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Editor's Choice

Time to leave home

BMJ 2006; 332 doi: (Published 30 March 2006) Cite this as: BMJ 2006;332:0-f
  1. Fiona Godlee, editor (fgodlee{at}

    These are bad times for the NHS. The words “crisis” and “meltdown” are flying around and few people say these are exaggerations. While the health secretary Patricia Hewitt maintains an impressive Thatcheresque public facade, her department is believed to be in panic. Record spending has delivered record deficits and uncertain value for money. For the first time in anyone's memory, sizeable numbers of NHS staff are losing their jobs (News, p 743). How has this happened and what's to be done?

    Last week's edition of the BBC's Panorama roundly blamed the government. It concluded that ministers had gravely miscalculated the cost of their reforms, especially the doctors' pay awards. Interviewed on the programme, John Appleby, senior economist at the King's Fund, agreed. The Department of Health must take the blame, he said, because it sets both the NHS's cost environment (most notably the doctors' pay increases) and its targets.

    But government ministers blame managers. On Panorama Patricia Hewitt spoke of “a few bad apples”—incompetent managers who have failed to balance their books—and a culture of overspending. The managers interviewed on the programme cried foul. They said they had done what the government asked. They had met government pay awards and targets on waiting times, only to be told that there was no money for this additional activity. New accounting rules mean they must pay off the deficit and have the same amount deducted from next year's budget.

    As the NHS slows down, perhaps to a standstill, two things are particularly depressing. First is the missed opportunity. The government found huge amounts of taxpayers' money and poured it into the NHS. Nothing like this is likely to happen again in our lifetimes. Second is the waste of energy and goodwill as staff and patients are buffeted by one policy change after another, often seeming to bring us full circle. And we are left not knowing whether we have gone too far with these reforms or not far enough. Are these the NHS's death throes or just the end of a painful adolescence?

    If this crisis tells us anything it is that health care is too important to be left to politicians. Five or even 10 year terms of office do not lend themselves to long term strategic planning. If the NHS—the 33rd largest economy in the world—is to stop being a political football kicked from one party's version of an internal market to another's, it needs to be protected from party politics. An independent NHS authority (or four authorities for England, Scotland, Wales, and Northern Ireland) could do this. Each would be run by a board of governors responsible for managing health care within a set budget and a broad political framework. The analogy to that other great British institution, the BBC, is obvious.

    Gordon Brown's first act as chancellor was to give the Bank of England independence to set interest rates. His first act as prime minister should be to give independence to the NHS.


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