It is a great privilege to stand here before our profession. As I stand before you, we all stand before 153,000 members of the British Medical Association.
For every one of us, there are 300 BMA members. For every one of us, there are more than a hundred thousand patients. We must carry their hopes, and we must voice their fears.
Colleagues, we have four days of debate ahead of us. When I look at the agenda, at the things that doctors know to be important, I’m left with a question that it saddens me even to ask.
The question is this:
Do we have a government that really gets the NHS?
Imposing policies that force us to do the absolute opposite of what our patients need.
Making cuts to frontline services that eat away at the fabric of care and destroy innovation….
… and when everything goes wrong, blaming those who provide the care.
I’m not giving up hope, even though I fear some of our politicians are more interested in the next government than this one.
It’s not too late for the government to change.
But first, they must face up to the damage that they have done.
It all began with a broken promise.
Four years ago, the coalition said in its programme for government, I quote: ‘We will stop the top-down reorganisations of the NHS that have got in the way of patient care.’
No-one’s perfect. We’ve all made the odd promise we couldn’t keep. But has a promise to the NHS ever been quite so needlessly, recklessly broken as that promise not to impose change from the top?
A broken promise that imposed in England a new NHS without evidence, without mandate and without support.
A broken promise that cost at least £1.6 billion, possibly much more, to implement. One that continues to consume the energies of thousands of NHS staff who never even wanted it, just to stop it unravelling.
We have now experienced the first full year of the Health and Social Care Act.
It’s been a bumper year for the multinationals. For their armies of lawyers and accountants who find the curative so lucrative.
But for those of us who work in and are cared for by the NHS, we have been dragged further from the founding vision.
The NHS was founded with a promise of healthcare for all. Sixty-six years on, it’s still free at the point of delivery, and while it can’t do everything, it does more with its budget than any other healthcare system in the world. But there is something missing. An implicit part of that promise has never been fulfilled.
Think of the elderly patient who has suffered a fall. She has a long list of needs – emergency medicine, X-ray, blood tests, orthopaedics, anaesthesia, physiotherapy, geriatric medicine, community nursing, general practice.
But that list is for us to worry about, not her. She might just want to get her leg better and to know that someone is feeding the cat.
To give one person, just one person, optimal care can involve a dozen different elements. If they’re not working together, if the care they give – however good individually – is fragmented, then they are failing the patient.
Of course, they may be harming the patient too.
This has never been easy. We have all shared the frustration of patients who find their care needs unnecessarily complicated or obstructed by referral management rules. There are some excellent examples of integrated care, but these are despite, rather than because of, recent changes.
I’m not going to take a lazy swipe at the managers over this, and I’m not going to deny that we doctors mess up sometimes too. It’s difficult.
But while everyone else in the NHS has been working to make it better for patients, the government, through its misguided legislation, has been doing the exact opposite.
How can we ever achieve whole and seamless care when so many services have to be touted to private bidders?
How will these services work together for the good of patients when they are constantly eyeing up each other’s business?
How can services improve when the law can impose competitive tendering but cannot be used to protect or prefer publicly-run services?
The possible benefits – which certainly didn’t need this piece of legislation to make them happen – have been weakened.
Doctors may be more involved in commissioning, but in a fragmented NHS. There may be a theoretically independent board to run the NHS, but it has not stopped political interference driven by ill-informed dogma and ideology.
Public confidence has been drained. Two thirds of people think the NHS would be better off without politicians being involved at all.
And I’ll tell you the biggest myth of all. That this is all about efficiency. Let me give you an example…
In Bedfordshire and Milton Keynes, there’s a review of NHS services going on. It’s costing more than £3 million, with Monitor picking up the tab. McKinsey, those management consultants you might have heard of, are providing ‘expert analytical support’.
The two CCGs involved say it’s about making services less fragmented and promoting collaboration rather than competition. They say that the Mid-Staffordshire Trust and the 14 others with higher than expected mortality, show the need for a caring and learning culture.
I’ll take them at their word, and I hope they succeed in improving care. So when I tell you about the next bit of market lunacy, I say it out of sympathy and not out of contempt.
As part of the review, they wrote to a number of providers. They were looking for high quality services they said, and wanted to know what they could provide and the data they needed. Anyone expressing an interest would have the chance to talk to commissioners.
Now, you wouldn’t just invite anyone in, would you? I mean, if it were quality you care about, you’d need to know the provider was up to it before you even asked them to express an interest? Otherwise you risk wasting everyone’s time with all those meetings with commissioners that you promised.
So who were good enough for Bedfordshire and Milton Keynes to ask for expressions of interest?
Well, they asked Mid-Staffordshire, even though it’s about to be dissolved. They asked South London NHS Trust, even though it already has been dissolved.
They asked each one of those 14 trusts they mentioned with higher than expected mortality.
They wrote to the usual suspects, of course, the healthcare conglomerates. But they also asked small hospital groups in the mid-west of America who may not have even heard of Bedford, Massachusetts, never mind Bedford, England.
