The final frontier
Of all the government’s public-service reforms, its bid to reshape the National Health Service may prove the most painful
Jan 13th 2011 | Print Edition
ONE of the problems governments face in attempting to reform health care is that the National Health Service (NHS) is a symbol as well as a service. Nigel Lawson, a former Conservative chancellor, observed that England only had one national religion: the NHS. The coalition agreement signed last May by the Tories and Liberal Democrats described the NHS as “an important expression of our national values”. Meddling with it can be dangerous—as the coalition is discovering.
Whereas the Conservatives’ plans for welfare and education reform were described in their election manifesto, the ongoing shake-up of the NHS was not. As it turned out, Andrew Lansley, now the Tory health secretary, was stealthily working on a plan for major reforms. He proposes to dissolve both Primary Care Trusts, which commission hospital care on behalf of GPs (family doctors), and Strategic Health Authorities, regional organisations that issue guidance and directives about expenditure. Instead, GP practices will be obliged to form consortia to commission care themselves. European competition law will ensure a level playing field between public and private providers.
This is a big shift, but not a wholly original one. Margaret Thatcher initiated the division between the purchasers of hospital care (local doctors commissioning services for patients) and providers (usually large hospitals). The new plan revives a Tory experiment of the early 1990s, which placed budgets at the disposal of some GPs.
The arguments for it look strong. The budget of the NHS in England (health care in other parts of Britain is organised separately) ballooned in the boom years to £104 billion ($164 billion), and is protected from the spending cuts affecting most other government departments. Yet David Nicholson, the NHS’s chief executive, has estimated that the service faces a shortfall of up to £20 billion in the next three years. To meet increased demand, NHS productivity—which has remained static since 1997—needs to rise by 4% per year. Already the financial strain is showing. A shortage of flu vaccine in a cold January looked like a harbinger of shortages ahead. The Royal College of Midwives has warned that it is dangerously short-staffed when it comes to delivering little Britons. In theory the reforms will save money, by cutting administrative costs and giving GPs more incentive to spend wisely.
And the NHS is still widely variable in outcomes, as well as in efficiency. Some GPs embrace the task of chivvying specialists for better and quicker care for their patients; some do not. The new arrangements might oblige the slacker ones to be more engaged. Meanwhile, Mr Lansley’s bid to extend choice among providers will involve publishing more transparent data on clinical performance—long viewed by hospitals and consultants with suspicion, but an advance for patients in making decisions about where they are treated.
Predictably, the health secretary faces formidable opposition. Medical practitioners are prodigious and well-organised complainers—and skilled in persuading voters that their interests are aligned.
Spokesmen for family doctors say they do not wish to become administrators—to which the government replies that it is happy for GP practices to appoint others to bargain with providers on their behalf, and to switch to new intermediaries if they find the results unsatisfactory. Another doubt is whether the breakneck pace that Mr Lansley envisages—all GP practices will be required to be part of consortia by 2013—will create problems of its own.
Sarah Wollaston, a doctor and since last year a Conservative MP, has warned Mr Lansley that the threatened speedy dissolution of existing structures is causing staff to quit, just at the time when experience of commissioning will be at a premium. Doctors are also concerned about the legal framework of consortia and the possibility of financial failures.
The suddenness of the changes, and fears about the accountability of the new organisations, disturb even some who are broadly supportive. Opponents also worry that private providers could undercut existing public ones, in effect running loss-leader services to drive others out of business. In response, Mr Lansley offers a robust defence of deregulation and its benefits to consumers, based on his experience in helping the Thatcher government deregulate the telecoms industry in the 1980s. In truth, no one knows what will happen until the reform is tried.
These heckles have unsettled some in the government. In the roster of its reforms, education has always taken pride of place, in particular the Swedish-style “free schools” intended to shake-up comprehensive education. Welfare reform comes next. Some think upheaval in the NHS would leave the government fighting on too many fronts at once—and that a battle royal with doctors and nurses is best avoided, given the resistance of other public-sector unions to the coming cuts.
That is to say nothing of the Liberal Democrats, the Tories’ coalition partners, who have already been bruised by rows over hikes to university-tuition fees and free schools, and whose grassroots are suspicious of Tory intentions on health. Oliver Letwin, the Cabinet Office minister and a trusted ally of Mr Cameron, has been drafted in by Number 10 to try to limit the ructions. That has led to tension in the inner Tory team over how uncompromising the reforms should be, with the “managerialists” arrayed against “true believers”.
Mr Lansley is a quietly spoken man with a big vision. But he needs more than a plausible bedside manner to reassure patients and professionals alike that his proposals will be therapeutic. He might well find himself compelled to alter the pace of his reforms, if not their scale.
from PRINT EDITION | Britain
Source: http://www.economist.com/node/17909835?story_id=17909835
Accessed 17 Feb 2011
