Top GPs debate pros and cons of NHS reforms

GPC chairman speaks out against NHS reforms as a leading supporter explains why he backs the plans.

Dr Buckman (left) has concerns about the reforms while Dr Alessi (right) believes they are for the best (Photograph: JH Lancy)
Dr Buckman (left) has concerns about the reforms while Dr Alessi (right) believes they are for the best (Photograph: JH Lancy)


Dr Laurence Buckman, GPC chairman
The Health Bill, and the mounting criticism of it, has been plastered across newspapers for months. BMA experts have been poring over the Bill's 288 clauses, and the more we find out, including what is missing, the more concerned we become.

Monitor and the NHS Commissioning Board will have the power to set a maximum national tariff, with flexibility to negotiate below it. So, as in the 1990s the door will be opened to price competition. Despite what some people claim, evidence shows clinical quality fell.

NHS chief executive Sir David Nicholson this week claimed the tariff flexibility would not lead to price competition. However, we need more than a promise - the Bill must be amended to reflect this.

Private providers will be able to complain to Monitor if they think consortia are behaving anti-competitively, smaller providers may be unable to compete on price, and, perhaps most importantly, there is the dire financial climate. There is a real risk price, not quality, will be the driver in the new NHS.

Wording in the Bill on consortia is worrying too. They will find themselves utterly controlled by the Board and Monitor. The Board and the health secretary will have wide-ranging powers over consortia and there appears to be little duty to consult them on issues that will directly affect how they operate.

Accountable officers will be answerable to Monitor for compliance and good practice. They will be appointed by the Board, so it will be regulating effectively from within. More regulations will be set out in secondary legislation. We don't know what restrictions, or freedoms for others, they will contain.

The BMA is seeking amendments on aspects of the Bill that cause concern. If you don't like what is being planned, contact your MP. We know the NHS needs to change to cope with demand, and not all of what the DoH wants is bad, but we want the NHS to change for the better, not the worse.


Dr Charles Alessi, National Association of Primary Care executive member
The health reforms change everything. They make clinicians the key link between the patient, the outcome, the process and the institutions and functions they discharge.

We have been through a journey in the NHS from the days of fundholding, which in its pure form as total fundholding was the progenitor of this policy.

The reforms capture the importance of population health, which is now part of every interaction with a patient. As clinicians we have to accept that we practice within a financial context - in essence what the state can afford and has determined is appropriate to treat our population.

There is a debate to be had about the size of that budget.

We are pegged at around 8 per cent of GDP for health as against 12 per cent for Germany and 16.5 per cent for the US.

However, what is a fact of life is that we need to live within our means, although many of us would prefer to practise the pure art of medicine without the need to worry about the means to pay for our decisions.

Someone needs to make the judgments around prioritisation of care within a budget. Do we prefer to let people divorced from care make that judgment? We have seen some effects of that with unresponsive commissioning, which did not connect with the needs of our patients.

We need to make the small changes that will transform our patients' journey, from one of frustration and complexity to one where we spend less time complaining around lack of care and more time ensuring the care is appropriate.

Politically it may be easier to blame someone in an ivory tower for the poor care our patients receive, but I feel this is an abrogation of our responsibilities as health professionals.

The new world is around inclusion, distributed leadership and not imposition. We are at the start of an exciting but difficult journey.

Dr Laurence Buckman and Dr Charles Alessi recommends

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