They wrote to an American provider offering ‘faith-based’ healthcare – as they put their own faith in this bizarre and burdensome approach.
Somehow they were worth the prospect of all that paperwork, all that time digging out data, all those meetings that might have to be set up.
They wrote to 500 providers. Five hundred. Let’s imagine the bureaucracy that this could generate. Let’s imagine the other commissioners that, right now, might well be doing exactly the same.
Now, the government will no doubt say that commissioning decisions are made locally. Monitor has told us that not all services need to be put out to tender. But whatever the reassurances, a bizarre market culture has been created.
So I say it again, colleagues, I sympathise with commissioning managers. Why? Because there are decent, intelligent people trying to manage the NHS, people who really want to achieve all those things they said in the review. They want to promote integration and make care better.
But these same people are being driven to distraction by the madness of the market.
They can’t do both.
And a government that thinks they can, just doesn’t get it.
Do we really want an NHS that is so obsessed with private companies tendering for the work? Or do we want a National Health Service that is passionate about tending to the weak? It doesn’t have time to be both.
And that’s why only five per cent of doctors think the Health and Social Care Act has improved quality of services. Sixty per cent think it has increased fragmentation.
Colleagues, the one cause for celebration about the Act is that most of it doesn’t apply in Scotland, Wales and Northern Ireland.
But there is an even greater threat that affects us across the UK. A more pernicious example of the government just not getting the NHS.
It is this – whatever the good intentions of national governments or employers, it is the Treasury’s agenda to override any investment, suppress any incentive, erode any service, in the single interest of bleeding every penny it can out of the system.
The Treasury says that it takes the money for our own good. It’s all about improving efficiency, they say.
But it ignores a simple fact. The NHS is given virtually nothing above inflation, but demand rises at four per cent a year. So every year, that same four per cent has to be cut.
Other public services might have been cut even more, but it makes me angry every time I hear a minister saying that NHS spending is protected.
The so-called efficiency savings are cuts. The experience of every healthcare worker, every doctor, is of having resources cut every year.
Does anyone really believe that the teaching and medical research at Kings College, London, is going to become more efficient if it carries out its plans to make 120 people in the health schools redundant?
We are seeing cuts that are driven by an uninformed and arrogant assumption that the NHS is bloated and inefficient.
But when they have gone looking for savings, the bulk has not come from reducing waste. They have come from reducing tariffs, and this has destabilised services. They have come from targeting the staff who themselves are keeping the service going.
Even Jeremy Hunt himself has admitted that pay freezes – real terms cuts to you and me – are not sustainable. He says he needs to be ‘more imaginative’.
There’s certainly a lack of imagination, but not in quite the way Jeremy Hunt sees it. There is a severe lack of imagination that says the NHS will become more efficient by refusing to invest. By cutting what they can see, rather than by seeing what needs to be cut.
This obsession risks undermining the contract negotiations for consultants working in England and Northern Ireland, and for junior doctors across the UK.
We have gone into the negotiations in good faith and with good reason.
We are negotiating for the junior doctors who are pressured to under-report their hours and whose work goes unrecognised.
We are negotiating for the consultants who want to deliver high-quality care, but are told that this year’s savings target is the time they spend on quality assurance and quality improvement.
These issues matter to our patients as well as our doctors.
It is in everyone’s interest to resolve them. They are about recognising the professionalism that doctors bring to the NHS, the expertise, the years of training and above all the care that they provide for millions of patients every day.
It is also a basic principle that as a doctor proves they are gaining skills and taking on more responsibility, this is reflected in their pay.
The details of how this works are a matter for negotiations.
But how is either side supposed to negotiate when we have a chancellor who talks of ‘automatic’ pay rises and wants them all stopped?
Chancellor, they are not ‘automatic’. The only ‘automatic’ pay rise I can see is the 11 per cent that MPs are due to get next year. Where are the public sector pay freezes when you make the rules yourself?
There are certainly savings the government can make. We can all see how the NHS is wasting money. If the government doesn’t get it, let’s show them.
The PFI deals signed off and egged on by the Treasury. The billions spent on fragmenting care by forcing the NHS to open up to private bidders. The droves of management consultants with their pointless flipcharts.
But despite this, the Commonwealth Fund has just compared healthcare systems in eleven leading countries and guess which one it found the most efficient, and the best system overall? … The NHS.
And which was the least efficient? Funnily enough, it was the country where these healthcare Goliaths have been given free rein. If these multinationals are supposed to make healthcare more efficient, why have they achieved the exact opposite in, you’ve guessed it… America?
Colleagues, the biggest source of waste in the NHS is failed ideology. The King’s Fund talks of the irresistible tendency of ministers to want to be seen to be in charge. It says short-term political initiatives get in the way of delivering long-term change.
All the political parties have been guilty of this. We have a general election ten months away. I can only urge the politicians to learn from their own mistakes and those of this government.
