Bloody Mediocre Actually

May 8, 2007

Let me start by saying that I am deeply suspicious of professional trade unions. I do not regard myself as a disenfranchised working man who needs the resources of a trade organization to negotiate on my behalf, and I don’t believe in a number of things that my own trade union, the BMA, woud regard as sacrosanct (eg national terms and conditions of service for consultants). I am not convinced that the BMA serves the interests of its members, let alone the general public, and I often ask “what is it for?”

The BMA has issued a document called A rational way forward for the NHS in England, which I read today with a mixture of sage nods and spluttering in the style of an HM Bateman cartoon


Here’s a synopsis of the main themes:

1.) NHS to be taken out of day to day political control and put in the hands of a board of governors

Well, fine but is it realistic to think the NHS can have access to £90 billion without accountability to the treasury and the taxpayer. I’m pretty sure Gordon won’t go for it unless he has a ‘stealth’ hand on the purse-strings

2) Explicit acknowledgement of and discussion of rationing

Absolutely-and about time too

3) Increased Autonomy for local health economies

Leaving aside whether an economy can have autonomy, I know what they are saying and this is devolution of decision making to a local level. This has to be good, too.

4) National quality standards to “underpin local management and provision of services”

I can buy into this, but the language is getting more obscure which suggests catastrophe looming

5) “A more mature form of commissioning would diminish the need for a purchaser-provider split. Commissioning should be clinically led, based upon collaborative relationships between primary and secondary care, and seek to develop integrated care systems. Commissioning must be led by the public sector.”

Now they are beginning to lose me altogether. How can you have commissioning without a purchaser-provider split? It may be that they are saying that commissioning bodies should have representation form both primary and secondary care, which I would entirely agree with.  I’m all for collaborative relationships but I think we’re getting into motherhood, apple pie and management jargon

6) Private sector provision should only be commissioned where there is no NHS capacity to provide the service. There is no evidence that the private sector offers improved services or better value for money than the NHS. There should be no further central procurement of private sector provision. The private sector should support the NHS rather than be seen to be supplanting it

No NHS capacity? This has to be wrong. I’m not a fan of central commissioning of private sector services, but it does drive down costs, and may be appropriate in some instances. Why should the private sector support the NHS? Surely both should work, together where necessary, for the improvement of patient care. This doesn’t mean the private sector “supporting” the NHS

7) In order to enable the development of integrated care systems, clinical networks need to be established. This requires a commitment by the service to make protected time available for clinicians to plan service development.


8.) Areas should be encouraged to move toward single-system working, as exists in Scotland, where commissioners and providers work within a single structure. This is because efforts to move towards a different form of commissioning and the development of clinical networks may be frustrated by the formal existence of a
purchaser-provider split. We believe that a HEFT model could achieve this. Boards would include provider and commissioner representation from hospitals, general practice, community providers and public health.

This is unquestionably (to my mind) the right way to develop commissioning-but no mention of patients here

9) Clinical networks should have patient, carer and user involvement at their centre.

stating the bleedin’ obvious

10) We recommend the formation of local health councils to provide a link between the community and health professionals/managers who are shaping local services. Their membership will be elected.

Great idea. These were called community health councils. New Labour abolished them

11) Commissioners must be given freedom to make investments without showing a return within the financial year… greater financial flexibility is needed.

Common sense

12) A new agreement is needed for managers’ relationships with clinicians, together with a new agreement between the government and the NHS, and between the NHS and its constituent parts. This will involve devolving responsibility for the management of care to clinicians and a shift in managers’ priorities. Primarily this will mean a move away from an obsession with external political expectations and towards a focus on clinical quality and service development.

This is true, but see below

etc etc. There were 24 recommendations in all. Some of them were sensible, some of them were stating the obvious. What was said was considered and generally sound.


There was no mention of other critical reforms that need to happen: Giving patients information about their health service and doctors, and the choice of which doctor to see and which hospital to be seen in. No mention that if doctors are to take responsibility for the innovation and development they need to be trained to do so. And, by the way, that they need also to take responsibility for the failings of the system as well. No mention either of improving doctors’ productivity with incentives and financial or other penalties.

In short no mention of fundamental reform of the way in which patients interact with their doctors. Only limited mention of empowering the patient in this discussion. No mention of managing doctors’ performance.

