Ctrl-Alt-Pause
==============

* Tony Delamothe

The popular uprisings in north Africa and the Middle East could never have happened as they did without the new social media. Yet, for the creators of Facebook, YouTube, Twitter, and Google these were outcomes that they could never have envisaged.

It’s fanciful to imagine that the current NHS reforms could provoke a similar uprising in England, rather than just a drubbing of the government via the ballot box. Nevertheless, it’s intriguing to watch the new social media take on the Health and Social Care Bill.

A few weeks ago Martin McKee and friends described how Twitter was providing immediate scrutiny of the bill and giving a voice to those who usually go unheard (*BMJ* 2011;342:d948). Since then, the Andrew Lansley Rap has gone viral thanks to YouTube ([www.youtube.com/watch?v=Dl1jPqqTdNo](http://www.youtube.com/watch?v=Dl1jPqqTdNo)). In as many words as appear in this column each week, MC NxtGen skewers the government’s health reforms and still has room to reference the health secretary’s relationship with the food industry and his claims for parliamentary expenses. A quarter of a million people have now watched the video, and “likes” are outnumbering “dislikes” by forty to one. All harmless fun? Maybe—except that the surest way to undermine a person’s authority is to turn them into an object of ridicule.

The rap’s release coincided with the government’s realisation that it has lost the battle for England’s hearts and minds over its reforms. Last weekend’s newspapers trailed stories of the reforms being diluted or delayed. A gang of peers was said to be waiting to mug the bill when it arrived in the House of Lords. So it was a downcast secretary of state who told the House of Commons on Monday that “we propose to take the opportunity to take a natural break in the passage of the bill, to pause, listen and engage with all those who want the NHS to succeed” (doi:[10.1136/bmj.d2216](https://www.bmj.com/lookup/doi/10.1136/bmj.d2216)).

This week’s journal provides some useful reading for the break. Allyson Pollock and David Price, academics at Barts and the London, think the government’s Plan A would result in a competitive market of corporate providers, despite the absence of evidence that such markets bring cost efficiency, improved quality, and greater equity. They propose eight key amendments to preserve comprehensive healthcare throughout England (doi:[10.1136/bmj.d1695](https://www.bmj.com/lookup/doi/10.1136/bmj.d1695)).

We asked Kieran Walshe of Manchester Business School and Chris Ham, chief executive of the King’s Fund, to suggest a Plan B. Their suggestions focus on three main areas: general practice commissioning consortiums and primary care, competition and choice, and system governance and accountability (doi:[10.1136/bmj.d2038](https://www.bmj.com/lookup/doi/10.1136/bmj.d2038)).

It’s clear from both articles that the government’s real intentions over the role of competition have emerged as the great, disconcerting unknown in the reforms. Andrew Lansley did himself no favours when he refused to share with a Commons select committee the legal opinion on the effect of European Union competition law on the NHS under the reforms (doi:[10.1136/bmj.d2180](https://www.bmj.com/lookup/doi/10.1136/bmj.d2180)). We’ve just posted a detailed discussion of the issue online (doi:[10.1136/bmj.d2071](https://www.bmj.com/lookup/doi/10.1136/bmj.d2071)), which will appear in the print journal on 16 April.

In his commentary discussing the challenges the government now faces, Nigel Edwards, acting chief executive of the NHS Confederation, says that fixing the technical issues is only part of the problem (doi:[10.1136/bmj.d2093](https://www.bmj.com/lookup/doi/10.1136/bmj.d2093)). “Fixing the politics, telling the story, and containing the anxiety that has been created may be much harder.” A strong narrative about why the inevitable upheaval is worthwhile is missing. And “even if the case for change is strong, the government has not made the case that this particular set of reforms is the answer.”

We’ll know whether the government has been listening when we see what it comes up with—after the break.

## Notes

**Cite this as:** *BMJ* 2011;342:d2219

## Footnotes

*   Follow *BMJ* Editor Fiona Godlee on Twitter at [twitter.com/fgodlee](http://twitter.com/fgodlee) and the *BMJ* at [twitter.com/bmj_latest](http://twitter.com/bmj_latest)