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Sometimes it helps to take a different point of view. Doctors puzzled by what is happening to the National Health Service in England do not have the time or the inclination to wade through the blizzard of documents that issue from the Department of Health. Doing so would not guarantee understanding, anyway.
What follows is an idiot's guide to the new look NHS in England, written from a different perspective. Lenin famously asked, "Who whom?" What he meant was, "Who has the power over whom? Who is the master, and who the servant?" Seen in this light, the English NHS reforms become more understandable. As they move the pieces about the chess board, ministers talk grandly about "strengthening the architecture of the NHS," but what really matters is who does the kicking and who is kicked.
Power shift
Almost all the changes that have been introduced in recent years are driven by power, not architecture. Independent sector treatment centres did increase capacity as ministers claimed, though not by much, 1 but their real purpose was to undermine the power of surgeons to control waiting lists. Patient choice had the same motive. Payment by results aimed to exploit market power to squeeze high cost hospitals, while practice based commissioning was a counterbalance to prevent the low cost hospitals expanding their market so fast they ran away with all the cash. The idea was to give general practitioners incentives to produce alternative services that would treat patients more economically by allowing them to keep some of the savings.
Liberalising measures, including foundation trusts and plurality in primary care, were aimed at undermining union power and central bargaining. The unions quickly realised that, which is why they stamped so hard on former NHS chief executive Sir Nigel Crisp's order that primary care trusts should stop employing health visitors and community nurses and concentrate on commissioning care from others. This might have left some NHS staff with new employers in (heaven forbid) the private sector. Unions could see a kicking coming and forced the government to retreat.
The reorganisation of strategic health authorities and primary care trusts can be seen in the same light. As kickers, primary care trusts have been a serious disappointment, forever in thrall to the...