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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 June 2; 334(7604): 1129.
PMCID: PMC1885314

Nuffield Trust backs independence for the NHS

The English public loves the idea of a national health service but is less enchanted by the way it delivers health care, a new report into the independence of the NHS has concluded.

A greater distance between ministers and day to day decisions in the service could improve staff morale, boost patients' confidence in doctors, and encourage young people to take up a career in medicine, says the report from the independent health policy and research charity the Nuffield Trust.

“If the political process becomes tainted, this will rub off to some extent on the organisations that are being managed by the process,” said Brian Edwards of the University of Sheffield, who wrote the report with the help of Patricia Day of Bath University and Scott Greer of the University of Michigan.

The report makes it clear that the NHS can be depoliticised in many ways but that politics has a tendency to creep back in when so much public money is at stake. And without politicians the NHS would never have been created or provided with the huge budget increases it has enjoyed under Tony Blair.

The idea of NHS independence divides NHS managers and commentators (see Feature doi: 10.1136/bmj.39223.746042.59) but finds more unequivocal support among doctors. The Nuffield Trust's report, although it leans in favour of independence, does not favour any particular model.

The choice is complicated by the split between purchasers and providers of services and by the emergence of islands of independence such as the foundation trusts. General practices have always, in essence, been independent operators working under contract. And the NHS is no longer UK wide but four separate organisations going in different ways.

This leaves a lot less of the NHS to liberate than would have been the case 20 years ago. Professor Edwards—dealing only with England—toys with the idea of an NHS corporation on the BBC model, a diluted version of the present NHS that deals only with planning and commissioning, and an NHS commissioning authority on the model of the Higher Education Funding Council, operating as a non-departmental public body.

In favour of independence, he says, is that the NHS would be liberated from meddling politicians; against independence is the constitutional principle that huge public spending must be publicly accountable to parliament through ministers. But few politicians, he admits, ever take this responsibility to the point of resignation when things go wrong.

That said, Professor Edwards finds twice as many reasons to opt for independence as he does against the idea: better decision making, a more public face behind decisions, greater professional involvement, less risk of political bias, lower overheads, and the liberation of the Department of Health to concentrate on public health.

Against are the issue of accountability, the risk that funding will shrink, and the risk of more organisational change at a time when the NHS wants less.


An Independent NHS: A Review of the Options is available at

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