Every week we read of pressures on various groups working within the NHS. Although my background is in general practice, it is evident that everybody is unhappy and ever-increasingly preoccupied by the funding of care.
While some awareness of the potential cost of things is necessary I now reminisce about the NHS before the ‘internal market’ was introduced to enable fundholding and, subsequently, commissioning. In those days clinicians cared about patients and managers managed (though they were never popular).
It seems to be forgotten that the internal market is founded upon ‘pricing’ dependent upon national tariffs – those tariffs are now more representative of ‘true’ cost than when they were first introduced, but they have always been open to manipulation.
It was intended that the purchaser-provider split would enable responsible clinicians to steer the development of the NHS and the use of its scarce resources. However, fundholding never matured into a united consensus approach and was spoiled by a lack of cooperation between primary and secondary care.
I can see little threat to patient care if we were to abandon our current mishmash of bean counting and return to direct funding of services
We live today with an NHS largely devoid of a clinically driven consensus and where short-term horizons limit any true development by any level of management. Commissioning processes are targeted and manipulated by the Department of Health and NHS England, in a mockery of the principles behind the internal market. What was supposed to be self-regulation by the market is now top-down (mis)management by any means possible.
Is it not time to take stock and remember that the internal market was supposed to enable the development of the NHS, recognise that it has therefore failed and review things?
I can see little threat to patient care if we were to abandon our current mishmash of bean counting and return to direct funding of services by a responsible level of management that is open to consensus, and driven by 5-10 year planning as well as financial constraints.
We may have some shroud-waving by certain clinicians but commissioning certainly didn’t stop them.
There are no simple answers to managing the NHS but sometimes remembering the (far from halcyon) past can help point out when things have gone wrong.
Dr Richard Melton is a retired GP in Warwickshire
