The Government’s controversial Health and Social Care reforms have left the NHS and doctors across England in distress, Dr Clare Gerada has claimed.

The chair of the Royal College of GPs again voiced concerns about the introduction of the Health Act and the consequences of the reforms for the NHS and healthcare professionals.

Speaking at a conference in Glasgow, Dr Gerada claimed the NHS is experiencing the “mother of all top-down reorganisations” – which were the most “radical” in its 60 year history.

Dr Gerada said that as a result of the reforms the health service and GPs had been left “in distress” after the Act was “rushed through at breakneck speed.”

“We GPs will always make the system work for our patients,” she said. “But we will never compromise the founding values of our NHS. And each of us must continue to play our part in raising concerns wherever we see inequalities and unfairness in our health system.

“We’ll show courage, just as our forefathers did as they rose to the extraordinary challenges posed by post-war austerity and the uncertainties of the new NHS.”

“Yet despite her opposition to the Health Act, Dr Gerada called upon doctors to embrace our future with optimism and confidence.” A statement echoed by the Department of Health.

“Local doctors are the right people to lead the NHS,” said a spokesperson. “They will make this system work and make sure the NHS is locally led. They know what their local health and care issues are and will ensure patients are treated as individuals – with dignity and respect – improving services and the quality of care.”

The Government needs to do more to support life sciences in the UK and create an environment where the industry can flourish, a new survey has found.

RSA’s The UK Life Sciences Leaders’ Survey 2011 revealed worries over the NHS reforms, medicine pricing and reimbursement, employment issues and the cost of research amongst its leaders.

Nick Stephens, CEO of RSA, says the Government “urgently needs to do more to ensure that education, regulation, access to medicines and the NHS research base align to support the industry’s continued contribution to the UK economy”.

The report is the second annual survey of industry bosses. Last year the general feeling was of optimism with leaders believing the recently elected coalition Government would improve the business environment.

But twelve months later the mood has changed with results finding leaders claim the UK is not competing effectively globally, creating opportunities for early phase/smaller companies or making the most of its unique selling points: the NHS and skills in innovation and discovery.

Leaders also raised concerns about the increasing cost of working in the UK, the implication of R&D as a result of the NHS reforms, the regulatory burden on operations and the process from development to market. They also advised that fiscal and tax incentives should be given to SMEs to help their growth and the UK compete globally.

Worries were also raised about the introduction of value-based pricing. However, in contrast, health technology assessments were broadly welcomed as a means of enhancing value and meeting therapeutic requirements, the report found.

During the tough economic environment, the survey found that leaders would focus on innovation, creating flexible organisations and processes, and refocusing research and development to weather the current storm.

In a perfect world, leaders revealed they would investing in R&D and make the healthcare sector, regulatory and commercial environment work closer together to achieve better outcomes for patients and the pharmaceutical industry.

Stephen Whitehead, CEO, ABPI, says the survey shows more support is needed for biopharmaceutical companies in the ever-changing NHS. “There is much that the Government has done to support the industry, particularly through the Growth Review and the Office for Life Sciences,” he said. “But we need to build on this as part of a continuing relationship with NHS and Government to explore how unnecessary bureaucracy can be eliminated from the healthcare system so that new treatments can reach patients as quickly as possible.”

Andrew Lansley has insisted he and his successors as Health Secretary will have a duty to provide a comprehensive health service via the NHS Commissioning Board and CCGs.

The Secretary of State for Health has said it will remain incumbent for those in the position to ensure services currently provided by the NHS.

Speaking at the National Association of Primary Care conference, Mr Lansley said “that is in law, in essence, what is described as a comprehensive health service.”

Changes to the duty of the Secretary of State to provide a comprehensive health service have been one of the most controversial aspects of the Health Bill since its release and its debate in the House of Commons and the House of Lords.

“It’s the duty that has been placed on me and my predecessors for more than 60 years and it will be incumbent on you to discharge that duty in the future - and it will remain incumbent on me and my successors to ensure that through the NHS Commissioning Board and through your CCGs that service is provided,” Mr Lansley told delegates.

The Health Secretary also emphasised the freedoms CCGs would have under the NHS reforms. But he outlined the opportunity would only come with the responsibility to ensure patients have “access to the NHS services” they require.

“You will have the freedom to choose who should support you in taking charge of local health services,” he said. “Clinical senates and clinical networks will be there to advise you, not to tell you what to do.

“You will have the freedom to structure yourselves to meet the needs of your population, providing you involve members of the public, with nursing and secondary care experience on board.”

