Leading article: Andrew Lansley's gamble with the nation's health

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Gordon Brown was cautious to a fault when it came to policy-making. The Coalition is making the opposite mistake. This summer, the Health Secretary, Andrew Lansley, unveiled the most radical institutional overhaul in the history of the National Health Service. He announced that the commissioning powers of primary care trusts (PCTs) and their combined £80bn budget would be transferred to consortia of local GPs by 2013. He did so with little warning and minimal consultation.

Tomorrow Mr Lansley is expected to announce a pilot scheme in which family doctors in some areas will take control of commissioning hospital services for patients. A trial is a good idea. But the sensible way to proceed would surely have been to have run the tests first and then to have constructed the policy based on the results. Mr Lansley has put the cart before the horse. The policy is decided. The trial is an afterthought.

This rush does not inspire confidence. The reform is already of questionable democratic legitimacy, given that it featured in neither the Conservative manifesto nor the Coalition Agreement. Indeed, the latter document promised that there would be no "top-down" reorganisation of the NHS.

Mr Lansley cannot put this haste down to a lack of time in his post. He has been in the health brief for a full six years, longer than almost all of his Cabinet colleagues. It is difficult to avoid the conclusion that either Mr Lansley devised this policy in a rush after the general election, or that he chose not to share his intentions with the electorate. Neither is very palatable.

It is true that there is some logic to this reform. Devolving commissioning powers to GPs should, in theory at least, help to keep a lid on health costs since doctors, unlike PCT managers, deal directly with patients and understand best what their needs are. And if family doctors are placed in personal control of commissioning budgets they are, again in theory, less likely to be wasteful. The NHS certainly needs to make considerable savings over the coming years and it makes sense to seek economies across the service.

But the policy is a significant gamble nonetheless. The British Medical Association was cautiously positive about Mr Lansley's White Paper in the summer. Yet there is a question mark over whether GPs are willing to take on these new commissioning responsibilities. In 2003, GPs were all too pleased to hand over their responsibility for providing out-of-hours patient services to primary care trusts. Many doctors see themselves as medical practitioners rather than managers.

In 1948, Aneurin Bevin said he had to stuff the mouths of doctors with gold in order to buy the support of the medical profession for the nascent NHS. Now their mouths are being stuffed with responsibility. As well as commissioning services, doctors will henceforth be tasked with deciding whether their patients should be given expensive drugs as they take on the rationing role that was formerly the preserve of the National Institute for Clinical Excellence. The new chairman of the Royal College of GPs, Dr Clare Gerada, warned last month that this could lead to patient unrest and intolerable pressure on doctors.

Such fears might prove unfounded. And there is a strong case for requiring family doctors to take on more responsibility to match their now elevated pay. Yet even the best-intentioned institutional overhauls run into problems unless they are properly planned and informed by evidence of what works. As things stand, Mr Lansley's revolution is looking disconcertingly unplanned and uninformed.

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