Risks of health reform are branded “unacceptably high,” as wave of opposition breaks over health secretary’s head

BMJ 2010; 341 doi: (Published 21 December 2010) Cite this as: BMJ 2010;341:c7359
  1. Adrian O’Dowd
  1. 1London

Opposition to the government’s reforms of the NHS reached a crescendo in the second half of December as doctors, politicians, and health policy analysts all went on the offensive.

The wisdom of the changes—to replace primary care trusts with GP led commissioning consortiums and to have the new bodies operating by April 2013—was questioned by numerous diverse sources. The criticisms came in the same week that the government published its response to the consultation on its white paper Equity and Excellence: Liberating the NHS by declaring that the reforms would go ahead with minimal change.

More than 200 clinicians signed a joint letter published in the Times on 13 December warning that the government’s plans would “destroy” the NHS (BMJ 2010;341:c7224, doi:10.1136/bmj.c7224).

The letter, signed by 206 medical professionals, said that the desire of England’s health secretary, Andrew Lansley, to put patients at the heart of care and involve clinicians in decisions about service provision could be achieved without the “massive structural upheaval” of abolishing primary care trusts and health authorities.

A day after the letter appeared politicians across the spectrum on the parliamentary health select committee published a report from their recent inquiry into public expenditure, highlighting their worries (BMJ 2010;341:c7217, doi:10.1136/bmj.c7217).

The report said that there wasn’t a sufficiently detailed and credible plan for how the NHS would meet the government’s expectation of efficiency savings of £20bn (€24bn; $31bn) over the next four years.

NHS staff will struggle to maintain NHS services at their current levels, given the unprecedented financial challenges they are working to meet, the MPs said in their report.

Evolution rather than revolution was the route suggested in the week’s third critical report. The right leaning independent think tank Civitas took many of the government’s proposals to pieces in its report A Risky Business: The White Paper and the NHS, published on 15 December (

James Gubb, director of the Civitas health unit and author of the report, said, “The risks of ripping up the current commissioning structure in its entirety in favour of new, inexperienced organisations at a time when the NHS must focus squarely on driving productivity like never before are unquantified and in all likelihood unacceptably high.”

On the same day, the Guardian newspaper published a letter predicting that the reforms would turn out to be “this government’s poll tax disaster” (

Commenting on the wave of criticism, Chris Ham, chief executive of the health policy think tank the King’s Fund, told the BMJ that “a lot of external organisations and stakeholders have been consistent in expressing their concerns about the reforms.”

He said, “As people studied in more detail what the white paper and then the consultation documents said, there was an increasing sense of more and more concerns being expressed. People took time to get their minds around how radical the government’s reforms were going to be in the context of the funding pressures.

“I think a lot of organisations, such as the BMA and the Royal College of General Practitioners, have been expressing their concerns without coming out and saying the government has got it completely wrong. It’s been a reasonably measured response from the medical profession.

“But over time there have been more concerns and criticisms expressed than was the case when the white paper was published.”

Professor Ham considers the letter in the Times to be significant, saying, “There are some very respected senior figures in the medical world who are now prepared to be more vocal and visible in expressing concerns.

“Now we are getting closer to the health bill being published, and [given] that the government has reaffirmed its continuing commitment to go ahead with the reforms, it’s not surprising that more people are willing to put their heads above the parapet.

“The combination of taking forward the white paper and the structural changes, delivering the efficiency objectives, and taking out management costs to the level of 45%, as the government is requiring, is a very powerful cocktail of policies that are being pursued all at the same time when the NHS budget is getting very tight.”

Judith Smith, head of policy at the fellow think tank the Nuffield Trust, said, “I think many doctors agree with the spirit of the reforms in terms of greater clinical engagement in shaping services and commissioning and the stronger focus on patients.

“But I also think what they are voicing at the moment is concern about the scale of organisation and management change at the same time as the very significant efficiency challenge. It’s an expression of significant concern rather than it being actual resistance.

“As time goes past and people think through the nature of the changes, they see they are radical.”

Given the growing scepticism in the medical profession, it seems unlikely that the health bill will have an easy ride when it is published in January.


Cite this as: BMJ 2010;341:c7359