Consensus out of crisis?
Authors: J. Warden
Journal: BMJ (1988)

The Easter break marks only a pause in the great debate which has so far characterised the 40th anniversary year of the National Health Service.It brings to an end a winter of distraction, if not discontent.Is there a spring of discovery to follow?The curious feature as MPs dispersed on Maundy Thursday was a distinct feeling that the air had been cleared.After weeks of turmoil there is a better idea of the political realities.The first of these is that the government is not going to capitulate to campaigns for amorphous amounts of cash.In its view the NHS suffers from no more than an occasional cash flow problem that can be met by relatively minor adjustments from time to time.From this there follows an expectation that the doctors' and nurses' pay awards this month will to all intents be fully funded.Also it is clear that Labour has shot its bolt for the time being.It is long on protest and short on policy.So much for the small change of controversy.The big pay off is to be the "fundamental review" of the NHS, possibly in time for its 40th anniversary on 5 July, though more likely after the summer.Even that far ahead, MPs believe they can discern an emerging pattern.With little that is positive to go on there is nevertheless a collective impression forming of the way forward.The Secretary of State, John Moore, has kept silent about the review, yet the components of a package are seen to be falling into place without his intervention, almost as a byproduct of the public discussion.The Westminster consensus is that the radicals are in retreat, meaning that solutions based on an insurance system or the introduction of health vouchers as a means of funding health care are out.So also it seems are new methods of delivering health care in the fashion of American health maintenance organisations.On the contrary, political opinion is hardening that Mr Moore, essentially a cautious man, will produce reforms that are perceived to be on the modest side.Medical opinion, however, may well have a different perception of the Moore package when doctors find themselves the main targets of Mr Moore's efficiency blitz.The implications for clinical practice can be assessed more appropriately on other pages if and when the time comes, but to seasoned Thatcher watchers the politics of it is clear.The underlying philosophy is that for the NHS to be efficient everyone should be made aware of exactly what it costs-the taxpayer in general and the patient in particular.The practical way for Mr Moore to achieve this brings us back to insurance funding or vouchers, for which it is believed the public is not yet ready.As a start, therefore, the drive to be cost effective must be directed at the NHS itself-to health professionals in general and doctors in particular.In other words, if the public is not quite able to face reality the drive must begin with doctors.What is the practical way to achieve this?Look no further than Mr Moore's growing enthusiasm for performance indicators.They do what they say, which is to compare variations in performance at every level of health care.The aim is to extend the approach to each hospital, right down to unit level where the clinical decisions are taken.Mr Moore's aim, by the end of next year, is to include all doctors and nurses in a "medical audit" of the resources JOHN WARDEN is a parliamentary lobby journalist they use under a system of peer review.That is the shape of things to come.