Can the government’s proposals for NHS reform be made to work?BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2038 (Published 31 March 2011) Cite this as: BMJ 2011;342:d2038
All rapid responses
ROBBING PETER TO PAY PETER
I have been a GP in Central West London for over twenty years and
like most of my colleagues am willing to embrace change if it drives up
the quality of what we do. Of course this must be in a measureable way
which can be shown to benefit our patients.
The 'Big Picture' sounds sounds great in theory but for me it remains
a mirage. I guess Messrs Cameron and Lansley have it framed on a wall
somewhere in Whitehall.
A good example is the lack of joined up thinking in trying to reduce
costs and maintain quality. I am being asked to reduce my referrals to
Outpatients. I am also being asked to maintain or reduce my spending on
It does not need a rocket scientist to work out that if patients are
being seen less in secondary care then prescribing costs from secondary
care will be transferred to primary care. It probably does need a rocket
scientist to work out whether I am saving money by referring less and
I am in a no-win situation. Please give me a magic wand and a crystal
ball to put next to my stethoscope and auriscope.
Competing interests: No competing interests
Having been among the earliest and staunchest critics of the proposed
NHS reforms, this effort at conciliation or appeasement looks decidedly
odd and unconvincing. It's puzzling, too, why the authors felt moved to
produce it at all since it rather undermines their previous stand against
the insanity that pervades many of the proposals. Why, one is moved to
ask, would one want the present reforms to be made to work when the case
for them remains deeply suspect? The risk is that Walshe and Ham's
beguiling offer to help the government simply ensures that many of the
worst aspects of the proposals could survive in some form, even if
slightly represented, to win much-needed support. At which point, their
'dark side' and true intent would be reasserted.
Why on earth would anyone remotely critical of the changes want to
give the government a lifeline? It is truly mystifying, especially coming
from 2 such long-standing and well-informed health policy-watchers. What
is especially alarming are the flimsy assumptions underpinning many of the
suggested means of redirecting the proposals to ensure that they remain
under firm control. Somehow, we are led to believe rational policy-making
will prevail despite all the evidence to the contrary hitherto.
Similarly, we are reassured that market forces can be controlled,
harnessed and directed by government in order to ensure that the optimum
balance between competition and collaboration is found. This doesn't
resonate with the blundering style of government we've enjoyed for much of
the past 20 years or more during which time competence and trust in
government have got worse.
What confidence can there possibly be in controlling the ideological
urges of a government that is hellbent on pressing forward with changes
designed to roll back the State that go far beyond anything New Labour
contemplated. Surely a political analysis of this nature has to be the
starting point rather than a belief that somehow the government can
realise its ambitions with a tweak here and there.
In the real messy word of realpolitik phrases like 'the bill needs to
create ways to allow commissioning consortiums to use competition and
contestability to improve performance rather than stipulate competition in
all circumstances' conceal so much that is uncontrolable or impossible to
predict or regulate that at the very least the risks of going down this
road need to be fully articulated rather than ignored. Elsewhere, the
authors state that 'the introduction of greater competition needs to be
phased and evaluated to ensure it is delivering improved performance'.
Again, in the real world the reality tends to be quite different and
events take over which can produce a totally different dynamic. We know,
too, from the evaluations of the experiment with ITSCs, that the evidence-
base is rarely unequivocal or uncontested. At the end of the day, it is
unlikely to provide the answers needed to steer policy. It hasn't
hitherto so why in future? The same applies to pilots and experiments
which the authors call for. Governments instinctly detest these and where
they do permit them, they generally fail to wait for the results to emerge
before rolling out their pet schemes anyway.
It's inconceivable that Walshe and Ham are unaware of these dynamics
in the system that result in policies that are invariably not aligned and
which give rise to unintended consequeneces and perverse incentives that
become almost impossible to control. Regretably, their paper reads like
the kind of anodyne tract management consultants would (and do) produce.
From two of our most experienced observers one would have expected a far
more insightful analysis grounded in the complex realities of reforming
Competing interests: No competing interests
We need a health system that encourages specialists to support GPs to
provide care close to the patients home. The current internal market
system and proposed GP commissioning do the opposite and encourage "cherry
picking". I have asked my hospital colleagues to train me in
dermatological surgery. I could "cherry pick" simple procedures, removing
small cancers for ?100 in primary care that would cost over ?700 in
hospital. They have refused as they are worried they will lose income.
This income is used for managing chronic conditions such as psoriasis that
do not "generate" income.
If GPs shared the budget with hospitals we could work together to reduce
overall spend. Rather than scrapping primary care trusts, we could become
integral members of them. The Kaiser model might be a start.
Will Ridsdill Smith (GP),
Woolpit Health Centre
Bury St Edmunds
Competing interests: No competing interests
Clive Peedell makes some very important points in his rapid response.
