The NHS in our hands

doi:10.1136/bmj.a663

Published 2 July 2008, doi:10.1136/bmj.a663
Cite this as: BMJ 2008;337:a663

Editor's Choice

The NHS in our hands

Fiona Godlee, editor, BMJ

fgodlee{at}bmj.com

The founding principles of the NHS are safe, for the momentat least, from whatever marauding hordes we might have thoughtwere out to get them. Last week’s BMJ and King’sFund debate concluded overwhelmingly in favour of their continuedrelevance (doi: 10.1136/bmj.a628), and BMJ readers agreed (www.bmj.com/campaigns/nhsat60/index.dtl).Polls elsewhere in the run-up to the NHS’s 60th birthdaythis week have shown similar commitment to the ideals of equitablecare funded by central taxation and free at the point of need.And now we have a draft NHS constitution that seeks to enshrinethese principles in law (doi: 10.1136/bmj.a640). All of thismeans we can get back to the job of nurturing this great beast,the NHS, with all its inherent conflicts, contradictions, andlimitations, and somehow continuing to make it work. Lord Darzi’sreport on the next stage of reforms for the NHS in England givesus a place to start.

The report is an odd beast in itself. It’s a good read,with a welcome absence of national targets or service restructuring,and the promise of more local decision making (doi: 10.1136/bmj.a642)—thoughhow this squares with an end to local variation in provisionremains unresolved, as Rudolf Klein points out (doi: 10.1136/bmj.39262.746238.47).There’s an equally welcome emphasis on better care foreveryone, with substantially increased funding for faster evaluationsof treatments (doi: 10.1136/bmj.a660) and, crucially, the promiseof funds to make all approved treatments available to all.

It’s beyond the report’s scope to say where thisextra money will come from, but we can’t escape the question.The launch of a government review of copayments for cancer drugsmeant that Darzi didn’t have to tackle this highly contentiousissue, which hits at the heart of the NHS. In their editorialthis week, Ilora Finlay and Nigel Crisp conclude that copaymentsare inevitable, but they want them introduced in ways that willpreserve equity and deliver data on outcomes (doi: 10.1136/bmj.a527).Cam Donaldson disagrees absolutely (doi: 10.1136/bmj.a578).He argues that although they are dressed up as a means to increaseaccess, copayments would do the reverse. "User charges are anidea that is intellectually dead," he says. "If we want to raisemoney in a way that is consistent with what we want to achievein health care, there is another way—it’s calledtaxation."

Darzi reiterates choice and competition as key drivers for changein England. These have so far largely failed to deliver improvementsin care, according to Tony Delamothe (p 25, doi: 10.1136/bmj.a524).Darzi hopes that better information will fuel an appetite forreal patient choice, and Bruce Keogh’s plans to deliverthat information (BMJ 2008;336:1464, doi: 10.1136/bmj.39618.627951.80)deserve our support.

We will have to wait and see what sort of meat is put on theelegant bones of this report. But there’s one crucialaspect of Darzi’s vision that will happen only if doctorsacross the NHS step up to the plate: much greater leadershipfrom clinicians. If this review is, as Gordon Brown has said,a once in a generation opportunity, the next generation of cliniciansand patients won’t forgive us if we fail.

Cite this as: BMJ 2008;337:a663

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