The costs of the reverberating bedpan.

“ There is no doubt that frontline general practitioners have unrivalled experience of the health needs of the population and valuable insights into how the service could be improved in the interests of patients, perhaps particularly the most vulnerable. However, this does not mean that patients are then best served by removing GPs from the front line of care, for which they have been painstakingly and expensively trained, to undertake the immensely complex task of commissioning services for which few have appropriate expertise. Indeed, the readiness with which the government wishes to redeploy GPs may reflect the traditional undervaluing of the clinical task of general practice. Nonetheless most practices already have difficulty in meeting the growing needs of patients, and it is far from clear how the workforce is supposed to cope with these vast additional tasks. It must be possible to give GPs much more influence over the planning of services and to cut the costs of the burgeoning bureaucratic superstructure of health care while retaining the best of existing management expertise and without the upheaval of complete reorganisation. If the delivery of health care could once again be made a cooperative and collaborative endeavour, the benefits in terms of morale, enthusiasm, and renewed altruism could be enormous. Difficult debates lie ahead concerning the increasing costs of medical technology, the medicalisation of an ever greater proportion of human experience, the increasing futility and even cruelty of inappropriate and ineffective treatments at the end of life, and the optimal balance between curative and preventive health care. None of these can be solved by competition. Only broad public debate and a politics of consensus offer real hope for the continuation of a humane, inclusive, and affordable health service. It must be worth a try. Iona Heath is a general practitioner, London [email protected] Cite this as: BMJ 2010;341:c5541 The NHS grew out of the communitarian sense of social solidarity that arose from the shared experience of the second world war. It is loved by the British people because it represents what is best about British society and is, and has always been, a collective achievement despite the deep social and economic divisions that mar other aspects of life in this country. Funded through general progressive taxation, the health service is provided for the people by the people; and since its inception many, many people, including myself on more than one occasion, have had cause to be profoundly grateful for its existence and for the comprehensive care it can provide. Throughout the more than 60 year history of this great national institution the clanging of bedpans has continued to reverberate in Whitehall. Each successive government has reiterated its commitment to the NHS’s founding principles, albeit principles that seem to vary according to the prevailing ideology, and almost all have succumbed to the temptation to radically “reform” the service. There is much to admire in the proposals of the current coalition government but also much that seems misguided and precipitate. The white paper Equity and Excellence: Liberating the NHS, the public consultation on which closed on 5 October, is refreshingly well written and missing those gruesomely upbeat illustrations that so blemished every consultation document under the previous government. I admire health secretary Andrew Lansley’s energy and his stated determination to listen to clinicians and to ensure that “healthcare will be run from the bottom up, with ownership and decision-making in the hands of professionals and patients.” His emphasis on valuing the experience and insights of frontline health service staff is hugely welcome after too many years in which those struggling to deliver care have felt pressured and even demonised by the ever growing panoply of surveillance, regulation, and micromanagement. But, at this point, I begin to wonder whether political honesty is almost an impossibility—an enduring oxymoron. If the coalition is genuinely committed to the elusive bottom-up approach, why has there been so little direct involvement of clinicians in the development of policy? Why is implementation being planned before the consultation is complete? Why has there been no open public debate about the creeping privatisation of provision and the ever expanding role of management consultants and large commercial firms? Why the apparent decision to prioritise general practitioners in the hierarchy of decision making, and why the determination to persist with the quasi-market and the purchaser-provider split after the “twenty years of costly failure” so graphically described by the parliamentary health select committee and in the face of widespread opposition from professionals and citizens alike? The devolved governments of Wales and Scotland have both abjured the market in healthcare. As yet there is no evidence of resulting harm, and indeed the morale of doctors in both countries seems consistently higher than in poor old England, which seems to be always in the forefront of the government’s enthusiasm for economic experiments imported from the United States. If we are to ensure the future of a genuinely national health service, we urgently need a willingness to learn from the different parts of the United Kingdom, across political boundaries, and a commitment to consensus and collaboration rather than conflict and competition. Clinicians are heartily tired of competition, knowing, from the experience that the health secretary purports to value, that patients do much better when generalist and specialist clinicians cooperate with managers and patients themselves in the planning of care and that competition takes a huge toll of time, effort, and resources. The opportunity costs for UK general practice are potentially enormous. The readiness with which the government wishes to redeploy GPs may reflect the traditional undervaluing of the clinical task of general practice