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Rapid Responses: Rapid Responses published:
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Imminent collapse of NHS will be triggered by a catastrophic demoralization of leadership
- Bruce G Charlton (31 March 2006)
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The NHS: reports of its death are not greatly exaggerated
- Peter Fletcher (31 March 2006)
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NHS like the BBC??
- F C Gray Southon (3 April 2006)
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Where is the money going?
- Graeme M Mackenzie (4 April 2006)
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A 'leaderly' editorial!
- peter j mahaffey (4 April 2006)
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Intuitive reasoning is alive and well
- Jeffrey C McILwain (5 April 2006)
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If not now, when?
- Julian T Hart (6 April 2006)
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Fat Cats
- David R Partridge (6 April 2006)
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If not Ourselves, then who ? Re: If not now, when?
- L S Lewis (7 April 2006)
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letter and opinion
- benjamin dean (7 April 2006)
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Should have been the lead editorial
- Neville W Goodman (7 April 2006)
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Re: letter and opinion
- L S Lewis (8 April 2006)
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reply
- benjamin dean (10 April 2006)
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NHS devolution requires devolution of funding
- C. David H. Wrede, Christoph Lees, Karol Sikora, Maurice Slevin, Stephen Smith, Jim Thornton (11 April 2006)
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Evidence-based management
- Richard Bartley (11 April 2006)
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Re: NHS devolution requires devolution of funding
- L S Lewis (12 April 2006)
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Bruce G Charlton, Editor-in-Chief - Medical Hypotheses University of Newcastle upon Tyne, UK, NE1 7RU
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The BMJ editor is candidly bewildered by the current NHS financial crisis: her acute despair is likely to be a barometer of mood among those responsible for NHS policy [1]. But the NHS is a Soviet-union-style centralized command economy which is destined for the same fate and for the same reasons. The NHS has accumulated inefficiencies and internal contradictions over many decades. Attempts at reform have always failed because there has never been a sufficient surplus of health care to survive the downturn in production entailed by significant structural change [2]. It now seems that – like the Eastern Bloc in 1989 - the NHS will soon collapse very suddenly and quickly; triggered by catastrophic demoralization among a political leadership confronted by the inescapable fact that the UK health care system is so deeply defective that massive and economically-unsustainable infusions of cash have only hastened its demise. 1. The Economist. National Health Service: Grappling with deficits. March 9 2006. www.economist.com 2. Charlton BG, Andras P. Modernizing UK health services: 'short- sharp-shock' reform, the NHS subsistence economy, and the spectre of health care famine. Journal of Evaluation in Clinical Practice. 2005; 11: 111-9. Competing interests: None declared |
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Peter Fletcher, retired CO92RU
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A long time ago and, gratefully, for a mercifully short period I was a Senior Principal Medical Officer and Chief Scientific Officer with Civil Service Grade of Under Secretary in charge of all scientific services for the NHS. Even in that distant past it was clear beyond all reasonable doubt that, in the end, the NHS was doomed to failure. Demand would always exceed supply in a "freely" available service. Before the present multiplicity of financial indiscretions can be solved some check, some control, some encouragement to limit demand has to be accepted as an essential element if an NHS is to balance its books. At the present time the most trivial perceived malady demands immediate attention and treatment. For a number of years, together with my family, I lived in another EU country where you were required to settle up the bill before you left the doctor. You could go straight to the local Town Hall, present the bill and receipt and be repaid for about 90% of the cost. That gave you food for thought even though the financial loss was small. The elderly, indigent and others were repaid in full. Competing interests: None declared |
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F C Gray Southon, Honorary Research Fellow University of Auckland
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Fiona is correct in questioning the political impact on the NHS, but the comparison with the BBC is extremely naive. First, of course, the size is very different, but more importantly the nature of the activity is completely different. The results of the BBC are quite substantially controlled by management decision and are open to the public for all to see. The results of the NHS, however, are largely controlled by the practices of thousands of clinicians engaged with the private lives of many millions of patients, and are only very crudely presented in the performance measures which management handle. While management structures may need to be changed, the solution lies much more with the engagement of clincians and patients. Competing interests: None |