The top-down reorganisation of the NHS is David Cameron’s “biggest single mistake” during his time in office, Shadow Health Secretary Andy Burnham (pictured) has said.

Mr Burnham claims the decision to combine the challenge to make £20bn of efficiency savings at a time of the biggest reorganisation in the history of the NHS is a “catastrophic error of judgment” by the Coalition Government.

Bringing a day motion on the coalition’s record on the health service, he accused the Prime Minister of breaking promises to push through the Health Bill and using pre-election statements to “help the Conservatives win votes in marginal seats”.

“People will remember only too well, running up to the general election, the then leader of the opposition’s ostentatious shows of affection for the NHS,” said the MP for Leigh. “His airbrushed face on the posters and three very personal promises: real terms increases in every year in this Parliament; no A&E and maternity closures; no top-down re-organisation of the NHS.

“He protested his love for the NHS, and at photocall after photocall on the wards, routinely wore his heart on his sleeve. He was protesting a little too much and today we expose the hollowness of his promises.”

The Shadow Health Secretary added that if Mr Cameron continues with the Health Bill he will “ultimately pay a heavy price for it”. When speaking about his counterpart Andrew Lansley, Mr Burnham also claimed that the controversial Bill was “unravelling before his eyes” and that the health policy introduced by the Government was currently in a chaotic state.

The BMA has again called for the Health and Social Care Bill to be withdrawn or undergo further substantial amendments in a letter to peers in the House of Lords.

Although BMA Chairman Dr Hamish Meldrum recognises significant changes have already been introduced, he outlines how the Bill lacks clarity and how the reforms offer serious problems for the NHS.

In the letter, Dr Meldrum says “the BMA still believes the Bill, as it currently stands, poses an unacceptably high risk to the NHS in England”.

He adds that the proposed reforms will make it harder for the health service to “create the seamless, efficient care that everyone agrees is key to future sustainability”.

While the Association is not against all of the proposals in the Bill, it says the Government’s plans are the “most radical restructuring of the NHS in a generation”.

Ahead of the second reading of the Bill next Tuesday, the BMA believes the most pressing concerns the House of Lords needs to address are:

• The need for an explicit provision that the Secretary of State will retain ultimate responsibility for health services
• Assurance that increasing patients’ choice of provider for specific elements of care will not be given priority over the development of NHS services and fair access for all
• Greater scrutiny of the plans to tackle underachieving hospitals

Concerns were also raised by Dr Meldrum about the threat to the capability of public health in the future; unnecessary and unhelpful bureaucracy around the development of CCGs and the NHS Commissioning Board; and the plans to abolish the income cap Foundation Trusts can generate from private patients.

The BMA’s letter follows a similar epistle from 400 public health experts who voiced their concerns over the reforms and called for Lords to reject the proposals.

Read more on this story on Medtech Business.

Up to 400 public health specialists have voiced their concerns about the Health and Social Care Bill and called for the House of Lords to reject the controversial reforms.

In an open letter published in The Telegraph, the specialists warn the proposals will put patient safety at risk, waste money and weaken authorities’ abilities to fight diseases and tackle health emergencies.

Dr David McCoy, who coordinated the letter, says the Bill will “erode the NHS’s ethical and co-operative foundations and that it will not deliver efficiency, quality, fairness or choice”.

The second reading in the House of Lords begins next week with Baroness Williams expected to lead the opposition against the legislation.

The letter is a blow to the Government who had hoped to gain their support following the amendments to the Bill after the recommendations made by the NHS Future Forum.

Shadow Health Secretary John Healy said the Prime Minister was in “denial” about the level of support the reforms have and the “damage his plans are doing to the NHS”.

He said: “There is no mandate for the Bill, either from the election or the coalition agreement. With the Government having railroaded its plans through the Commons, heavy responsibility is now going to be shouldered by the Lords.”

Mr Cameron accepts there are healthcare professionals that are “wary about parts of our proposals” but says that “many GPs, many doctors and many in the health service recognise that change is necessary” to improve standards of care.

'”I think the reforms are right, I think they will improve patient care,” he told ITV’s Daybreak. “Above all, they will be good for patients. They are going to give you more power and control over the care you get, a greater choice too, which I think patients will welcome.”

A Department of Health spokesman said they were disappointed that the specialists “who pride themselves in the use of evidence” have fallen back into “such generalised assertions for which there is not one shred of evidence” when writing the letter.

“The reforms to public health arrangements are a once in a lifetime opportunity to put public health at the heart of local health plans,” he added.

