Feature

An opportunity to put health before health care

The NHS reforms together with the forthcoming restructuring of local government provide the perfect moment for a paradigm shift which would put health back at the centre of health policy, argues David Hunter

A number of important, though discrete developments are occurring in the health field which are likely to have a major impact on future policy. The general election will to a limited degree determine the outcome of these but it is virtually certain that an unrivalled opportunity to bring about a paradigm shift in the UK’s health policy will pass unheeded.

This is regrettable, especially as the Labour Party has spent the past few months reviewing its health policy, which will have been relaunched by the time this article appears. While it should provide a sharper focus for Labour’s health programme in government, it is not expected to depart radically from the principles and issues detailed in A Fresh Start for Health. If a Conservative government is returned we can expect a quickening of the pace of the NHS reforms introduced last April but without any major departures from the course that has been set.

What are these important developments? First, there is the health strategy for England, The Health of the Nation. The proposals in the consultative document and subsequent white paper mark a potential watershed in the evolution of health policy in this country. The strategy offers an opportunity to attend to broader public health issues which go beyond the responsibilities of the NHS.

So far, so good, although it is not clear what the precise mechanisms will be in central or local government to ensure this broader perspective is not lost from view. The government appears sanguine, arguing that high powered teams working in the Department of Health and the NHS Management Executive, coupled with the development of the purchasing role at district health authority level, will ensure progress and keep the strategy alive. Clearly it is too early to pass judgment and we must wait upon events. But certain doubts remain.

The second development is the reorganisation of local government. There has been virtually no discussion of the forthcoming changes in the context of health care. This may be partly because the proposals for change remain vague and imprecise. Nevertheless, an opportunity presents itself for fresh and imaginative thinking around the interface between health and health care since many, if not all, of local government’s responsibilities have a health dimension.

That these two major initiatives have proceeded separately with no apparent awareness of their obvious links is illustrative of what Bevan called ‘the poverty of imagination’ which blights policy-making in the UK. An opportunity to reconfigure health policy in a way that would go far in putting health before health care will be lost, and it is one that will most likely not be repeated for some time to come. A framework for such a reconfiguration was put forward last summer in a report published by the Institute for Public Policy Research (IPPR), Health before Health Care.

The report’s starting point was that health policy in the UK is dominated by an unhealthy concentration on health services. The NHS has many strengths but a major weakness is its ability to divert the attention of policy-makers from taking a broader view of health and, in particular, from the appropriate policy instruments available to promote and sustain it. In short, the urgent forever drives out the important. Since its genesis, NHS policy thinking has been largely devoted to sorting out the service’s structure, financing and management in an attempt to get these ‘right’.

The problem has been one of equating health policy with health care and the public interest with professional interests. The result is quite impossible and conflicting demands on the NHS to deliver the undeliverable, and a tendency to see the service as a catch-all for all aspects of health: cure, care, prevention and promotion.

The authors of the IPPR report, while not denying the value and importance of health care services, take the view that the impact on health of health care services is marginal and neither the NHS or any other health system can by itself shoulder the wider governmental responsibilities for improving the health of the nation. Central to the proposed scheme is local government and its future.

The IPPR report is not alone in suggesting a key role for local government in the NHS. The Association of Metropolitan Authorities published a report at around the same time making a similar case and John Stewart, a long time commentator on and analyst of local government, argued that the forthcoming local government reorganisation provided an opportunity to end the great divide between the NHS and local government.

Of course, the case for local government taking a closer interest in health care is by no means new. It has been argued consistently since the NHS was introduced but been rejected by successive governments. The report of the 1979 Royal Commission on the NHS was lukewarm about a local government ‘takeover’ but did not rule it out altogether if regional government became a serious prospect.

The renewed interest in the local government option over the last year or so has its origins in recent developments in health care reform and is not entirely driven by the traditional concerns of those articulating the alleged virtues of democratic accountability in the NHS, and the development of a unified approach to service provision across health and social services in particular.

There are four main reasons why the local government option has stimulated interest and found favour in certain quarters. First, somewhat ironically, the NHS reforms have raised yet again questions about the role and purpose of health authority members, particularly non-executive directors. Their role remains as uncertain and confused as that of their lay predecessors on health authorities.

