Changes 'could force patients to go private': Nicholas Timmins on an exercise that gave a glimpse of the future NHS

CHANGES in the National Health Service are likely to lead to such disillusion that those who can afford it will opt out to the private sector, according to an NHS-backed simulation of where the health-care market is leading.

Family doctors - who are traditionally seen as strong advocates for their patients - risk losing the trust and credibility of patients as more of them become fund-holders. And the new health commissions - whose job it is to buy hospital, community care and GP services for patients - found themselves losing control and unable to deliver either national policy objectives, or those the public wanted, the study found. It said the 'alarming' results point to 'a system which could rapidly get out of control'.

The findings come from 'Rubber Windmill' - a war-game type simulation of what is likely to happen in the NHS. It has been run each year since 1990 by the East Anglian Regional Health Authority to highlight problems in the new NHS market with the aim of avoiding them, and each time has affected the NHS agenda. The two-day exercise involving managers, doctors and patients 'runs' the NHS forward for two years to see what is likely to happen.

This year's offering saw patients progressively losing faith in their GPs as fund-holding took a stronger grip. As time went by GPs' business interests were 'beginning to threaten the regard in which they were held by the public'.

As fund-holders took an increasing share of the NHS cash, health commissions found themselves with less leverage over hospitals and other providers - and thus unable to shift resources in line with national priorities and the demands of the public. It says: 'A way must be found to hold GP fund-holders to account to ensure that not only do they provide the best care locally for their patients, but they also contribute to the overall strategic direction of the NHS.'

Members of the public, who for the first time were involved in the play-acting, found themselves unable to affect the agenda, in which hospitals and other providers became increasingly powerful at the expense of those meant to be 'buying' the care. Those who could afford to 'vote with their pockets' turned increasingly to the private sector, which 'appeared to listen and respond to their concerns'.

Better ways of involving both the public and GPs in overall health planning must be found, the study concluded.

'For some players these results were alarming - the apparent incapacity of health commissions to step up to their new role, and the resulting sense of disempowerment, even despair - among the general public; the apparent strength of the providers in a 'too free' market and the 'disappearance' of central management and strategic direction for health suggested a system which could rapidly get out of control,' the study concluded.