Healthy reforms?

One of the surprises of recent months has been the emergence of proposals for substantial change in the way the NHS is managed. They emerged gradually and quietly in Opposition, in contrast to the Education changes which were well heralded.

They contain two principal elements. The first is part of the general policy of cutting back the central overhead. Health, like eveything else, will have to demonstrate it is reducing the numbers of central executives, and curbing the amount of central and regional interference with the local surgeries and hospitals. That makes sense, and can be done.

The second is to transfer responsibility for “commissioning”, for selecting hospital or other treatment, from Health Authorities to GPs. This is the ultimate empowerment of the professionals, the ultimate localist move. Out will go the PCTs, Trusts of officials and part time unelected members, and in will come the budget holding GP.

I would be interested to hear your thoughts on this. Will GPs want to do this? What back up will they need to do it? Will it lead to higher quality of treatment and more patient choice?


  1. nonny mouse
    August 31, 2010

    The idea of GP based commissioning will be great for patients. It will empower GPs to choose the best treatment for their patients rather than treatments being chosen to meet arbitrary PCT targets.

    The best thing about it is that it will encourage a more diverse array of treatments to become available rather than pushing people into one size fits all hospitals. Small procedures could be undertaken at GP surgeries rather than having to go to the expense of attending a hospital far away from where patients live. The private sector will be able to provide additional (but not replacement) treatment options. GPs will be even more incentivised to practice preventative medicine because the cheapest treatment is one you don't need to make at all.

    I'm not sure how much money it will save, except that the ever increasing PCT management teams will no longer be needed and there will be less form filling and more treatment by health professionals.

    Overall a radical overhaul to a system that has been allowed to forget why it exists – giving us the best possible health care without bankrupting the nation. Now all we need is a government who can sell the idea to the country.

  2. Iain Gill
    August 31, 2010

    my view is individual "commissioning" decisions should go whenever possible to individual patients and not their GP, and throughtout the treatment cycle not just at the beginning

    GPs at the moment mostly dont get to see how back it can be from a patient perspective

    individual buying decisions from patients can force timely appointment keeping, cleaner buildings, docs who speak English clearly, and so on, in ways which commissioning higher up the hierarchy will never achieve

  3. Nick
    August 31, 2010

    If its all local, there is no need for an NHS.

    Keep up the good work in your campaign to get it abolished John

    Reply: I am not running such a campaign.

    1. waramess
      September 1, 2010

      What a pity

  4. tomsmith
    August 31, 2010

    It would be better if the patient was allowed to spend their health service allocation however they wanted. Why do we assume GPs will be any more competent and less power hungry than the current officials?

    1. David in Kent
      August 31, 2010

      While your position is logical the reality is that most patients, I include myself, have no idea who would be the best surgeon to remove their tumour. They might have an opinion about the hospital they would prefer to go to and that opinion should be respected by the commissioning GP but that GP should have a much better idea of the best choice.
      So long as GPs get appropriate support and there is a high level of transparency to avoid kick-backs, this reform should be helpful.

      1. Lola
        September 1, 2010

        Patients control the money. GP's act as gatekeepers. The GP will need to inform himself/herself where the most effective treatment camn be obtained and recommend that to his patient/client. You only have to look at the law or accountancy or what I do to see how this works, and work it does. Centrally the money HAS to follow the patient. And if you are clever enough to comment on here (!) you are certainly clever enough to manage your own healthcare – wit the help of an informed GP ( – or 'choice adviser' as I have heard some stupid bureaucrat call it yuk).

      2. Iain Gill
        September 1, 2010

        not at all in large parts of the NHS folk are mainly seen by locum GPs with less local knowledge than the patients

        mainly GPs have little idea how to support the mobile workforce who maybe in another city next month and therefore more appropriate to see a consultant in that city

        and educated diabetics often know more about their condition and treatment centres than their GPs as an example, giving those patients a little buying power would soon change the terrible quality eye care dished out in some parts of the NHS – and the GPs are not qualified to comment on the quality of eye consultants either!

        so often even the best GPs have little idea of the terrible attitude and bad service suffered by their patients, and others are politically motivated to support one provider or another regardless of needs of patients

        so all in all give the power to the patients not the GPs

  5. Simon_c
    August 31, 2010

    I think the key thing to find out, is if the number of hours in direct patient care, vs the number of hours in management. (or probably, the cost of those hours actually)

    If the new setup will result in fewer hours (or £) going to running the business, and more going to the core activity (treating patients) then I would call it a success. I've no idea if such an analysis has been done for the current situation but, it really needs to be predicted for the future setup.

