Labour has two distinct parts to its NHS modernisation programme - a health outcome agenda and a service delivery agenda. Recognising and managing the tensions between the two is crucial to achieving its goals. The service delivery agenda (creating a consumer-responsive public service) is regarded by health service professionals and the public as subordinate to the health outcome agenda.
The four-year plan for the NHS must be explicit about the scale of the investment required to improve service delivery while financing the better health outcome agenda. Ambiguity at this stage will kill the attempt to improve service delivery.
Plans to improve health outcomes through the national service frameworks, National Institute for Clinical Excellence, Commission for Health Improvement, clinical governance and the erosion of geographical variations can potentially transform the consistency and quality of NHS care. Improving service delivery is just as radical and ambitious. In health secretary Alan Milburn's words: 'We want the whole patient experience to be transformed.
Services that are fast enough and good enough to meet public expectations and to maintain public support [and] will make people think twice about going private. . .'
1A hierarchy of needs
Yet for NHS professionals, the health outcomes agenda comes first. Saving lives comes before patient experience.
Inevitably, operations for waiting-list patients are cancelled when another patient has a more urgent need for theatre time, or for a bed. For some professionals, NHS Direct and walk-in centres are seen as irrelevant gimmicks that take money away from more important NHS activities.
The public worries about waiting times because it takes quality for granted. Yet there is no point in having quick access to poor-quality treatment. We will achieve more for the health outcomes of cancer patients by implementing the Calman-Hine recommendations than by introducing two-week maximum waiting times for a first appointment. Health outcomes come first - yet achieving the quality agenda cannot become an excuse for not making the NHS more patient friendly. There is now money to do both.
Improvements in service delivery should not automatically be expected to be cost-effective in delivering better health outcomes, though some improvements will also reduce costs or improve health outcomes. NHS Direct will divert some people from calling out their doctor, visiting casualty departments or going to their GP surgery.
In general, however, improving service delivery is about improving access to NHS services (for example, NHS Direct and walk-in centres) and about making the receipt of healthcare more convenient for patients (for example, booked admissions).
It is about meeting consumer expectations and will require major changes in the way health professionals work. NHS Direct should be judged primarily on whether it delivers convenient and accessible NHS advice, not on whether it diverts demand.
Until now Labour has pursued the service delivery agenda by stealth. Money has been top-sliced for pilot programmes. Only in the case of NHS Direct has a decision been taken to achieve national coverage. Apart from waiting-list targets (which repeat pressures imposed by the Conservatives) the service delivery agenda has had little impact on most of the NHS. That position is not sustainable. For example, booked admissions have the potential to transform both the organisation of hospital services and - where GPs can book a procedure without a referral to outpatients - to change GP/hospital working relationships. A booked operation cannot be cancelled if booked admissions are to be of value to patients. This requires more sophisticated scheduling but also more staffed capacity in hospitals. Eliminating trolley waits also requires more capacity. This may not all be at large acute hospitals, as Mr Milburn has recently pointed out - but some will.
2It will be expensive wherever it is provided.
A convenient NHS service cannot be provided simply by adding walk-in centres. It requires better access to GP services, too. And it requires substantial investment in information technology if medical records are to be accessible whenever and wherever a patient contacts the NHS.
Labour has to be much more explicit in its service delivery intentions for the NHS, as the resources required to deliver them are large. While these intentions are being signalled in ministerial speeches they are not percolating into NHS and public consciousness. Although the health outcome agenda has to come first and be seen to be properly funded, the Budget announcement provides a one-off opportunity to demonstrate that both agendas can be achieved. NHS professionals cannot be allowed to regard service delivery changes merely as a tool to achieve better health outcomes. The four-year plan for the NHS needs to be clear on health outcome and service delivery objectives. Ambiguity at this stage will kill the service delivery agenda.
REFERENCES
1 Reinventing healthcare. A modern NHS versus a private alternative. A speech by Rt Hon Alan Milburn MP, secretary of state for health. Institute for Public Policy Research, 20 December 1999.
2 The NHS: the case for modernisation. A speech by Rt Hon Alan Milburn MP, secretary of state for health. King's Fund,2 February 2000.
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