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BMA condemns competition and payment by results in the NHS

Annabel Ferriman BMJ

The competitive market in the NHS and the policy of "payment by results" were both condemned by representatives at the BMA’s annual meeting in Manchester this week. George Rae, a BMA Council member, said that the government seemed to be "obsessed with the private sector." Payment by results, whereby hospitals are paid for operations according to a set national tariff, could only work if all parties, both public and private, were treated equally, he said.

"There must be no preferential treatment for the private sector. We must not have a competitive market that works against the NHS." Dr Rae asked the government not to dilute or fragment the health service and not to engage in superficially attractive policies with potentially damaging results.

Jacky Davis, a consultant radiologist in London and a member of the BMA’s consultants committee, pointed out that this government had once described the internal market as a cancer, but now favoured a rigged market, in which independent treatment centres were given a guaranteed income.

The meeting unanimously passed a motion that said that "more emphasis should be placed on collaboration as opposed to competition," and that the new competitive market must not prejudice the NHS through any guaranteed flow of income to the private sector. But it threw out a proposal that the BMA should join with other unions to campaign for the restoration of public and planned provision of the NHS as the only way to maintain a universal equitable health care system.

The meeting passed a separate motion calling on the BMA to vigorously oppose payment by results on the grounds that low cost private treatment centres would cherry pick uncomplicated cases, leaving more complex cases to NHS hospitals. The motion also said that the diversion of funds to the private sector threatened NHS trusts.

Chaand Nagpaul, a north London GP and a member of the conference of local medical committees, said that there was nothing wrong with the principle of funding healthcare providers according to results. "Indeed, we currently have a bizarre system of ‘payment regardless of result,’ where providers are paid block sums of money, not sensitive to their workload, quality of care, and with little incentive to make improvements," he said.

But "the ‘results’ the government speaks of are confined to activity," he said. "You’re paid for how many patients you process, never mind the quality or outcomes. There’s no recognition, for example, for postoperative outcomes, complications, or relapse rates."

The proposals were "fodder for gaming," with trusts coding care episodes creatively to gain greater income, known as "coding creep," and they provided perverse incentives. The meeting demanded "a robust independent monitoring system" to compare clinical outcomes from independent sector treatment centres and NHS establishments.