Feature

An alternative NHS reform

The government claims to be ‘reforming’ the NHS, but has only succeeded in raising public anxiety and alienating health professionals. An alternative strategy is needed, says Steve Iliffe

In the last issue of healthmatters, Dexter Whitfield was quoted as calling for an alternative modernisation strategy for the NHS. This is an intriguing proposal that acknowledges that change is necessary, and implies that the traditional remedy of adding extra resources is no longer sufficient. It is a sign that a complex response to the strategy of attrition launched against the NHS by prime minister Tony Blair’s ‘Big C’ conservatives may be emerging.

Most of those who have waited in A&E, been discharged from hospital, or tried to book an appointment with a physiotherapist will probably sympathise with this effort to understand the complexity of the changes needed. Citizens’ experiences of the NHS are, on balance, good. But there is more than enough that is poor, shabby or downright bad to qualify public judgements and even weaken public support. So what might such an alternative strategy contain?

I am going to suggest that three assumptions are fundamental to an alternative modernisation strategy. First, increasing the NHS budget to something near eight per cent of gross national product may be necessary, but is not sufficient for renewal of a public health service. The reasons why it is insufficient lead us to the detail of an alternative strategy.

Second, the devolution of responsibility from central management to work unit is essential but difficult for the command-and-control apparatus of the NHS to deliver. A change in the political culture of the NHS at the centre is needed before any effective re-engineering can take root at the periphery.

Third, consumerism leads to a dumbing down of decision-making, as in the debate about MMR risks, but it is clear that there is no easy response. Exploring the route from participation to citizen control of the NHS is more complicated than a simple denunciation of consumerism but seems likely to be more productive.

The hazards of investment

Increasing the amount of money available to the NHS increases the competition for resources in the industry, with the advantage lying with the medico-industrial complex – the primary alliance of the medical profession and the pharmaceutical industry – and the secondary alliance between the medical profession and commercial medicine. This professional and industrial complex defines the nature of medical care to its own advantage and develops a patient support base, enrolling influential voluntary organisations in a common cause.

Increases in funding will tend to be routed towards irresistible treatments and technologies, which have been the main cause of rising health care costs in the past two decades. An alternative strategy will need to identify the medico-industrial complex as a problem, and its regulation as one of the core tasks of modernisation, because without this regulation necessary cost containment will fall disproportionately on low-profit aspects of healthcare.

The National Institute for Clinical Excellence and the concordat with commercial medicine are the beginnings of this regulation but more is needed. The voluntary Pharmaceutical Price Regulation scheme that controls drug prices to the NHS should be expanded to separate the industry from both research and education by introducing levies based on proportions of profit allocated to external research, advertising and direct education.

What is needed is an industrial market, in which the NHS underwrites the profitability and continued existence of the pharmaceutical industry. This would be in return for both drug prices below-market rates, and research and education funds that can be dispensed in ways that are more socially appropriate and less commercially biased. A re-labelling of the ‘independent’ or ‘private’ sector as frankly commercial – in it for the money – would be a good precursor to negotiating reimbursement for the training of commercial sector staff carried out by the NHS.

A political culture

Attempts to counter budget hijacking by ring-fencing money for other, less technological approaches to health promotion or maintenance will provoke further competition and internal conflict, which will be inescapable. Like it or not, the NHS will become increasingly politicised. If the ring-fencing of funds is supported by regulation of practice and a professional ethic emphasising equitable resource allocation, then the destabilising effects of technological expansion may be avoidable, but this combination is difficult to achieve.

There are three reasons for this. Ring-fencing is easy to initiate but harder to sustain. Regulation of practice provokes resistance among those most culpable of inflating costs through cultivating a self-serving science, but also among those who see it as eroding the high-trust relationships that make healthcare work well. The professional commitment to equity exists, but it is neither a core construct for the profession nor something that is favoured politically by the governing party.

New Labour is little different from old Labour in its reluctance to foster debate about the kind of health service citizens want or to mobilise support for its programme among the professions. Trapped inside the belief that it merely needs to seize the levers of government to bring about reform, it has missed opportunities to create a critical mass of supporters in the NHS.

Citizens see the extension of new technologies as evidence of improvement in healthcare, probably because there is no common-sense debate about other options. Popular reactions are then polarised into naive choices, between so-called orthodox and alternative medicine, or between paying for quality or getting something less but seemingly for free.

