In an earlier response to this article, Dr Mathews was absolutely right to highlight the importance of health care rationing to this debate.

I would disagree that the reforms are primarily about rationing however.

Initially, it was claimed we needed reform to reverse the UK’s flagging health outcomes. Enthusiasm for this argument has waned as government claims of poor patient satisfaction, cancer outcomes, and heart disease, have each been shown to be spectacularly false.[1,2,3]

Increasingly, cost-efficiency has been cited as a key objective but this has been contradicted by government action. For example, one of their first initiatives was to create a £50m fund for cancer drugs deemed not cost-effective by NICE, despite the fact this system produces amongst the best, most equitable and most cost-effective outcomes for cancer of all OECD countries.[2] And just recently we learned three tiers of management are to be replaced with five [4] – hardly a stride towards cutting bureaucracy costs.

Rather than being about rationing, these reforms are about blindly pursuing neoliberal, free-market policies. They are an expensive, unnecessary distraction from the essential task of rationing health care in the face of increasingly limited resources. Although markets may occasionally improve quality and micro-efficiency, they cannot be relied upon for the strategic planning needed to ration care equitably and efficiently.

Attention should be directed towards addressing health service inefficiencies imbedded in customs, rules, professional values and institutional structures.[5] For example, some of the greatest improvements under Labour came from centrally determined waiting-time targets [6], the NSF for heart disease [7], and the NHS Cancer Plan.[2] Such reforms avoid the administrative costs associated with shoehorning health services into a market model – costs which have risen from 6% to over 14% of the NHS budget since market experiments began in 1990.[8,9]

This week Mr Lansley argued his reforms did not amount to privatisation of the NHS.[10] It is important to be clear however that it is not just the privatisation, but the extensive marketisation mandated by his reforms, that threatens to destroy the NHS as we know it.

1.Appleby J & Robertson R. A healthy improvement? Satisfaction with the NHS under Labour. In: Park A, Phillips M, Clery E, Curtice J, eds. British Social Attitudes Survey 2010-2011: Exploring Labour’s legacy—the 27th report. Sage, 2010.

2.Pritchard C & Hickish T. Comparing cancer mort and GDP health expenditure in England and Wales with other major developed countries from 1979-2006. British Journal of Cancer. 2011;105;1788-94.

3.Appleby J. Does poor health justify NHS reform? BMJ. 2011;342;310-11.

4.URL: http://www.guardian.co.uk/politics/wintour-and-watt/2012/jan/27/andrewla... [Accessed 7th Feb 2012]

5.Light D. Effectiveness and efficiency under competition: the Cochrane test. BMJ. 1991:303;1253-4.

6.Brereton L & Vasoodaven V (2010). The Impact of the NHS Market: An Overview of the Literature. CIVITAS, London.

7.Smolina K, Wright F, Rayner M & Goldacre M. Determinants of the decline in mortality from acute MI in England between 2002 and 2010: linked national database study. BMJ. 2012:344;d8059.

8.Pollock A. NHS PLC: The privatisation of our health care. Verso: London. 2004.

9.URL: http://www.guardian.co.uk/society/2010/mar/30/nhs-management-costs-spending [Accessed 7th Feb 2012]

10.Lansley A. Why legislation is necessary for my health reforms. BMJ. 2012. 344;e789.

Competing interests: None declared