BMJ  2007;334 (12 May), doi:10.1136/bmj.39210.699502.47

Editor's Choice

Editor's choice

A more independent NHS

BMJ

Greater independence for the NHS is either naive nonsense (BMJ 2006;333:251-2 doi: 10.1136/bmj.333.7561.251) or an idea whose time has come. Gordon Brown, the UK's premier in waiting, was this week reported to have reversed his earlier enthusiasm for it. But independence now has the support of the BMA (doi: 10.1136/bmj.39210.522188.4E) and will be the subject of a report from the Nuffield Trust to be released later this month.

In a report published this week, the BMA sets out its vision for the future of the NHS in England. It calls for a constitution for the NHS reaffirming its core values and with a charter explaining the public's rights and responsibilities; an independent board, appointed by parliament, which would set the agenda, the resources, the standards, and the broad scope of NHS provision; an executive management board, comprising the NHS chief executive, the chief medical and nursing officers, and other senior healthcare managers, accountable to the board; and strategic health authorities and "local health economies" to shape and manage the delivery of care.

The aim is to move away from ministerial micromanagement (what the chairman of the BMA's council, Jim Johnson, calls "political dabbling"), which the BMA believes has fragmented the service and marginalised health professionals and patients alike. Instead, a new system of reform would give local managers the freedom to decide on organisational development and clinicians the freedom to manage patient care. Unencumbered by the day to day running of the service, politicians would focus their attention on public health and on establishing an open and fair approach to priority setting and rationing.

To someone who has been supportive of a more independent, less politically managed NHS (BMJ 2006;333 (1 April) Editor's Choice doi: 10.1136/bmj.332.7544.0-f), this all sounds very sensible, even if the report is thin on some of the detail. But this report is as much in response to the growing anguish among BMA members about the nature of the reforms—the shift towards private sector provision—as it is to the top-down way in which the changes have been implemented. Would an independent NHS mean a move away from the market, a shift to more European models of health care?

Not unless doctors wake up, says Julian Tudor Hart, socialist, pioneer researcher, long term champion of the NHS, 80 years old this month, and still as angry as ever. Interviewed by David Brindle (doi: 10.1136/bmj.39204.639711.94), he says that the medical profession has failed miserably to challenge effectively the slide to a market NHS. He wasn't asked what he thought of greater independence for the NHS, so after the BMA's press conference I phoned him. "It's a red herring," he said. "Tony Blair has already taken the NHS out of politics by turning it over to the markets, making people into consumers, not citizens." But he also said: "If what independence really means is that professionals and patients would reassert themselves—well, ok."

It seems that this is exactly what the BMA is saying. Brown may not be convinced, but for the moment his main rival for office, David Cameron, has retained his pledge for a more independent NHS. Now is the time to move the argument from whether to how.

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