The US academic credited with thinking up the ideas behind the Conservative reforms has suggested 'one good way forward' for the NHS would be to 'reinvent the internal market'.

Professor Alain Enthoven says: 'I doubt that it is possible to create and sustain a culture of innovation, efficiency and good customer service in a public sector monopoly whose services are in excess demand and whose units do not get more resources for caring for more patients.'

He suggests that primary care trusts should be allowed to 'evolve into competing health maintenance organisations' buying from genuinely competitive providers - with NHS hospitals privatised as 'non-profit voluntary hospitals under local control'.

He adds that 'everyone should be covered by non-governmental health insurance' with the government paying into low-priced plans and people topping this up with their own money.

In Pursuit of an Improving National Health Service . The Nuffield Trust, 59 New Cavendish Street, London W1M 7RD.

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