Bob Bury: Let's cut the bureaucracy... and trust the professionals

One of call-me-Dave's most fundamental proposals (indeed, one of the few concrete proposals we have heard from him) is the pledge to turn over the day-to-day running of the NHS to an independent body.

Having argued the case for this previously on these pages, I have to welcome it – anything that reduces the intrusive micro-management of the NHS by politicians ought to be a good thing.

As always, however, the devil will be in the detail, and so far we have no evidence of any detailed planning for this ground-breaking change.

We don't know just how detached from government the new body will be, or how it will interface with the GPs and hospitals at the sharp end.

What it mustn't be is just another layer of bureaucracy interposed between the politicians and the health care providers, with Whitehall still actually pulling the strings – the NHS is already top-heavy with management, and the last thing we need is more of it.

What we do know is that the Tories' NHS Board will consist of a majority of members of the public, a decision which is linked to their (and New Labour's) agenda to increase patient involvement in health care provision.

At the risk of sounding like one of those arrogant, elitist consultants you read so much about, the uncritical acceptance of increasing lay involvement and "patient choice" as self-evidently good worries me, not because I don't think that patients should be actively involved in their treatment – they should – but because allowing the NHS agenda to be driven by lay opinion can produce undesired consequences.

In other words – and here comes the arrogance and paternalism – what patients want isn't always what they need. For example – patients suffering from colds or other viral infections often demand antibiotics, but they don't need antibiotics, and it's the GP's job to avoid the inappropriate prescribing which encourages the emergence of resistant strains of bacteria (think MRSA).

So the message to Mr Cameron is: while lay input is often valuable, and patient choice is fine in those areas where a genuine choice exists, professionals do sometimes know best, and allowing focus groups to direct resources will result in the waste, as typified by NHS Direct.

Those of us who despair of the present Government's tendency to meet any problem with the imposition of another ill thought-out target will also welcome Mr Cameron's pledge to move away from target-setting to the application of outcome measures.

However, he will need to pick the right outcome measures. For example, it has been suggested that one measure of a GP's performance might be their patient satisfaction rating on sites such as iWantGreatCare.org.

We only need to recall that most of Harold Shipman's patients would have rated him very highly to realise that glowing references don't always tell the whole story.

These sites can also attract the discontented "I want antibiotics" patients mentioned above, which can skew the results, with the GP who gives patients everything they want, regardless of need, scoring higher than their more conscientious colleagues. Identifying the "best" hospitals is also not as easy as it sounds.

We have, hopefully, moved beyond the uncritical comparison of mortality rates, but any measures which are not sophisticated enough to allow for differences in population and case mix are not only unhelpful, they can be misleading. In many areas of practice, we have no good measure of outcome – this is something we will need to work on with the new NHS Board.

Finally, assuming that Mr Cameron is at least as keen on the involvement of the private sector in health care as his nominally more socialist predecessors were, I hope he will have the sense to ensure that any decision to award contracts to a commercial provider is based on a fair assessment of price and quality.

Just comparing the raw cost of a scan or operation performed by an NHS hospital, dealing with a mix of simple and complex cases and carrying the overheads of training and research, with the price offered by an independent sector treatment centre which cherry-picks the simple cases and has none of those overheads is bound to disadvantage the public provider.

Add to that the disregard for quality which has characterised Labour's love affair with commercial health care, and he will ensure that public money continues to line the pockets of entrepreneurs, while the NHS is left to pick up the pieces.

There was a time when we would have greeted the arrival of a new government with at least a degree of eager anticipation, and David Cameron has certainly offered a couple of suggestions for the NHS which sound sensible. Whether he can deliver, given the state of the nation's finances, remains to be seen.