    Then what should happen is the new system should be trialled and after 18months or so evaluated against the forecasts before rolling out nationwide.

    Just my thoughts.

  6. Mike Stallard
    August 31, 2010

    In theory, I am all in favour of this. Out with the drongoes!
    this may be helpful (or not).
    In old style schools, the Head was a professonal teacher who taught and was proud of that and his degree. His right hand was the School Secretary, usually a lady, who actually ran the school, answered the difficult phone calls, did all the lists and fended off silly bureaucrats. She was paid a pittance and had her own tiny office.
    Maybe the NHS could learn from that?

  7. StrongholdBarricades
    August 31, 2010

    As I explained to my own MP, the only problem with GP's having the final say is that they are already independant contractors to the NHS, and their practices are run for profit because without the profit they would not be paid.

    Thus it seems stange to give the budgets to people who's sole raison d'etre is to stop spending of money to inflate their own salaries, and we didn't see them cover themselves in glory over the out of hours coverage.

    My MP also told me that the people to whom the GP's are accountable are not publically electable.

  8. Brigham
    August 31, 2010

    GP's will be reluctant to go back to the fund holding status. They, because of the completely stupid arrangement by the last government, will just want to carry on getting loads of money for doing less work. After all we would all do the same, wouldn't we. GP's are the best bet, but I can't see them doing more work for the same money. This is going to cost. I'm an ex medical rep and I think that periodic exams should be taken by all doctors. As Lord Tebbit once said, "I used to be an airline pilot and we were tested every six months, and the passengers really appreciated that." Why not the same for doctors?

  9. Michael Read
    August 31, 2010

    No problem with reducing central costs.

    But putting the buying function in the hands of GPs? Come on, you don't believe this guff for a moment.

    Nothing in their training prepares them for that. Reducing the scale of procurement reduces one key element of negotiation. The risk of malfeasance is enormously increased. And I've just been thinking for one minute.

    Wait until the Daily Mail picks up on the cock-ups.

  10. Will J
    August 31, 2010

    As far as I understand the plan the GPs will not each be budget holders, but rather will be obliged to join one of a number of local consortia, through which they will manage their combined budget. They will therefore not each be managing a budget but will employ people to manage a joint budget, and they will be like the members or the trustees of the fund, overseeing the managers and setting policy. I believe this system is less about empowering GPs (though it does) and more about connecting those who authorise treatment with an appreciation of budget limitations. It ends the current separation between those who make funding decisions (the PCT) and those who make specific spending decisions (GPs). This introduces a new systemic incentive on the part of GPs to keep costs down. It is, therefore, largely irrelevant as to whether they want this power – a more efficient and responsible structure requires them to have it. As for the skills required to do it – these come from the managers they employ.

  11. Stephen W
    August 31, 2010

    I can't offer any specialist advice on this, due to being in no way a health professional.

    But I feel I can say that not all GP's will want to do it, but that isn't an insurmountable problem. What will make it work or fail is whether there is sufficient back-up and support for GP's who may struggle with the new system. The government must concentrate its efforts to make sure the system works there.

  12. Epigenes
    August 31, 2010

    "Out will go the PCTs, Trusts of officials and part time unelected members…"

    Mr Redwood, why not go one step further and scrap the NHS. It is the biggest waste of money ever.

    An organisation run for the benefit of its employees and the Labour party.

    1. Stuart Fairney
      August 31, 2010

      Despite what some of them may privately think, they dare not express it for fear of

      (a) the media distortion/reaction and
      (b) front bench anger

      I do not know of a single sensible person who thinks the government runs things better than the private sector, but there is this huge blind spot about the nationalised health service and no-one will make the case. It's the truth that dare not speak its name.

      Today's tories are fundamentally patrician social democrats not the radical Austrian-economic free-marketeers we need and the maintenance of the nationalised broadcaster, schools, the NHS, EU membership etc is ample proof of this.

      1. nonny mouse
        September 1, 2010

        Try living in the USA for a few years and you will soon change your mind. The NHS may be an overly centeralised burocracy, but it still produces better results for less money than a purely private system.

      2. Epigenes
        September 1, 2010

        Stuart, I agree absolutely.

        The von Mises Institute is a source of distilled wisdom.

