Letters: Unpalatable medicine for the NHS

Julian Glover warns the government not to lose its nerve and advises it to enter into negotiating some compromise amendments (The coalition must hold its nerve on NHS reform, 4 April). He argues that "the art of 'trimming' is to protect the core of a project" but it is to the "core" that the fiercest opposition is mounted.

Let us be clear about the opposition to Lansley's version of the NHS. It is not opposition to competition ? our NHS professionals work hard to be the best in the world ? and many succeed. It is not opposition to innovation ? the NHS has a proud history of contributions to medical science and technology. The opposition is not to using money better ? the NHS was a pathfinder in seeking best clinical value for taxpayer money and hates wasting cash on pseudomarket bureaucracy. And we certainly do not oppose the greater involvement of health professionals or the return of democratic accountability to the NHS; we have been pressing for their extension for decades.

Our opposition is to making a spurious financial profitability the "metric" which drives the NHS, aping the US market model though more heavily "managed". This unmandated Lansley proposal is costly, inefficient and unfair. Costly because of its wasteful infrastructure of bean-counting, bill-writing, debt-collecting, and uncreative accountancy. Inefficient because the use of scarce resources is determined not by where they will do the most good but where they will earn the best financial return; doctors should not be put in the position of marketing their services. Unfair because, with the private earnings limits removed from NHS foundation trust hospitals, they will "market" their best opinions, their most modern tests, their shortest delays to those able to find the extra cash; ordinary, perhaps more needy, patients will get what's left.

Lansley's market plans should be abandoned and the path to a more efficient and acceptable future NHS democratically sought in an open, national review.

Dr Peter Fisher President, NHS Consultants' Association, Professor Harry Keen President, NHS Support Federation, Professor Wendy Savage Co-chair, Keep Our NHS Public

? Julian Glover displays a fundamental misunderstanding of what commissioning healthcare services involves when he dismisses calls for greater public accountability of GP commissioning groups on the grounds that councillors (and presumably anyone else other than doctors, nurses and therapists) are not well-placed to make clinical judgments.

Commissioning is not primarily about making clinical judgments ? it is about the use of resources. For example, should resources be spent on expensive drugs that keep cancer patients alive for a bit longer or on midwives whose interventions have been shown to reduce child mortality? These sort of decisions are not things that only GPs should decide. GPs undoubtedly have a role to play in commissioning ? and have been playing a role for a number of years. But so do councillors, patients and the public ? all of whom have legitimate views on how NHS money should be spent.

Iain Kitt

Newcastle upon Tyne

? Andrew Lansley cut a lonely figure as he announced a "natural break" to review his NHS reforms (Scramble to save coalition NHS reforms, 5 April). I would suggest that he and the prime minister use the time to subject the existing proposals to two stress tests. First, the reforms themselves which, it is claimed, will reduce overall costs while maintaining quality. Can the data be provided that have been used to make this assertion? And will competition assist or detract?

Second, the central proposal that GPs in consortiums can manage (not just spend) 60% of the NHS's �103bn budget. Here the stress test would need to set the current resource base of suitably trained GPs against the need to manage large budgets and complex commissioning decisions, including the implications of closing existing facilities and health programmes ? both inevitable in economic terms and as care technologies change.

To prejudge the reaction to my suggestion, I can only imagine the prime minister and Lansley would not find clarity to be necessarily helpful nor would they even be willing to embark on the stress tests in the first place. In the absence of such action a bonfire of the vanities is the only solution.

Morton Warner

Professor emeritus of health policy,

University of Glamorgan

??Do not be fooled. The government is as determined as ever to introduce a commercial system of healthcare. Lansley made clear that the aim of the planned PR offensive is to pause, listen and engage rather than to change the fundamental principles of the bill. By allowing a "pause" in the legislative process, the government hopes that the force and focus of the recent campaign against the bill will be dissipated.

What is urgently required is a select committee within the House of Lords to scrutinise those hidden aspects of the bill that will do most damage.

Roz Dixon

London

??Mr Lansley is to pause in his attempt to marketise and privatise the NHS. Meanwhile, at grassroots level, staff are being lost at an alarming rate, GP consortiums are being established and services are being trimmed daily. All of this in advance of legislation which is less than halfway through its parliamentary programme. This is what must stop.

Mike Wood MP

Labour, Batley and Spen

??"Cameron may be a PR man by trade, not a doctor" (Busy shift at Westminster hospital, 5 April), but PR is a medical term for "per rectum". Perhaps this is why the medicine is so unpalatable.

Dr John Davies

Kirkby in Cleveland, North Yorkshire

??While welcoming the further consultation period for the health bill I fear irrevocable damage has already been done to the NHS. In my area, having endured a five-month scheme to delay referrals to allow the "books to be balanced", we already have a situation in which all commissioning decisions will be made by a board of five GPs (plus a medical chief executive and finance director). The primary care trust will cease to exist from June this year, some of its functions being taken over by an amalgamated "rump" PCT. Many good managers have either lost their jobs or moved on.

Nevertheless, we are still being told GPs will have two years in which to learn the skills to commission, but this is patently untrue. Improving patient care by collaboration and integration between primary and secondary care would seem a much more sensible approach that I believe most GPs and patients would support. Let us hope this "consultation" will be genuine and the damage already done can be repaired.

Dr Tony Rimmer

Warrington, Cheshire

? In the course of the forthcoming "pause", let's hope that Andrew Lansley or his new puppet masters in No 10 will ensure that the commissioner/provider conflict of GP interests, the omission of other clinician involvement such as nurses, allied health professionals and secondary care medics in consortiums decision-making and the failure to follow through the essential requirement for consortiums to be geographically integrated (to avoid no-go zones of residual second-class consortiums full of poor GP practices developing) are tackled.

In addition, while pausing, if Lansley really does decide to ban competition on price and the ability to cherry-pick, as he claims, the global health companies may not pursue their expected predatory raids on the NHS. It just won't be worth the outlay. What would really make the NHS's day would be for the full status of Nice to be protected so that national guidance on the cost and benefits of new drugs was maintained and reliance on the variable decisions of GPs avoided.

Gillian Dalley

London

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