Intended for healthcare professionals

Rapid response to:

Editor's Choice

NHS reforms—why now?

BMJ 2011; 342 doi: (Published 26 January 2011) Cite this as: BMJ 2011;342:d552

Rapid Response:

Wants and needs

To be effective, health professionals must learn how to speak truthfully but very simply. This compels us to face the limits of our own understanding; if we can't explain problems simply to our patients, we probably don't understand them ourselves. The cover illustration of last week's BMJ (Lansley's monster) showed that at last the BMJ is learning to do just that, but we need a lot more, and fast.

In the same week, the second reading of the Health and Social Care Bill got a large majority in parliament. Once people understand what this will mean for NHS England, and that Scotland, Wales and Northern Ireland have already refused to go down this path (so there is an alternative) it is still just possible that enough backbench MPs will fear for their seats, to defeat the Bill on its third reading. Lansley got over 6,000 responses to his so-called consultation. Though these were overwhelmingly critical, and from virtually every representative professional body, the Bill plunged even faster and deeper into privatisation than his draft. When the electorate finally understands the scale of this betrayal, defeat on a scale similar to 1945 will probably follow. If the Labour Party can find the courage to admit that its commercialising "reforms" were utterly wrong, probability will become certainty. Conservative MPs who know their history have lots to think about. Andrew Lansley could still find himself twisting in the wind.

Or more likely, it could be defeated on the streets, like the Poll Tax. All depends on public understanding of an essentially simple issue, the relation between wants and needs.

Market choice claims to give everyone access to whatever they want from a wider range of competing providers. This, it is said, will compel providers to work harder and more efficiently, simply to survive in the marketplace. So everyone will have what they want, at a price even our now impoverished nation can afford.

The nationalised NHS, on the other hand, aimed to meet not wants but needs. Needs were defined not by patients who had them (but couldn't understand them), but by expert professionals, doctors educated to know what's good for people, better than they can know themselves. Needs were assumed to be less than wants - according to generally accepted mythology, very much less. The main reason the pre-Thatcher NHS could operate at less than half the cost per patient of that in USA, and provide care free for our whole population, was generally believed to be that NHS care was planned and provided according to professionally defined needs, not consumer wants.

Needs cannot be rationally defined by professionals alone. Unless patients contribute to definition of needs, medical views reflect medical wants. Doctors like patients to have diseases they can name, resembling those found in books. As everyone experienced in primary care knows, most if not all patients have real needs which are only crudely, often misleadingly reflected either by wants as defined by patients alone, or needs as defined by professionals alone. Both need time to talk, listen and learn from each other, before needs can be rationally defined and efficiently addressed.

The market may pretend to do some of this, the central function of GPs in primary care, but in fact marketisation will put progress of this sort to an end. It wouldn't be profitable. Do you really want Wales, Scotland and Northern Ireland to become the only parts of the British Isles where history still advances to a more human future?

Julian Tudor Hart

Competing interests: No competing interests

08 February 2011
Julian T Hart
retired GP
Research Fellow Swansea University Medical School