The NHS has grown used to a pattern of crisis followed by review followed by reform - yet many fundamentals remain little changed. Will the past keep shaping the NHS of the future or will the service explore different paths, asks Nigel Edwards
Predicting the future direction of policy is helped a little by the fact that many decisions are determined by the power of previous choices. Policies also tend to be mutually re-enforcing - having choice requires a tariff; making providers more autonomous makes regulation more important.
The biggest changes will have to be made by leaders and staff, not policy makers
This “path dependence” means future policy options are constrained by the decisions of the past, especially when resources are tight. The question is whether this might be disrupted by pressures from rising expectations and a public view that only efficiency improvements rather than radical change are needed to reduce the deficit. There might be a more sudden and radical change arising from a worsening of public finances or a failure of the quality, innovation, productivity and prevention programme - QIPP - to deliver to the scale required. The next once in a lifetime review may produce a more fundamental challenge to the NHS model.
There have been some major shifts in the way that patients are seen, in how the system works, in the approach to quality and safety and in where power is located. This process will not stop, although the direction is often uncertain.
Patients and personalisation
The 2000 NHS Plan still sees the patient as the somewhat passive recipient of services that will be better designed. More recent policy documents have often made reference to the need to “personalise care”, “design care around the patient”, “empower patients”, provide care navigation, and care planning. Although many of the changes have been at the level of rhetoric rather than reality, the expectation now is that patients will be regarded as partners or even consumers. This is positive and irreversible but it may represent as big a challenge to the NHS as the financial pressures we now face. A further push on personalisation, empowering patient groups, new models which engage users more in the design and delivery of care and even more radical approaches might be expected.
The use of competition and choice as a policy instrument, even with the debate about the preferred provider policy, seems to be embedded. This is a feature of most other health systems in Europe although often these have more competition at the individual doctor level than in England. The focus has been on competition at the margin in elective surgery and a few other areas. The question is whether, when the present limited reach of competition is appreciated, it will start to be extended elsewhere into commissioning and primary care, the franchise to run hospitals, or even competing provision within existing facilities, for example in maternity care. Long term condition care is more likely to go down the integrated care route but there will continue to be a push for more contestability and competition in this area.
The bringing in of new providers has been slower than expected and it is still not clear to what extent there is enough of a critical mass to really tip the balance. Most of the debate still is focused on elective surgery - a relatively small part of the system. All the main political parties are in favour of introducing new providers but so far the barriers to entry remain high - not least the clunky procurement processes. This looks like an area where there is further to go but it might be harder in tighter economic circumstances.
Some form of commissioner/provider split has been part of the system for 20 years but the extent of commitment to it has varied and there remains concern about the capacity and capability of commissioners to deliver on increasing demands - with 30 per cent less management. It seems possible there will be some rethinking of the model, with all of the familiar risks that come with reorganisation. The debate has often been rather poor and has tended to concentrate on the size of commissioning organisations rather than their functions.
There remains divergence between views of the NHS. Is it more like an organisation, where change can be mandated, good practice spread by fiat and interventions made in the operation of providers, or a system which needs to be planned, co-ordinated and corralled, or a market of independent parts linked together by contract?
It is some mix of all three but without a clear consensus about where the balance is and parts of the system are still prone to an approach more reminiscent of a nationalised industry. The NHS will not get the level of innovation and risk taking required while this persists.
Quality, safety and regulation
Quality and safety are now established as central parts of any policy framework, but this has taken time to develop. There were significant policies published on quality, clinical governance and standards in 1998 and safety in 2000. However, for the first four to five years of the past decade the main policy statements tend to use a narrow definition of quality, mostly relating to access, convenience and reduction in variation. As noted above, while quality of patient care is often referenced, this tends to be rhetorical. Similarly, safety, while acknowledged as important, seems to have operated on a parallel track to other policies. Despite the visible leadership of Sir Liam Donaldson as chief medical officer for England, it did not occupy centre stage except in the area of healthcare-associated infection control which, had become an issue of public concern, thereby lifting it into the policy mainstream. The ability for a scandal, such as Mid Staffordshire Foundation Trust, to send policy off in new directions is still present.
Regulation is here to stay, but in what form? The multiple changes in the regulatory machinery suggest that there has not been clarity on what regulation is for and how it should operate. Is it light touch or based on inspection? Is it supposed to stop bad things from happening or just guarantee a minimum standard or promote improvement? We need a regulatory system which creates a positive culture, putting patient safety at the heart of everything the NHS does. The suspicion at present is that the system has the potential to take the initiative and accountability away from boards, frontline clinicians, managers and commissioners.
An important part of the policy rhetoric over the period has been the intention to shift power from the centre to the front line. Early manifestations included budgets for ward sisters and community matrons in which ministers reached over the heads of local managers to centrally impose decentralisation. With Shifting the Balance of Power in 2002 a more systematic approach started, with budgets devolved to primary care trusts and the creation of foundation trusts in 2004. The decentralisation of budgets to PCTs was associated with very detailed performance management and nervousness about the capacity of PCTs and frontline managers to deliver. There continue to be wobbles in the approach: for example, complaints from politicians and pressure groups about earmarked money being used for local priorities. The “look out, not up” mantra is undermined by some approaches to policy implementation, for example, in transforming community services.
The move away from detailed performance management of targets is also an area where there is some consensus. Whatever happens the policy zeitgeist seems to be about transparency, the publication of data, standards rather than targets and moving the focus from process to outcomes. This change could be as revolutionary as the changes in patient expectations.
Will this shift in power survive more failures in quality? The push for politicians to do something will continue and will always be hard to resist. The highly interventionist style of early years of this decade still seems to set the tone for public and political expectations of the health secretary.
Now there is a general policy consensus in favour of localism, although the public are still very concerned about postcode lotteries. This could go in several directions. The logic of closer integration with local government appeals to some but strong practice based groups for commissioning suggests a different type of local structure. Interestingly, some politicians have started to question whether variation is escapable or even necessarily a bad thing.
There is significant unfinished business in areas including social care, general practice and its contracts; the role of many hospitals; commissioning; inequalities; and integration between primary, secondary and social care and between health and local government.
Whatever happens to policy, as the NHS Confederation’s recent Rising to the Challenge report points out, the most significant changes are going to have to be made by leaders and staff in the NHS not by policy makers.
The chance of some or all of the present situation being challenged is quite high.
When looking at the history of the NHS over the past few decades there appears to be a pattern of crisis, followed by review, followed by a reform programme which leaves the key fundamentals in place: tax funded, centrally run, free at the point of use. The question we need to consider is whether we respond to the challenge facing the NHS right now with the same or similar approaches to managing change as before. Will the next high profile failure call into question some of these fundamentals?
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