  13. A G
    August 31, 2010

    In the eighties hospital consultants were paid much more than GPs reflecting their extended training and higher responsibility. It was assumed that medics became GPs because they weren't clever enough to get on in hospital medicine. There were of course some very good people who chose general practice as their vocation and it appealed more to women who wanted children and a less onerous career. If you fast forward to today it is quite different with GPs often earning much more. I think this is because the GPs are better at representing themselves to politicians and the final hike in pay under Labour was driven out of desperation because they are the gatekeepers holding back the tide of insatiable demand which if not met will bring a government down.
    It is a big mistake to hand over all the power to commission services to the GPs because they are the least well qualified level of service of doctor and the correct specialty would have been public health medicine which has a fine tradition but isn't good at lobbying or self promotion.
    There are so many problems with health care that it's difficult to know where to start but here is a brief list-
    Core science has been removed from medical undergraduate education and replaced with touchy feely rubbish.
    The research assesment exercise has destroyed academic medicine and the spurious specialty of 'medical education' has slipped in to fill the gap.
    The change to five year run through training instead of the open ended experience based kind has resulted in good doctors being unprepared when they hit their first consultant posts and there is no way of weeding out the useless or dangerous but the politicians can boast that we have more consultants.
    The working doctors time directive has resulted in the loss of the consultant team led hospital care which has been replaced with shift systems which means there is no continuity of care.
    If you add in all the other little quibbles like loss of medical dining rooms (where discussion and debate took place), expensive staff parking and a reward structure that pays bonuses to doctors for swanning round the world as an expert rather than for productivity or innervation in the job and you start to get a flavour of the sheer stupidity of how health care is delivered.
    I think there's a gap here for a principled politician to throw out the rule book and start afresh much as IDS has done in welfare. He has shown us that he is a politician who cares about the population enough to fight for it. We need someone to do this for health. As a start they should begin by talking to older and retired doctors to find out how quality has been lost before it's too late and then work out how to meet, change or cope with the exponential demand.
    A final thought, I believe that with the right changes we could deliver not only a better health system but one which could earn money for the country by capitalising on the intelligence of our professionals by providing a climate where research and development can truly blossom.

  14. Mark
    August 31, 2010

    We rely on our vet to have good contacts for any specialist treatment that our dogs may require. That process seems to work well. When I have consulted my GP and he has referred me to a consultant specialist, that also works well. When I am hospitalised, either as a result of consultation within the NHS, or as an emergency admission, then the standard of care becomes a lottery. I have had to have a minor operation repeated because the appointed surgeon decided he would attempt to save the cost of an anaesthetist and then discovered he couldn't complete the job adequately under local, ignoring the consultant's advice. I suffered a further string of mistreatment following an emergency admission, ending with an extended recuperation lasting many months rather than a few weeks because I was disconnected from hospital equipment and discharged too early in order to free a bed for someone else. My experiences tell me that things don't work currently, with false economy attempts to save costs and meet targets that wind up adding to costs. Perhaps the first experience would not have occurred with more direct commissioning and a clear line of responsibility. I'm not so convinced about the aftermath of the emergency admission, where it is much less likely that a GP would have been able to assess the consequences of a rare condition.

    Few of us are experts in the medical conditions to which we succumb (at least unless they are chronic ones we have lived with for a while, or we are motivated to find out more because treatment has failed to work properly). Of force, we rely on medical expertise. GPs have always relied on their consultant contacts for specialisms, although in some cases consultants merely act as gatekeepers to the facilities of hospitals, although the real gatekeepers are the administrators.

    An acquaintance of mine, now well in her 90s and still full of life, discovered the virtues of moving when she was denied a heart bypass operation aged just over 80, and found the Health Authority where her daughter lived would give her the operation. This kind of postcode lottery is likely to increase.

    I don't have the answers: I'm not an NHS insider. I have seen some of the problems.

  15. backofanenvelope
    August 31, 2010

    Some years ago I had a conversation with a GP about the fund holder system introduced by the Tories. She said it was the best thing since sliced bread – her practice was introducing things they had thought about for years but which were not introduced because of the central bureaucracy. I would rather the government re-introduced this system.

  16. Tim
    August 31, 2010

    This is a missed opportunity. GP's will become ever richer and will find ways of passing the Commissioning accountabilities onto others. Can you imagine a GP Commissioner being sacked or removed because of a failure to do their job properly? (They are to be compelled to take on the role under a new contract.) I can't.
    PCT's could have been developed into competing Health insurers/Healthcare Commissioners. That expertise will now be scattered and the real opportunity for reform lost
    Mr Lansley has spent years thinking about it, and has come up with a dogs breakfast.

