comment: Fundamental change in funding of acute trusts is high-risk strategy

Published: 24/10/2002, Volume II2, No. 5828 Page 21

What will history say about 17 October 2002 - the day that the government published its proposals to reform the way in which acute trusts are paid for the work they do (news, pages 4-5)? Will it be remembered as the moment the Patient Choice agenda was given financial muscle and real momentum created in the drive to tackle waiting lists? Or might it instead be recalled simply as the launch of yet another financial reform doomed to run into the sand while accountants and clinicians squabble over its implementation? Or will it gain notoriety as the day on which market forces started to place intolerable strain on the cohesiveness of the NHS - perhaps signalling its end as a national institution.

At first sight, the proposals have obvious merit. Rewarding efficiency is morally right and could underpin the future stability of the NHS, in that underperforming trusts will have powerful incentives to improve. But in developing the proposals there are clear guidelines the government and service must bear in mind.

The proposals do not deal adequately with the need for service redesign. They must take into account, for example, the growing role of intermediate care. Incentives to improve the management of chronic disease must also be included.

And the new system must not undermine the position of primary care trusts as the main arbiters of care for their populations. Clinicians must be strongly encouraged to help develop the proposals. Their input is vital if the system is to reflect reality and not accountants' version of it.

Finally, managers must be given the tools to make the new system work.