Whatever other changes are made to the NHS Bill, Andrew Lansley should stick to his guns when keeping hospital consultants out of the commissioning boards. It is all too easy to argue they should be there to ensure "joined-up care", but the historic influence of the hospital lobby has dominated NHS investment decisions to the detriment of the overall service.
The NHS spends too much on hospitals, too little on prevention, primary care, and services to keep people out of hospital. The hospital lobby has made it almost impossible to undertake the most rational and well-argued reconfigurations.
Twenty years after it was first proposed, for example, we are struggling to reduce the number of children's heart surgery units despite compelling evidence that child mortality rates at bigger centres are lower.
For NHS reform to deliver real improvement, it is vital that the power of incumbent lobbies is broken and that we put investment decisions in the hands of those who will put the interests of patients before the interests of powerful lobbies.
Dr Stephen Black is a health management expert at PA Consulting Group.
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