Editor's Choice Editor’s choice

Meddling and bearing witness

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1293 (Published 14 August 2008) Cite this as: BMJ 2008;337:a1293
  1. Jane Smith, deputy editor
  1. jsmith{at}bmj.com

    For as long as I can remember the government has been reorganising the NHS, and a series of commentators, ranging from interested outsiders to official auditors, has been saying, in effect, “stop meddling.”

    The most recent interested outsiders have included Don Berwick and Donald Light in their commentaries on the NHS (BMJ 2008, 26 July, doi: 10.1136/bmj.a838, doi: 10.1136/bmj.a824). This week it’s the turn of the official auditors. The Audit Commission and the Healthcare Commission have recently reported on the success of the latest reforms of the NHS in England, and Gwyn Bevan discusses their findings in an editorial (doi: 10.1136/bmj.a935). The auditors find little evidence of benefit from the four main changes—foundation trusts, greater use of the independent sector, more choice for patients, and payment by results. In dissecting why that is so, Bevan provides a potted history of the NHS and its reforms since 1976. Since 1991, he says, “the NHS in England has been subjected to too many top-down impositions of reorganisations and system reforms,” and within weeks of this latest report “another programme of system reform was promulgated following the Darzi review.”

    Bevan’s story provides the ideal backdrop to Rhema Vaithianathan’s and Geraint Lewis’s proposals for operational independence for the NHS (doi: 10.1136/bmj.a497). This is an idea that we have promoted in the past (BMJ 2007, 12 May, doi: 10.1136/bmj.39210.699502.47), and Vaithianathan and Lewis explain how it might work. Using the example of independent central banks, they suggest that four aspects of the NHS might usefully be managed independently. These are areas of decision making subject to governments’ “dynamic inconsistency” (the tendency to yield to short term temptations against their better long term judgments) and where the benefits would outweigh the reduced democratic accountability. The authors reject the idea of a single independent NHS board because it would be responsible for mutually inconsistent aims. Instead they suggest four separate boards for making decisions about cost effective treatments, structural reorganisations (ideally rarely), local service reconfigurations, and patient safety issues. NICE almost matches their requirements for an independent board for cost effectiveness decisions, but they want it strengthened by legislation so that parliament would set a transparent threshold for cost effectiveness and its rulings would be binding.

    Independence of a different sort is lauded in the editorial on the disaster that is Zimbabwe (doi: 10.1136/bmj.a1286). Dan Ncayiyana and colleagues document the effective destruction of Zimbabwe’s health system and “in the midst of this mayhem” credit the Zimbabwean Association of Doctors for Human Rights with documenting and investigating human rights abuses and consistently raising the alarm. It has, say the authors, served as the moral conscience of the medical profession in braving the wrath of the regime and waging “an unequal battle with an autocratic government contemptuous of basic human rights.” Ncayiyana and colleagues sound optimistic that the political violence may end soon, but it will take much longer to rebuild society and a health system that was once among sub-Saharan Africa’s best.


    Cite this as: BMJ 2008;337:a1293

    View Abstract