With Andrew Lansley approaching his first anniversary as Secretary of State for Health and his health reforms more controversial than ever, much of the debate has focused on the extent to which the proposals represent a radical departure or more of a logical, if rapid, extension of existing trends. So, are the current health reforms really a break with the past, representing a complete smashing and rebuilding of the system, or do they follow a logical continuation of what was undertaken by the prime ministers and health secretaries of the past?
Competition between providers runs through the DNA of the current reforms. The role of competition in the NHS has been a developing theme. The fifties, sixties and seventies saw an emphasis on central planning and coordination in the NHS. It was, however, under the Thatcher Government that competition between component parts of the NHS (and private providers) was introduced through the creation of an internal market. When the Labour Party won the 1997 General Election, early proposals to re-introduce needs-based planning were quickly abandoned in a surprising u-turn favouring the re-enforcement of the Conservative’s market approach. The current emphasis on competition represents continuity with the broad direction of health reform over the past twenty years. Where there is a difference is that the competition envisaged by the current government is system-wide, with virtually no areas of service being immune from its force.
Of course for competition to work, it requires a range of potential providers. When the NHS was established in 1948 it was based on a plurality of providers. GPs, community pharmacists, dentists and optometrists have always been independent contractors to the NHS. As the NHS developed and with the introduction of Enoch Powell’s 1962 Hospital Plan, services run exclusively for NHS use became common place and private providers were not funded by the NHS. However, with the changing needs of the population and hospitals becoming unfit for purpose, a more diverse range of providers have been reintroduced into the NHS. Between 1998 and 2007 Labour delivered a significant step change in the role of the private sector with the introduction of PFI hospitals and independent sector treatment centres (ISTCs). In 2004 the Labour Government introduced foundation trusts which were NHS providers, but also autonomous entities, accountable to their members and with enhanced borrowing powers. Where the current reforms differ from the past is in their explicit intent to create a level playing field between all providers. Every NHS provider is to become a foundation trust, eliminating the two tier system. Similarly, all providers will have to deliver services on the same contractual basis and on a competitive playing field.
Equity and excellence proposes the fundamental redesign of the system architecture of the NHS. Doing away with primary care trusts and strategic health authorities and passing 80% of the health budget to GP commissioning consortia. Unsurprisingly, the current move to GP commissioning consortia has been compared to (and in some quarters described as a move back to) the GP fund holding model, one of the most controversial policies implemented by the Thatcher Government. GP fund holding enabled family doctors to buy healthcare from NHS trusts and the private sector needed by their populations, but flaws quickly became apparent. GP fund holding was not compulsory and only about 50% of GP practices adopted these powers, leading to patients in areas where fund holding was in operation often able to access services more quickly and establishing a perceived ‘two-tier’ NHS. Andrew Lansley has clearly learnt from this failed attempt to bring money closer to the patient. His intention is that GP commissioning consortia will be operational across the whole of England, eliminating the prospect of unacceptable variations. Additionally, a much higher proportion of the NHS budget will be put in the hands of GP commissioning consortia, giving them purchasing power for a much more comprehensive range of services.
The ultimate measure of success of any healthcare system is the outcomes of the patient (do they get better?) and whole system effectiveness (does the health of the population improve?). In the past process targets were used as a proxy for good outcomes because data and tools to measure outcomes were not widely available. As more robust data about the performance of services are made systematically available, it will be possible to tell in near real time clinical outcomes achieved. Between 1976 and 2007 a wide number of national targets were introduced, including waiting time targets, clinical targets, and use of incentivisation mechanisms. Such targets have met with a mixed response and healthcare professionals have often resented what they see as being a restricted on their professional freedom. By 2007, politicians on all sides had declared themselves to be wary of targets. Lord Darzi’s review heralded a new focus on data collection and the measurement of clinically- and patient-reported outcomes. By providing information about outcomes to the market the theory is that it won’t be necessary to use top-down targets because healthcare consumers will incentivise quality through patient choice. ‘Outcomes not targets’ may sound like a radical shift, but there is a good deal of continuity in the philosophy underpinning it.
It is clear that current government health reforms borrow heavily from initiatives of the recent past, learning lessons from and building on health policies implemented by both Labour and Conservative governments. The reforms may be a blend and adaptation of what has gone before, but they are nonetheless radical in the scale and pace of the change proposed. The real test of the extent to which the reforms represent change or more of the same will be the way in which commissioners, patients, professionals and the public use the new levers which will be at their disposal. As some commentators have pointed out, culture can be more important than systems or structures in the change that it delivers. How NHS culture adapts to the reforms will go a long way in determining the next chapter of the NHS.
A more comprehensive article on this topic is available here.