Letters Unethical health reforms

This ethical argument seems irrelevant to the real world

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1946 (Published 29 March 2011) Cite this as: BMJ 2011;342:d1946
  1. Stephen Black, management consultant
  1. 1PA Consulting, London SW1 9SR
  1. steve.black{at}paconsulting.com

Sheehan’s core conflict is less concerning than he supposes, as individual GPs are not allocating resources—that will be done by the consortiums, giving GPs a stronger influence but not individual responsibility.1 But rather more concerning is his assumption that “decisions about resource allocation are increasingly being made within a robust system.” The robust system that has persistently allocated too many scarce resources to hospitals rather than prevention or primary care? That has heaped public money on the problem of health inequality without apparently making any noticeable change? That has allowed large variation in clinical activity unrelated to need to persist for decades?

What matters in the real world is not the theoretical ethics of hard situations, but the practical realities of real decisions. Putting GPs closer to resource allocation means their incentives will be more closely matched to the needs of patients. Imagine, for example, that the NHS has to balance investment in hospital treatment with investment in primary care and prevention. Currently no GP has to worry about long term costs, most of which will be incurred in hospitals. In many cases the GP could strive for more investment in primary care, but it will be a fight against a powerful hospital lobby and the GP will see no gain from the saving made by the NHS.

But if the GP is part of a group holding the whole budget, the decision is easier: he sees the gain when the investment in primary care keeps the patient out of hospital and saves the NHS a packet. Moving the GP closer to resource allocation may well make it better. Doing a better job for their patients doesn’t seem to me to be such a significant ethical dilemma.


Cite this as: BMJ 2011;342:d1946


  • Competing interests: None declared.


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