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Dr Hamish Meldrum's letter to Lord Darzi

BMA chair of council Dr Hamish Meldrum warns Lord Darzi about the huge concerns of the BMA and doctors in general abour the NHS Next Stage Review and its plans to roll out polyclinics.

I am pleased that our diaries have permitted us to meet in a couple of weeks' time and hope that this will enable a more in depth discussion than perhaps our regular telephone conversations have allowed.

In advance of our meeting, I thought it would be helpful to indicate some of the concerns that the BMA has been made aware of regarding the NHS Next Stage Review process in general, many of which we have discussed before. Doctors, like the government, wish to see significant improvements made in the NHS.

Our representatives on both national and regional working/clinical pathway groups are committed to trying to make the review process work but we are concerned that, in places, the process is flawed and as a result, will produce rushed, incomplete and potentially unsound conclusions.

One overriding concern we have is that the Department of Health appears to be looking for, or perhaps has been led to believe that the answer to the NHS' problems lies with some kind of big-bang approach, exemplified by the perception amongst some that the Next Stage Review is ‘the review to end all reviews'. We see this as overly simplistic and very much in conflict with our own understanding of the needs of the NHS.

Whilst we acknowledge that there may be a need for a sea change at many levels across the service, we see this as a long-term, incremental process, which can only be achieved collaboratively through a culture change in government, in management, in the profession and even in the public, about the way the NHS is run and used.

I am concerned that there is a danger of public expectations being raised, then unfulfilled and that there is an increasing cynicism in the profession about the objectivity and effectiveness of the whole process.

As you will be aware, the BMA has representatives on a number of the national workstreams and related subgroups; I myself am a member of three (not including ‘Leadership' and ‘NHS Constitution' that have yet to meet). Following discussion with colleagues who sit on other workstreams, we share an overwhelming concern that the timescales set for this work are over-ambitious.

Group members are being asked to consider numerous and lengthy papers on important issues within an extremely short timeframe, often sent 24 hours before meetings, or, worse still, tabled on the day. More worrying is that, on occasion, the content of what is subsequently produced does not reflect the views of, and the discussions in, the group.

I would highlight, in particular, a recent exercise where members of the national workstreams were asked to state five priorities or key points from discussions to date within a very tight timescale (some were only given 48 hours to do this).

Such an approach would again appear to be symptomatic of both trying to meet impossible deadlines and the desire to oversimplify arguments; we find this particularly worrying given the complexity of the issues being considered by the workstreams.

I note from a timeline shared with those attending the ‘Workstream Integration Presentations' event on 14 February 2008 that there is to be an ‘Intensive stakeholder engagement' exercise from April to mid-June on the findings of the national workstreams.

We certainly welcome the intention to seek wider engagement on this work before publication of the final report and I would be grateful for clarification on what this engagement exercise will involve. I would also request that stakeholders are given sufficient time to consider the proposals.

The BMA secured ninety-seven places for representatives on SHA clinical pathway groups across the country (despite two SHAs not appointing any BMA nominees and one SHA appointing only one). In January, we sought their feedback.

Although reports were variable, many voiced serious concerns regarding the rushed nature of the task. In a number of cases, it was felt that the very short timeframes did not allow for all the necessary areas to be explored adequately. As meetings were called at very short notice, members, and not just BMA representatives, struggled to attend and this would have affected how clinically representative these meetings actually were.

As with the national workstreams, members were expected to read and digest many lengthy documents/papers, but were not given sufficient time to do so. Although many representatives found certain aspects of the process helpful, in particular, having the opportunity to take a cross-sector and multi-disciplinary approach, there was a notable level of scepticism in the feedback we received, with a few respondents believing that the final reports had been predetermined.

It is not that we wish to be critical of those running the groups; rather we wish to make the point that they have been set an enormous task and it would be wrong to assume that this exercise will have unearthed all, or even the most relevant, answers.

Our current understanding is that SHAs' visions are to be published in April-May. We assume that there is no longer an intention to issue these visions locally for formal, public consultation, as was the original plan. We find this adjustment to the review process disappointing, in particular the fact that it has not been openly communicated.

Following publication of the visions, we understand that there will be a ‘SHA and PCT process of involvement and engagement on vision' from mid-May to mid-August. Again, I would be grateful for clarification on what this engagement exercise will involve and also, what scope there will be at that stage to make amendments to the visions if appropriate.

I hope that the comments and feedback provided in this letter can be used constructively rather than being viewed purely as criticism. I would also like to reiterate the fact that the BMA and the profession are committed to identifying and delivering improvements in the NHS.

When the Next Stage Review report is published in July, we would expect to see the inevitable limitations of such an exercise being openly communicated as well as the strengths of the service already being delivered by the NHS and its staff duly acknowledged.

We want this exercise to work but any conclusions and, more importantly, the effective engagement of clinicians that is so fundamental to its success, will only happen if these concerns are addressed and if, as a result, there is a realistic acceptance of the limitations of the process and a pragmatic approach taken to any conclusions reached.

I look forward to meeting you.

Dr Hamish Meldrum

Chairman of Council

Dr Hamish Meldrum

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