John Appleby, chief economist, The King’s Fund

The underlying argument of Equity and excellence seems to be that although choice, competition, plurality of supply, and devolved decision making were the health policies eventually reached by New Labour, they had never really been tried out properly. The market had always been constrained and a bit half hearted. Choice was never a reality for most patients, and as for primary care trusts as commissioners—total (and expensive) failures at their jobs. A harsh diagnosis perhaps, but what to do to achieve an NHS that is the “envy of the world” and which “achieves results that are among the best in the world”?

Much of the prescription is essentially to retain the economic architecture—for example, choice and competition—but to shake up the organisational structure: out with primary care trusts, strategic health authorities, targets, and ministerial “meddling”; and in with compulsory GP commissioning, an independent NHS board, and “outcome goals.” Whether you see this as evolution, revolution, devolution, or just the same old solution depends on your point of view—although views seem unconventionally split; there are ex-Labour health advisers supporting the white paper’s proposals 1 2 and right of centre think tanks opposing them.3

The crucial question is not how all this will be implemented—although there’s some way to go via consultation, legislation, and negotiation on much of the white paper—but whether these reforms are a cost effective way to achieve better health outcomes for patients and more productive use of every NHS …