Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Enoch Powell on independent management of the NHS
- Richard Smith (13 May 2007)
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A Rational Way Forward for the NHS
- David Allen (15 May 2007)
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Re: Enoch Powell on independent management of the NHS
- susanne mccabe (15 May 2007)
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Re: A Rational Way Forward for the NHS
- LS Lewis (16 May 2007)
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Independence for Trusts too
- Michael R Peel (16 May 2007)
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Re: Re: A Rational Way Forward for the NHS
- David Allen (17 May 2007)
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Richard Smith, Growing old London SW4
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Many people think that Enoch Powell's book on the National Health Service is the most insightful thing ever written about the service.(1) In the book he discusses the question of whether the service might be managed by an independent board—as proposed by the BMA. “One of the most persistently recurrent proposals made for alteration of the National Health Service,” he wrote, “is that management should be vested in one or more independent statutory bodies, so as to “take medicine out of politics.” I suppose one should not say that anything is impossible; but the prospect of Parliament raising an annual sum exceeding £1000 million [now £92 billion] in taxation and handing it over to one or more corporations over which it would have as little control as it has over the BBC, strikes one as near enough to the impossible for practical purposes. Nor, one would suppose, would the public find it tolerable that their medical care, financed by their money, should be provided and administered by autonomous authorities, not accountable to their representatives either nationally or locally. A more perfect exemplification of power without responsibility could hardly be devised. It would be no use for the dissatisfied member of the public to try to raise his grievance with his Member of Parliament. “My dear Sir,” would be the reply, “I have no standing in this matter: you must complain to the Corporation, and if you do not like their answer, I can only advise you to grin and bear it.” Transfer of management to independent authorities would not even “take medicine out of politics.” It would certainly take the details out of Parliament; but since the independent authority would be operating with funds supplied exclusively by the government, its answer to every complaint of deficiency or shortcoming would be: “It is the fault of the government, which does not provide us with sufficient money.” Being without responsibility either for raising money or for any of the consequences of doing so, the independent authority would be uninhibited. The fatal divorce between getting and spending would be absolute.” The only way it could happen, he argues, would be for there to be a major source of revenue apart from taxation. “In fine,” he concludes, “the whole idea of non-ministerial management of a health service wholly financed from taxation is a chimera.” Richard Smith 1 Powell, EJ. A new look at medicine and politics. London: Pitman Medical, 1976. Competing interests: I was once the editor of the BMJ. In 1968 I marched in protest to Enoch Powell's house only to be told by a polite policeman that the other protestors had got fed up and were in the pub round the corner. |
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David Allen, One time SL in Health Service Management University of Manchester, M13 9PL
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There is much to support in “A Rational Way Forward for the NHS in England” (1); the restatement of core values, the endorsement of the need to develop care systems and increasing local accountability. The imperatives of “Giving patients more choice and the need for local decision making to decide what is needed in a locality”, the need for managing resources more effectively and a framework that is more independent of government’s day to day involvement. As the document says, despite record government spending on the NHS the current reforms are “proving ineffective” and the public is unhappy with the NHS. I agree with the document that some of the problems occur from weaknesses in commissioning and we need to consider alternative approaches to health reform. However, there are other alternatives approaches, which have the core values and provide a better health service, than that suggested by the document. As the document says “At present patients and public are seen as noise to be managed” and “doctors want patients to have more say in their care”. The document is rightly critical of the misunderstanding of patients’ views; we need a system which is more sensitive to the needs and wishes of patients. So, “Increase the power of the public” by allowing them to choose which PCT receives the capitation payment paid by the DoH to provide their care? If a patient thinks they could receive better health care elsewhere then they should be able to transfer their capitation. This would “engage the public” in a very “meaningful way”. “Move away from banner based debate to power of patients to decide what health service they need”. In order to protect vulnerable groups these PCTs would have the same obligations as current PCTs; including a legal requirement not to cherry pick the “cost effective” patients, but to be open to all patients who present. Also the Government should experiment by inviting other organisations to manage PCTs. Private sector firms and third sector organisations could be invited to set up or take over existing PCTs. A prime objective of these PCTs would be to provide case management. Working with their primary and secondary care providers, these PCTs would develop a package of services, which would be sensitive to the needs of their customer patients. If patients do not like what they receive from their current PCT, patients could switch to another. Why should commissioning remain as it is? Why should private firms not be involved in