Sir: With NHS waiting lists rising again (report, 18 November), last week's unveiling of the Government's plans for transferring secondary healthcare purchasing to GP collectives prompted another airing of your belief that the internal market has provided a "lever to efficiency" in the NHS (leader, 12 November). If this were true, any benefits have been squandered by the extravagant contractual paper chase inherent in the purchaser/provider split.
The longer-term contracts proposed should reduce bureaucracy and there is a slim hope that GP collectives will prove more sensitive than health authority officials in judging priorities in hospital practice. However, the fundamental flaw in the contractual approach to hospital funding will remain: over-performance is anathema and trusts invariably strive to do the minimum for their allotted income. By this time of year, a large proportion of surgical teams are under instruction not to treat waiting-list patients covered by completed health authority contracts or by the increasing proportion of impecunious GP fundholders. These restrictions apply irrespective of spare capacity and the knowledge that 70 per cent of NHS spending is consumed by salaries, so that the cost of treating additional patients in terms of drugs and disposables is relatively small.
Before 1990, the ethos of NHS hospitals was to undertake as much activity as possible within a fixed budgetary allocation. The challenge to the Health Secretary is to revive this simple concept alongside rigorous resource management and performance monitoring. The information systems necessary for analysis of activity and outcome are in place. A national inspectorate ("Offsick"?) could set standards and should be able to reward excellence or improvement with modest financial incentives in the form of development grants.
Selly Oak Hospital