Second, and closely related, the purchaser-provider split and the development of the purchasing role has raised fundamental questions about its nature. Is the purchasing role in fact a management role as the government would have us believe, or is it rather a governance role involving values and political judgment? Since priorities and choices are an essential part of the purchasing role, then it is a governance rather than a technocratic role which is at the heart of decision-making within health authorities. This is surely a task for elected representatives, not managers who are directly accountable not to the local community they serve but to the secretary of state, who is somewhat remote from their activities.

Third, as already mentioned, the arrival of a health strategy embraces issues which go well beyond the NHS. Local government has a major part to play in the strategy’s success.

Finally, the community care reforms now being phased in are subject to frontier disputes between health and social services as each agency seeks to pass the buck, and therefore the cost implications of providing care, to the other. Such tactics are hardly conducive to achieving seamless or integrated care.

Underlying these developments is a more fundamental belief in local authorities as the natural leaders of local communities. The argument is that the local authority is a natural broker and co-ordinator and a focus for partnership at local level; it can mobilise public opinion and take a holistic view of the local environment.

In addressing these concerns, the IPPR report made a distinction between the health improvement system and the health and social services system. The health improvement system requires the government to have a clear overall vision and direction for health policy. This must be the starting point for a consideration of both health promotion and health care delivery issues, with the former given equal attention and not tacked on as an afterthought.

It is vital to see the health improvement system and the health and social services system as inseparable, with the latter growing out and reinforcing the former. Their development must go hand in hand so that their joint contribution to a strategy for health is acknowledged. Their relationship needs to be made explicit in regard to their respective roles and structures. The purchaser-provider split is central to the relationship. This may prove an obstacle for the Labour Party given its continuing opposition to the potential merits of such a separation of planning responsibilities from direct management and delivery of care responsibilities.

Under the IPPR scheme, the purchaser-provider split would be maintained in order to create a separation between strategic management and operational management. There would be no market in terms of buying and selling services, which the Labour Party and others seem to suggest is an inevitable consequence of the purchaser-provider split. This is not so. Local authorities would serve as the purchasing authorities for health and social care for their resident populations. The NHS would be the provider of health care to meet needs identified by local government. It would be established as a ‘next steps’ agency, that is, an agency hived off from government and given devolved responsibility for the management of services, with the NHS Management Executive being responsible for the overall management of the NHS. NHS provider units at local level would become the local arms of the Executive.

What are the advantages of such an arrangement? There are at least five. It:

• starts from a wider vision of health rather than the organisational needs of the NHS;
• provides a local democratic base for the articulation of a health strategy developed within the overall framework set by the national strategy;
• sidesteps the historical difficulties encountered in proposals for local government ‘control’ of the NHS, since health professionals would be employed by the provider units and not by local government;
• avoids the difficulties of separate funding arrangements for health and social care;
• avoids major organisational turbulence or restructuring since many of the essential components are already in place or will be when local government is reorganised.

What about central government’s role in all of this? Clearly its role remains crucial, especially in respect of the health improvement system. Much of the improvement sought in health status can only be achieved by macro social and economic interventions in various fields including taxation, employment, health and safety, and so on. These issues span many central government departments and so mechanisms which enable a horizontal view of health policy will need to be created. To give the necessary thrust to these initiatives a lead agency will be necessary in Whitehall. At first glance, the Department of Health seems the obvious candidate. But is it the natural central department for the broader role which the IPPR envisages? The Department of the Environment (DoE) would be a more appropriate location given the proposals’ focus on local government. Of course, the Department of Health would continue to have regulatory, scientific and licensing responsibilities but these could be handled in a slimmed down department with the strategic aspects of its current role transferred to the DoE.

The IPPR proposal has been described as an elegant solution to problems that have never been satisfactorily resolved by policy-makers. It confronts head on the central puzzle confronting policy-makers - how to shift the balance so that health rather than health care is given genuine priority and is not merely seen as a rhetorical device to create the illusion of change. Much work remains to be done on the details of the IPPR proposals. But a necessary prerequisite is to accept the key principles of such a shift.

Sadly, the election result is unlikely to make any difference to the take-up or acceptance of these ideas. Little separates the two main political parties in this respect. For both, ‘sorting out’ the problems confronting the NHS remains the priority although each approaches this task from a different standpoint. What a pity that solution which could begin to address many deep-seated policy problems in the health field also happens to be the one that is furthest from the political agenda. Perhaps things will be different by 1997 when the political parties will again have to confront the electorate

Health before Health Care is available from IPPR, 30-32 Southampton Street, London WC2E 7RA, price £7.50.