commissioning ? Private sector PCTs would be very accountable to the public; their customers would have the choice to go elsewhere. Secondly they would be accountable to the DoH to meet national standards. The PCTs would “assess population needs, plan integrated systems of care to meet these needs, evaluating outcomes and feed back lessons from this to local strategic plans”, exactly as the document says. A key aim of the PCTs would be to find pathways, as recommended in the document. In this way we would continue to have “healthcare resources (which) would be pooled and distributed according to need, not ability to pay and individuals would have the right to make decisions about their own care”. “The health system (would) provide a system of care that is based on core values of integrity and seamless care.” And patient involvement would be core to good health services. The NHS would remain free at the point of need and we might get the health service the public deserve. (!) “A Rational Way Forward for the NHS in England”. www.bma.org. Competing interests: Taxpayer, parent, present and future NHS patient. |
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susanne mccabe, retired cf5 su6
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It is difficult to imagine that the management of the NHS would ever be genuinely independant of politicking when it is not only politicians who put the politics into medicine. Many practitioners have allegiances to political parties and will support or obstruct certain government policies. This is problematic when as stated the public pay taxes to fund NHS services but have little input into what provision is set up in their area. For example those who are advocates of 'social medicine' do at times have support and more importantly funding directed through political channels to set up projects such as Home Start or the new Psychotherapy Centres. Other practitioners have taken a different view by supporting more capitalist agendas such as partly privately finaced projects or suppport the introduction of payment for services which go against the grain of a traditional NHS. Most individuals who register with particular health centres have no real idea of the political agendas which effect the running of services and no opportunity to influence their NHS. It would be useful then if practice leaflets were to be more informative not necessarily of individual practioner's involvement in politics but overall if there is an overtly political agenda which effects the running of services. Competing interests: None declared |
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LS Lewis, GP Surgery, Newport, Pembrokeshire
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State-funded, free at the point of need, Universal health care ought logically to have maximal potential for delivering value-for-money, when compared as a system to a private competition, or an Insurance-based scheme. Our difficulty, of course , is that state-run services tend to grow an apparat of pen-pushers and time-servers, who manage poorly, and demand ever more taxpayer money. Thus there is a constant need for 'political' action - usually in the form of 're-organisation'. It being practically impossible for patients to switch PCT (except by moving house cf. State schools and Parental choice), that idea is a non- starter. It is unwise, if not impossible, to take 'politics' out of healthcare - particularly so for State tax-funded healthcare. Attempting it would simply make for more arguments. The obvious way to involve the CITIZEN in local decision-making and prority-setting is to place PCTs and LHBs into 'Local Public Service Boards' under the democratic control of Local Authorities. Citizens can then have the RIGHT to locally vary the National service requirement, and would have the RESPONSIBILITY to fund the difference. The obvious way to enable PATIENT choice is to have patients choose, as now, between individual local GP practices ( contracted AND independent - are they public or private? ). To provide the pepper of 'competition' to generate value-for-money, between contesting secondary care providers, then GP decision-making, with referral through GP commissioning, provides an answer. Unfortunately the apparatchiks have made another pig's ear of that good idea, by requiring 'control' and 'management superiority' - in the form of an expensive IT debacle. We need more expert players, more patient choice, and LESS of the Apparat, and this will mean one more reorganisation - which, of course, the bureaucracy will oppose. Competing interests: citizen, taxpayer, NHS GP and potential patient |
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Michael R Peel, Medical doctor Medical Foundation N7 7JW
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It is not just the National Health Service (NHS) as a whole that needs an independent management board. The current structure of Foundation Trusts for hospital groups and of Primary Care Trusts make the entire NHS vulnerable to being privatised at this level. The solution would be to make each trust a community based NGO. This would give them the autonomy necessary to meet the needs of the community, increase local democracy, and make it almost impossible for a Chancellor of the Exchequer to sell them off to the highest bidder. Competing interests: None declared |
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David Allen, ex- SL in Health Service Management Manchester University M13 9PL
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In answer to L J Lewis I am sorry, I did not explain my proposal to give people the choice of PCTs very clearly. I am suggesting that private sector and third sector organisations be invited to take over or set up PCTs to offer choice. So all areas would be served by several PCTs. So there would be no need to move house to get a choice of PCT. (There has been some discussion of the proposal in the Rapid Responses to Uwe E Reinhardt article “Why single-payer health systems spark endless debate” BMJ 2007; 334: 88. http://www.bmj.com/cgi/eletters/334/7599/881#165691) Competing interests: None declared |
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