Chris Lancelot on...Free markets in the NHS

Good heavens. I actually agree with something Patricia Hewitt has said. Commenting on Gordon Brown's idea of removing the NHS from direct political control, she said it would be better to build on existing reforms.

In particular, she argued that national targets for the NHS would become increasingly redundant as independent foundation hospitals are forced to improve their performance because in future they will be paid according to the number of patients they treat.

Quite so. It's called 'a free market' coupled with 'a level playing field', and it's been missing from the NHS for many years. As Baroness Thatcher once memorably remarked, 'You can't buck the market'. You can undermine it with preferential treatment, you can get round it with the gaming of targets, but ultimately the market wins in the end - and kicks you in the teeth if you've been trying to bend it. And a truly free market is the cheapest and simplest to run.

Let's apply this logic to general practice. The government tried to manage primary care by setting complex targets, both medical and managerial, and making it difficult for practices to close their books.

What sort of free market is that? You can't regulate your own demand; you can't respond to local needs; you can't choose to run a small, high-quality practice in restricted premises. Instead you have to accept all-comers, lower your standards and become exhausted as a result.

There is another way: open up the whole of primary care to the free-market ethos with no preferential treatment for anyone. Ditch the targets. These have improved slightly the health of target groups but at the expense of the rest, while the access targets have been gamed to extinction. Allow all practices to close their books when they feel they have reached their limits. Publish the patient acceptability and waiting-time scores, and let patients vote with their feet. They will soon trade off their wish to see that nice Dr X against the fact that they will have a much longer wait, and they will be the ones to decide whether it is worth it. It's called choice - remember that much-misused word?

The only remaining question, Ms Hewitt, is this: if the free market is so powerful, and such a good idea for foundation hospitals, why didn't you insist long ago upon using it in primary care?

- Dr Lancelot is a GP from Lancashire. Email him at

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