Ethical medical practice and the NHS.

SIR I enjoyed the paper by Persaud about ethical medical practice and health service organisation (1). The author chronicles some of the ethical disadvantages of the American system. However, he mistakenly equates the health service reforms with an American-style system. This is wrong, because the internal market envisaged by the health service reforms is quite different from the mainly insurancebased systems in the United States. The provider incentives are not as sharp with the British system, where the treatment of patients can produce a departmental surplus for reinvestment in patient services. Contrast this with the American system, or indeed other systems with fee-for-service provisions where the sharpened incentive of personal profit results in overprovision. Over-provision cannot be expected to occur at the same level in the reformed health service. At the same time, by moving away from the command economy of medicine, staff are at least given the incentive to create thriving clinical departments. Thus, the health service reforms represent the ideal compromise between stultifying central planning (characterising Communist health services and the NHS before the reforms) and market failure endemic to all systems with feefor-item-of-service methods of doctor imbursement. Furthermore, your author has completely missed one of the further ethical advantages of the reforms. This pertains to the fact that consultations with individual consultants need no longer be the determining factor in access to services. Purchasers will now decide how resources should be spent and who is eligible and who is not. This, in my view, is greatly preferable, since it removes the bargaining component of many consultations and allows hospital doctors to return to their traditional role as advocates for the patients they treat.