Letters: The NHS ? pause for thought

The Federation of Surgical Speciality Associations is right to say that any decisions to restrict clinical care should be evidence-based (NHS cuts force 'rationing' of operations, 18 April). The �15-20bn savings challenge for the NHS means that effective commissioning is more important than ever before. It also means the NHS faces tough choices.

In some cases this may mean reducing access to treatments that offer limited clinical benefit to patients or putting in place alternative options which are high-quality, but lower cost. NHS commissioners will always aim to ensure that treatments are not evaluated solely on the issue of cost, but on the wider value they offer patients and health service.

It is crucial that primary care trusts are wholly transparent on any decisions they take to limit treatments available to patients. It is also essential that clinical staff are involved in these decisions to ensure that standards of care do not drop as financial constraints loom.

David Stout,

Director, Primary Care Trust Network

??Every time the prime minister or Andrew Lansley speak about the NHS, they say that change is necessary because clinicians must be responsible for healthcare rationing rather than "unaccountable" managers. This is surely unethical. Patients need independent advice on what treatment they require according to the medical condition they have ? not what it costs. They cannot work this out for themselves because medicine is too complex, and most will not have health insurance because it is assumed that the NHS will provide comprehensive care according to need ? there is no guide to what treatments will not be provided on the NHS in future. Restricting the range of treatments to be provided, whether this be the latest drug therapy for cancer, obesity surgery etc, should be a matter for politicians and local management trusts ? not clinicians, although they should of course be advised by clinicians as to the likely impact of any decisions they are considering.

Dr Richard Turner

Harrogate, North Yorkshire

??It would seem that our good friends the GPs, who give us an occasional tonic and refer us to hospital when our need for care exceeds their expertise, have been asked to manage the NHS. GPs are like sailors steering small boats to harbour, sometimes off-loading passengers and taking on new ones, and it's not always a smooth ride. Could they really become the captain of NHS Titanic?

GPs are not paid employees of the NHS but businessmen funding their practices from a centrally allocated pot; they obtain revenue by treating patients. Each GP interprets central guidelines in their own way, setting different standards of care throughout the country, with some less desirable than others. Let's also not forget it was the GPs who moved away from "out of hours" services just a few years ago as they were overworked.

Yes, the NHS is a big ship but it needs a real captain at the helm, not a politician on a failing power trip trying to deliver his personal decade-old policy. I hope and pray Mr Lansley comes to his senses soon.

Philip Chilvers

Thrapston, Northamptonshire

??Prevention of disease and early referrals are key to the future efficiency and effectiveness of the NHS. Utilizing fully the services of other healthcare practitioners ? such as pharmacists, dentists and optometrists ? will help achieve this goal.

For example, optometrists in the US play a critical role in diabetic screening programs, have diagnostic and therapeutic prescribing rights, and some have minor surgical rights. All our primary care professions should be encouraged to grow this way. At present only dentistry has done so. This proposal requires an expansion of undergraduate degrees, not a contraction. Although spending more money on higher education would not be viewed as a vote winner, it would provide an array of national health screening programs and an army of practitioners working outside the NHS for the benefit of the NHS.

Stephen J Anderson

Professor of optometry and visual neuroscience, Aston University, Birmingham

??The concerns expressed by surgeons about the blocking of access to surgical procedures is yet further evidence of the perverse effects of the separation into purchaser and provider, particularly in times of financial restriction.

If clinicians from primary care and the hospital service were represented on a single, democratically accountable, authority, which had the responsibility for providing all aspects of healthcare for its population and distributed its funds accordingly, more rational decisions could be made. Hospital managers would know what their budget for the year was and how best to use it would then be for clinicians to decide.

The budget itself would be significantly larger if the market bureaucracy became redundant.

This authority might be called a health board, as I am sure our Scottish colleagues would allow us to use the term. Such an arrangement would allow us to return to the situation where the problems of individual patients could be discussed between GP and specialist without the current absurdity of such telephone conversations being discouraged, banned or charged for.

The current "pause for listening" would command a lot more respect if there was any possibility that commonsense might prevail over free market ideology.

Peter Fisher

President, NHS Consultants' Association

??Government plans for the NHS, in as much as one can understand them, seem plain daft ('NHS plans: In the waiting room', Editorial, 21 April)! It appears they are conflating two main objectives: a need to limit expenditure and a desire to change the whole way the NHS operates to a more "commercial" activity. Surely, if there is a prime need to limit expenditure the best way to achieve this is to use the system you have got, with all its existing understanding and experience of how things work and where savings might be made. To change the whole mode of operation inevitably means that no one with responsibility knows anything about how things work ? the "system" is broken. Not only that, but large amounts of money can be expected to be needed to accommodate the changes proposed ? money that should be used for treating patients. How daft can you get?

John Chubb

Cheltenham, Gloucestershire