There are a couple of intrinsic dilemmas in NHS reform.

The first relates to the current debate about markets and competition. Monitor chair David Bennett's recent interview with The Times demonstrated that he's comceptualising NHS reform - at least, to The Times audience - as akin to a pre-privatisation utility.

Bennett said, "I worked for a very long while in lots of different countries in the energy sectors, in power and gas, doing exactly this sort of thing. There’s lots of evidence of benefits being produced … Some people talk about the idea that foundation trusts could link up into chains and there are some arguments for doing that.

“We, in the UK, have done this in other sectors before. We did it in gas, we did it in power, we did it in telecoms, we’ve done it in rail, we’ve done it in water, so there’s actually 20 years of experience in taking monopolistic, monolithic markets and providers and exposing them to economic regulation”.

This is a very unfortunate metaphor. Even if we accept that markets are efficient, this argument fails to understand the fundamental difference between:
- those utilities where choice can be meaningful for users, since supply is diverse (telecoms, gas, electricity),
- and those equally crucial utilities which can very rarely or never be diverse for users since supply is an intrinsic monopoly (water and sewage, railways).

Of all utilities, the one that's first essential to our lives and wellbeing - water and sewage - is the one that is least meaningfully amenable to marketisation and competition. There is one supplier per area. Market and competition fundamentalists should take note.

The idea that there is 0% of room for markets and competition in healthcare is as ridiculous as the argument that there is 100% room for them. If market-type mechanisms can increase our 'bangs-per-healthcare-buck' in access or quality in a demonstrably cost-effective manner, then they should be used.

But their introduction should be done carefully and with evaluated trials. Assertion, commercial-in-confidence and smoke-and-mirrors bullshit like the revise-at-will public sector comparator in PFI have been far more prevalent.

So we should properly be cautious.

The second dilemma springs to mind reading a paper by Ireri, Walshe, Benson and Mwanthi in the new issue of Journal of Management and Marketing in Healthcare (COI declaration - I'm on the editorial board).

The paper is 'A qualitative and quantitative study of medical leadership'. It's based on self-reported interviews with UK doctor managers (which as the authors rightly note, have limitations). The qualitiative research involved purposive sampling from medical and clinical directors from across two SHAs; the quantitative from a postal questionnaire which gained 186 responses (a response rate of 38%).

It comes to two unsurprising but relevant conclusions. UK doctor managers "possess a wide variety of management and leadership skills, but rate professional credibility as the most important quality to succeeding as a doctor manager. Doctor managers expressed the greatest need for training and development in financial and human resources management".

In other words, medical credibility is they key to medical and managerial leadership as it is now. Leadership for the world as it will be involves skills this group of doctor managers does not currently think it has.

This reform is going to require medical leaders - as NHS Supreme Soviet Chair Comrade Sir David Nicholson told Health Service Journal recently; he wants most consortia to be medically-led.

The same need will exist in providers: medical directors will need to jointly lead FTs with CEs / CEOs, if the changes required for reform is to have face validity and earn buy-in from medics.

Because without buy-in from medics, this reform is certainly going to fail.

Possibly quite spectacularly.