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Education And Debate

Reforming the NHS reforms

BMJ 1994; 308 doi: (Published 26 March 1994) Cite this as: BMJ 1994;308:848
  1. A W Macara, chairman of councila
  1. a British Medical Association, London WC1H 9JP

    Rather than improving efficiency, the reforms imposed on the NHS have increased bureaucracy, reduced patient choice, limited the range of core services, and led to inequity of treatment. In this paper I examine how the medical profession might help to solve these problems. Priorities must be set for health care since no government can afford all the possibilities offered by medical science. It is essential to forge a consensus of patients, carers, professionals, the public, and government if a system of priorities is to be equitable and just. We also need to be able to measure quality of outcome in health care. This requires consensus on what is the desired outcome and the development of appropriate guidelines, audit, and performance review. This is primarily a task for the health professions supported by management and by adequate investment. Basically, the government must reinstate the three traditional values of the NHS--equity, consensus, and regard for representative professional advice.

    Case for the prosecution

    It gives me no joy to say so, but the BMA was largely correct in 1989 and ‘90 in its predictions of the consequences of the NHS reforms. We anticipated that they would damage the integrity of the NHS and would lead to a fragmented service. We predicted increased bureaucracy, although we could scarcely have foreseen its scale.1

    The purchaser-provider split, with its perverse philosophy of winners and losers, was foreseen to diminish rather than to increase patient choice, to limit the comprehensiveness of core services, and to force some patients to travel out of their locality for treatment. Rather than money following patients, patients have had to follow the money, until it runs out, with little relevance to relative need. Resources remain inadequate to cope with the demoralising effects of demographic change and social deprivation. The BMA is not alone in highlighting …

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