignoring the ongoing correlation between better financial and clinical performance and FT status, the BMA objects to the White Paper's idea that all must become FTs. Their first-stated reason is because a small minority of FTs have performed badly. Which is not a great argument.

The document warns "intensifying the pressure on NHS trusts to achieve foundation trust status within the next three years will drive more of them to place the achievement of this target above all others, including safe patient care. The BMA would like NHS hospitals to be part of a collaborative publicly owned system of the provision of care for clinical need. We do not believe poorly performing hospitals will improve their standards by moving to a more autonomous system of financial regulation. The BMA believes the abolition of the cap on the amount of income foundation trusts can earn from other sources has the potential to act as an incentive for FTs to undertake more non-NHS activity at the expense of NHS provision. If unfettered, this could lead to a two-tier health service, as FTs invest more resources in non-NHS facilities".

Pensions, pensions, pensions
On the credit side, the BMA have spotted that very few NHS staff really seems to want to join a social enterprise. Pensions crop us as part of this thinking - SEs must, the BMA says, have access to the government-underwritten and thus unbustable NHS pension, which "is sustainable and represents value for money for the public". Nor, staggeringly, do they want to see an end to national pay bargaining.

In its full-length document, the BMA locates its response to the White Paper "in the context of our continuing opposition to the commercialisation and promotion of the market in the NHS and to the threats to national terms and conditions of service and education and training for doctors contained in the White Paper. Moreover, the frequently expressed wish to improve the patient experience and provide more seamless, integrated care, seems at odds with many of the policies which will, inevitably, widen the purchaser-provider split.

"We wish to see the NHS restored as a public service working cooperatively for patients. We are committed to an NHS that
1. Provides high quality, comprehensive healthcare for all, free at the point of use
2. Is publicly funded through central taxes, publicly provided and publicly accountable
3. Significantly reduces commercial involvement
4. Uses public money for quality healthcare, not profits for shareholders
5. Cares for patients through cooperation, not competition
6. Is led by medical professionals working in partnership with patients and the public
7. Seeks value for money but puts the care of patients before financial targets
8. Is fully committed to training future generations of medical professionals.

"There are aspects of the White Paper’s proposals which have the potential to undermine these principles and about which we are extremely concerned. Foremost amongst these are the policy of ‘any willing provider’ and the proposal that all NHS trusts should become, or become part of, foundation trusts".

I don't think we're in stance-taking any more, Toto.