BMJ  2005;331 (19 November), doi:10.1136/bmj.331.7526.0-f

Editor's choice

An uncomfortable ride

Whatever the pros and cons for patients, the UK's healthcare reforms promise an uncomfortable ride for doctors. The BMJ's series on the NHS revolution, which continues this week, may be a wake-up call for doctors who haven't yet seen the writing on the wall.

Competition is changing the face of health care in the UK. As Nick Timmins explains (p 1193), competition in secondary care has already forced both the NHS and the private sector to change their behaviour. In response to the first wave of independent sector treatment centres (ISTCs), provided mainly by foreign contractors, BUPA and other private health providers have lowered their prices, and NHS surgical teams have raised their output considerably. Timmins quotes Simon Stevens, Tony Blair's former health adviser: if NHS consultants did not perform the operations there was "a bunch of Germans coming round the corner who would."

Martin Marshall and Tim Wilson paint a similar picture of the impact of competition in general practice (p 1196). They point out that private provision is and always has been a big part of NHS primary care, but market forces didn't impinge because general practitioners had a virtual monopoly. It was said that new entrants would find it hard to compete because GPs were already highly cost effective. But is this still the case? The new GP contract has greatly increased spending on general practice and reduced access. Are GPs in danger of pricing themselves out of a market that they did not realise existed?

Will the reforms improve quality as well as efficiency? Marshall and Wilson think that despite the quality improvements achieved in general practice in the past 10 years, new providers may be able to compete for discrete conditions, such as diabetes, but not for treating patients with complex comorbidities. They counsel against creating silos for different diseases or populations. Instead they argue for competition from more integrated models—larger primary care units created by mergers and takeovers of existing practices.

How should we judge the potential for these reforms to succeed? Marshall and Wilson say that we should do this based on whether they improve responsiveness to patients while maintaining quality and not damaging equity or efficiency. So what do patients want? Angela Coulter summarises what we know about this from patient surveys in primary care (p 1199). "Humaneness" ranks highest followed by competency and accuracy, patients' involvement in decisions, and time spent on care. But patients also see themselves as citizens and taxpayers, says Coulter. Changes that are perceived as undermining the founding principles of the NHS are likely to be strongly resisted.

With the whole future of the way doctors work in the balance (p 1154), can we put aside professional self interest and make decisions based upon whether the changes will deliver better care to patients? It's obviously easiest if both sets of interests are aligned, but in this period of transition they may not be. There will be winners and losers.

(fgodlee{at}bmj.com)

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