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Fighting talk

Fighting talk
5 November 2011

Amicable and welcoming on my arrival at BMA House, Dr Laurence Buckman is brisk in manner as he pours coffee and passes the biscuits. His direct, purposeful conduct suggests something is rattling him beneath the surface, and indeed it doesn’t take long to identify the source of this.

Amicable and welcoming on my arrival at BMA House, Dr Laurence Buckman is brisk in manner as he pours coffee and passes the biscuits. His direct, purposeful conduct suggests something is rattling him beneath the surface, and indeed it doesn’t take long to identify the source of this.

Asking the chair of the British Medical Association’s (BMA) GPs’ Committee (GPC) for his thoughts on the listening exercise proves something of a catalyst. “I actually think the pause should have happened a long time ago and we should have waited until the legislation before moving on things,” he says.

“The idea that a minister can announce something and immediately it has to happen and the whole health service collapses, when actually none of this is legal, none of this has gone through parliament and we don’t know the shape of the health service after parliament’s finished with it, yet we’re busy dismantling everything now… that seems to me to be inappropriate.”

The northwest London GP is in relentless form, and he seems almost happy to relieve his frustration, even anger, over aspects of the Health and Social Care Bill, the issue of choice and competition and, in particular, the quality premium.

In June, Buckman, described the concept of the quality premium – rewarding clinical commissioning groups (CCGs) for “delivering the best possible results” (in the words of Care Services Minister Paul Burstow) – as “disgracefully unethical”.

He does not backtrack from this in any way, claiming this would mean GPs would be given financial bonuses for achieving cost-savings. “To give me money on the basis that I withdraw service from patients is unethical,” he says. “It’s a nasty little idea.

“However you measure it, the only way I can save money for the health service is to cut something, to not provide something, to do something cheaper. Now, why should I take a personal financial reward based around reducing service to a patient?”

Burstow called Buckman’s criticism “a caricature, a gross distortion of what we are trying to do here” and said CCGs would be rewarded for “improving survival rates, improving the quality of care delivered to their patients”.

Yet Buckman queries how this can be measured. He insists: “When you go away from the headline rhetoric, the only way you can reward outcomes today [is by asking] ‘how much did they spend last year versus how much did they spend the year before?’ Most healthcare is not measured in immediate outcomes. Most of what I do has a timescale of five, 10, 15 years. That’s not an outcome measure that governments could cope with. So we’re talking about the only outcome, which is cheap. I don’t wish to receive a financial reward for depriving patients of a service. I think that is dreadfully unethical. And we’ve made it clear we’re having nothing to do with it.”

The power and the Tories
Buckman speaks from longstanding experience in facing up to the government. Elected to the GPC in 1990 and a negotiator since 1997, he has been the committee’s chairman since 2007. But having spent more than 30 years as a GP, the concept of family doctors now being handed responsibility for £60bn of budgets doesn’t seem to excite him. Doesn’t he find it empowering?

“Nothing empowers GPs,” he says. “Any sense of empowerment will be taken away by people elsewhere. For all the claims of ‘bottom-upness’, this is a very top-down set of reforms; every single brick in the wall has been very carefully placed there by the government thence to the NHS Commissioning Board (NCB). I think the NCB is going to have very tight control over what goes on.”

However, he does appear supportive of the concept of clinical commissioning, which he describes as “probably one of the few really good things” about the bill. However, the Future Forum report and subsequent government acceptance has not changed the BMA’s outright rejection of the bill. “The BMA position is that we’d like the bill withdrawn, we think it’s badly written, we think it’s going to introduce competition in a way that will damage the health service,” he says. “We actually think it’s going to introduce competition as a mantra, as a religious belief almost, and we think that’s actually bad for patient care.”

The doctors’ trade union, the BMA, is of course expected to oppose steadfastly any hint of privatisation of the health service. Nevertheless, the robust position seems surprising in light of the government’s response to the Future Forum’s recommendations, as it would appear that major concessions have been made to the GPC over the Health Bill.

Before the Forum’s report in June, Buckman set out the GPC’s three key demands as to amending the bill: an explicit duty on CCGs to involve all relevant clinical staff; the regulator Monitor’s primary duty to ensure integrated services rather than to promote competition; and a more realistic timetable for handing over commissioning responsibilities to CCGs.

The Future Forum included all three points in its published recommendations, and the government’s subsequent response indicated that it would accept them. So why is Buckman not reassured by these developments?

“I was quite reassured by the Future Forum report,” he says. “But when you look at the amendments to parliament, they are not as clear as the government’s statement after the Future Forum published. So if you take Mr Cameron’s statement and match it against the legislative amendments, they don’t match. So I will wait and see.”

Indeed, despite his outspokenness, he appears cautious when making comment on the specifics of the bill. “Ask me when I’ve seen the legislation” is his line when asked whether the government’s noises over increased safeguards on competition have placated him in any way. “I am pleased they made the noises they made, but I don’t believe necessarily that is enough,” he says.

Survival instinct
Years of debating unpopular government health policies with the government seem to have left him with a sense of world-weary dejection. When asked if he feels positive for the future, Buckman replies, tellingly: “I’ve learned never to be optimistic. Then you’re never disappointed.”

Speaking of the work ahead for the GPC, he despairs at the lack of variety in modern politics. “Who are we appealing to?” he rhetorically asks. “Parliament is dominated by the three main parties, all of whom agree this [the thrust of the health reforms] is what they want – with different nuances, possibly, but they all broadly agree. So who are we going to have backing us? Nobody. A few cross-bench peers in the Lords, perhaps, but you can’t fight governments on that.”

This may seem rather disconcerting coming from the chair of the GP’s Committee, but he is adamant that the reforms will not overturn the world of general practice. “Various things have come and gone, health services have appeared, there’ll be another set of reforms no doubt after this, which will overturn what’s been done completely. I don’t think this set of changes particularly alters the way [our] businesses work. Whatever happens to the health service, GPs and their practices will survive.” Plus ça change indeed.

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