Letters NHS reforms

Wants and needs

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d984 (Published 15 February 2011) Cite this as: BMJ 2011;342:d984
  1. Julian Tudor Hart, retired general practitioner and research fellow1
  1. 1Swansea University Medical School, Swansea SA2 8PP, UK
  1. julian{at}tudorhart.freeserve.co.uk

Once people understand what the reforms will mean for NHS England,1 and that Scotland, Wales, and Northern Ireland have refused to go down this path, enough backbench MPs might fear for their seats to defeat the bill on its third reading. Lansley got over 6000 responses to his “consultation.” Although these were overwhelmingly critical—and from virtually every representative professional body—the bill plunged even faster and deeper into privatisation than his draft.

All depends on public understanding of the relation between wants and needs. Market choice claims to give everyone access to what they want from competing providers. This is said to compel providers to work harder and more efficiently just to survive.

The nationalised NHS, on the other hand, aimed to meet not wants but needs. Needs were defined not by patients but by experts—doctors educated to know what’s good for people, better than they know themselves. Needs were assumed to be very much less than wants. The main reason the pre-Thatcher NHS could operate at less than half the cost per patient of that in the US, and provide care free for our whole population, was thought to be that NHS care was planned and provided according to professionally defined needs, not consumer wants.

Needs cannot be rationally defined by professionals alone. Unless patients contribute to the definition of needs, medical views reflect medical wants. Doctors like patients to have diseases they can name. Most patients’ real needs are only crudely, often misleadingly, reflected by wants as defined by patients alone or needs as defined by professionals alone. Both need time to talk, listen, and learn from each other, before needs can be rationally defined and efficiently dealt with.

The market may pretend to do some of this—the central function of GPs in primary care—but marketisation will put progress of this sort to an end. It wouldn’t be profitable. Do you really want Wales, Scotland, and Northern Ireland to become the only parts of Britain where healthcare still advances to a more human future?


Cite this as: BMJ 2011;342:d984


  • Competing interests: None declared.