  17. Alan Jutson
    August 31, 2010

    So is there any difference between this proposal and the old fundholding GPs of the past.

    Concerned at how exactly each GP will have their allocation/budget worked out, Will it be patient numbers, areas covered, history of past illnesses What happens when a particular GP has used up their budget with a couple of months to go, does he turn patients away, or are we asked to register with another Doctor who still has some money left.

    GP's have got very profit orientated in the past few years, and I can see a number becoming very rich indeed with swanky premises if they are to be given control over millions of pounds.

    All for reducing the overheads of the existing system, but we need safeguards in place to stop abuse when such vast amounts of money are being passed around.

  18. DBC Reed
    August 31, 2010

    Gp's will not manage these enormous responsibilties themselves but will delegate them to specialist profit-making companies, probably American.GP's don't have the time.

  19. Shaun
    August 31, 2010

    Thinks its a great idea my wife is a nurse and her hospital hs seen the writing on the wall and is now starting to ask the hard questions on mangers in preperation to offer a good service to the G.Ps some have already been given their redundency packages not to mention a sudden urge to deal with the long term sick cases among the nursing staff and as far as understand it the PCT's wont be greatly missed many of the skills of the PCT staff will be in demand for the G.Ps, and the ability of the G.Ps will decide the sucess or failure of the system a trial to demonstrate and iron out bugs would be great help it may take a little longer but would save heartache and cost in the long run.

  20. London Calling
    August 31, 2010

    I wonder you much appetite GPs will have for taking over a budget that is in deficit? That's the reality for many budgets in the South East, where the appetite for health treatment does not square with the reduced allocation per capita resulting from the DH's crooked and political allocation formula – favouring labour territory and disadvantaging healthy and wealthy Tory shires.

    The big lie is that the "poor" need more money because they need more healthcare. False. If you look at the relationship between deprivation and hospital admission, the only thing the poor used more of than any other group is maternity services. Poor = many children. The healthywealthy long-lived needed more because they live longer to need them, but the age-weight is overpowered by lots of bogus proxies for "need".

    Go back to basics: the capitation allocation formula. Its crooked, and Labour Political, capital P. And ditch the hand-wringing worthless Directors of Public Health who get paid an enourmous amount for worrying about how unfair life is to the poor. Get the allocations back into balance and give GPs a proper budget.

    Go futher than who manages the budget.

  21. Bill
    August 31, 2010

    What is not clear to me is how we should calculate the cost of the NHS in the light of (a) the ageing population (b) increases in the cost of technology and drugs. In the light of (a) costs would go up anyway and in the light of (b) they may go up or plateau. In any case, if TV shows about the NHS are to be believed, one of the problems is that the facilities are underused because, for instance, anesthetists refuse to work on Friday afternoons and thereby stop surgeons operating then and affecting the hours of theatre sisters. Consequently we have the double problem of built in increasing costs produced by longevity and inefficiency caused by partial use of the plant. By all accounts, the expensive managers cannot solve any of this because the medical staff refuse to be pushed around by bureaucrats.

  22. Ross
    August 31, 2010

    I don't think it will last. The early PCTs were run mostly by the retired GPs who made up most of their directors. Then politicians decided that PCT directors had to be mostly 'independent'. So out with the GPs and in with the worthies; all of a sudden a new PCT director was typically the wife of a local Labour party constituency chairman.

    This process has been going on for at least the last thirty years – the last lot's quangos are slain, independent bodies are set up, and then they're captured by the whips. The circles of influence radiate ever more pervasively from 12 Downing Street. And why will it be different this time?

    At least they will be Conservative and Lib Dem constituency chairmen's wives. They will hate foxes and fly-tippers, not Iraqis,

  23. Andrew
    September 1, 2010

    In some places and on some occasions it will increase choice and improve outcomes . However how will "market failure " be addressed ?. If too many customers have too many bad experiences with a retail business they go elsewhere and the business goes bust. A bad experience with a GP who commissions badly could have rather more serious personal health consequences.

  24. Andrew
    September 1, 2010

    Also, –and this applies to other sections of the putative "Big Society", –GP's will need support from some sort of bureaucracy,– no matter how skeletal,— mainly when problems occur.. So the theoretical financial savings , and "empowerment premium " will not be fully realised .