However, I feel a duty to defend the authors. As one of the reviewers of
their paper, the first paragraph of my review read "At the outset, this
paper must define what it means by "NHS". Is it, as is commonly understood
by the public, a largely publicly delivered health care system, albeit
with some private provision at the margin, or simply a financing shell,
ensuring that, at least for now, health care is provided free at the point
of delivery, potentially by an entirely privatised system (a scenario that
has not been denied by government ministers). Throughout this debate, a
major problem has been terminology, with ministers using words that many
of us regard as deliberately ambiguous or that have subtly been
redefined." Unfortunately, in their decision letter, the editors advised
them that it was not necessary to address this point.
It is now clear that the Prime Minister and Health Secretary are to sell
their proposals, as they seem determined to do despite overwhelming
opposition. Their task may require more than explanation given that this
opposition seems to be strongest amongst those who have had the stamina to
read all 350+ pages, plus the over 100 amendments introduced so far by the
government itself, plus the detailed proceedings of the Commons scrutiny
committee that have been characterised by the failure of ministers to
answer questions put to them (or even, in some cases, seemingly to
understand the rather simple questions).
Even after such detailed study I cannot decide whether this dog's
breakfast of a bill is the consequence of cock-up or conspiracy, but
whichever it is, a first step will be to provide some very simple and
unambiguous answers to basic questions about what the words "NHS" and
"care" [provided by it] will actually look like for patients and health
workers in the future. Perhaps, to kick start this process, Kieran Walshe
and Chris Ham might share their understanding with us?
Competing interests: As I state in the response I was a reviewer of the paper. I believe strongly in the founding principles of the NHS.
"They do not know what they are doing nor have they any idea of the
consequences of their action"
Lord Owen Independent April 3rd 2011 writing about the Government's
The Kings Fund needs to be far bolder in stating that the proposed
reforms will worsen the existing problems of poor communication and
collaboration in the NHS and will fail to address poor standards of care
and will widen inequalities.
Those parts of the bill that may be of benefit, such as greater
clinician involvement in decision making are too tightly hitched to the
most damaging parts, such as the purchaser-provider split and the external
market. The damaging parts of the bill are so dangerous that no amount of
amending can make it safe.
The NHS is in need of reform. There are problems that urgently need
to be improved.
1.Improve collaboration. Community, primary care and hospital
specialists need to work together. At present shared care is on the whole
poor to non-existant, though there are patchy exceptions.
2. All providers need to share responsiblity for the health of a
defined population.We must abandon the purchaser-provider split. GPs are
providers of health care. If GPs are purchasers there is no way to avoid
the potential for conflict of interest. The purchaser-provider split
damages relationships between GPs and specialists and hinders rather than
facilitates joint responsiblity for patient care because GPs are trying to
reduce medical interventions to save money at the same time as hospitals
and others are trying to increase interventions to earn money. It is an
3. We must continue to invest in NICE and improve the dissemination
and monitor the use of guidelines. There is a great deal to be gained from
better adherence to clinical evidence. Guidlines are all too often not
followed because of lack of familiarity rather than clinical reasoning.
4. Measure outcome data more effectively. The outcome of health care
is health gain. It is very difficult to measure health gain because of the
huge numbers of variables, the social determinants of health, the
subjective nature of health, the variable time-lags between interventions
and outcomes and more. If we are to become more efficient, then we need
also to agree on how to measure efficiency.
5. Federate GPs in a geographical area so that they work
collaboratively, to and share resources and take responsiblity for peer
performance. The failure of PCTs and the GP profession to manage
underperfoming GPs is inexcusable. It is part of the political
justification for competition on the assumption that it will drive out
poor quality despite there being no evidence that competition between GPs
will do this. Because of their long history of independence GPs are not
used to working with their peers. This situation is not sustainable and
urgently needs to change. The Royal College of GPs has proposed this in
the past. This is an excellent idea, but will need firm leadership, expert
management and a range of incentives if it is to succeed.
6. Reduce health inequalities. Having worked in deprived and affluent
areas I know that general practice in deprived areas is far more
clinically challenging and less financially rewarding. There are serious
inequalities in the resources available, the quality of care and the
incentives for GPs. The govt has made a serious error in assuming that
inequalities are not an issue. Proposed funding allocations will widen
inequalities and threaten the financial viabilty of general practice in
areas with the greatest health needs. Efficient care depends on efficient
patients and the impact of markets on inefficient patients will result in
the Inverse Care Law. The appalling capitulation to food and junk-food
manufacturers under the guise of public health policy is an indication of
the government's failure to recognise the social determinants of health.
Strong public health leadership and close collaboration is essential here.
Other important areas for improvement are greater financial and
clinical transparency and accountablity. Greater patient involvement.
Improved multidisciplinary teamwork between doctors, nurses and other
allied health professionals. Better management training: for managers and
This bill is not fit to be amended.