“NHS staff and the general public are looking to senior leaders in public health to lead the implementation of the changes to secure better health results for all, not to rubbish them.”

In recent years the German government has introduced a series of reforms designed to radically cut the costs of drugs. With VBP being considered here in the UK, Dr Arnim Jost explains how these measures have affected pharma companies in Germany.

As the biggest pharmaceutical market in Europe and a price reference point for other European markets, success in Germany has always been essential for pharmaceutical companies. However, recent changes in legislation have combined to make Germany an increasingly tough challenge even for the pharmaceutical originators delivering innovative new drugs.

Germany was one of the last countries in Europe to allow pharmaceutical companies to determine prices. Now, with an estimated goal of cutting €2 billion from pharma spending, that is changing, with even new drugs facing tough value assessments before prices are set. With the UK Government considering the adoption of VBP, with fees negotiated on the scienti­fic assessment of a drug’s clinical value, once the Pharmaceutical Price Regulation Scheme expires in 2013, the impact of this change in Germany will be keenly watched by pharmaceutical companies in this country.

Price pressure

Since 2007 and the introduction of GKV-WSG (Gesetzliche Krankenversicherung-Wettbewerbsstaerkungsgesetz), which allowed public insurers the chance to negotiate discount agreements with pharmaceutical companies for generics and off-patent products, companies have seen prices erode.

These public health insurers represent 90% of the population of 82 million, and hence have signi­ficant influence. Over the past twenty years there has been significant consolidation of these organisations, from 1,100 in 1990, to 226 in 2008, and 155 today.

Within the next three to five years that number is set to fall further to just 50. For pharmaceutical companies this consolidation is a double edged sword: there are fewer organisations to target and understand; but each insurer has a far greater buying power and can drive ever stronger discounts across the market.

Price pressure increased in 2010 with the GKV ÄndG (Gesetzliche Krankenversicherung-Aenderungsgesetz), which demanded mandatory discounts for non-reference price products to increase from 6% to 16%, and introduced a retroactive price freeze for all non-reference price products from 1 September 2009 until 31 December 2013, a move expected to save €1.15 billion, according to Policy.io.

Innovative overspend

At this time, pharmaceutical companies were at least allowed to set prices for innovative new products after a drug’s introduction to the market. However, this changed in January 2011, in response to €32 billion spent on medicines by the public health insurers in 2009, creating a signi­ficant deficit.

With the Health Minister claiming innovative drugs were responsible for the overspend, a new law was passed which limits the amount that pharmaceutical companies are allowed to charge for new prescription drugs.

AMNOG (Arzneimittelmarkt-Neuordnungsgesetz) demands pharmaceutical companies provide a value dossier within three months of the product launch, demonstrating the medicine’s cost and bene­fits. If a new drug is found to have additional medicinal benefits, its price will be negotiated between the manufacturer and the insurers within a year.

However, maximum prices – reference prices, in Germany called “festbetrage” – will be set for drugs which do not have any additional benefits over an existing drug.

Evidence based

The implications for pharmaceutical company market access strategies are significant. Market access has now shifted towards justifying the price, towards conducting cost benefit analysis and evidence based medicine. Of course, for the first three months of any product’s life there is little opportunity to undertake evidence based assessment.

Companies in Germany are, therefore, now involving business units, including sales and marketing, up to 12 months before a product launch to create cost benefits dossiers and prepare the value arguments for the medical and pharma-economical experts within the regulatory bodies G-BA (Gemeinsamer Bundesausschuss) and IQWIG (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen).

Companies now need access to greater depth of information regarding the decision makers within G-BA and IQWIG to determine the on-going strategy for this value-based assessment.

Indeed, this process requires far greater information resources – from therapy data, to information about comparable products and product costs. Pharmaceutical companies must now analyse the entire health chain, from diagnosis through therapy to rehabilitation to assess and demonstrate the true potential value of the new product.

They are not, however, as yet able to work effectively with hospitals to ensure drugs are used appropriately in order to achieve the expected benefits. Unlike the UK, where the NHS is being actively encouraged to co-operate with pharmaceutical companies to promote research, innovation and better practice, in Germany the boundaries between health provider and pharmaceutical company are still strong, with hospitals looking to optimise their own working practices without pharmaceutical co-operation.

Clinical autonomy

At primary care level, meanwhile, clinicians have limited opportunity for any strong decision making. Whilst the UK is now pushing hard to reinvigorate the role of clinicians within the health service, clinicians in Germany continue to lose decision making power. GP prescribing is strongly led by the discount agreements between pharmaceutical companies and the public insurance companies: if a prescription does not reflect the agreement, it will be automatically substituted by the pharmacist when it is fulfilled – unless the GP has specifically requested no substitution.