New Labour now fears the Daily Mail but it also ensures that tabloid editors set the agenda. New Labour’s current challenge is reasserting control of the debate on health and healthcare in a consumer society, not winning the argument on waiting-list length. For example, the discipline of health technology assessment is central to controlling the claims brought by the medico-industrial complex that new investigations and treatments will have dramatic effects on our lives,. But it needs to function in a culture that is rationally sceptical about the claims of science not fearful about hidden menaces and lurking risks.

Resistance to change

Even when resource allocation can be controlled, funds will tend to flow down traditional channels because these paths are smoothest. It is often easier to work in the old way – changing practice or thinking smarter are harder to do. How much of this inertia is deliberate, how much a consequence of the dullness of the professional classes, and how much a by-product of service overload is difficult to know without studying specific cases.

Asking nurses how to make a hospital run more efficiently may, in some instances, unlock the secret of re-engineering. But given the influence of financial and legal rules on clinical practice, as well as the responses of communities to change and the effect of the division of labour and the impact of the medico-industrial complex on decision-making, there is no certainty that any one group has the knowledge to produce change.

The NHS runs on the goodwill and commitment of its staff, whom a wise government would not label as ‘wreckers’ simply because they are reluctant to change. However, loyalty to the health service is not a sign of the innovation that is needed to change the way care is delivered. Attention to whole systems is important here, because it makes simple truths vanish and whole pictures emerge. The work of the Commission for Health Improvement is the beginning of such a critical systems approach, which might deepen the debate about the NHS if governments can resist the desire to control the commission’s activities.

Professional activity is the foundation of healthcare but it has its own dynamic and rules. One of them is the tendency to fragment activity into increasingly specialised subtasks, another is to create specialist workers to carry out these tasks, and the third is to reduce productivity in the name of better quality (without necessarily having the evidence to support the claim).

These realities are understood throughout the NHS, yet it is impolite to talk about them too loudly. Since NHS policy is seen as a technical concern, and not a matter of public interest, technocrats control it. Sensibly, they tread a fine line between trying to regulate professional trends that are counterproductive and destabilising the system, while supporting professional creativity and commitment.

Reform from above

The NHS management structure, built on the command-and-control model inherited from the Second World War and instinctively appropriate to a hierarchical, class-conscious society has to implement the wishes of a government that lacks deep support in the NHS, while keeping the hospitals and clinics going.

Top-down initiatives designed to promote changes in clinical activity – such as the national service frameworks and the health improvement programmes – overburden work units with multiple tasks and introduce monitoring systems that are viewed as signs of a lack of trust, thus eroding commitment to the NHS itself. The management structure tries to mitigate the damaging effects of this dictatorial approach but by doing so appears to impede change and becomes part of the forces of conservatism.

The result is a further round of change, in an attempt to reshuffle the administration, and an intensification of reform pressures from above. Despairing of the capacity of the existing administration to change, New Labour seeks inspiration from the unstable relationships and institutions of the commercial world.

This approach is unsustainable and will inflict significant damage on the NHS and on New Labour. A modernisation agenda that is broadly on the right track will then be in peril, because the people required to bring it about will be confused and disempowered at best and cynical or hostile at worst. This is probably avoidable, but not if the present course is continued.

The idea of earned autonomy for hospitals and community services is a good one, but can a centralising control-freak government let go? If New Labour can let go, and promote high trust relationships with successful innovators in the NHS, it will send a signal to the rest. If it can avoid interfering in the management of the health service and halt constant reorganisations it will allow managers and clinicians to get to work on the slow process of change. It can help them by creating firmer regulatory boundaries and clearer systems perspectives that are shared with the public but without scapegoating and blame.

If it can stop the efforts to change clinical practice by introducing increasingly complex targets and standards, and instead let practitioners achieve realistic if more modest objectives, it will be able to boast about palpable successes. On the other hand, if it presses forward with demands for a faster pace of change and introduces commercial management organisations to remedy the tardiness of the existing administrations, it will rightly be blamed for being meddlesome and destructive.

When health secretary Alan Milburn and his team decide to take a hands-off approach, the free time released at the Department of Health can be used to think about how to make the NHS more political, not less. If the government applies itself to explaining its ideas and the rationale of its policies to a population that is today more educated and aware than ever before, the television debates and press coverage of the NHS can acquire a depth that is currently lacking.

A professional commitment to change can grow if New Labour supports its potential supporters and talks honestly with them about the real potential for modernisation. This means concentrating on fostering a political culture not manipulating opinion, but given the evolution of the Labour Party this may be difficult for Bevan’s descendants. But it is worth a go, before we sell the whole NHS to the highest bidder for lack of a better idea.