Ctrl-Alt-Pause
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2219 (Published 06 April 2011) Cite this as: BMJ 2011;342:d2219
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Given that nobody has identified any evidence that the reforms will
actually liberate anything, that nearly everybody who is familiar with the
NHS has serious reservations and that nobody voted for major NHS changes
last May, wouldn't a more appropriate title for Tony's piece have been
'Ctrl-Alt-Delete'? Or maybe I've anticipated next week's Editor's Choice?
Well someone was going to say it...
Competing interests: Practising GP who wants 'the NHS to succeed'
Dear Editor
It was interesting to read Delamothe (Editor's choice:
Ctrl-Alt-Pause)(1)
My comment is that
the new social media were a revolution in North Africa and Middle
East Countries and soon they will extend to other developing and developed
countries. Probably soon we will have Saturday or Sunday of
anger, departure .. etc. It is a movement by the majority of the poor people
against their dictators and social injustice. All respect to the creators of
Facebook, YouTube, Twitter, and Google. I think politicans
everywhere nowadays need to think carefully before making any
unwise decisions.
References
1. Delamothe T, Editor's choice:
Ctrl-Alt-Pause. BMJ 2011 342:d2219; doi:10.1136/bmj.d2219
Competing interests: No competing interests
Time for a Plan C for the NHS?
Plans A and B (1), and the general debate, about the reforms deny the
fundamental challenge facing the NHS and are a missed opportunity to
explore what should be the main organising principle for the NHS.
The challenge is the ability of the NHS to provide world class health
care to everyone - increasing advances in science and technology and
population demographics, now coupled with the financial situation, mean
that this aim is not possible/affordable. Denying rationing of health care
remains an obsession despite evidence that it already exists, and is
(reluctantly) accepted. Surely it is time to resolve the long overdue
debate. In the 21st century whilst good health is a right, 'best' health
care, free to all, may be a privilege - heresy but an increasingly
necessary fact of life.
Re how to organise the NHS, we have been locked into the
commissioning paradigm since Working for Patients introduced by the
Thatcher Government, despite limited evidence of its effectiveness. Rather
than making this paradigm work, should we not look for alternatives? Here
are my two suggestions.
First, if we do want to run the NHS as a national and integrated
system and if we are serious about Big Society then there is a previous
model. Although not advocating going back to the late 1980s I believe that
the system that existed then with regions, regional planning of services
and workforce, directly managed provider units with single district health
boards populated by mostly volunteers for example was a classic big
society model - a case of local clinicians, managers and the general
public owning their NHS, pulling together to meet their population's needs
and making the best use of limited resources. I sometimes think that if
only we had held the same structures, reviewed the processes, and even put
in half the extra money that has gone into the NHS in the last decade we
would have been much better off.
Second, if we do want to stick with competition, then a potential
option would be to fund providers directly and get them to ensure
vertically integrated systems by bringing together primary and secondary
care clinicians designing pathways of care and moving care between
community and hospitals as appropriate. Given the power of providers and
our inability to control them currently, turning the heat on hospitals may
just do what the last 20 years of experimenting with
purchasing/commissioning has failed to achieve. Nothing like poacher
turned game keeper. Most commentators agree that the biggest fault line in
the NHS is the primary: secondary care divide, so rather than reinforce it
why not put them together as integrated provider systems and let them
compete with similar groups elsewhere and drive standards up (2).
You can not 'Ctrl' the NHS as currently organised, we need new 'Alts'
and hence the 'Pause' should be used to go back to the basics (I use this
term advisedly given the previous record of Back to Basics!) to redefine
the scope and main organising principle for the NHS. Tinkering at the
edges will not solve the problems facing the NHS; it is time for a rethink
and bold measures.
Rajan Madhok
Medical Director
NHS Manchester
rajan.madhok@btinternet.com
12 April 2011
1. Delamothe T. Ctrl-Alt-Pause. BMJ 2011; 342: d2219
2. Madhok, R. Yes, but not on the commissioning platform. BMJ Rapid
Responses 2 April 2011.
Competing interests: The views expressed here are personal and not that of the author's organisation.