YORKSHIRE TERRIER

It is typical of politicians to propose two contradictory things at the same time - and to imagine no-one will notice. Now the government is intending to crack down on consultants working outside the NHS, while simultaneously proposing that the service should contract out more work to the private sector.

I support one of these two proposals - the one on contracting out to the private sector. Most healthcare in Britain is already contracted out: to GPs, who, with a few minor exceptions, never have been NHS employees but private subcontractors since 1948 - or indeed since 1911 if you go back to the National Health Insurance Act. So why not contract out other services, too?

Contracting out hospital services would kill two birds with one stone: the argument about whether consultants do too much non-NHS work would simply disappear - since all their work would then become private.

And perhaps the internal market could then become a real market, and really begin to respond to demand.

No longer handicapped by the institutionalised inertia which exists in the NHS, necessary closures and the reallocation of resources could proceed much more rapidly.

If the government really wants to renege on agreements made between it and the medical profession, at least let it do so in a helpful way. Instead of cancelling the agreement thrashed out between Aneurin Bevan and consultants' leader Lord 'Corkscrew Charlie' Moran back in 1947 - which gave NHS consultants the right to continue to practise privately - why not renege on some of the agreements that allow other practitioners too much involvement in the NHS?

It is anomalous that GPs and general dental practitioners, both independent contractors, should have been permitted to join the NHS pension scheme. More recently, it is even more anomalous that GPs' employees - sub-contractors of subcontractors - should also be allowed to do so.

There is no logic there. If GPs' receptionists can join, then why not dental receptionists, community pharmacists, optometrists and their staff - or even hospital cleaners and caterers working for outside firms?

The present arrangements are simply irrational.

On the other hand, forcing consultants to reduce their private work is really as illogical as forcing the local chemist's shop to stop selling bottles of vitamins and jars of cold cream. The fact that chemists sell lip-stick and suntan lotion doesn't seem to mean automatically longer queues for dispensing prescriptions.

Now seems to be a good time for a radical rethink, a root-and-branch reassessment of how the NHS provides services. There is surely no fundamental reason why all healthcare provision could not be contracted out to the private sector, saving money, improving responsiveness and doing away with the NHS's increasingly Byzantine structure.

It is quite easy to visualise a future in which all community services are provided by the independent sector:

if all GPs are self-employed, then why not midwives and community nurses? And if some private hospitals already treat NHS patients, why not privatise all hospitals?

If catering and cleaning can be contracted out, why not NHS management, too - or at least support services such as the financial and administrative functions? And come to think of it, why is NHS Direct being run by the NHS and not contracted out to one of the myriad call-centre operators which could surely organise things more efficiently and at less cost than an in house service ever will?

These are, of course, rhetorical questions. The answer is that the NHS by its very nature is perpetually blighted by being handed piecemeal solutions to 'political' problems.

One could be forgiven for thinking there is no strategic vision about the NHS at all; more often than not it progresses, or at least changes, simply as a kneejerk reaction to the hot issue of the day so that the 'solution' to every new challenge is merely bolted on to the existing structure without much regard to how it may fit in with the whole.

The result of that constant tinkering is that the NHS is left looking like one of those aged industrial buildings which have had so many lean-tos, annexes and extensions constructed around it over the course of decades that it is no longer capable of efficiently fulfilling its intended purpose. When that happens in industry the only solution is to tear the factory down and start afresh.

What the NHS lacks is a rational operational philosophy against which all its activities, current and proposed, can be tested.

Un less such an over-arching logical framework is formulated, short termism and expediency will continue to dominate thinking at the top; pointless pilot projects will continue to proliferate while illconceived, unco-ordinated initiatives will be forever springing up like flowers sown in a madman's garden.

Sadly, the belief that contracting out will really help reduce waiting lists, or that restricting private practice will do the trick, is typical woolly thinking. Step back a little further and one sees that unless the number of consultants increases, then globally the total amount of medical care will remain the same.

But increase the number of consultants, and there will be plenty for both the NHS and the private sector.

Manpower - surely that's the real issue. But logic will never get too far in the NHS while politicians think that we, like the Red Queen in Alice in Wonderland , are capable of believing six impossible things before breakfast.

Steve Ainsworth is a former primary care manager.