Competition and planning in the NHS

Reaching the end of this book you cannot help but feel that you were warned. The journey through this broad-based evaluation of the NHS reforms leaves one feeling rather punch-drunk. This is most ably summed up in the penultimate chapter where a picture of tinkering with the current system is likened to punching a balloon - if you get rid of a swelling at one part, you are likely to create an equal swelling elsewhere.

Following the first edition published in April 1992, where an earlier leg of the journey was aptly encapsulated in the sub-title 'The dangers of unplanned markets', this edition effectively attempts to evaluate the more recent reforms - or at least those that evolved from 1992 up to 1997 with the arrival of the Labour government's white paper.

In the early chapters, the author paints a picture of where we are today, laced with painful summaries of reality. A good example of these is the interpretation of the reforms arising as a result of actions to address pressures on public expenditure, or put another way: 'Ad hoc reactions may throw up possibilities; 'cock-ups' can be used in emerging conspiracies.' The author also refers to ideology and the design of reforms, arising from those least able to reach solutions that are effective or can be put into action by frontline staff. Certainly a lot of truth there, and we can only hope that lessons have been learned.

Having defined the central features of the reforms, which will be all too clear to many readers through bitter experience, the book moves on to the results of numerous research studies, including wide-ranging analysis of the market, the purchaser-provider split and contracting.

Great stuff. Clear messages come through and the anecdotes we have all discussed about facets of purchasers' and providers' attitudes and actions - buck passing, for example - the factors that drive the market and what was really going on in the so-called marketplace are brought into stark relief. It would be unfair to list them all - buy the book.

Sad though the dip in 'Needs assessment and involvement of local communities and/or GPs' is, the penultimate chapter contains many pearls of insight into what really happened, while also posing the next set of questions to be answered. One example of this is a statement from the first edition, repeated in this, that capital allocations are in essence central to planning - whoever allocates capital is the planner, overtly or not.

So what are the conclusions? The 'NHS reforms', in the sense of the market and the purchaser provider split, were in fact the latest in a long line of management reforms of the NHS. The reforms of 1974 created a perceived bureaucratic, top-heavy 'planning' reorganisation, leading to consensus management. Those of the early 1980s aimed for a leaner and more flexible organisation, but in fact were an addition to the bureaucratic process and a continuation of the tension between central policy making and local initiative - the former still winning through, even up to the present day.

One area where a common theme does run through is the absolute necessity for greater private involvement and greater public-private symbiosis in provision - hooray to that.

The concluding chapter presents 'An alternative policy'. Many would subscribe to this, and one cannot help feeling that the government and its advisers are already moving to instigate a number of these initiatives. Overall, this is a comprehensive book, reviewing the present reforms. For the informed reader, much anecdote is converted into academic parlance, and forward- thinking alternatives to our current system are presented.

Peter Buckley

Service development and contracting director, St Andrew's Hospital, Northampton.