The NHS in our handsBMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a663 (Published 02 July 2008) Cite this as: BMJ 2008;337:a663
- Fiona Godlee, editor, BMJ
The founding principles of the NHS are safe, for the moment at least, from whatever marauding hordes we might have thought were out to get them. Last week’s BMJ and King’s Fund debate concluded overwhelmingly in favour of their continued relevance (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 birthday this week have shown similar commitment to the ideals of equitable care funded by central taxation and free at the point of need. And now we have a draft NHS constitution that seeks to enshrine these principles in law (doi: 10.1136/bmj.a640). All of this means we can get back to the job of nurturing this great beast, the NHS, with all its inherent conflicts, contradictions, and limitations, and somehow continuing to make it work. Lord Darzi’s report on the next stage of reforms for the NHS in England gives us 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)—though how this squares with an end to local variation in provision remains unresolved, as Rudolf Klein points out (doi: 10.1136/bmj.39262.746238.47). There’s an equally welcome emphasis on better care for everyone, with substantially increased funding for faster evaluations of treatments (doi: 10.1136/bmj.a660) and, crucially, the promise of funds to make all approved treatments available to all.
It’s beyond the report’s scope to say where this extra money will come from, but we can’t escape the question. The launch of a government review of copayments for cancer drugs meant that Darzi didn’t have to tackle this highly contentious issue, which hits at the heart of the NHS. In their editorial this week, Ilora Finlay and Nigel Crisp conclude that copayments are inevitable, but they want them introduced in ways that will preserve 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 increase access, copayments would do the reverse. “User charges are an idea that is intellectually dead,” he says. “If we want to raise money in a way that is consistent with what we want to achieve in health care, there is another way—it’s called taxation.”
Darzi reiterates choice and competition as key drivers for change in England. These have so far largely failed to deliver improvements in care, according to Tony Delamothe (p 25, doi: 10.1136/bmj.a524). Darzi hopes that better information will fuel an appetite for real patient choice, and Bruce Keogh’s plans to deliver that 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 the elegant bones of this report. But there’s one crucial aspect of Darzi’s vision that will happen only if doctors across the NHS step up to the plate: much greater leadership from clinicians. If this review is, as Gordon Brown has said, a once in a generation opportunity, the next generation of clinicians and patients won’t forgive us if we fail.
Cite this as: BMJ 2008;337:a663