How to run the NHS

In the week when Britain's secretary of state for health invited the public to give its ideas on improving the NHS—as part of the government rush to “modernise” the health service (p 1292)—this week's BMJ has plenty of suggestions—some of them contradictory.

On p 1329 Alain Enthoven suggests first that the government should stop looking for quick fixes. Enthoven, a professor from Stanford Business School, is the man who brought market forces to the NHS by influencing Mrs Thatcher's reforms of the early 1990s. In the first of a series we have commissioned to help the current prime minister produce his plan for modernising the NHS Enthoven comments that it will take years to change NHS culture, train people, and create information systems. He also warns that a centralised approach will fail and that the answers lie in setting incentives for profound cultural and organisational changes that will lead to continuous quality improvement. He also warns, “The government must prioritise: it can't have continuous quality improvement and everything else it is demanding every week.”

The sense that the government is demanding too much—and of a backlash against it—bubbles up in an interesting story that hit the headlines last week and is retold by Jeremy Laurance on p 1348. The winner of a byelection for a seat on the General Medical Council was a doctor who had previously been struck off by the council for serious professional misconduct (and later reinstated). This prompted hostile headlines in the newspapers, but Laurance, the health editor of the Independent, unearths a more complex story. The winner (and several other candidates) were standing on an explicitly anti-GMC platform, critical of its ways of working and seeing it as making doctors scapegoats for an underfunded health service. Laurance interprets the result as a cry of pain and anger from beleaguered doctors. It is, he says, “the clearest possible signal from a section of the profession that it is sick of being criticised . . . and has little appetite for Tony Blair's programme of modernisation and still less for that of the president of the GMC, Sir Donald Irvine.”

Those doctors, and many others, probably won't like the personal view of Donald Light, another American with ideas about the NHS (p 1349). He criticises the NHS for the incentives it gives to private practice, which, he argues, serve to undermine its attempts to shorten waiting lists. Consultant contracts, too few doctors, and perverse charging are among the elements “that have reinforced each other so well that the public and doctors think that long waits are as much a fact of life as waiting nine months for a baby to be born.” Yet Nigel Edwards, in his letter on p 1336, has a much simpler explanation: “the NHS has too little capacity run at too high a rate of use.”