Feature

Time for a closer look

With NHS reform in full swing, it is essential that the voice of public opinion gets heard, says Paul Evans

The government has finally started to invest the sort of public money that the NHS needs, but how can we be sure it is being spent wisely? Answering this question is part of the mission of a new health policy forum that will bring together groups that want to keep the public and NHS staff involved in this discussion.

The pace of reform has been so rapid that there is little chance to look at the context of the changes and their overall impact on the health service. The NHS Support Federation, which is launching the forum, believes in establishing a strong sense of NHS values to help decide which approaches are likely to bring about the change the public want.

Just as companies and charities have mission statements, the NHS has founding principles, expressed in terms of a comprehensive system of healthcare equally available to all, and free at the point of use.

These principles are cited in the introductory sections of The NHS Plan, the government’s blueprint for change, seemingly to offer reassurance that there is no ideological shift within. Yet read on and you find clear challenges to them, in terms of how services are provided and who pays for them.

Government policy is far ahead of any public consensus on the direction that the NHS should take. And there is even a queue of reforms waiting to be implemented, such is the weight of change. There are plenty of good ideas, but there has also been a significant shift from the ethos of public service that has underpinned the NHS.

The belief that services should be owned by, and accountable to, the public to ensure that they remain responsive has gone. Health secretary Alan Milburn stressed in a recent BBC documentary that the public still owns the NHS – but it is hard to see how recent policies support his statement.

The role of the private sector in the NHS is expanding, without any great degree of scrutiny or control. A new market to provide services on behalf of the NHS has been created, inviting companies worldwide to step in. The private finance initiative has loosened public control over NHS resources, while changes in governance have given the NHS a corporate structure that is policed by quangos with little room for elected representation.

The government says that this is simply the best approach for getting the job done. After all, it has set itself the target of having no patient waiting over six months by 2005, and will certainly not allow ‘ideology’ to stand in its way.

Its approach challenges supporters of the NHS to define what they mean by a public service ethos. The question of whether it matters who provides NHS services has been debated in policy circles, but not by the public at large. The NHS needs to reassert the values it represents and provide policy-makers with clear guidance.

The NHS Support Federation believes the public should be able to have an independent voice, and we hope that the Health Policy Forum will strengthen that voice. Groups currently involved in the forum include the NHS Consultants’ Association, the Association of Community Health Councils for England and Wales (ACHCEW), Medical Practitioners’ Union and the think-tank Catalyst. At a time of great public investment, the forum wants to raise public involvement in the strategic direction of our health service.

There is a gulf between the traditional perceptions of the NHS and its new direction, and most of us sit somewhere in-between. Policy is moving apace and many people would be surprised by some of the changes that are occurring.

More patients are being treated in their own homes or in nursing homes instead of hospitals, and many are finding that they have to pay for some aspects of care. The move from hospitals is popular, but the charges for health authority-funded care that patients will need to pay when they are treated outside the hospital setting will not be.

‘Healthcare’ is increasingly a consumer product that is just as likely to be bought in supermarkets and railway stations as in hospitals or chemists. Locally, new privately funded health centres will put the NHS and private providers under the same roof, which will have an impact on the range of NHS services on offer. For example, physiotherapy could become available for a fee from health centres, with an ensuing reduction of access to equivalent NHS services.

More NHS patients will find that their care is provided by private contractors – and the long-term impact of this is uncertain. There is already evidence that private providers, keen to keep costs down and reduce risk, are ‘cherry-picking’ the least complicated patients and leaving more complex cases for the NHS. This may undermine the equity of access we want from our health service.

Public awareness will catch up with policy, but the public should not be too disconnected from the process. The Health Policy Forum is a step towards raising the public debate on the direction our health service takes. As citizens, our money is going into the service, and so should our views – they should be contributing to building an NHS that delivers care and embodies values we believe in.

If you would like to be included in the circulation list for the Health Policy Forum, email paul@nhscampaign.org