Intended for healthcare professionals

Editor's Choice

Ideology in the ascendant

BMJ 2010; 341 doi: (Published 14 July 2010) Cite this as: BMJ 2010;341:c3802
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

    “Radical and risky” is how Chris Ham describes the new government’s plans for the future of health care in Britain (doi:10.1136/bmj.c3790). An independent commissioning board, the abolition of strategic health authorities, an end to primary care trusts, and performance driven by markets instead of targets all add up to fundamental changes to both the anatomy and physiology of the NHS, he says. But how effective will GPs be at commissioning, will the government allow unsuccessful providers to fail, and what hope for collaboration and service integration when competition is king? No other country has given primary care such responsibilities for service provision and now commissioning. “The government’s visceral dislike of managers has trumped thoughtful analysis of what is needed and may yet prove to be an Achilles’ heel in the plan,” he says.

    Tim Lang and Geof Rayner are equally critical of the new government’s plans for public health—in particular its proposals for the Change4Life social marketing campaign set up by the last government to tackle rocketing rates of obesity (doi:10.1136/bmj.c3758). The plan is to cut public spending on the campaign and ask local authorities, charities, and the commercial sector to fill the gap. As Lang and Rayner point out, with charities and local authorities strapped for cash, this will hand the campaign over to the food industry. It amounts to “ideological reassertion” under the guise of fiscal constraint, they say.

    The food industry doesn’t have far to look for examples of how to fight public health initiatives that threaten their profits. As Melissa Sweet reports, food companies are now adopting the successful strategies pioneered by the tobacco and alcohol industries (doi:10.1136/bmj.c3708). Although the food industry’s emphasis on exercise appears wholesome enough, it deflects attention from efforts to reduce the amounts people eat while providing cover for sophisticated attacks on any government intervention that might affect profits. As Doug Kamerow comments from the US frontline (doi:10.1136/bmj.c3719) when American cities and states tried to impose a tax on fizzy drinks, “public health was outgunned and outspent.”

    Obesity may be, in Lang and Rayner’s words, the worst public health crisis since HIV, but the HIV crisis is very far from over. Next week thousands of people working or living with HIV will descend on Vienna for the International AIDS conference in the hope of advancing efforts to end the pandemic. A key question, addressed by a cluster of articles in this week’s journal, is how best to reduce the harm caused to and by injecting drug users (doi:10.1136/bmj.c3538, doi:10.1136/bmj.c3439, doi:10.1136/bmj.c3374, doi:10.1136/bmj.c3360, doi:10.1136/bmj.c3172). Most countries have embraced harm reduction policies to some extent, including needle exchange and opioid substitution, and there is now a good evidence base to support these measures. But as Evan Wood writes (doi:10.1136/bmj.c3374), effective interventions are far from universally available and policy makers prefer ideology to evidence. In a beautifully argued essay (doi:10.1136/bmj.c3360), Stephen Rolles calls on us to envisage an alternative to the hopelessly failed war on drugs. He says, and I agree, that we must regulate drug use, not criminalise it.


    Cite this as: BMJ 2010;341:c3802