A written constitution for the NHS, overseen by an independent Board of Governors are two of the major recommendations published today (Tuesday 8 May 2007) by the British Medical Association (BMA) in its proposals for the future of the NHS in England.

In a discussion paper A rational way forward for the NHS in England outlining an alternative approach to health reform, the BMA suggests a system which would separate national politics from the day-to-day running of the health service.

Core values and core services

The NHS constitution would contain the core values of the NHS incorporating new ones such as supporting education and research alongside the founding values. It would include a charter explaining what the public can expect as patients and carers and what the NHS expects from them. Crucially it would also contain arrangements to determine the range of services that are nationally available on the NHS, together with nationally-agreed standards for the quality of those services.

Mr James Johnson, chairman of the BMA, said: "The BMA believes that the NHS should provide a comprehensive range of services, available to all on an equal footing. If we are going to retain an equitable, universal approach within limited resources then priority setting is inevitable. Politicians need to acknowledge this, and that it happens already but in a non-transparent and piecemeal fashion. A clear and transparent approach is needed.

"We need a public debate to decide a process to define a list of core NHS services - it will be a very substantial core - that will be nationally available. We need an ongoing mechanism to review and amend priorities in the NHS which must include an effective way of incorporating the views of patients, public and professionals."

The BMA suggests enhanced local groupings, which would include patients and clinicians, to agree and define a process for delivering the national core services and to decide on any additional health services (also funded from central resources) which would be available in that area.

An independent Board

Under the BMA's proposals, parliament would establish and appoint the NHS Board of Governors. The Board would be responsible for ensuring compliance with the NHS Constitution and be accountable to parliament. An executive management board, appointed by the governors, would guide the performance and national operation of the NHS.

Mr Johnson said: "As the ultimate guardians of the public purse, politicians and parliament should decide the high-order questions around setting priorities and funding. When it comes to the day-to-day running of the NHS, the role of national politics should be significantly reduced. The time has come to look at a much more independent framework for the NHS to allow greater flexibilities for health economies to develop care systems and to find ways of increasing local accountability."

Other recommendations in the BMA report include (recommendation numbers in brackets) :

-- A shift in focus by the Department of Health towards public health to reduce health inequalities (5)
-- An independent review of the structure for the provision of public health (6)
-- Clinical engagement with health professionals early on in the process of shaping health policies (8)
-- Improved commissioning of services, led by the public sector (10)
-- Private sector provision should only be commissioned where there is no NHS capacity, supporting rather than supplanting it - no further central procurement of private sector provision (11)
-- Making the provision of high quality medical education a central part of improved commissioning (12)
-- Clinical networks should be established through which clinicians agree, implement and monitor provision of care for their patients with patient involvement and connected to education and research networks (13, 14)
-- A move away from the purchase-provider split towards single-system working possibly using Health Economy Foundation Trusts - HEFT - models(15, 16)
-- Creating elected Local Health Councils to link the public to health professionals and managers (18)
-- Local Directors of public health should have their own budgets and statutory powers (20)
-- A new agreement for manager-clinician relationships, devolving management of care to clinicians and shifting managers' priorities to a focus on quality and service development (21)

Mr Johnson said: "We advocate an alternative, rational approach to health reform. The government's injection of funds has led to considerable improvements but there has been a failure to engage either the public or clinicians in the government's reform agenda. That reform is destabilising the NHS and the system of care is becoming fragmented.

"Our proposals reflect a long-term commitment to the NHS. Doctors want to play a leading role in recasting reform for the benefits of patients. We wish to work with other health professionals, patients and managers to agree a shared vision for the future that engages the public and professions alike. Together we can make the NHS work for the 21st century and beyond."

A short overview of the report and the full report A rational way forward for the NHS in England can be found on the BMA website at : www.bma/rationalwayforward

The discussion document will form part of the debate at the BMA's Annual Representative Meeting (ARM) in Torquay, June 25 to 28 2007. The ARM debate and comments on the discussion paper, will contribute to a further paper in the autumn.

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