Similarly within secondary care, there is a lack of clinical empowerment. Many hospitals are part of purchasing groups, which has increased buying power, but limited the decision making options for both individual doctors and hospital pharmacists.

However, there are signs of a new level of interaction between pharmaceutical companies and health care services in Germany on the joint development of innovative services. Whilst in the past pharmaceutical companies were constrained from negotiating contracts direct with hospitals or doctors to deliver such services, over the past two years there has been a evolution towards more integrated healthcare contracts that have evolved beyond basic discounting towards shared risk models based on the joint delivery of services – most notably within diabetes.

Moving forward

Given the emphasis on the reduction of drug prices across Europe, the evolution of cost saving on pharmaceuticals within the German market is notable for any similar sized market place, such as the UK. From initial focus on generics, with reference pricing and discount agreements to the impact of AMNOG on the new chemical entities, every aspect of the pharmaceutical market has been affected.

Indeed, despite the market size, this new price point has resulted in companies deciding not to launch new products in the German market due to the problem this would create across Europe with reference pricing: get it wrong in Germany and a pharmaceutical company could end up with an unsustainable price point in many other countries.

The biggest test for pharmaceutical companies in Germany in the coming months will be to understand the challenges created by AMNOG and to determine how best to create the value dossiers. To date, only one product, Merckle Recordati´s Pitavastatin, has passed the examination of the G-BA, but without the approval of a pre-price, there’s only the allocation of a reference price – so the industry has no real evidence of how this process works, or how successful companies will be.

However, with 15 products currently under review, this model will become far clearer in coming months. Market access strategies must be supported by a new depth of information relating to this value-based decision making, most notably granular visibility of the key influencers within G-BA. Armed with this insight, pharmaceutical market access teams will be able to refine their information analysis and determine how best to disseminate the value message to the market.

Dr Arnim Jost is General Manager, Germany, and VP REGION D-ACH, for Cegedim Relationship Management.

The revised Health and Social Care Bill remains contentious, but appears likely to pass into legislation. Simone Carron-Peters of Frost & Sullivan analyses its probable impact on the UK healthcare market.

The Government’s contentious Health and Social Care Bill has raised many concerns among the various stakeholders. The eight-week NHS listening exercise conducted by the NHS Future Forum has resulted in the proposal of multiple changes to the Bill, whose passage towards legislation is summarised in Figure 1 below.

This article evaluates the planned NHS reforms for impact on the health system and the life science industry.

Overview of the Bill

The Health and Social Care Bill proposes to create an independent NHS Board, promote patient choice and reduce NHS administration costs.
Its key focus areas are:

• To establish an independent NHS Board to allocate resources and provide commissioning guidance.
• To increase GPs’ powers to commission services on behalf of their patients.
• To strengthen the role of the Care Quality Commission.
• To develop Monitor, the body that currently regulates NHS Foundation Trusts, into an economic regulator to oversee aspects of access and competition in the NHS.
• To reduce the number of health bodies, including abolishing PCTs and SHAs, in order to help the Government cut NHS administration costs by one-third.

More power (and money) to the GPs

In its initial form, the reform aimed to improve the quality of service delivery by devolving NHS commissioning powers and responsibility into the hands of GPs. The GP consortia would receive budgetary allocations from the new NHS Commissioning Board, which would be responsible for managing and allocating about £80 billion of the health budget. The consortia would, in turn, devolve the funds to the various practices under them.

The new GP consortia would replace the 302 PCTs in England, which would be abolished by 2013. All NHS trusts were set to become Foundation Trusts by April 2014. It was anticipated that the consortia would require significant assistance, including support from the private sector, in exercising these new commissioning functions.

Medical organisations and NHS trusts were immediately sceptical about the implementation of this reform, saying that the changes could have negative effects on NHS services. Some trusts argued that it is risky to reduce the central grip on commissioning at a time where urgent savings are being made. Others agreed that GPs are well positioned to make decisions on the use of resources for their patients.

The BMA: a critical response

The reform plans have also not gone down well with the British Medical Association (BMA), who expressed concerns about the level of responsibility being bestowed on GPs. One of the BMA’s major concerns was the lack of clarity in the Bill with regard to the roles that the GP consortia would be expected to perform. The BMA also believes that it is important to ensure the funding for GP practices remains distinct from other budgets, as it would cause significant complications if GP consortia were to be made responsible for amalgamated budgets that included the management of standard GP contracts.

