“Mr Rationing” is unafraid to speak out

BMJ 1998; 316 doi: (Published 10 January 1998) Cite this as: BMJ 1998;316:91
  1. Jo Waters

    Stephen Thornton is the new chief executive of the NHS Confederation. An outspoken advocate for explicit priority setting in the NHS, he tells Jo Waters that there is a gap between rhetoric and reality which the confederation must help the government to close

    Stephen Thornton is a man whose professional career was changed forever by the rationing row over “child B”. He may well have an impressive 18 year track record in NHS management, but as far as the public is concerned he will always be “Mr Rationing”–the man who would not sign the cheque to pay for controversial cancer treatment for Jamie Bowen.

    As chief executive of Cambridge and Huntingdon Health Authority, the media demonised him as the bureaucrat denying hope to the family of a dying child. “I received hate mail and death threats. It was a very difficult time for my family … my wife had difficult interchanges with people, and I worried about how my children would cope at school,” said Mr Thornton.

    “We didn't say ‘no’ because we were short of money but because the overwhelming clinical advice we got was that it would be ineffective and inappropriate. It's ironic that the one case that has been seen to symbolise rationing in the NHS wasn't about rationing at all—it was not about money—but about appropriateness and effectiveness.”

    He maintains that what the authority decided was right, and the case has prompted a much more open debate about the whole issue of setting priorities, blowing apart the myth that the NHS provides a comprehensive universal service.

    Doctors critical of the old National Association of Health and Authorities and Trusts for being too closely aligned to the government in the past are waiting to see if Mr Thornton's appointment as chief executive of the NHS Confederation reflects a change in political style for the new organisation.

    The “child B” case was clearly a turning point in his professional life and one that has left him unafraid of speaking out, but he is coy about the prospect of head-on confrontation. “We like to feel that we are fiercely independent—but what we do has to be seen in the context of all our members being government appointed. A lot of the business we do with government is on the inside. I wouldn't want the confederation to be known as a super-lobby—I don't think lobbying is what we're about. We're about looking objectively at a situation, doing some analysis, getting information from our members about what life is like in the field, and reflecting that back to government in an intelligent way.”

    He said that he wasn't angry with the government when the row over “child B” broke and that he received a lot of high level support from politicians. “My quibble, if I've got one, is that our national politicians ought to be prepared to set the scope of the NHS—decide what the NHS will pay for and what it will not.”

    He said he was “disappointed” to hear health minister Alan Milburn say on television that there was no rationing of cancer services in this country. “There are a lot of people who are trying to get their health authority to fund the drug Taxol for cancer treatment—so there is a gap here between rhetoric and reality that we have to help the government match.

    ”There is rationing going on out there—let's open our eyes to it, let's be honest about it, let's admit it and do something about it.

    “There is rationing going on out there—let's open our eyes to it, let's be honest about it, let's admit it and do something about it. I'd love the NHS to be completely free at the point of use, comprehensive and universal, but it isn't and only will be if it is properly funded.”

    He said that what disappoints him most about the recent white paper is the belief that further efficiencies in the system and a concentration on effectiveness alone will solve the funding crisis.

    It is for others, he argues, to take up the cudgels to protest about job losses caused by the “slimming down” of health authorities outlined in the white paper, but the confederation would be asking the government to be careful about stripping out too much management capacity.

    As a manager who gained most of his experience working in community and mental health services, he welcomes the white paper's emphasis on a primary care led service. “The GP, the community nurse, the chiropodist, the speech therapist, the mental health team can all be subsumed under one set of organisational arrangements. There is now an opportunity to get some proper multidisciplinary care up and running.”

    He acknowledged that this will mean that difficult decisions about acute care lie ahead. “A senior player in the NHS Executive said to me a couple of years ago that in the next 10 years between 30 and 40 acute hospitals would have to close. But it isn't just about closing hospitals—it's about painting people a picture of what the alternatives are going to be.”

    Doctors, he believes, are well ahead of managers and politicians in accepting that certain highly specialised, expensive services can be provided only in a relatively small number of centres.


    Stephen Thornton sees the medical profession as an ally


    He sees members of the medical profession as allies and recognises that they will be a powerful force in the new primary care groups detailed in the white paper. He wants to collaborate more on joint projects with the royal colleges and is keen to create a third council for primary care groups within the organisational structure of the confederation.

    “I see very little potential conflict between doctors and mangers. The NHS works at its best when clinicians and managers have thrashed out what needs to be done and then find ways of convincing and involving the public in that decision.” He adds: “I am pretty optimistic about that—I have never been of the school of thought that believes doctors are the enemy.”

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