It appears that participants in the roundtable discussion on independence of the NHS pulled their punches. Let me not pull mine.

It appears that participants in the roundtable discussion on independence of the NHS pulled their punches. Let me not pull mine.

The path of change is becoming clear, but it is not easily articulated. Indeed, there is a concordat among policy makers and opinion formers to avoid this clarity.

I joined the NHS for a brief period in 1975, just after McKinsey had guided the government towards consensus management. The remnants of that structure have been difficult to eradicate. But then came general management, then trusts and the internal market, then reverse gear back to a more collective approach, and now full speed ahead to what is a new market for health care provision.

The essence of this perspective is that it reduces options. If New Labour is more Tory than the Tories, then what will Brown Labour be, or indeed the New Tories when they get their hands on power again? If not 2009, then 2013, working on the assumption of four-year average terms of office. But the NHS will not need to wait until then to become independent.

However, what is the NHS? It is the use of taxpayer pounds to buy health care. It is no longer provision. This is an important distinction, since it lets us understand where we have come from, where we are, and where we are going.

First, buying health care. The streamlined PCTs, both in number and through their divestment of provision, are a beneficial step on the reform path. The next stage of the evolution will be fewer still, and the end of SHAs. We'll then jettison 'PCT', as a meaningless acronym, for something like 'NHS Commissioner', which more effectively defines the role.

These organisations will be slick, information-rich, quasi-democratic, incentivised and highly accountable. Independence will come through taxpayer cash being spent by these autonomous organisations against agreed short and long term targets set by the government. This will be the NHS, but these commissioners will be free to attract additional cash into their local system.

Second, the providers. The dye is case. Trusts will become Foundation. Foundation will become private. But this equation is not readily understood. There is no going back, so the logical conclusion of this process is unfettered competition for the commissioner pound. Quality and transparent information will tell an informed public what is on offer and what they will get. Let's not dismiss the maturity of the market to have an interest in choice, or a willingness to exercise it. The market is changing fast, and old style bureaucratic NHS providers are being left behind. The shackles of this bureaucracy will not hold back the rush towards competition, since this process is already leveraged by government itself.

My crystal ball shows Foundation Trusts going to the market in the period 2013-17, akin to the electricity and water industries. This is the logical conclusion. It is not the end of the NHS, since tax pounds will purchase care from what is already a mixed economy of providers. Augmenting tax funding will be private and corporate resources. The NHS will remain free at the point of use for those who rely on tax pounds, but other sources of income will reduce dependency by providers on the government purse.

What of GPs? This cottage industry has no place in buying health care. It is largely immature in its ability to exercise effective commissioning, and in any case this is a conflict of interest with its provision role. Let the entrepreneurial GPs turn their businesses into competitive provider entities, competing for business. If there was one lesson from GP fundholding it was that these people exist, and they are straining at the leash. There is nothing like incentivisation to get things done. It is sad that the Wanless cash has been so horribly wasted across the service in the absence of effective incentives.

The environment is changing so fast that we can no longer be safe in our certainty of rolling forward the past to become the future. The NHS had a great run in its old form, but it is now time to change its function and recast its form. The sooner this reality is embraced, the better.

John Deffenbaugh Frrontline Consulting (john.deffenbaugh@frontlinemc.com)

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