Does anyone understand the government's NHS reforms, asks senior professor?

Despite 25 years of experience researching health systems, including writing over 30 books and 500 academic papers, Professor Martin McKee from the London School of Hygiene and Tropical Medicine says he still can't understand the government's plan for the NHS.

In a Personal View published on bmj.com today, he writes: "I have tried very hard, as have some of my cleverer colleagues, but no matter how hard we try, we always end up concluding that the bill means something quite different from what the secretary of state says it does."

McKee notes that even Malcolm Grant, the incoming chairman of the National Commissioning Board, has described the bill as "completely unintelligible."

Each year Professor McKee teaches a course on health systems. This year, he knows his students will expect him to explain the changes proposed by the Department of Health in England, but he says: "If I am to do so, I need to understand them first. Here lies the problem."

His first problem is understanding what the changes are trying to solve. The government argues that reform is needed because the NHS is performing so badly in international terms. Yet the evidence it has produced, such as deaths from heart attacks, has been totally discredited, while independent reports show that the UK is now improving at a faster rate than almost anywhere else.

Furthermore, the Organisation for Economic Co-operation and Development (OECD) has argued that the UK would have done even better if it had not continually been reorganising the NHS.

His second problem is to understand what is being proposed. "The has reassured us that he will not privatise the NHS. Yet the management of one hospital has just been handed over to what is essentially a ," he writes.

The secretary of state's role is also a puzzle to McKee, who reads that he will no longer have a direct role in the management of the NHS, but sees "ever more examples, from to refusals to treatments, where he is actively intervening."

His third problem is understanding why so much is happening now. Unlike the US, where the president cannot do anything without the approval of Congress, the Health and Social Care Bill is already being implemented even though it has not passed into law.

McKee concludes: "I realise that my bewilderment may simply be a consequence of my own failure to understand the insights that have been granted to wiser and more learned individuals than myself … But I'm also hoping that someone, somewhere, among the BMJ's extensive and erudite readership, will be able to help me."

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