I was thinking about Ahmad's post while I was writing an editorial this
afternoon. Since, in my opinion, "Choice and Opportunity" is impractical
and "A service with Ambition" says nothing at all, perhaps we could have a
go at redesigning the NHS.

In no particular order, and without any attempt to be comprehensive, here
is my bid. It is intended to stimulate debate!

1) Joint commissioning: We need to produce an area of joint finance
between HAs and SSDs so we can dump all the crap associated with Coninuing
Care, and quit arguing about whether someone's problems are mainly
health-related or social care related. The radical solution would be to
merge the NHS and SS budgets.

2) We need to muzzle the NHSE. The Executive produces just under 1,000
pieces of guidance a year and it is giving the NHS constipation.

3) We need to shut down the Regional Offices, so that there is a driect
link between HAs and the NHSE (which this government considered, but shied
off from).

4) We need to take the knife to the Community Units and put community
nursing directly into primary care teams.

5) As a fundholder it hurts to say this, but we need to bin the
fundholding as it stands, because all it seems to do is to generate
enormous finance departments. The political pressure being applied means
that HAs are accepting many practices as fundholders which are simply not
capable of controlling a budget.

6) We need to "cost-centre" practices so that the resource implications of
particular patterns of health care are clear to GPs. Personally, I would
devolve the HA budget down to practice level, implementing a "total fund"
concept, but with a lower list size of around 20-25,000. The HAs could be
slimmed down, with management budget devolved to the practices, and the
byzantine system of Trust budgeting revised. At present the money does not
follow the patient in Trusts, and this is the root cause of many of the
problems in the NHS.

7) The waiting times limits need to be revisited. In my opinion, waiting
times are one of the best ways of managing resources. Many procedures do
not need doing within one year and there should be an allowance for local
agreement on "opt outs" - agreed between CHCs, practices and Trusts.

8) (Getting bolder now the gin is sinking in). I would allow Trusts to
make a profit on services as long as their prices were in the lower
quartile. This would free up money for the development of new services.

9) I would send the SAS into the York Centre for Health Economics.

10) I would produce an electronic version of the Red Book, with decent
cost-rent allowances.

11) I would take steps to stop me posting drivel like this.

OK, guys and gals. Take aim. Fire!

FX: ducks.

Andrew

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Dr. Andrew N. Herd MRCGP
GP, Journalist, and Medical Adviser to Durham Health Authority
[log in to unmask]
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