|Implemented in this survey?|
The Government is being heavily criticised in the media for the financial deficits that are reported in the NHS, despite historical rises in NHS expenditures over recent years. Some experts believe that the deficits are the result of large increases in doctor?s salaries and ?heavy-handed? performance targets, which are costly to meet. The Government is therefore keen to emphasise the ?success? of its reforms, and send out the message that it will not be dissuaded from its plans.
The Government has introduced a large number of mutually inconsistent health care reforms over the last nine years. Very briefly, they have focussed on
The Government has offered no explicit recognition that some of their individualistic policies (e.g. expanding patient choice) is fundamentally at odds with some of their communitarian objectives
(e.g. improving social equity), and also does not seem to recognize that the individualistic policies could fundamentally undermine the communitarian objectives (i.e. equal access for equal need) on
which the NHS is based.
In the face of strong criticism of how they have handled NHS reform, the Government regularly restates its commitment to the reforms and its future plans, which in essence focus upon more patient choice, a re-introduction of GP-fundholding and more performance targets. Nonetheless, the Government has managed to significantly reduce waiting lists (although through a combination of targets and money, rather than choice-based reform), and has implemented some reforms that do appear to be quite sensible, with respect to, for example, dentistry and social care.
The Government's main objectives were (and, according to their rhetoric, still are):
There is a mix of financial and non-financial incentives. For example, managers of hospitals now have to meet certain performance criteria which relate to such things as financial management,
waiting times targets etc. If they meet these targets, they earn greater managerial autonomy, and can also benefit financially. If they fail to meet the targets, they can be (and in some cases, have
As one can imagine, this creates significant pressures on personnel within the system, and it is far from clear that this serves to improve the overall service within the NHS. Possibly the most high profile incentive in the NHS at the moment is the introduction of patient choice of hospital provider at the point of referral. Coupled with the introduction of the new payment system per hospital procedure (the 'HRG', very similar to a 'DRG'), whereby the patient in a sense takes a little pot of money with them to the hospital they choose, the intention is that hospitals will 'compete' for patients on the basis of waiting times and other indicators of 'quality'. Whether this incentive mechanism will actually reduce waiting times (and/or improve other indicators of quality), not to mention the broader implications of this mechanism in terms of raising expectations in the NHS and undermining other important NHS objectives such as universality and affordable care at the point of use, remains to be seen.
Every conceivable group in the NHS, and, indeed, in the population in general, but obviously, patients, the public, hospitals, primary care trusts, the pharmaceutical industry, patient advocacy groups etc.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
I think I've already made my views clear above. The policies are very risky, and if they backfire they could fatally harm the NHS. It is possible, however, that the existing ways of doing things (i.e. the existing institutions) in the NHS will dilute the most harmful potential effects of the reforms, and that the positive aspects of the Government's initiatives (e.g. increasing capacity, reducing waiting lists) will be the things for which the reforms are most remembered. We can live in hope that this will be the case.
It is a little difficult to speculate exactly why the current Labour Government has chosen a 'competitive market/choice-based' reform programme, not least because this does not sit well with
'traditional' Labour Party 'welfare state'-type ideology. The current Labour Party Leadership seem to be genuinely convinced that markets and choice are the way to improve quality and performance in
public sector health care. Some may attribute the Government's path to advice received from key academics, but I suspect that the Government formulated what it was going to do and then targeted
particular academics to 'justify' rather than 'inform' its direction.
Much of the content of the reforms probably has to be attributed directly to Tony Blair. Some academics would argue that Blair himself was merely responding to societal pressures to introduce more choice in health care, although I am not entirely convinced of this line of reasoning. The public, in general, seem to want better quality services rather than more choice (i.e. they want to continue visiting the same GP practices and the same hospitals in their locality - they just want these services to be better). Moreover, the first two Labour Party majorities (elected in 1997 and 2001) were so large and the majority of Labour MPs were so eager to court favour with the Labour Leadership that Blair was in an ideal position to 'shape' policy whichever way he felt was best. It's just that he chose the 'competitive' way, underlining his genuine (although perhaps somewhat simplistic) belief that markets are the unquestionable answer to improve the NHS.
|Implemented in this survey?|
See above. It was probably about 2000 with the publication of the NHS Plan (the ten year 'blueprint' for the NHS) that the Government's NHS policy direction became clear, and the commitment to choice and competition has been regularly re-emphasized since that point in time.
|Government||very supportive||strongly opposed|
|Those on the political right||very supportive||strongly opposed|
|Those on the political left||very supportive||strongly opposed|
Discussed above. The Government still has a healthy majority in the House of Parliament, but it is no longer an overwhelming majority. Therefore it is now less easy for the Labour Leadership to trample over the views of its own party members. So, we may see some interesting times ahead.
|Those on the political right||very strong||none|
|Those on the political left||very strong||none|
Discussed above. Most of the direction came from senior members of the Government and civil servants working closely with these individuals.
The Government regularly issues updates on the progress of its reforms, and there are of course a great many academic articles and policy reports produced by think tanks that detail progress on
The main indicator of 'success' has thus far been the very substantial reductions in waiting times (although, as stated above, these have been achieved through targets and money, not choice and competition). Deaths from the big killer diseases have also been declining, although the size of this effect that can be attributed to the NHS (let alone the NHS reforms) is unclear.
Incidentally, Patricia Hewitt, the current Health Secretary, has recently said that the goals that she has for the NHS (e.g. the 18 week waiting list target) cannot be achieved through national targets and command and control measures. However, from evidence from the UK and overseas, targets, command and control (and money, of course) seem to be the most effective way by which to improve performance, and that there is in fact little evidence to suggest that the competition and choice incentives that the Government has introduced are an effective way of improving performance.
Mid-term review or evaluation
Structure, Process, Outcome
The main results thus far are that waiting lists are significantly down, and that the Government has managed to increase the capacity of the system (e.g. more doctors, dentists, nurses in training), but to reiterate, all this has thus far been acheived through money and targets. Moreover, the massive increases in NHS expenditure seem to be coming to an end, and thus the future financial situation of the NHS, given that the Government's reforms have substantially increased expectations and that some hospitals are already in the red, seems quite perilous.
I personally think that the Government's reforms may potentially undermine other, more important, objectives of the NHS; i.e. that it covers everyone within the population, and that it be readily affordable to everyone at the point of use. The basic structure of the NHS serves the population very well, and it would be unfortunate (to say the least) if the Government's reforms undermine this basic structure. The unfortunate consequences of some of the Government's policies (e.g. by increasing doctors' salaries too much and by introducing potentially very costly expectations the NHS has overspent) is already showing signs of playing into the hands of those who, through self-interest, would want to fundamentally change the structure of the NHS (e.g. by expanding the role of private financing).
|Quality of Health Care Services||marginal||fundamental|
Too early to determine the impact of the competition and choice-based reforms. I expect the impact to be disappointing (and possibly damaging), but I could be proved wrong.
Department of Health. Health Reform in England: Update and Next Steps. Department of Health: London, December 13 2005.
Department of Health. 2006 - A Year of Transition, A Year of Reform. Department of Health: London, January 10 2006.
Adam Oliver, Elias Mossialos and Alan Maynard (Eds.). Analysing the Impact of Health System Changes in the EU Member States. Health Economics 14 (S1), September 2005.
Department of Health. The NHS Plan: A Plan for Investment, A Plan for Reform. The Stationery Office: London, 2000.