There is a strong consensus amongst independent experts, medical professionals and politicians that major NHS reforms are both desirable and inevitable. Healthcare is one of mankind’s greatest priorities. An aging population and medical advances mean that healthcare expenditure is bound to grow as a proportion of the economy over the long term. If the current, fundamental values of the NHS are to be preserved for our children, efficiency must be improved, not slightly but dramatically.
The original proposals of the current Government were never billed as being perfect but the broad strategy was right. The most important feature in my view was the move towards aligning the interests of patients, medical professionals and Government. Other important principles included reduced bureaucracy; less layers of management; decisions taken at the lowest appropriate level; clear and measurable goals of direct relevance to the purpose of the organisation; and independence from political meddling in operational matters.
The main problems that have arisen since last July’s publication of the Government’s original White Paper have been:
- Limited support from healthcare professionals, reflecting a view that general practitioners might be asked to make decisions outside their areas of competence with too little support and in accordance with too tight a timetable.
- Fears that competition might harm quality and weaken the NHS, for example, by private contractors cherry-picking the most lucrative services.
- Concern that the independence of the NHS could reduce the accountability of Ministers.
None of the compromises reached over any of these problems has been great enough to undermine the main thrust of the Government’s proposals. I find the latest proposals as easy to accept as the original ones. A great deal still depends on the detailed management of the changes and on whether medical professionals are now truly more supportive. I have some concerns about details but less than I had with the original proposals.
My concerns over whether GPs had all the skills required to undertake the originally proposed roles and over whether two doctors were enough to give a balanced view have been met by including hospital doctors and nurses in commissioning as well as a number of other safeguards. The timetable has been adjusted to provide much more time for changes to be made, satisfying another of my concerns. The drawback to the new proposals is less reduction in bureaucracy.
The reduced emphasis on competition worries me most but a lot depends on how the new policies are interpreted. The danger is that the drives for improved quality of care and better value for money will be so confused and watered down as to be largely ineffectual. Competition should not be mainly price-driven because providers would aim to provide the minimum service that fulfilled the specification. Nevertheless, a fixed-price system where competition is purely on quality is not perfect, because two operators may provide genuinely indistinguishable quality but one may be cheaper for wholly valid reasons (e.g. it may be bigger and therefore have more buying power or it may simply be more efficient). Competition must be arranged so as not to lead to perverse distortions or serve inappropriate vested interests. In addition, the framework for competition must take account not only of value for money in buying the relevant services but also the implications for the rest of the NHS. For example, a wonderfully high-quality, low-cost catering system may not be a good idea if it requires a huge amount of kitchen space and so deprives a hospital of space for life-saving new equipment. The best forms of competition will put the main emphasis on quality (measured in the ways that best reflect clinical outcomes and patient preferences) but will include some element of price competition. Full allowance must be made for knock-on effects elsewhere in the NHS and for the full resources required (e.g. floor space, cleaning, security), which must not be regarded as “free”. Cherry-picking can only occur if a service is out-sourced at a higher price than is in the overall interests of the NHS or too low a quality is accepted. Competition should reduce, not increase, this risk.
The debate about ministerial responsibility is in my view a side issue. Healthcare in the UK is mainly about the NHS. If the NHS underperforms, health will suffer. In such a situation the Ministers concerned have a responsibility to put things right (and can justly blame other political parties if the necessary legislation gets blocked).
As previously, the planned legislation does not focus on a number of important policy areas. These include drug pricing; raising funds from the provision of non-medical services by the NHS; and the desirability of research within the NHS. An Ipsos MORI research poll published this month has found that 97% of the public believe it is important that the NHS should support research into new treatments.
The big picture is that the UK Government’s pioneering proposals remain broadly intact and continue to merit support. Success is not yet guaranteed because the full cooperation of medical professionals is not yet assured and the detailed plans over implementation are crucial. The Government must work at carrying the Public and enough medical professionals on its side. The importance of the changes must be communicated with as much help as is necessary from the Prime Minister and political opinion leaders. Detailed planning must take into account expert opinion at all stages and must not end once policies have been decided. The benefits of controlled competition, even if it is called integration and collaboration between different classes of service provider, must be safeguarded.