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Graeme M Mackenzie, GP Whitehaven CA28 7RG
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I can only speak for primary care and my impressions of the primary care and secondary care interface. For many years I have being trying to get the simple message over to anyone that listens that the simple (albeit old fashioned model) of general practice is excellent value for money. We take ownership of problems and if motivated follow them through. In addition we do what is required and have the independence to interpret guidelines within the context of patients and presentations. These things combine to make use very cost effective. Unfortunately, some of our work has been interpreted as "half doing things", which in many ways it is. Single issue vested interests have won over the holistic GP and that have driven costs up. Each problem is done to the nth degree. Not investigating and treating as per guidelines written by the single issue groups is now seen as cavalier and negligent. The "find rate" from investigation is plummeting and the "benefit rate" from treating (increasingly asymptomatic patients) has similarly dropped. Costs have risen because too much is done to too many people. Private sector involvement will of course increase costs even more as "providers" seek to extract as much money from the system as they can to fund their infrastructures and make profits. I have seen a blossoming of targeted specialist services (often well meaning and nurse led) which are not part of the front line and are amazingly unaccessible to the GPs. Thus we continue to provide the very services these staff are meant to be providing because they do not offer accessibility and do not even approach our pragmatic productivity. Costs as a result at least double as everything is done twice. The increasing complex "front" of the NHS may have created choice but complexities create costs and more worringly create the ability of costs to become more and more difficult to disentangle. Once again I refer to the simple gatekeeper role of the GP and how if supported enough is a key part of cost containment as long as the way we do things is respected by the rest of the NHS. I look at the impending nightmare of the failing Connecting for Health and the resultant cost waste. Why should I watch my prescribing when £6 billion is potentially being wasted on a project that is Orwellian in concept but also doomed to failure because of the nature of medical information. I may be wrong but is the cry from most IT interested GPs that there was little consultation of, or deference to, the most computerised part of the NHS (i.e GP) when this misguided project was started. I am a GP IT amateur but have seen the difficulties of transferring medical type information, even within a local team, increase above a certain organisation size. There are reason for this which do not appear to be addressed within Connecting for Health. Primary care has been supported financially with the new contract and I am grateful for that but the waste is not in primary care but in the vast network of extras the NHS seems to generate that have no patient accountability and make no attempt to match the legion accessibility of the GP. Competing interests: I am a GP being rewarded by the extra NHS money |
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peter j mahaffey, consultant surgeon Bedford MK42 9DJ
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If anything is designed to pluck the ostrich-like heads of Government ministers out of the sands that presently represent the present disastrous state of our NHS, it is Fiona Godlee's masterly editorial of 1st April. Whilst all around appreciate the apocolyptic situation we have reached through disastrous over-management, the Health Secretary is in a state of complete denial. It is tragic to see the institution for which one has worked for 30 years being wantonly destroyed. Thank goodness that the BMJ is now speaking up, and unlike Mrs Hewitt, is able to propose a remedy for independence which has much merit. Peter Mahaffey FRCS(Ed) Competing interests: NHS employee! |
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Jeffrey C McILwain, Consultant, Clinical Risk Management St Helens & Knowsley NHS Trust
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The BMJ editorial 1st April about founding the NHS upon an independent corporation is a profound timely stroke of genius by the Editor Ms Godlee. Interestingly, I very recently had exactly the same thoughts prior to this editorial being published. The fifth paragraph is exactly what I would imagine a modern strategic NHS healthcare delivery model should be - free from political soccer. This seed of a concept must be very actively promoted by the BMJ as a world class journal in debate with clinical professionals. The political football of the NHS is driven to provide politicians with their own ammunition in a war that has really nothing to do with them as they (politicians) envy the ability of clinicians to administer the NHS and seek to remove their authority and knowledge. The rapid expansion of medical advances in diagnostics and therapeutic interventions (both pharmaceutical and surgical) in the late 20th Century and the early 21st Century has outstripped the standstill economic model that