Every flashy, untested, unfunded promise might be just an easy headline for you, but it is another burden on those who have to make it work, and another distraction from serving our patients.
If you scandalously blame a failure of policy on the people who work in the NHS, it has consequences. Five years of real-terms pay cuts, a culture of blaming doctors for every gap in the service they work desperately hard to provide, a failure to listen, a failure to invest, has human consequences.
This is felt across the branches of practice. A quarter of junior doctors are thinking of leaving the profession. Almost a third of consultants have considered working overseas. Forty per cent of SAS doctors are concerned about their job security. Two-thirds of GPs feel their workload is unmanageable or unsustainable.
And when a government fails to see the problems it has caused, and is light on solutions to tackle the real issues, all it can do is meddle.
It meddles with the DDRB, set up more than 50 years ago to take politics out of doctors’ pay. It doesn’t get that the DDRB is meant to be independent; a judge of what is fair to the public and fair to the profession.
The politicians have dragged our pay into the political arena. They have dragged in out-of-hours, and the pressures on emergency care with it.
No-one benefits from this. But if they want that argument, we’re up for it.
We’ll show the public that money is wasted on untested policies, not hard-working public servants.
We’ll show the public the care we already deliver out of hours, in hospitals and in general practice, and that we designed it and do it for them.
We’ll show the public the chronic lack of investment in emergency medicine, in general practice, in public health, in mental health, across the NHS.
Who should the public blame? The people who work in the NHS, or the government that holds the purse strings?
And with the general election just 10 months away, we could be fighting like this every day.
Or maybe there’s another way.
Four years into this government, less than a year to go, we might be tempted to give up. But colleagues, we can’t afford to. We can’t afford to lose another year.
We can hope, but I’m talking about more than hope. The road to Damascus doesn’t seem to run through Whitehall.
Instead of appealing to the heart, we should appeal to the head.
I want to ask the government this….
Do you really want to be forever remembered as the government that spent five years breaking a promise, five years frog-marching the NHS towards fragmentation, five years attacking the morale of its staff and burning the rich fabric of goodwill?
As the government that didn’t get it?
It’s not too late.
Government, this is how to do it.
First, you stop the screaming headlines and the starving of resources.
Those sly briefings that blamed emergency medicine pressures on GPs, when the evidence said the opposite, and when practices are offering 40 million more appointments than they did five years ago.
Spreading the myth that consultants are not delivering urgent, emergency and acute care out of hours. When I and my colleagues are in hospital at 2 o’clock on a Sunday morning, what do you think that does for our morale?
So if politicians want to make any promises ahead of the election, this is one to keep – a promise to allow doctors to be the professionals, the leaders and the innovators that they have proved time and again they can be.
And free us from unnecessary targets which benefit an agenda and not the public. Every time one of those diktats vanishes, patients benefit.
Our GP colleagues have shown us the way, rolling back the ridiculous impositions of the previous year, and enabling more time for patients.
Poorly-designed targets can create more problems than they solve. In Scotland, a drive to limit newly-appointed consultants to one SPA a week, might have seemed a quick fix to get more operations done in the short term.
But how can the NHS improve, if those providing the care are denied the chance to develop new services? If we are told the service does not care for quality assurance and quality improvement?
Do we really want those people at the frontline to be told that the NHS is closed to new ideas, and that however good their idea, they will never be given the time to develop it?
Secondly, you recognise that no organisation in history has improved through a blanket refusal to invest. It is economic illiteracy. Services move around, every sector experiencing an increase in demand and a need to reconfigure, but there has been no extra investment to match.
Finally, I say to the government work with us, not against us. We stand by the issues that benefit our patients, and we will stand by you in supporting them.
Issues like plain tobacco packaging. There is international evidence that it reduces smoking and saves lives.
You were with us, then you wobbled, and now it looks like you might be back. If the tobacco industry kicks up, we’ll stand by you.
I have always said that the BMA is ready to work with government on improving patient care. The offer will always stand, because I know that the experience of doctors can make it better.
There’s an important lesson here. It’s not too late to change.
I’m not expecting four years’ damage to be cleared up in the ten months before the general election. But it’s not too late to start.
It’s not too late to recognise that every day, the time and energy of thousands of people are serving a failed ideology rather than the benefit of patients.
It’s not too late to realise that every time the NHS is carved up and fragmented, instead of dedicated to the pursuit of seamless care, patients will suffer.
It’s not too late to solve chronic shortages of money and staff, rather than exploit them for a cheap headline.
When I have a good day I know that patients were front, back and at the centre of my world. I know I have made things better.
It’s not too late for politicians to share that feeling.
After four years of waste and cuts and missed opportunities, the government and its opponents can’t just switch off and start planning the next general election.
They need to show us they get it.
It’s never too late to change. And as anyone who works in the NHS, or is cared for by the NHS, or who cares for the NHS will tell you, it is never too soon to act.