Debating the future of the English National Health Service

This post is the second half of a two-part series by guest blogger Kate Thomson which explores proposed changes to the National Health Service in England. The first post provides useful background information (particularly for those living outside the UK) on these proposed changes. In this post, Kate explains in greater detail the areas of reform which are of greatest contention. Kate is a Senior Lecturer in the Department of Public Health at Birmingham City University and is currently researching health reforms in the Russian Federation.

In a previous post, I outlined some of the major changes taking place within the English health service (NHS) via the Health and Social Care Bill. Here, I go into more detail on some of the main areas of contention.

Who are the providers? Competition and ‘choice’

The extent to which NHS services will be opened up to the private sector is one of the battleground areas in debates about the Bill. Government contends that ‘competition’ between providers incentivises quality improvement. Opponents suggest that increasing private sector involvement is an ideologically-informed step by a government that is inclined to be ‘on the side’ of big business. The link between provider competition (regardless of whether or not private sector providers are involved) and quality has been questioned. Key evidence cited by the Prime Minister as supporting this link has been subject to critical appraisal by a number of scholars who question its conclusions.

The term, ‘any qualified provider,’ is used in the Health and Social Care Bill to emphasise that healthcare services should be commissioned(purchased) via a competitive process. NHS providers, in other words, will not automatically be preferred over new and/or private sector organisations.  As well as ‘qualifying’ on grounds of quality and capacity, it seems that there will also, in practice, be financial criteria: is the company /enterprise solvent enough to bear the ‘risk’ of providing such services?

An unintended consequence may be tension with another much lauded principle of public sector reform – the Big Society, an idea which promotes extended involvement by charities and ‘social enterprises’ in providing public services.Such organisations are meant to be able to act more flexibly and be more in touch with needs ‘on the ground’ than state bodies. However, there is evidence that they may be ‘squeezed out’ of competitive tendering processes.All this adds up to what commentators have called an ‘intrinsic bias’ in the commissioning processes towards private, for-profit bidders.

Objections to private sector involvement go beyond the ideological (principled resistance to the idea of public money going ‘outside’ the system and into the pockets of shareholders). It is likely that there will be less competition to provide services in the most difficult and complex areas of care (e.g.intensive care), than in areas with relatively predictable costs and outcomes (such as non-urgent surgery). This could make it difficult for NHS hospitals that provide a range of interventions to compete in the local market; will a district hospital, for example, be allowed to ‘fail’?

Evidence is already emerging that newly formed clinical commissioning groups (CCGs) are directing GPs in what are effectively rationing decisions (e.g. relating to overall number of referrals to hospital; or access to specific interventions). This does not appear to fit with the model of shared decision making between practitioner and patient (‘nothing about me without me’), touted in government rhetoric. Nor does it entirely match the notion of clinically-led decision making about appropriate treatment  and availability (as opposed to decisions made by ‘bureaucrats’).  Such developments raise serious questions about equity and appropriateness in access to care.

Beyond problems around equity and consistency of ‘rationing’ decisions, CCG responsibilities raise the possibility of conflicts of interest. To a greater degree than in the past, ‘commissioners’ (CCGs) will be able to both plan (purchase) and provide services (i.e. they may ‘commission’ from their own members, such as GP practices or ‘spin-off’ enterprises). They will also be in a position to explicitly ration (limit access to certain treatments ‘on the NHS’) while offering themselves to patients  as willing providers of a fee-paying service.

The rhetoric of reform links competition with ‘choice’ for patients/consumers. ‘Personalisation’ is a health policy buzzword. Health and social care services are to be tailored to individual needs, with increasing individual choice about what, where, how and by whom care is provided. One of the mechanisms for this is the ‘personal budget’ – a direct payment, initially for patients with long-term conditions, to spend on an individually-determined package of services. Undoubtedly there are benefits from self-determination – an empowered service user getting the services they desire. Demand for under-resourced services may stimulate supply (and quality improvements).  However, there are also potential difficulties, such as the burden of administering such budgets; the negotiation of boundaries between personally budgeted care and access to commissioned services; and the possibility that less popular, yet important, services, could be undermined.  Personalisation and choice also need to be fully realised principles within the entirety of the system, rather than becoming ways of describing mechanisms for choosing services.

Public Health

In parallel with these changes there are proposed changes to the provision and structure of Public Health (which had its own White Paper in late 2010). The headline change was a move of public health responsibilities from within the NHS, to local authorities. This offers the opportunity for public health concerns to be effectively ‘joined up’ with the very wide range of policy decisions and service provisions offered by local authorities (the generation of ‘healthy public policy’ at the local level). However many public health practitioners fear dilution of expertise and reductions in clout and budgets to act. Amendments to the Health and Social Care Bill emphasised CCGs’ responsibilities for health improvement and public health; and for the health of all in their geographical area (not just ‘their’ patients). However, the demarcation of responsibilities in practice, between health care commissioners and local authority public health bodies, is yet to be clarified. There are certainly grave concerns about the impact of restructuring and other elements of the Bill, among many public health specialists.

Bureaucracy

Finally, it is worth questioning the extent to which the reforms will reduce ‘bureaucracy’ in the NHS. The Bill was promoted as a way of creating a leaner health service, that operated closer to the patients and their clinical needs.  However, as the Bill has developed, proposed CCG roles have changed such that these will now be quite large organisations with a layered structure, and with a duty to consult with experts and the public, to inform their decision making. This is actually a rather different model to the original vision of GPs (primary care physicians) making decisions as a collective. Doctors are concerned about how far the burden of ‘bureaucracy’ for these organisations, will fall upon them. Perhaps an additional layer of oversight or management will be brought in – however this moves closer to our starting structure of Primary Care Trusts and Strategic Health Authorities.

Internal contradictions within health policy are nothing new to the NHS. Tensions, for example, between devolution of decision-making and imposition of national standards; and between the ‘choice’ agenda and the requirement to spend budgets in the most rational and equitable way, were features of the previous government’s approach too. We will discover whether the current reforms spell ‘the end’ of the NHS, or a more efficient and ‘modern’ reconfiguration, as the changes bed down over the coming months and years.

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