The coalition's NHS reforms - far enough or a 'quick fix'?
The NHS was recently ranked as one of the most efficient and effective health systems in the world, so is radical reform an unnecessary risk? Dr Greg Parston looks into the matter.
The coalition government's plans for the NHS involve a rapid and radical transfer of financial control and accountability and – once again – significant structural upheaval. No part of the service will remain untouched; some are slated to disappear. Certainly, there are many aspects of health and social care in the UK that require change if those services are to help us improve national health, but are these plans – parts of which are exciting and welcome – and the speed which they portend the right ways to go about it?
The key to the government's reform is to put funding for the majority of patient care directly in the hands of general practitioners. The rationale is to reduce NHS management – which by international standards is already lean – and trust the people who provide our care with the responsibility to manage our public money. At a time when the highly respected Commonwealth Fund has just ranked the NHS as one of the most efficient and effective health systems in the world, this proposed transformation brings with it significant risks.
Many critics feel that GPs with overall budget responsibility may become more concerned about keeping their costs down than with improving patient well-being, never mind broader community health. In addition, the complexities of contracting for service provision are immense, heavily bureaucratic and often adversarial, with high transaction costs including the need for timely information to make reliable decisions. Most GP practices currently are ill-equipped to undertake these responsibilities – some could do it, many cannot, probably most do not want to and a small but real number will exploit it for their ends. How is the Secretary of State going to train, equip and ultimately compel GPs to commission health services well, in the public interest and with the outcome of better health?
The recent report of the Commission on 2020 Public Service's Health Work Group demonstrates how different ideas about what could be done to improve health and social care – including those on offer from the government – could be considered with a clear consensus about what the long-term outcomes should be. We believe that reforms to the NHS must be judged by the extent to which they achieve three seismic shifts advocated by the commission: a shift in culture from social security to social productivity; a shift in power from the centre to citizens; and a shift in finance to reconnect it with social purpose and public accountability. Together these three shifts offer an effective way of making sense of changes that can meet the health and social care needs of citizens. One or two or partial shifts – as the coalition's plans propose – may not be enough.
'Improving Health Outcomes: A Guide for Action' aims to promote an informed debate on the direction of reform within the NHS, local government and with the public. Changing established structures and patterns of working is necessary but it is also difficult and probably impossible to achieve without the engagement, debate, and active contribution of the people who work to deliver services and – as important – the people they serve. That wide stakeholder discourse and involvement needs to happen now.
While advocating robust reforms in preventative care, commissioning and home care, our report argues that the principal concern in the immediate term should be about creating the conditions for continuing improvements that both professionals and the public must lead. Too often, top-down public service changes aim too narrowly at overcoming specific obstacles or are driven by favoured reform mechanisms or ideology. 'Improving Health Outcomes' provides a practical framework for helping people make strategic decisions and align needed new behaviours with improved outcomes. It offers a way of thinking systematically about needs, problems, drivers of change and solutions – including the tremendous capacity within the system for innovation and leadership.
The government's current plans do not yet make those connections and do not offer the engagement and time needed for successful large-scale change. They also presently leave a host of unanswered questions, such as what happens when commissioning consortia overspend, what happens to hospitals that cannot become foundation trusts, and what happens when the government's well-intended goals of improving health outcomes do not actually occur.
The commission believes that a real transformation to 21st century public services will only be achieved through shifts in culture, power and finance that are vital to creating a society of capable, resilient citizens, making choices for themselves, accepting responsibility and being able to make social contributions within a positive and reinforcing environment. That is the big society that public services – that health services – should help us achieve.
Dr Greg Parston is chair of the Health Working Group at the Commission on 2020 Public Services
» Read it here: Public Servant
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