budgetary projections from Government seek to use to deliver an advancing care system. Secretaries of State and Ministers are but short term visitors to healthcare - only patients and clinicians are there for the duration of the disease processes and clinical careers, so who therefore knows the best strategy and the consequences of advancements - the people within it! Yes, it is time. Time for the tax paying voters and clinicians to have a complete direct right to influence and control the NHS's future untrammelled by political power controls and shenanigans. Time for an independent autonomous NHS Board of Governors who can see beyond political aspirations and set the clinical prioritisation and strategy for the country's health service. Time for the NHS to be free from political control and be a democratic unit for the country. Time for a NHS Board of Governors to tell the politicians what is going to be done in healthcare and not respond passively. Time to let the professionals run the system that they know best and are committed to for their career duration. Time for a NHS Corporation with elected Governors and a conduit of regional subservient Boards with local influence. Time for a NHS Corporation that embraces Royal Colleges, British Associations of 'x' into one strategic force of care delivery. As so eloquently stated by the Editor, if Gordon Brown can do it for rates of interest using the Bank of England, why can politicians not do the same for the NHS? It is time to put the power back into the hands of the professionals and the patients that they serve through an independent NHS Corporation. Competing interests: None declared |
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Julian T Hart, research fellow Swansea University Clinical School Singleton Park, Swansea SA2 8PP
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Fiona Godlee calls for the NHS to “stop being a political football kicked from one party’s version of an internal market to another’s”. Her solution is an independent NHS analogous to the BBC, independent and “non- political”. But who decided that all major parties share one or another version of a more or less privatized market? Not the voters; when New Labour was first elected in 1997 its manifesto promised an end to the internal market and a return to tax-funded public service, and its first minister for health, Frank Dobson, promised to “renationalize the NHS”. So-called reform of the NHS came from neither voters nor the Labour Party’s annual conferences, but from the Prime Minister and his chosen friends and advisers. Opinion polls confirm that few people now believe the NHS in the hands of any major party will remain a free and universal public service, but that doesn’t mean they don’t want such a service, only that they see nobody close to power with the political will to provide it, and resist the international drive to open all public services to commercial investment. The price paid by politicians for power is to become non-political. They disagree not about the kind of society we hand on to our children, but about who pretends to guide the profit-seeking global missile on which all are condemned to ride, because they no longer look for any alternative. We are free to choose from an absurd variety of commodities, but have no choice over how we relate to others in society. So long as a few live from what they own and most live from what they do, society is divided, but we should at least be able to choose whether or not to discard what hitherto held it precariously together - social solidarity in health care, education, social housing, and the other reforms following the second world war. The pre-“reform” NHS gift economy worked. Its biggest problem was systematic and deliberate under-funding by a state whose leaders believed, and still believe, that as our gross social product expands, its capacity to fund social solidarity must diminish. If so many people can now afford to pay for private care, why can’t they afford to pay income tax instead, a far more efficient way to provide care according to need? The NHS in England is being reduced to a brand name, with all its real work franchised to “preferred bidders”, recent examples apparently selected for their track record not in the NHS but in Health Maintenance Organisations in USA. Why are we compelled to ape a system so far incapable even of including all its own employed population? No general election has been fought on this issue, and this policy has never been endorsed by annual conferences of any of the major parties. General practitioners have a remedy for this in their hands, if they have the courage and imagination to use it. Whatever our views on the future of the NHS, surely we can all agree that our people as a whole are entitled to choose whether health care should return to progress as a tax- funded public service, or continue its present headlong flight into competitive markets, with winners and losers, fragmentation of services, and rising management and transaction costs its inevitable consequences – and that so far they have not had that choice. If the BMA were to organize a nationwide petition, directed by GPs to their registered lists, simply asking for a national referendum on this question, real politics could resume and people could regain faith in their votes. Evidence that a huge majority of voters want a public service serving their interests rather than shareholders could change the balance within parties, away from careers and back towards principles. What stands in the way? NHS doctors have never before been so rich. Bevan, so he said, got support for the NHS from the consultants by choking their mouths with gold. Will Patricia Hewitt buy silence from today’s doctors by the same tactic, as she sends it back to the marketplace? I think not. Most doctors today know that they will sink or swim with their patients, and that in the market whirlpool personal care for most people will drown. Competing interests: None declared |