Currently there are about 177 GP ‘pathfinders’ (pilot groups of GPs testing the system’s concepts and functions) who are taking the lead in implementing the new commissioning roles.

In May 2011, the BMA’s Health Policy and Research unit conducted a national survey of GP opinion that received a response rate of 39%. The survey findings revealed an alarming 55.8% of the respondents citing NHS reforms as a reason for their intention to retire in the next two years. That figure was composed of 59.4% of the 688 principal or contracted GPs, 41.1% of the 30 employed salaried GPs and 35.8% of the 39 freelance GPs who participated in the survey.

The survey also asked GPs how confident they were that the GP commissioning consortia would be appropriately skilled and supported. 65.6% were ‘not confident’ that the consortia would be appropriately skilled, while only 15.8% were ‘confident’ that they would be. In addition, 70.9% of the respondents stated that they were ‘not confident’ that the consortia would be supported, while just 10.2% were ‘confident’ that they would be.

Amendments to the Bill

Based on the recommendations of the NHS Future Forum, the Health Secretary announced changes to the Health and Social Care Bill in June 2011. The Bill is due for its third reading on the 6th and 7th September 2011.

The role and functions of GP consortia are now better-defined. The consortia – now called Clinical Commissioning Groups (CCGs) – would be required to publish details on their constitution and how the allocated budgets have been used. They would also be required to follow guidelines from, and be accountable, to the NHS Commissioning Board. GPs are also bestowed with a responsibility to promote research and innovation.

The plan for all NHS trusts to become Foundation Trusts by April 2014 has been amended. NHS trusts would become Foundation Trusts by 2016, based on their clinical readiness for transition. They would be given the liberty to make use of private health treatments, and would compete among themselves for patients.

The role of the National Institute for Health and Clinical Effectiveness (NICE) would increasingly focus on giving authoritative advice to clinicians on when and how the most effective treatments can best be used, and also on the development of quality standards for the NHS to aim for in the treatment of certain conditions.

Value-based pricing (VBP) would replace the Pharmaceutical Price Regulation Scheme (PPRS), which has existed since 1957. The purpose of VBP is to improve NHS patients’ and clinicians’ access to effective and innovative drugs and medical technologies by ensuring they are available at a price that reflects their value, based on an assessment of the outcomes they can achieve.

Impact assessment of the health reforms

The implementation of the Health and Social Care Bill will witness an increase in private sector and voluntary involvement in the delivery of healthcare. GP commissioning will allow the use of private healthcare for NHS patients. Healthcare vendors and providers can capitalise on this shift by offering products and services best suited to patients’ needs in order to influence GP commissioning.

The aim of value-based pricing is not to achieve the lowest price possible, but to encourage the development of new therapies and promote innovation. The principle of linking the price of innovations to their value has already received support from a broad range of stakeholders.

The priorities of the health reforms are ambitious; if instituted, they will have far-reaching effects on the way the British public accesses the health system. It will also affect the role of the private sector in the UK healthcare system, increasing opportunities for private providers of both clinical and support services to become involved in providing healthcare to NHS patients.

According to the Government’s calculations, the reforms will bring about a huge cost saving for the NHS. However, negative consequences such as redundancy for administrative staff in the health authorities will pose a huge socio-economic threat.

How will the savings affect the prospects for innovative medical technologies? The adoption of such products has always been necessary for medical professionals, predominantly because new technology aims to provide healthcare at a quicker rate – minimally invasive technologies being a major example. The Government has vowed to ensure the system delivers effective and appropriate healthcare to all who need it. Moreover, GPs have a greater understanding of patients’ needs than the managers or PCTs who at present make funding decisions. Thus the demand for innovative devices will arise regardless of the allocated NHS budgets.

One of the main objectives of the reforms is to put patients and public first by implementing a ‘no decision about me without me’ policy. National standards and independent inspection will continue to assure patients that all NHS-funded services are safe and of a high quality. Patients will have much more information about individual services and their performance, enabling them to choose the services that best meet their needs.

The reforms will ensure that services are easier to access and more responsive. Shorter patient waiting times, one-stop clinics for diagnostics, and increased provision of healthcare in patients’ homes are some examples of services that are likely to develop in response to new incentives. Patients will be able to gain access to healthcare in new ways that are more flexible. This is likely to mean more services delivered in local communities, such as urgent, preventative and rehabilitative care, thus helping to avoid unnecessary hospital admissions. Better information will help patients to understand and make the best use of the options available.

