Dear Mr Lansley

Your proposals to transfer the role of purchasing NHS services for patients from primary care trusts to general practitioners is appealing in as much as it promises some reduction in the excessive bureaucracy that resulted from the “low trust” culture introduced by the Thatcher reorganisation of the NHS in the 1980s and never reversed. However, as was so eloquently pointed out by the late Douglas Black—an eminent physician and someone who had much experience in government as well—none of the reorganisations since (and including) those of 1973 have succeeded in improving function by tampering with structure.1 Indeed they have all done the reverse, essentially, as Sir Douglas also pointed out, because they fail to appreciate that health care should be treated as a service rather than as a business. Business based models have not fared well when it is a service that is required.

However, I imagine that the main aim underlying your proposals is to save money and to provide better healthcare delivery at lower cost. There are, indeed, at least three ways in which very large sums of money could be saved in the delivery of health care, with improvement rather than detriment to the quality of service. However, none of these changes would be universally popular, and they would require time, tenacity, and political courage to bring them about. Nevertheless, without them the future of health care, not just in the United Kingdom but elsewhere, will be imperilled by ever rising costs.