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David R Partridge, Doctor Shropshire SY6 7EJ
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Control of spending and balancing budgets are crucial to any business. At a time when "fat cats" in charge of large multinational business are critiscised for high pay awards, large pensions and golden handshakes on retirement (whether forced or otherwise) shouldn't we level a similar level of critiscism at the NHS? As the countries largest employer, and almost certainly largest beurocracy (although perhaps DEFRA or the IR run a close call) why shouldnt managers be culpable; admit that they settle awards, sign off pay cheques, submit expense claims and live in a world where management (self) job creation schemes abound. I have yet to meet an idle NHS Manager they all work their socks off running in ever decreasing circles. Surely we should have (and deserve) inspirational focussed leadership hell bent on delivering the best health care. One has to ponder the management abilities vested in career civil servants, perhaps those fat cats prepared to risk personal failure in return for delivering results have some lessons for us all? Competing interests: Employed by NHS |
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L S Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
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Julian Tudor Hart gives the cri-de-coeur of a lifelong Socialist.. that plainly , Nye Bevan's vision ( see: http://newportsurgery.mysite.wanadoo-members.co.uk/NHSbyNye.doc ) of a tax -funded NHS free-for-all MUST be more efficient than all the newly-vaunted ( old wine in new bottles ? ) capitalist models. Whilst he recognises that the State might have 'systematically and deliberately underfunded', he does not acknowledge that the Apparat ( the NHS management ) might themselves have systematically falsified the figures, and worked to sustain their own positions rather than make health care their main objective. These criticisms of the 'State-Socialist model' will not easily go away. Two points that everyone seems to agree on are :- 1: Need exceeds supply 2: Demand exceeds willingness to fund "Doctors for Reform" believe that these failings can be addressed by 'co-payments', whilst Julian feels the State could levy that same cash, and spread it more efficiently. And people still DO give money to NHS charity boxes.. I agree with Julian that 'General practitioners have a remedy for this in their hands, if they have the courage and imagination to use it.' but I wonder how courageous and imaginative he is prepared to be.. I believe that GP-led Commissioning ( let's make them local Worker's Cooperatives ) in tandem with a locally-elected Health Authority ( let's call it a People's Soviet ) is that courageous and imaginative 'Great Leap forward'. It need NOT change any of Nye's founding principles, but it could mean placing contracts anywhere in the UK market ! Godlee is naive to imagine that Politicians will ever accept a 'BBC' model upon which they have no steer - and why should they ? They believe they are the 'duly-elected representatives of the people' who are raising the tax we need ! And Julian is turning a blind eye to the lickspittle management Apparat, which always seems to grow in size and strength despite its every failure to manage. It is in my view no accident that it has all but destroyed the prospect of Practice-led commissioning, has overseen the greatest investment of cash in half a century, yet has avoided any responsibility for the current failure to show matching outputs. The Apparat may proceed to turn the current drama into a crisis.. Witness the current scandalous directive to avoid appointment of non-EU doctors - Wonder why ? We might both recall the rise of fascism. Competing interests: I am a GP 'stakeholding' in my beloved NHS |
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benjamin dean, sho australia
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Here is a recent letter I sent to Julian Le Grande, one of the backers of the market based destruction of the NHS, it sums up my thoughts on the matter: Dear Julian, I recently read your talk on the NHS and found it very hard to swallow your opinion, given the lack of any decent evidence to back you up. (http://www.lse.ac.uk/collections/LSEPublicLecturesAndEvents/events/2006/20051206t1246z001.htm ) Most of your talk was based on surveys of public opinion, hardly a good way to produce effective policies! Asking people from low socio- economic groups exactly what to do with the NHS is not exaclty a scientific way of producing good policies. However this is precisely what the government has done with patient choice or pseudochoice, they have often backed up their decision with the use of similiar surveys as 'hard evidence'. Either I am wrong, or next time I am not sure what to do as regards a disgnostic dilemma- I will simply ask the patient what to do- simple, problem solved! The internal market approach is significantly flawed. One of the few pieces of evidence that has been used to add weight to the market