The reforms will also support services to become more integrated. Improved information systems will play a key role, enabling healthcare providers to exchange clinical data more easily and so gain a complete view of the patient’s condition. Increasingly, there will be opportunities for patients to influence the pattern of services within their locality. Local practices will have incentives to provide locally-based health improvement and health protection services. Patients will be in a better position to manage their own health.

Financial goals

The Government is confident that the health reforms will allow it to save billions. Figures from the Impact Assessment published alongside the Health and Social Care Bill earlier this year claim that the structural reforms to the NHS will save £5 billion per year, though this is a gross rather than net figure. The Bill promises to reduce NHS administrative costs while promoting patient choice. However, time alone will tell whether these reforms prove to be economic.

 

Simone Carron-Peters is a Research Analyst for growth consultants Frost & Sullivan.

Thousands of fewer redundancies will be made following a recalculation of the cost of the NHS reforms, the DH has revealed.

The revised Health Bill assessment predicts that up to £700m will be saved than was originally planned and 8,000 positions will no longer need to be axed.

The report found that gross savings created by the reforms will in fact by £4.5bn and not the £5.2bn estimated in the original assessment due to changes being introduced less quickly and administrative spending was £600m lower than estimated.

But despite the savings being lower than first planned, Health Secretary Andrew Lansley says the reforms show the “cost of modernising the NHS is only a fraction of the savings which will result”.

Spending in 2010-2011 in administration is now believed to have been in the region of £4.5bn, instead of the £5.1bn which was estimated at the start of the year.

The original figures published in January were found to not calculate public health staff correctly, and did not take into account the high salaries of PCT commissioning staff when compared with those in provider divisions.

The report also states the over-estimation is due to the NHS going “further and faster with reductions” in staff number than was anticipated.

Overall, around 12,900 redundancies are expected to be made by 2014-2015. Nearly 10% of this reduction will now be conducted in 2013-2014, the final year of the cuts.

Mr Lansley says that despite the recalculation, the Government is “still on track” to reduce administrative spending by a third. “Every penny saved will be reinvested into patient care, delivering significant long-term benefits to patients,” he said.

“Our plans, which have been strengthened by the listening exercise, will both safeguard the future of our NHS and move us closer to a health service that puts patients at the heart of everything it does.”

“They ensure that future generations can rely on an NHS that is always there, always improving and always free at the point of use, based on need and not ability to pay.”

Protests are being planned ahead of the Health and Social Care Bill’s passage through Parliament next week.

UNISON and the BMA are planning to show their opposition to the controversial reforms to coincide with report stage and third reading of the Bill on the 6th and 7th September.

Local events nationwide are planned to coincide with Bill entering the House of Commons with NHS staff and patients set to gather for a candlelit vigil outside Parliament. The BMA is also urging campaigners to take part in online action to email their MP signalling their opposition, and to use Twitter and Facebook to voice their concerns.

BMA Council Chairman, Dr Hamish Meldrum, has also written to all MPs saying the reforms still present an “unacceptably high risk to the NHS” warning them it threatens its ability to operate “effectively and equitably, now and in the future”.

Despite the amendments following recommendations from the NHS Future Forum, the Association still believes the Bill should be withdrawn or be subject to further substantial changes.

In his letter, Dr Meldrum continues to warn of the “inappropriate and misguided reliance on ‘market forces’ to shape services” with the Bill creating “a more central role for choice without a full consideration of the consequences” and the “potential to destabilise local health economies”.

There are several specific areas of concern the BMA has on the Bill including:

• The limit Foundation Trusts (FTs) can generate from private patients
• The proposed ‘Quality Premium’ for commissioners
• Forcing all NHS Trusts to become FTs
• That the Bill reflects an intention that any increase in patients’ choice of providers should not be given a higher priority than tackling health inequalities and promoting integrated care
• Ensuring there is a robust and transparent process which has the full confidence of the profession when it comes to how ‘failing’ FTs are dealt with
• The lack of satisfactory assurance that the Secretary of State will have ultimate responsibility for the provision of a comprehensive health service whilst also allowing other bodies, like the new NHS Board and Clinical Commissioning Groups, day-to-day operational independence.

In a response to the concerns over the responsibility of the Secretary of State, the DH says “the Secretary of State will continue to be responsible - as now - for promoting a comprehensive health service. The NHS will always be available to all, free at the point of use and based on need and not on the ability to pay. To say otherwise is absolute nonsense”.