Intended for healthcare professionals

Rapid response to:

Analysis And Comment NHS reorganisation

Who's kicking who?

BMJ 2006; 333 doi: (Published 21 September 2006) Cite this as: BMJ 2006;333:645

Rapid Response:

NHS "Internal market"

Nigel Hawkes states that in the third phase of the Government's
reforms, it has "reinvented the market mechanism".

If true, this might be welcomed. But one is reminded of the way, in
the Lord of the Rings, orcs were described as having been invented in
mockery of elves. The current "market mechanism" is a clunky and
grotesque parody of what was gradually developing in 1990-1999 and in no
way resembles a true market.

In a true market, change takes place at the margin. A new business
(eg Next, Top Shop) can grow fast, while their rapid increase from a small
base only implies a small drop in activity for huge existing businesses.
Likewise, a single GP practice sending a few patients to a private
hospital, which may send a message to the local DGH but will not
immediately cause wholesale redundancies. But if the new model is better,
it will gradually replace the old one.

Labour, in opposition, did a huge disservice by promoting two
false criticisms of the process of change. These were "the two tier
system" and "postcode rationing". By contrast, trying to impose
uniformity means that (a) change is sudden, indigestible, and possibly bad
and (b) local autonomy is not possible.

The usual criticism of markets in health care is that the patient is
not a rational consumer. I submit that the GP is a rational consumer, and
that practice level is the correct ethical and economic level for resource
allocation decisions to be made. Commissioning care on the basis of whole
counties or districts has been tried before and has failed. Practice based
commissioning will only contribute to healthy change in the Health Service
if it is truly practice based and resourced. For this to happen, the
government's intellectual journey away from command-and-control has one
more stage to go.

Competing interests:
None declared

Competing interests: No competing interests

10 October 2006
Jeremy D Budd
GP Principal
East Quay Medical Centre TA6 4GP