  25. StevenL
    September 1, 2010

    My experience's of the NHS are largely good. I think the people around the blogosphere who label it 'Stalinist' etc are pretty silly really. I don;t really understand how it works to be honest or how these changes would affect the patient.

    The NHS is bureaucratic though, I would welcome a reform that made it easier for patients that have a proven need for a paticular prescription drug to just be able to buy it in an emergency.

    September 1, 2010

    A couple of thoughts:

    1. Our local Surgery has 5 full-time doctors and runs very smoothly. It is well respected in the community and we've always thought it has the scope to play a bigger role in local health care by acting as the control point for all care and visiting services.

    2. To take on accounting services sounds a big 'ask' but we're going to get the local view from our doctors. The government must surely stop NHS staff from receiving redundancy payments and then being re-employed at a surgery as would most certainly have happened under Labour

  27. Glyn H
    September 1, 2010

    SHBarricades mentioned the out of hours service: It was the Major government that shafted the private sector and gave the out of hours service and gave it, plus £2K per head to the GP's to run. Then the Labour gov got the wind up during GP negotiations and made a horrendous mistake over the out of hours services + stupid targets. The GP's ran rings round HMG hence the £100K pa doctors. And the woman responsible was, as usual with Labour was promoted and got an NHS trust to run (there's another story there to – see Private Eye about 2 years ago).

    1. StrongholdBarricades
      September 1, 2010

      I had understood that the GP contract that became accepted was written by the BMA (The Union for Medical Professionals) and just pushed through by the Labour Administration inspite of the previous consultation.

  28. Epigenes
    September 1, 2010

    Mr Redwood, I do not think the NHS is capable of reform because of its size – apart from the Chinese and Indian armed forces it is the world's largest employer – and complexity.

    A whole new approach is needed. Why not let people keep more of the money they earn so they can insure themselves? Subsidised health care could be provided to those that cannot work due to chronic medical conditions and old age.

    Maybe it could be broken into competing organisations.

    A health care system free from politicians would be a start.

  29. Fox in sox
    September 1, 2010

    I am a hospital doctor, and quite happy that GPs will be taking back commisioning, including commisioning of out of hours services. The potential problem is that many practices are too small to do this properly, and the risk is that a single patient with an expensive disease such as leukemia will wipe out a practise budget. It is likely that GPs will work as local commisioning networks of about 30 Drs to conduct negotiations with acute Trusts and other providers. If not careful these could become a recreation of PCTs with all the associated beaurocracy.

    The ability to register with a GP anywhere also has some interesting implications. If a wokingham commuter registers with a London GP, it is not reasonable or possible for the GP to do home visits. The implication of ending geographic GP boundaries is the end of the obligation of the GP to do home visits. Commisioning by the London GP would also be problematic. Over subscribed GPs would need to restrict their list size, as taking on more partners is not always possible, at least in the short term. The temptation would be to exclude those with expensive diseases from the list, such as those with diabetes.

    Individualised health budgets, as advocated by Dan Hannan in his book the plan, would get around some of the problems above, but create others. I have seen my GP three times in 30 years so would have a considerable surplus, but there would be others who exhaust their budgets legitimately within months. What then happens?

    I am all for more private enterprise in NHS provision, unlike many other Drs, but it has to be done carefully. The track record of private contractors are quite poor, for example the PFI hospitals are very poor value for money over their lifetime, and private sector ISTCs such as Shepton Mallet have a string of clinical concerns. The risk is converting an unwieldy public monopoly into an unwieldy private monopoly, with only large American corporations benefiting. Done badly, we could be re-running the railway privatisation, a textbook example of state subsidy and poor services.

  30. Will J
    September 1, 2010

    As fas as I understand them the proposed reforms don't involve a return to GP fundholding as it was done before, since the GPs will not become individual budget holders but will be obliged to join one of a number of local consortia. The consortium will be given the budget for its members and they will oversee spending policy. However, they will employ a fund management team to handle the administrative work.

    This has two main effects: it gives GPs more freedom to find innvovative and cost-effective solutions to patient needs; and, crucially, it gives those same GPs a keen sense of budget constraints, giving them the incentive to find ways of making savings. This is a huge improvement on the current system, where the PCT tries to keep costs down but cannot tell GPs how to do things, while the GPs have neither the power to innovate nor the incentive to do so, or to otherwise find ways of keeping costs down. By addressing both of these problems the new system should bring significant rewards, both in terms of improving the quality of patient care and in finding more efficient ways of providing it. It will also make GPs less inclined to prescribe unnecessary treatment.

    ps: I posted a message yesterday morning but it never appeared.

