Evidence not ideology

This week I am opening my GPs' new surgery. It will be a proud moment for me—there'll be a plaque and everything. I'll be taking with me this week's special issue of Career Focus, devoted to GP training, but I'm especially looking forward to hearing their stories of the latest policy directives and how they are getting round them. Working in the midst of a giant and rapidly moving healthcare experiment is easier if you can laugh about it while carrying on doing your best for patients.

Of course the experiment itself is no laughing matter. The world is watching, huge amounts of public money are at stake, and working lives as well as patient care are being turned upside down. And the news is not good. Consultants are retiring early because of pressure of work (p 798), one trust is saying it will have to cut consultant posts to make savings (p 797), and the BMA has warned that the new private treatment centres will have no incentive to train doctors (p 797).

Robert Lane and Alex Paton are excoriating in their criticism (p 854). They highlight the potential for greater inequity as non-NHS providers cherry pick easy cases and also the financial gain for companies involved in this latest reorganisation. “It is clear that the NHS is being taken over by big business and private healthcare teams,” they say, “but markets have never yet delivered universal and equitable health care.”

For those in favour of reform, the problem is not that we have gone too far but that we have not gone far enough. Jennifer Dixon (p 852) calls for full implementation of the reforms already designed (payment by results, patient choice, and provision of care by non-NHS providers), but she also wants more: key elements, such as financial incentives and effective economic regulation, are missing, she says.

In her rapid response, Allyson Pollock calls on the BMJ to take a position on the NHS. Neutrality on the NHS is, she says, like being neutral on the war in Iraq, female circumcision, or tobacco sales. But there are problems with this. Each side of the NHS debate accuses the other of being driven by ideology, without seeing that ideology is equally evident on both sides. Ideology makes things simple when in reality they are irretrievably complex. The private finance initiative (PFI) may have seemed ideologically sound but its lack of flexibility has stymied it in practice (p 792)—an expensive mistake. Meanwhile the new pressure group “Keep our NHS public” tends to ignore the inconvenient fact that the NHS has always worked with private practitioners.

It is equally inconvenient that some aspects of the reforms may be working. Nick Timmins reports that, although the targets in the new GP contract were probably set too low, they show promise as a means of driving up the quality of care (p 800).

Having said this, there is one position the BMJ will take. Since this is clearly an experiment, we should demand good evidence before new initiatives are rolled out. Lane and Paton (p 854) complain that Kaiser Permanente has been accepted as the future model for the NHS on flimsy evidence of effectiveness. They are right. This isn't good enough.