BMJ  2006;333 (29 July), doi:10.1136/bmj.333.7561.0-f

Editor's choice

The clear vision of outsiders

It takes outsiders to see things with the most clarity. Thus, in our Health Policy debate this week—on whether the NHS should be more independent of government and politicians—it is two Americans, Don Berwick and Sheila Leatherman, who articulate most clearly what the NHS should be about and how it seems to have lost its way (p 254). "The NHS is not just a national treasure; it is a global treasure." It needs "the time, space, and constancy of purpose to realise its enormous promise."

Berwick and Leatherman, together with Stephen Thornton, Gwyn Bevan, and Stephen Gillam (pp 251-5), are responding to Fiona Godlee's call in her editor's choice earlier this year for an independent NHS authority, protected from the capricious effects of party politics. Interestingly, while all the commentators worry about constant reorganisation and inconsistent changes in direction, none want to see politicians removed too far from the scene. Stephen Thornton reminds us that the NHS would never have existed without a political vision (p 251), Stephen Gillam fears that an independent authority could promote an expanding market in a way a government "would never otherwise get away with." And Berwick and Leatherman argue against removing NHS leadership too far from government power. "It might prove unwise to trade the constructive role of engagement for independence."

Meanwhile the government is tinkering again. On p 211 Chris Ham analyses a recent update on England's health reforms from the department of health, which also gives guidance on commissioning. The guidance aims to boost the skills of primary care trusts in commissioning services and suggests offering incentives to general practitioners to tempt them take part in practice based commissioning. Ham is sceptical of whether these plans will work, not least because the same guidance document allows provider trusts to operate outside their own areas and beyond acute care. That may be good for seamless care for communities, but it further enhances the power of providers in the face of still weak commissioners.

In his NHS commentary Gwyn Bevan (p 252) sees NHS governance as essentially a choice between a competitive market and a centralised regime based on targets. The criticisms of targets are familiar, but an investigation from the Healthcare Commission shows that targets can also be bought at a price in human lives (p 215-a). From its investigation of outbreaks of Clostridium difficile infection at Stoke Mandeville Hospital the commission concludes that the hospital's senior managers were so preoccupied with meeting targets on waiting times in the accident and emergency department that they didn't heed the advice of their clinicians, infection control staff, or the local health protection agency. "Only the involvement of the Department of Health...and national publicity" changed the trust's approach. Once again, we rely on the clear vision of outsiders.