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Views & Reviews Personal View

Does anyone understand the government’s plan for the NHS?

BMJ 2012; 344 doi: (Published 17 January 2012) Cite this as: BMJ 2012;344:e399
  1. Martin McKee, professor of European Public Health, London School of Hygiene and Tropical Medicine, London, UK
  1. martin.mckee{at}

I was not looking forward to January. Each year I teach a course on health systems. My students are among the brightest and best of their generation. They come to London each year from more than 100 countries in a search for enlightenment about health and health policy. Last year the hot topic for discussion was the reorganisation of the US health system, led by President Obama. Although it required a few days of intensive reading, it was not difficult to explain. The justification for change was clear. There was a health system that was the most expensive in the world yet left over 40 million US residents without cover, and which, as we had shown in our research on avoidable mortality (Health Affairs 2008;27:58-71), was making almost no progress in improving health outcomes. The proposals were relatively straightforward to understand. It was essentially what is called “pay or play,” whereby any person not covered by an employer sponsored health plan or other public insurance must purchase health coverage or be penalised financially. It had a number of weaknesses, such as a failure to cover undocumented migrants and inadequate mechanisms for cost control, but these could be understood given the complex, but clearly defined, legislative process that had to be navigated through …

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