Editor's Choice

NHS reforms—why now?

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d552 (Published 26 January 2011) Cite this as: BMJ 2011;342:d552
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}bmj.com

Views on the government’s plans for the NHS in England have come thick and fast since the Health and Social Care Bill was published last week (doi:10.1136/bmj.d507). They add to an already solid base of criticism that met last year’s white paper. The recent crop—from organisations representing GPs, hospital specialists, doctors in general, patients, managers, policy makers, and NHS employees—makes interesting reading (doi:10.1136/bmj.d413). Each is careful to acknowledge the logic of handing more power to clinicians and providing greater choice for patients, before itemising a raft of general and specific concerns.

Picking through the special interests is important. But whatever the various angles, and while acknowledging some good ideas in the bill, we share the widely held fear that the reforms could destabilise the NHS and damage patient care. As our BMJ editorial says this week (doi:10.1136/bmj.d408), the scale of the changes and the headlong rush to implement them would be risky at the best of times. In these exceptionally tight economic times they seem crazy.

So why now? One answer from the government is that the reforms will save money—£5bn over three years, according to the Department of Health, including £3.9bn in savings from commissioning alone (doi:10.1136/bmj.d418). But most seasoned commentators are doubtful. Nigel Hawkes, who is otherwise more sanguine about the bill, suggests that the changes are likely to cost money in the short term and unlikely to save any in the long term (doi:10.1136/bmj.d470). And no one is claiming that they will deliver the unprecedented 4% efficiency savings required each year for the next four years if current provision is to be maintained.

Interestingly, the money saving justification for the reforms looks like it was bolted late onto Andrew Lansley’s plans, which—as Chris Ham explains in Peter Davies’s profile of the health secretary—were developed when the NHS budget was still growing substantially. “They would have been much easier to apply in 2007-8,” he says (doi:10.1136/bmj.d491).

The other main justification for the changes seems equally ill founded. In recent months we’ve got used to hearing government claims that the UK has worse health outcomes than other industrialised countries. France is currently the most popular comparator. But luckily we have the cool analytical head of John Appleby to unpick the numbers. Appleby is chief economist at the King’s Fund and from this week will write regular data briefings for the BMJ. His first one is published on bmj.com this week and will appear in next week’s print journal. He says that the government’s recent claims are misleading. Britons are indeed twice as likely to die from a myocardial infarction as people in France. But on this much quoted metric the UK has improved more than any other country in the past 26 years and at this rate will overtake France next year. What’s more, this has been achieved at much lower levels of spending.

Given the uncertainty, the risk, and the consensus of concern, the government would be foolish to press ahead. Let’s see whether GPs already involved in practice based commissioning deliver, before rolling out such untested changes across the NHS.


Cite this as: BMJ 2011;342:d552


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