Published: 10/03/2005, Volume II5, No. 5946 Page 3

The election campaign is, predictably, not throwing much light on the more substantive issues facing health service reform.

There is little debate, for example, about practice-based commissioning or payment by results - probably because Labour and the Conservatives are in broad agreement about the direction of travel, and the issues are deemed too complicated by the national media for general consumption.

HSJ readers know that without these two policy initiatives the introduction of choice would be impractical. They also know that the speed and nature of their introduction will have a profound effect on patient care.

Thank heavens, then, that the debate over payment by results inside the NHS is showing signs of robustness. Considering the heated political atmosphere, Department of Health head of capacity, plurality and choice Bob Ricketts took a risk when he raised the possibility that payment by results could lead to inappropriate treatment, while acknowledging that the developing system 'still has some pretty basic flaws' (news, page 13).

The lowering of 'treatment thresholds' is just one of the dangers of mishandling the introduction of payment by results. Mr Ricketts calls on commissioners, as well as the DoH itself, to 'raise their game' in combating the emergence of perverse incentives. It is a call that all involved in developing and implementing the policy would do well to heed.