Intended for healthcare professionals

Editor's Choice

The NHS in the age of anxiety

BMJ 2013; 347 doi: (Published 21 August 2013) Cite this as: BMJ 2013;347:f5221
  1. Trevor Jackson, deputy editor, BMJ
  1. tjackson{at}

This year is shaping up to be the NHS’s annus horribilis. Sixty five years since it began, the service has been subject to a constant drip of bad news—from Robert Francis’s report into what went wrong at Mid Staffordshire NHS Foundation Trust, to the so called crisis in emergency departments. Yet in his essay this week, Rudolf Klein tells us that statistically, there does not seem to be much wrong with the NHS (doi:10.1136/bmj.f5104). Key performance targets have been maintained in the face of fiscal austerity, hospital infection rates have improved, and the service seemed to be making good progress in hitting its savings targets. And the NHS “has successfully implemented” the Lansley reforms, even though, as Kieran Walshe says in his editorial (doi:10.1136/bmj.f4980), the new organisational architecture makes little sense to most of those who have to make it work.

Yet Klein acknowledges that there is a different story to be told, a story that has led many to ask what has gone wrong with the NHS. He looks at the gap between rhetoric and reality in recent NHS history, and identifies two themes that have intertwined to give the impression of a service “stumbling into crisis.” One of these is the quality theme, and the other is the patient empowerment theme. “The common element has been an emphasis on transparency, and the outcome has been a statistical striptease by the NHS, unveiling its activities in ever greater detail,” he writes. “Not only is more information available than ever before, but it is also more accessible than ever before.”

The NHS-meets-TripAdvisor mindset might seem inevitable in the internet age, as informed patients seek out those consultants and hospitals with the best record. But Klein warns that “more information may complicate rather than enhance the ability of consumers to make choices because they have to cope with an ever growing menu of indicators, varying in quality and sometimes pointing in different directions.” Witness the letter from Rachel Davis this week about the problems of conveying data from the friends and family test to the public (doi:10.1136/bmj.f5158).

Klein says that for the NHS, the “tough” choice includes decisions not about how best to maximise benefits, but about how to minimise harms. Diverting demand for elective surgery to the private sector for those who can pay might protect services for those who cannot. “But should policies that are undesirable in themselves be accepted as a price of safeguarding the core of the NHS?” he asks.

This cuts to the heart of much of the current debate about the NHS. Will the increased use of private provision save the service or destroy it? (Des Spence, in his column this week (doi:10.1136/bmj.f5199), is clearly of the latter opinion.) Does austerity necessitate reduced public borrowing, or is it the figleaf for ideologically driven cuts to services that some would like to have privatised anyway? Klein points out that many have challenged the hairshirt approach, concluding: “The best hope for the NHS is that the challenge will succeed before too many irreversible lesser evils have been found acceptable.”


Cite this as: BMJ 2013;347:f5221


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