In April this year, BMJ Editor Fiona Godlee called for an independent NHS run by a board of governors responsible for managing health care within a set budget and a broad political framework.
In this week's BMJ, four opinion leaders give their views on whether it is time to give the NHS greater independence from government.
"Democratic control is essential," argues Stephen Thornton, Chief Executive of The Health Foundation. "Democratic checks and balances are the best way to ensure we continue to move the NHS in the right direction, not the creation of a barely accountable technocracy that would place all power in the hands of professionals and bureaucrats."
The key issue is how to do this more effectively than at present. He believes the trick is to deal with the democratic deficit in policy making and commissioning while giving much more operational freedom to healthcare providers.
A second article, by Gwyn Bevan, Professor of Management Science at the London School of Economics, argues that the destabilisation of the NHS in England through successive reorganisations has meant that the only options for governance have been either a competitive provider market or a regime of targets.
Each has serious limitations, he says, and the movement from one to the other has contributed to the squandering of unprecedented increases in NHS funding. His call for 'independence' for the NHS is to design systems of local accountability that would offer an effective alternative to provider competition or a centrally-driven regime of targets.
General gractitioner Stephen Gillam warns that "an independent NHS will become a glorified commissioning agency as what used to be a national health service becomes an amalgam of free floating foundation hospitals, NHS trusts, private companies, and traditional primary care providers."
"We may now, indeed be ruled by fundamentalists whose faith in markets, competition, and the profit motive as the sole path to effective public service is unshakeable," he writes. "Paradoxically, an NHS agency could spearhead the crusade."
In the final article, two US health experts believe that the NHS has the inherent capability to become the greatest healthcare system of any nation.
They applaud Labour's original plan for "modernisation" and advise not to remove NHS leadership too far from government power. But they wonder whether something big should change to steady the NHS on its worthy, inspiring journey.
"The NHS is not just a national treasure; it is a global treasure," they write. "As unabashed fans, we urge a dialogue on possible forms of stabilisation to better provide the NHS with the time, space, and constancy of purpose to realise its enormous promise."
Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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