Published: 22/09/2005, Volume II5, No. 5967 Page 23
Commissioning a Patient-led NHS settles some old scores and honours promises the government made before the general election. While the publication and its timing has caused apprehension and anger in equal measure across parts of the NHS and with some trade unions, its primary thrust is sensible and well intentioned. However, it might still fail.
Policy officials and advisers are becoming increasingly concerned about the potential for a runaway increase in costs throughout the - as they see it - overly dominant secondary care sector.
The government's twin goals of reducing waiting times and making the NHS more responsive to patients has resulted in a significant investment in the supply side of the health economy. Increased infrastructure and capacity, more (and better paid) staff, independent treatment centres and plurality of provision are the clear and intended consequences of government policy.
However, the recent round of starrating assessments by the Healthcare Commission sparked a series of articles in the media over the summer about financial pressures and deficits. Reports suggested that nearly one in four NHS organisations were in the red.
This causes political trouble as well as clinical difficulties.
The Right will clearly argue that the NHS is a black hole and cannot be reformed with cash, while the Left will claim that more needs to be spent on a service which is still an under-funded national treasure. In this light, Commissioning a Patientled NHS now attempts to re-balance our focus on securing value for money, efficiency and service responsiveness, although many cynics might suggest that this was what Shifting the Balance of Power was meant to achieve. Regardless of past history, we certainly need to renew attempts to deliver on these aspirations with increased vigour now that post-2008 funding forecasts are beginning to dawn on NHS staff, policy officials and the public alike.
The job is going to be difficult irrespective of what organisational tinkering takes place because the demand curve is going to grow. This is why the reforms may fail and why we need a fresh debate on how - and whether - the NHS can actually change personal lifestyle behaviour without resorting to direct personal charges and a further widening of the health inequalities gap between rich and poor.
First, most considered opinion on healthcare need suggests that it will grow. The ageing population is accepted, but what might be less well known is the latent impact of demographic change and medical advance. Musculoskeletal disorders will grow as the population ages and becomes more obese and this, in turn, will produce an increased demand for surgery.
Respiratory disease is likely to increase, although this growth is dependent on smoking rates. At best, estimates suggest a sustained need for hospital services in this area. Cancer needs are set to grow as the model of the disease changes from acute to chronic. Demands in hospital services are therefore likely to be sustained, with continued growth in primary care. Heart disease is likely to increase as the population ages and diabetic rates rise because of obesity. Growth in ambulatory care can be expected.
Finally, increase in kidney disease is expected, with a consequent increase on ambulatory and hospital care. Increased drugs costs are predicted while, overall, medical advance across most disease types will improve health outcomes, but at extra cost.
So the hospital is most certainly here to stay, but can it get more efficient and do things more cheaply? The existing argument concerning the provider side of PCT services is sterile and unhelpful. The debate should not be about who employs which staff, but how services can meet need. All the disease conditions noted above will need to fuse elements of secondary and primary care if we are to stand any chance of responding to need in an affordable way.
Second, and more importantly, do we actually believe that existing and traditional funding and service provision models for dealing with the conditions associated with obesity, smoking, drinking and sexual promiscuity are actually working?
The evidence would suggest not.
Failure to arrest and reverse these trends will have catastrophic consequences for funding and is likely to cause an explosion in hospital use if demand has not been controlled (as the conditions concerned naturally present themselves, at some stage, as an acute flare-up). If the state continues to try to provide extra funds for the implications of personal decisions on health and lifestyle choices, can we expect people ever to assume more responsibility for their health status?
While very few people would deny all patients equal access to new treatments (not withstanding the recent conclusions about postcode prescribing from the Audit Commission) through a tax-funded system, should the same principle apply for those who choose a certain lifestyle? Of course, even raising this question is fraught with difficulties.
People already pay extra tax on the cigarettes they smoke and the alcohol they consume, while co-payment schemes would disadvantage and further discriminate against the poor.
However, the good work produced by Sir Derek Wanless illustrates the full financial horror of not assertively tackling certain lifestyle choices.
We should be honest enough to accept that existing public health initiatives will not be enough in the face of rampant Western consumerism. So, even if we are not yet prepared to have a full debate on individual choice, its costs and consequences, let us at least start with forceful public health messages and assertive legislation and ban smoking in public places. Delegates at the Labour Party conference need to do the right thing and stiffen the government's resolve. .
Mark Britnell is the chief executive of University Hospital Birmingham foundation trust and a senior associate of the King's Fund.
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