Competing interests: No competing interests
This analysis makes some interesting observations and suggestions but
is seriously weakened by a failure to address some of the more fundamental
political issues surrounding the NHS reforms.
Firstly, the authors have taken the Government's stated objectives at
face value, with no attempt to acknowledge and put into context the
political ideology underpinning these reforms. The coalition Government
has a clear agenda to replace a significant chunk of the public sector
with the private and third sectors. "Rolling back the state" through
privatisation and a reduction in the public sector workforce and national
pay bargaining and pension rights, is one of the key supply side economic
policies, which this Government thinks is necessary address our dire
economic situation. A low tax, low inflation, entrepreneurial environment
is seen as vital to securing the confidence of international investors and
the international bonds markets in the City of London.
This neoliberal approach to public sector reform builds on the previous
policies of the Thatcher and Blair Governments. This approach was well
summed up by the former New Labour cabinet Minister John Denham in an
article in the Chartist in 2006:
"All public services have to be based on a diversity of independent
providers who compete for business in a market governed by Consumer
choice. All across Whitehall, any policy option now has to be dressed up
as "choice", "diversity", and "contestablity". These are the hallmarks of
the new model public service"
Thus, the political and economic reality is that public services need
to be privatised and marketised and the Health and Social Care Bill has
been designed to do exactly that to the NHS. The key market levers
contained within the Bill that will drive this process are the mutually
reinforcing policies of patient/consumer choice, competition between a
plurality of any willing providers, payment by results, the purchaser
provider split, increased freedom for foundation trusts, the pro-
competition nature of Monitor and the NHS Commissioning board, and an
Lansley sees competition as the key and stated this in a speech to the NHS
Confederation: "So the first guiding principle is this: maximise
competition......which is the primary objective"
In same speech, he alluded to the importance of not only increasing the
number of providers to stimulate competition, but also the number of
consumers. He stated that:
"The statutory formula should make clear that choice should be exercised
by patients, or as close to the patient as possible, thereby maximising
the number of purchasers and enhancing the prospects of competition,
innovation and responsiveness to patients." 
This explains the rationale for the increased use of patient held
budgets, but more importantly explains why GPs are being given ?80 billion
of the NHS budget - they are closest to patients. Hence the transformation
from a Consultant led NHS to a GP led NHS.
However, simply leaving the budget in the hands of GPs is problematic
because most GPs and their patients want to be referred to a good local
hospital and this is fundamentally anti-market. Thus the Bill will use
Monitor, the NHS CB and EU Competition law to prevent GP Consortia from
favouring incumbent providers. In addition, the private takeover of
commissioning through FESC will further stimulate this process.
Since these mutually reinforcing polices are so crucial to the
political and economic objectives of this Government, any attempts to
seriously water them down will be met with significant opposition, despite
the very difficult and politically unpopular situation the Government
finds itself in. Thus any Government concessions that result in amendments
to these policies must be forensically examined for loopholes. There is
already concern that the widely publicised U-turn on price competition has
not gone far enough for example. 
As for some of the authors suggestions for making the Bill more
palatable, I fully support their views on public accountability, but many
of the other suggestions are flawed or too weak. I would make the
1. The idea of a graduated and phased approach to authorising
consortiums has rather been offset by the disintegration of PCTs all over
the country, which has left a black hole in NHS management that needs to
be filled quickly. Pathfinder consortia already cover over 2/3 of the
population and the legislation hasn't even been passed yet!
2. No attempt is made to describe "robust" mechanisms to avoid potential
conflicts of intersest. It has been reported in the BMJ that 1/10th of
consortium board GPs have roles in private companies for example. 
3. Watering down the competition agenda makes the market even more
inefficient. Lansley is driven by competition ideology and has already U-
turned on price competition, so further concessions are unlikely. What is
the point of taking such a political risk is the end product is nothing
like what was intended.
4. "Assessing the any willing provider" approach has already been done. I
refer the authors to the work of Colin Leys and Stewart Player. 
5. The idea of giving Consortia greater autonomy could have negative
impacts on the market and is not likely to be tolerated
In summary, the authors seem to have missed the point of these
reforms by focusing on the technical aspects of the reforms rather than
addressing the underlying political ideology of this coalition Government.
Their well meaning suggestions to reform the Bill will only serve to
provide Mr Lansley with some useful rhetoric take the sting out of the
"This is a new neo-liberalism for the 21st century - a merger of
Thatcherite neo-Conservatism and Orange Book Liberals which believes that
getting the state out of the way is the road to a stronger economy and
Ed Balls, Labour leadership candidacy statement 2010
 Government has not done enough to prevent price competition.
 A 1/10th of consortium board GPs have a role in private firms. BMJ
 Confuse and Conceal: The NHS and Independent Sector Treatment Centres.
Player, Leys. Merlin Press 2008
Competing interests: Co-chair NHS Consultants' Association.BMA Council.BMA Political Board.