based approach has been as regards cataracts, however this is arguably a clever manipulation of the truth: the Royal College http://www.rcophth.ac.uk/about/press/ website and elsewhere http://bmj.bmjjournals.com/cgi/content/full/331/7529/1356-a and http://bmj.bmjjournals.com/cgi/eletters/327/7415/580-d#91853. There are infact many examples of where so called private competition has led to spiralling costs and greater inefficiency, however these are ignored by proponents of the wondrous market- for example numerous PFI's, the oxford eye hospital, cataracts in portsmouth (http://www.portsmouthtoday.co.uk/ViewArticle2.aspx?SectionID=455&ArticleID=1387304 ) to name but a few. There are also deeper problems with the market based approach- training problems, procedures being done by foreign doctors who have not been sufficiently trained or supervised with these procedures ( Orthopaedics treatment centres on the south coast with failure rates of up to 25%!). Why in Oxford did the private company get paid over a hundred pounds more per catarct operation? Efficiency? I could waffle on with more evidence that wrecks the illusion that the market will solve the woes of the NHS, however that would be tedious. Fundimentally however I believe the problem comes down to ideologies. Proponents of the market based approach see the market as the saviour which will solve all the problems in the NHS that are a direct result of a NHS being a state controlled monopoly. They see state control as suffocating the efficiency of private enterprise. The evidence does not back this up unfortunately, efficiency and productivity have been on the fall ever since the market based approach came into vogue. This does not mean that private health care is an evil, far from it- it just means that the state should not directly fund private providers to do easy NHS work that the NHS could do for less. The problems of the NHS are complex but the internal market is not the cure. Also the state control at the moment is too stifling and centralised. Local bodies are given no autonomy and are dictated to from on high:((http://news.bbc.co.uk/nol/shared/bsp/hi/pdfs/fileon4_20040601_nhs_pct.pdf ). The cure is not easy, it requires the sensible local control of budgets and a cessation in the state funding of private providers. The state controlled dishing out of lucrative contracts to private firms is open to massive amounts of corruption, which is already happening (http://www.timesonline.co.uk/article/0,,2088-2114377,00.html). While there is a glaring lack of accountability of these private firms to fulfill their contracts, which has happened many times with PFI's- the state simply pays heavily for work not even done! (http://www.monbiot.com/archives/2005/06/28/our-very-own-enron-/ http://www.monbiot.com/archives/2003/09/30/the-patient-is-dying/ ) I do not know your personal motives for backing the market based approach. However it is abundantly clear that there is very little decent evidence or argument for it. Possibly it is comparable to the conservative American argument for the unfettered free market- as long as I'm rich and doing well, who gives a monkeys if society is collpasing around me? I wonder why private companies did not set up business earlier if it was so easy to undercut the NHS? Probably because it wasn't possible to undercut the NHS and make a profit for their shareholders. But now they can make a big profit as they get paid more than the NHS does for equivalent work, have no responsibility to even live up to their promises and get tax advantages over the NHS - all they have to do is make a donation to the Labour party and the profit is guaranteed! My, what efficiency! yours, Dr Benjamin Dean Competing interests: None declared |
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Neville W Goodman, Consultant Anaesthetist Southmead Hospital, Bristol, BS10 5NB
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Fiona Godlee's excellent words were wasted as 'Editor's Choice': they should have been the lead editorial. What I find surprising in the recent discussions is that no one has pointed out that the idea of the NHS having a similar structure to the BBC was proposed by the commission set up in March 1999 by the Association of Community Health Councils for England and Wales. (1) The response of the government to the commission was to ignore it completely; and then they abolished the Community Health Councils. I am afraid it is fanciful to think that Patricia Hewitt, or anyone else in this government, will take any notice of anything written in the BMJ. 1 Hutton W. (chair) New life for health. The commission on the NHS. London:Vintage, 2000. Competing interests: None declared |
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L S Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
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Ben, I try hard to get to grips with your many better ideas.. but I am switched off instantly by phrases like " Asking people from low socio- economic groups exactly what to do with the NHS is not exaclty a scientific way of producing good policies " The essence of the "NHS-for-all" is that most of us (socialists or not ) believe we ALL have rights, and needs, and we can ALL have valuable contributions. Competing interests: I am proud to have been born in Liverpool to an immigrant family of mixed race and 'low social class' |
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benjamin dean, sho australia
