Intended for healthcare professionals

Editor's Choice

Sleepwalking into the market

BMJ 2013; 346 doi: (Published 20 March 2013) Cite this as: BMJ 2013;346:f1850
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

Next week on 1 April, England’s National Health Service takes what may be an irrevocable step. Sixty five years after the legislation that established a publicly funded, publicly provided, and publicly accountable health service, new regulations come into force that will gradually open up the NHS in England to increasing competition by private providers. Will this overwhelmingly improve the service to patients and the public, as some people claim? Or will it lead gradually but inexorably to the dismantling of the NHS for profit, as others fear, and as Lucy Reynolds claims on (doi:10.1136/bmj.f1848)? The truth may of course be somewhere in between, but should we take the risk?

Understanding what has led us to this point is important, and I urge you to read Reynolds’s account. It won’t be the first you have read but it may be the clearest. She argues that the seeds for privatisation were sown decades ago with the introduction of the internal market and the purchaser-provider split; that NHS provision has been systematically undermined and, with the help of the private finance initiative, set up to fail financially; that the profitable parts will be hived off under cover of the trusted NHS logo; and that this is not about party politics but about making money from healthcare.

When the regulations requiring commissioning groups to put all contracts out to competitive tender were announced, very quietly, in February, they raised immediate concerns. The outcry was captured in a 1000-signatory letter to the Daily Telegraph and prompted the president of the Academy of Medical Royal Colleges, Terence Stephenson, to intervene. The coalition government has now made some hasty revisions. But as Martin McKee explains (doi:10.1136/bmj.f1733), although some words have changed. the essence of the regulations has not. The rules are now less clear but just as onerous, he says, effectively handing the future of England’s healthcare to competition lawyers. In an open letter to medical leaders (doi:10.1136/bmj.f1819), Jacky Davis and colleagues agree. They say that the revised regulations still break a public promise made by the former secretary of state Andrew Lansley that commissioners would have the right to choose whether to commission services.

Recent MORI polls show the public to be largely unaware of any major change to their health service. Despite the scandal of poor care in Mid Staffordshire, they remain intensely loyal to the NHS both as an idea and a reality. But we must expect a generational shift. Those who can remember the harsh days before the NHS make up a dwindling proportion of the population.

How much do those of you who are doctors working in England’s NHS really understand what is happening? How many people care if this unique experiment, this publicly funded and provided healthcare free at the point of delivery, changes gradually but inexorably to something that looks more like the US system? If you think we may be sleepwalking into disaster, now is the time to speak up.


Cite this as: BMJ 2013;346:f1850


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