Professor Alan Maynard casts a sceptical eye over the BMA’s unfavourable response to the ‘Equity And Excellence – Liberating The NHS’ White Paper

You have to love the British Medical Association. They are just so predictable.

The BMA is a trade union. The purpose of a trade union is to enhance the welfare of its members, particularly their income and security of lifetime employment. If they fail to do this, their august leaders lose corporate income; their jobs are in jeopardy; and the good life is threatened.

Typically, they oppose change - except when it offers rewards for their members. Consequently, their response to Lansley’s reform proposals is predictable.

With some of the comrade members of the BMA relishing the chance to manage their (hopefully increased) share of the NHS budget, it was inevitable that “some elements” of the proposed reforms, particularly GP commissioning, would be acceptable to the trade union.

A return to James Johnsonism
“Give us the money with no strings attached” is the BMA mantra. They must think Whitehall Village is lost in a haze of illicit substance misuse.

Much of the rest of the reforms are clearly a potential threat to the BMA comrades, and so are to be opposed. This opposition is dressed up in apparently derogatory terms such as “competition”, “privatisation” and “marketisation” - all of which tend to be undefined, but are by implication a clear threat to civil society and the future of the planet!

Cake and eat it
So the BMA wants to have what will benefit them and their members, but anything which appears to be a threat to their quiet way of life is clearly not kosher and unacceptable.

If the current government accepts this, they deserve their fate – which will be more of the same inefficiency and expenditure pressure endemic in all healthcare systems; public and private.

A significant proportion of the BMA comrades are general practitioners. Since 1948, these providers have been private entrepreneurs, offering a nice mix of care to patients – the quality of which ranges widely, from the excellent to the deplorable.

Their self-employed status in partnerships enables them to write off the wife and their pussycat as tax expenses; all the while taking home a nice income, especially since the new contract in 2005, from which they can get large tax breaks as they accumulate large pensions.

The BMA perceive a threat to this happy state of affairs for the comrades. Where care is awful, commissioners have been tendering services and private firms have entered the market. Many of these wicked private entrepreneurs have had to hire staff under NHS terms and conditions, sadly. This has inhibited their ability to substitute nurse practitioners for GPs and use under-employed pharmacists.

Sadly, so-called wicked capitalists have been captured by professional resistance and NHS pay and conditions, so that efficiency opportunities such as increasing GP-population list sizes to 3,000 and beyond have not been exploited. Such substitution would cut GP employment and costs.

How much is that shroud in the window?
If these wicked capitalists, or even nice old NHS managers, began to exploit these opportunities, the BMA would howl that patients’ lives were in jeopardy and the NHS was collapsing.

Politicians quail at such bollocks.

NHS managers and their private sector colleagues also quail when the local BMA shop steward turns up threatening to spread tales of NHS destruction and patient despondency and revolt into the local community. Managers faced by threats from these latter-day Soviet Commissars buckle and compromise, rather than risk having the local medics get their knickers in a twist as result of well-manufactured BMA propaganda.

How to drive change
The issue, as ever, is whether the private sector can be used efficiently to leverage change in the public sector to benefit patients and taxpayers. This requires careful regulation, transparency and accountability for public funds -requirements apparently alien to BMA acceptance of GP commissioning.

The BMA sits in its bunker resisting threats of competition and contestability, as it is potentially a threat to their members’ income and job security. But evidence-based threats of this kind are precisely what is needed.

’ The persistence of decades of observable inefficiency shows that change is slow to emerge’.

Of course we should expect the NHS to engineer change itself. But the persistence of decades of observable inefficiency shows that change is slow to emerge. Too slow - in a period of fiscal insecurity, for the NHS to be sustained and meet the expectations of the population.

The policy issue is whether change can be incentivised more efficiently by spreading terror - or at least the threat that evidence-free variations in care and local continuity of inefficiency is not acceptable.

For providers, uncertainty about their fate created by the threat of competition, which includes the use of targets, can improve the lot of the patient.

A farewell to certainty
Uncertainty is what the BMA wish to avoid. “Leave us alone” is their mantra. “We deliver good-quality care”, they assert, although there is uncomfortable evidence to the contrary. Some BMA members provide excellent care. Many other provide good care. Some provide poor care.

The BMA and Secretary Lansley have to address how they can demonstrate continually-improving quality - and how the performance of unacceptable outliers in primary and secondary care is to be corrected.

’ The BMA and Mr Lansley … sadly appear to be “jumping on the spot” amid much commotion and a storm of horse manure; rather than evidence of how they will improve the NHS’.

The BMA have been slow to meet this challenge. Lansley has adopted costly and ambitious policies which may merely translate PCTs into GP commissioners, with little gain for patients. Both parties sadly appear to be “jumping on the spot” amidst much commotion and a storm of horse manure; rather than evidence of how they will improve the NHS.