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just quickly to Dr Lewis, the reference to low socio-economic groups may make me sound arrogant. It has to be seen in context of Julian Le Grande's talk, it is in that specific context. Obviously I see it important that everyone gets an input into the NHS, it was just Julian Le Grande's opinion that needed to be mocked. There is a difference between valuing public opinion and basing public policy on wishy washy questionnaires. That was my point. Sorry for the misunderstanding. Competing interests: None declared |
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C. David H. Wrede, Consultant in O&G/CCSC Member Musgrove Park Hospital Taunton TA2 5DA, Christoph Lees, Karol Sikora, Maurice Slevin, Stephen Smith, Jim Thornton
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Madam, As a group of 900 NHS doctors we welcome your call for the NHS to be made independent of politicians (Editor's Choice BMJ 1/4/06). Indeed a recent poll conducted by ICM showed that 74 per cent of the public agreed with this idea. The NHS remains the only majority tax-funded system in the developed world, whilst you suggest creating boards of Governors for the Health Services of the four home nations, we would argue that devolution of responsibility for healthcare requires as a sine qua non, devolution of funding. A more balanced funding system, such as the compulsory insurance models used in Continental Europe, would allow Government to retain important regulatory and inspection roles, while not-for-profit mutuals would ensure equity of services, better clinical outcomes, value for money and create a clear link between treatment and payment to the provider. These ideas are further supported by another of the poll’s findings, that 67 per cent of the public believe that the NHS in its current form will never meet public expectations. We have written to the leaders of the three major UK political parties calling on them to review how we should meet the UK’s healthcare aspirations for the future. The British Medical Association must now enter this debate as its current policies, supporting your call for removal of the politicians from the day to day running of the NHS, while continuing to maintain the service should be 90% tax funded, are contradictory and cannot be sustained. No Government would ever relinquish control on the detailed delivery of health services when it was still responsible for the vast majority of funding. We would call for an open national debate on the structure and funding of the whole of the NHS; this is surely the very least patients and tax payers deserve. Yours faithfully, Mr Christoph Lees Professor Karol Sikora Dr Maurice Slevin Professor Steve Smith Professor Jim Thornton Mr David Wrede On behalf of Doctors for Reform (www.doctorsforreform.com) Competing interests: None declared |
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Richard Bartley, Chartered Physiotherapist Denbigh LL16 3ES
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I can’t imagine any government admitting that the NHS is not a viable system in its current form. It would be electoral suicide. Better in their eyes (i.e. the civil servants advising politicians) to manipulate the NHS through US-style management systems and allowing private initiatives. Of course, this is a recipe for disaster, as the editorial accurately pointed out. It all comes back to evidence-based management and accountancy, or more accurately, the lack of. We seem to lurch from one barmy American management system to another, none of which sees to make any sense to clinicians and patients. In fact the NHS seems to survive remarkably well despite these “blue sky” initiatives. Maybe our civil service mandarins may one day look to our European neighbours for inspiration, rather than across the pond. Competing interests: None declared |
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L S Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
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As a GP in Wales, my eye was caught by the word 'devolution'. I too wish for NHS reform, but cannot believe that the NHS should be 'independent' of the government which taxes a nation to pay for it ! The NHS already has a surfeit of tiers of management, with local boards giving voice to all sorts of 'stakeholders'. We in devolved Wales are reducing the prescription charge ( clearly a 'co-payment' ) on bilingual prescriptions progressively to zero, and have taken steps to ensure that English-only prescriptions do not benefit similarly. I agree that the four Nations might usefully raise a local 'health tax' ( not an individually-predicated national Insurance ) without changing the NHS fundamental principle that it ' gives according to need '. I would further suggest that an additional tax can be levied at local authority level, much as in Sweden or Oregon, to meet locally differing health challenges.. But I would expect then that 'Local Health Boards' would become a function of the Local elected Authority - extending democracy. It may be attractive to professionals who have suffered a surfeit of so- called reform, and interference from above, to call for 'independence'. But when one considers the utter failure of the NHS executive to secure value-for money from the billions of pounds recently invested, it looks like bad business management. It is also wholly immoral to take a compulsory tax only to give it to an 'independent' organisation without strings.. No taxation without representation !! Competing interests: NHS GP in Wales |
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