Operational independence for the NHS

BMJ 2008; 337 doi: (Published 22 July 2008) Cite this as: BMJ 2008;337:a497
  1. Rhema Vaithianathan, Harkness fellow1,
  2. Geraint Lewis, Harkness fellow2
  1. 1Harvard Medical School
  2. 2New York University
  1. Correspondence to: R Vaithianathan vaithianathan{at}
  • Accepted 14 May 2008

Ara Darzi didn’t suggest freedom from government control in his review of the English NHS, but it might sound attractive to many health workers. Rhema Vaithianathan and Geraint Lewis show how it could work using the theoretical framework of independent central banks

The long term interests of the National Health Service are often undermined by its political governance structure.1 2 Health ministers are diverted by the exigencies of a short electoral cycle and by the perception of personal responsibility for all failings. This has compelled them to interfere with health technology recommendations, to reorganise the NHS repeatedly, and to interject on transient, local issues.2

In the late 20th century, monetary policy likewise suffered from unhelpful ministerial interventions. The concept of an independent central bank arose from the belief that an independent agency would promote a politically neutral, long term approach.3 In 1997, the Bank of England was given operational independence from ministers, and it has since been highly effective in maintaining price stability. This has led several commentators to call for the NHS to be given operational independence,1 2 4 which would preserve its founding principles (free health care for all with revenue generated through general taxation) but would shift power away from politicians to an independent board. But does the NHS face comparable problems to those of monetary policy?

We argue that only certain health policy issues are analogous to monetary policy, and that delegation of these particular issues would indeed be warranted, but that independence would require several NHS boards—each responsible for a different area of healthcare policy.

Dynamic inconsistency

Sustained economic growth requires low inflation.5 However, allowing inflation to rise can temporarily boost growth and employment—but at the cost of harming long term price stability and hence long term growth. When politically elected governments …

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