Just what you would expect from a trade union, perhaps. Not necessarily what I want to hear from my professions’ “leaders”

Having said all that, if you add in some of the above details, and read it in the knowledge that it is written by a doctors’ trade union, it is a reasonable document with some well considered points, and may form the basis for sensible discussion. Myself I do not believe that it goes far enough. Root and branch reform is needed in the NHS, which is now performing incredibly badly compared with other international comparators. But the point that is made in the report is that the NHS needs to change by evolution rather than revolution. I believe that we need some genetic modification to speed up the process, though



  1. I’ll have to go and read the whole thing before I can comment sensibly (although I agree with many of your thoughts, especially “hmmmmm”) – but one question, what’s a “clinical network” when it’s at home? It sounds me me as though they’re saying that to solve the problems, we need to invent something that will solve the problems…….but maybe “clinical netwrk” has some existing technical referent of which I am unaware?

    Also sounds as though this document makes the common mistake of referring to “managers” without bothering to distinguish between the local ones and the Whitehall ones (what used to be Leeds before they changed the structure to disguise how many “head office” people there were. this will mean a move away from an obsession with external political expectations and towards a focus on clinical quality and service development. Well yeah, but for that to happe locally, local managers would have to stop being sacked for not attending sufficiently to the politically-driven edicts from the centre.

    And you’re right about (1). The idea that something currently accounting for about 9% of GDP could be genuinely independent of plitical control is cloud-cuckoo land. Moreover, it would be irresponsible of politicians to place it outside political control. And even if they theoretically attempted to do so, since Parliament can’t bind itself, it wouldn’t stay that way. I fear that any Bank of England-type arrangment will just end up with the politicians giving the health service not enough money and being able to distance themselves from any probllems thence arising by blaming it on the “indpepenent” management. And then the im, if it was any good, would attempt to fit a quart into a pint pot by organising a proper “Oregon” rationing method, which would be politically unacceptable, so the whole thing would be taken back under the politicians’ control.

  2. Ah, I’m much obliged to you for a few insights here. I did read the thing once but missed a few salient points.

    One of the problems with politicians is short termism; what’s the fashionable disease of the month, how rapidly can we reduce the morbidity, is this a good election pledge? This sort of interference has got to be counter productive. So I can see the BMA’s point in wanting less ‘tactical’ political control. But I wouldn’t leave it all up to the doctors. And with that level of tax funding, you need some level of elected representative oversight – not Parliament perhaps, but local bodies to whom budgets are devolved.

    I’m disappointed it didn’t refine the idea of local control further.

  3. It’s interesting how we look to Scotland for good practice (point 8), where they have still retained free university tuition. And they produce the best scallops and mussels too!

  4. Hi Mens Sana, sorry lost the thread
    did the words patient & patient care appear anywhere. Did I miss the words healing or curing.

    The BMA is about what is good for doctors, of course.
    I conced defeat, there is no hope for creating utopia on earth – there are too few utopians left.
    People will settle for riches now (on earth) – some will even sell their grandmother – but there is little room for thieves in ‘paradise’

    I am not saying no thief shall enter paradise
    I am saying there IS and can be NO thieving in paradise.

  5. Q9 welcome back. There was very little use of the words patient and patient care, as I alluded to. This is my major issue with the whole thing. Patient groups (ie carefully selected semi-lay people) are allowed to be invoved, but not really much mention of individuals

  6. It’s interesting how we look to Scotland for good practice (point 8), where they have still retained free university tuition

    (Says Ellee , ) at our expense of course.

    You say some of these ideas good ones Men sana but the overriding impression , once again , is of a protected and arrogant Union who feel they have a right to dispense other peoples money because they are “ Experts” ..in what though , not running anything I can think of ? Perhaps we should hand over education to the NUT they also think they are experts imagine the unholy mess they would make . In fact the unholy mess we have is a lot to do with their self serving influence. The NHS is the property of the tax payer and as such will be directed by the tax payer .

    This initiative could be presented as removing a layer of surplus ill informed bureaucracy as in the case of headmasters but the way it appears is calculated to infuriate with anti Doctor opinion already simmering. An own goal I think. Surely there are already avenues for Medical care providers to inform policy on an advisory basis …surely ?

    I like your opening paragraph.Good for you !

  7. NM I think thats a bit unfair. But on the whole I agree!

    The point about the BMA is that they are not the best or the cleverest or the people who have done anything to gain respect. In that sense they are no different from any other union. If their core business is to stand up for the interests of their members that is fine but anything they say needs to be seen in that context. It doesn’t mean its all rubbish, but it has to be looked at with suspicion

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