Intended for healthcare professionals

Analysis And Comment NHS reorganisation

Who's kicking who?

BMJ 2006; 333 doi: (Published 21 September 2006) Cite this as: BMJ 2006;333:645
  1. Nigel Hawkes (, health editor1
  1. 1 The Times, London E98 1TT

    Are you clear what a primary care trust does or how payment by results works? To help, we asked a health journalist to explain the numerous changes in the English health service and their implications

    Sometimes it helps to take a different point of view. Doctors puzzled by what is happening to the National Health Service in England do not have the time or the inclination to wade through the blizzard of documents that issue from the Department of Health. Doing so would not guarantee understanding, anyway.

    What follows is an idiot's guide to the new look NHS in England, written from a different perspective. Lenin famously asked, “Who whom?” What he meant was, “Who has the power over whom? Who is the master, and who the servant?” Seen in this light, the English NHS reforms become more understandable. As they move the pieces about the chess board, ministers talk grandly about “strengthening the architecture of the NHS,” but what really matters is who does the kicking and who is kicked.

    Power shift

    Almost all the changes that have been introduced in recent years are driven by power, not architecture. Independent sector treatment centres did increase capacity as ministers claimed, though not by much,1 but their real purpose was to undermine the power of surgeons to control waiting lists. Patient choice had the same motive. Payment by results aimed to exploit market power to squeeze high cost hospitals, while practice based commissioning was a counterbalance to prevent the low cost hospitals expanding their market so fast they ran away with all the cash. The idea was to give general practitioners incentives to produce alternative services that would treat patients more economically by allowing them to keep some of the savings.

    Liberalising measures, including foundation trusts and plurality in primary care, were …

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