  31. Monty Cristo
    September 1, 2010

    Are these the same doctors whose leaders constantly hector the public at every turn. Anyone here get piggy-pox? Anyone here drink more than the made up healthy limit for alcohol consumption? Do you like salt, do you cook with fat?

    Seriously, it won't work. Look towards the French system as a guide and re-invent the NHS in a blaze of PR.

  32. rippleog
    September 1, 2010

    "free at the point of delivery"

    How can we sensibly discuss, reform and economies in the NHS when this fundamental flaw remains a taboo subject…

  33. anon
    September 1, 2010

    will never work. governent will have to break up hospitals and force them to compete. public will not like that.

    all that will happen gps group up and do whatever hospitals and government tells them to do. esp when there is such huge regulations that are comming in to force coupled with a perception that gps are hugely overpaid which they may be

    fundholding worked but will never be implemented ever again.

    September 2, 2010

    We ladies got together this evening to watch the Marr/Blair interview and got just what we expected – a man now uncomfortable in his skin and still in denial. There were signs of frequent editing and perhaps the uncut version should be sent to Chilcot as he attempts to sift fact from fantasy in the scripted version of Blair’s staged performance.__2 points that we have regularly raised over the years again seemed apparent:____1.Blair raised as another justification for invasion Saddam’s use of rising oil profits to develop WMD. We ask still just how much extra profit was earned by influential Americans after the world price rocketed following the invasion and then again later when the White House ‘bigged up’ the possibility of bombing Iran.__2.Blair 3 times avoided directly answering the Marr question ’Would you invade again if you’d known then what you now?’ – the precise question we urged Michael Howard to ask at PMQs in 2004 and again in 2005.__We still believe that had he done so and retorted – ‘Well I wouldn’t’ after Blair had said that he would – Howard would have become PM in May 2005 making today's mountain much less steep __

  35. farmer geddon
    September 2, 2010

    I'm surprised most GPs even bother given the jealous, snide, ill-informed comments here. The number of illogical arguments littered with spelling mistakes is pathetic.

    This policy is a sham.

    'Empower' GPs by allowing them to commission,
    Cut budgets,
    GPs are then responsible for shortfalls in care not politicians

  36. HampsteadOwl
    September 3, 2010

    The generally-accepted number (we don't call it a target anymore, because, of course, such things are now taboo) is that the NHS needs to save £20 billion over the next three years to carry on meeting growing demand within an essentially static budget. I don't see anything in Mr Lansley's plans that will get us anywhere near that number. Indeed, he seems to me to be remarkably casual about making the NHS more efficient and I think that at some time in the not too distant future the Treasury will for that reason gobble him up and spit him out..

    The stock line about scrapping bureaucracy and central targets, and saving money that way, is just guff. Sure there is money to be saved by abolishing strategic health authorities and PCTs, but the "savings" will simply be recycled into all the attendant bureaucracy associated with the new GP commissioning arrangements. Managers will still be doing the same jobs, just in different organisations (and there will be three times as many of them!). Does anyone seriously think that GPs, who are trained and paid to treat patients, are going to be doing all the paperwork associated with organising healthcare themselves?

    Moreover, history teaches us that these smaller commissioning units will, over time, coagulate and merge into bigger bodies and though we won't be calling them PCTs or health authorities anymore, we'll think up a new acronym; and then along will come a new politician preaching localism, and the cycle will start all over again. You don't need a health expert to record all this. You need David Attenborough.

    For fifty out of the NHS' sixty years, we had an adequate health service, that could even be very good at its best, remarkably on the cheap. As a country we spent far less of our GDP on health care than any other OECD or comparable country. Along came Blair and Brown and their cash splurge took us more into line with the average for health spending. As a result we now have an NHS which is a bit better on the whole than it was, but certainly not three times better for three times the budget.

    The reality is that we are not going back to where we were and now we're in the same boat as everybody else, struggling to hold down health costs as the population ages and technology advances. Despite my scepticism above, I think the coalition plan is in the right direction in wanting to give more part to competition and market forces in driving efficiencies and improved outcomes. it could go further (for example in more explicitly facilitating the creation of competing "health plans" that people can opt in or out of). But let's not kid ourselves that we can drive "bureaucracy" out of healthcare – it is inherent in it – or that we can just wave a magic wand, say "abolish the NHS" and the problems will go away.

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