Published 24 July 2008, doi:10.1136/bmj.a953
Cite this as: BMJ 2008;337:a953

Editor's Choice

The world is watching the English experiment

It may seem parochial for the BMJ to use so much space discussing the NHS—and the English NHS at that. But I make no apologies—firstly, because if doctors are to take the lead in health care, as they must and as they are being encouraged to do, they need to understand the systems that deliver it. Secondly, because the wider world is watching what may come to be known as the English experiment. As evidence of this, the New England Journal of Medicine has published another paper on England’s use of quality indicators and performance payments. As Alison Tonks describes it (doi: 10.1136/bmj.a891), the paper from Martin Roland’s group in Manchester finds that GPs’ professionalism outweighs temptations to game the system. To minimise overtreatment, GPs are allowed to exclude clinically inappropriate patients from target calculations, but rates of such "exception reporting" among English general practices were low. I find this very encouraging.

More worrying is the effect of targets in other areas of medicine. In a personal view Nigel Rawlinson describes how the four hour target for processing patients through emergency departments has meant that, however hard they try to remain patient focused, good staff will now "treat the clock not the patient." He warns that a two hour target is proposed (doi: 10.1136/bmj.39604.711146.47).

Such politically driven initiatives are part of the problem outlined by Donald Light as he gives his verdict on the new strategic plan for the NHS—the Darzi report (doi: 10.1136/bmj.a824). Light, a long time observer of the US and UK health systems, condemns "the continued and costly pattern of ‘redisorganisation’ caused by too many changes not well thought out." Compared with this constant politically driven change, the clinical leadership of the US Veterans Health Administration took 10 years to implement one carefully designed plan that has transformed the service. Light predicts that the nearly £1bn that is being wasted on unevaluated reorganisation in the UK will result in comprehensive free care being declared unaffordable, requiring patients to pay fees for services and drugs.

This would take us inexorably closer to the US model, a fate that another experienced observer of the US and UK health systems, Don Berwick, warns roundly against. Berwick asks us to celebrate the ambition of the NHS (doi: 10.1136/bmj.a838). His 10 suggestions for making it even better include "stop restructuring . . . reinvest in general practice and primary care . . . please don’t put your faith in market forces" and "avoid supply driven care like the plague." As if to hammer home the point, a report published last week from the New York based Commonwealth Fund has ranked the US last among 19 industrialised countries across a range of healthcare indictors, the worst of which, and getting worse, was access to care (doi: 10.1136/bmj.a889). The report concluded that much of the problem stemmed from having a weak base of primary care doctors.

So let’s hold ourselves to a vision of health care that evolves organically rather than through constant political dabbling; that supports professionalism, is clinically led, and has strong primary care at its heart.

Cite this as: BMJ 2008;337:a953

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