BMJ  2006;332 (11 February), doi:10.1136/bmj.332.7537.0-f

Editor's choice

A time for courage

More than a decade ago, in an editorial entitled "Where now for the NHS reforms?" Chris Ham asked "what is the purpose of a national health service?" (BMJ 1994;309: 351-2[Free Full Text]) This week Neville Goodman says it's a question that governments refuse to ask (p 363). Until it is answered, he says, "we will stagger from crisis to crisis, pressure groups forcing the government to give in on expensive but dubious therapies, while the government imagines that all it needs is the next big restructuring to get things right."

It all sounds depressingly familiar. A range of news and views in this week's BMJ paint a picture of continuing turmoil and unhappiness within the NHS. A meeting organised by the National Patient Safety Agency last week heard that waiting list targets had pushed safety down the agenda (news extra bmj.com). A UK parliamentary select committee heard that prescription charges could seriously undermine plans to reach people most in need (news extra bmj.com). A King's Fund report concludes that almost 90% of new investment in the NHS has gone on higher pay and other costs rather than on direct improvements to patient care (p 319). A general practitioner in Halifax thinks that while expectations are rising, the NHS is being downsized and fragmented (p 363). A director of public health despairs at the impossible task of dealing with growing financial deficits at her primary care trust (p 363).

There is more. Sam Ramaiah bemoans the organisational disruption that is driving public health doctors away from the NHS at a time when the government wants them to help implement its white paper (p 370); and Michael Goodman (p 371) says managers are interfering with referrals between hospital consultants, prioritising referrals from general practitioners in order to meet government targets. He urges doctors to defend their professional position or risk "handing over clinical decisions to lay managers, acting under the diktat of politicians." The unedifying herceptin story is just another example of political interference (p 320, p 368). Even Richard Lewis (p 315), who seems upbeat about the government's "much needed reforms," ends by saying that the financial and managerial climate is not encouraging. Success will depend, he thinks, on political will.

So back to Ham's original question, what is the purpose of a national health service? Neville Goodman is not optimistic. "The sort of courage needed to even ask, let alone answer, the question does not go with the need for re-election," he says.

On another front, it just can't be right, in fact it is obviously wrong, that the tobacco industry can influence national governments and opinion leaders to the extent described in this week's BMJ (p 321, p 353, p 355) And it is depressing to hear from Ernesto Sebrié and Stanton Glantz (p 313) that WHO has been silent about countries that fail to honour its framework convention on tobacco control. WHO took a brave stand a few years ago in facing up to its own tobacco links (BMJ 2000;321: 314-5[Free Full Text]). Now is the time for WHO to speak out again.

Fiona Godlee, editor

(fgodlee{at}bmj.com)


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what is the nature of health services?
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