Creating a patient-led NHS: empowering ‘consumers’ or shrinking the state?
Creating a patient-led NHS: empowering ‘consumers’ or shrinking the state?
Abstract and Keywords
This chapter discusses developments in health policy. It makes clear that individual choice has a number of different roles to play in healthcare. It explains that the introduction of patient choice combined with payment by results further extends the use of market mechanisms as the means for achieving quality, responsiveness and efficiency in hospital care. It concerns policy towards health care outside of hospitals, since, with regard to the NHS in England, the government is increasingly turning its attention to care beyond the hospital doors. It focuses wholly on the NHS in England, since devolution in Scotland and Wales has resulted in health policy developments that diverge somewhat from the English model. It describes policies intended to ‘fix’ the hospital sector and offers an explanation for the shift in attention beyond this sector. It also examines demand and supply-side policies.
Health policy in England in recent years has been described as embodying elements of both modernisation and marketisation. These processes are intended to achieve a transformation from an ‘old’ monolithic service into a ‘new’ National Health Service (NHS), fit for the 21st century, and are to be pursued in part by curbing the monopoly powers of health care providers and ‘harnessing the powers of healthcare users as individuals wishing to access good quality healthcare’ (Allsop and Baggott, 2004, p 29). Following the Labour Party’s re-election in May 2005, while it commenced a third term in office with a much-reduced majority, this did nothing to dampen its commitment to increase patient choice and promote diversity in the provision of care. The Labour government’s role has also been described as moving away from management and towards regulation, setting standards and targets, but allowing local discretion as to how these are achieved (Klein, 2005). Whether this move to ‘enforced self-regulation’ (Hood et al, 2000; Dent, 2005) is perceived as allowing for greater discretion by those working in the NHS is a moot point, as is the extent to which central government is willing to withdraw from hands-on management. However, on the basis of policies announced in 2005, it seems clear that the government is serious in its intention to reform both the way in which care is commissioned and the way it is provided.
In March 2005, prior to the General Election, Nigel Edwards, Director of Policy for the NHS Confederation, addressed a meeting on the subject of ‘Payment By Results’ (PBR), a tariff-based system for paying hospitals (p.34) for care provided. The Confederation is the membership body that represents the vast majority of NHS organisations and the audience largely comprised NHS employees (see www.nhsconfed.org). Edwards’ suggestion that New Labour politicians think they have ‘fixed what’s wrong with hospitals’ and are now turning their attention to primary care was greeted with laughter by attendees. This perhaps reflects scepticism towards the potential for PBR to ‘fix’ the problems of secondary care within the NHS, but the shift in focus, towards ‘fixing’ problems outside of hospitals, is certainly borne out by policy developments in 2005. This chapter largely concerns policy towards health care outside of hospitals, since, with regard to the NHS in England, the government is increasingly turning its attention to care beyond the hospital doors. The chapter focuses wholly on the NHS in England, since devolution in Scotland and Wales has resulted in health policy developments that diverge somewhat from the English model (Greer, 2004). While not dismissing these developments, it is not possible to do justice to them in this short review chapter. The chapter is divided into four sections. The first briefly describes policies intended to ‘fix’ the hospital sector and offers an explanation for the shift in attention beyond this sector. The second and third sections examine demand and supply-side policies respectively, and the fourth presents concluding remarks.
Modernisation, marketisation and the reform of hospital care
Writing in Social Policy Review 17, Rudolf Klein (2005) outlined developments aimed at increasing opportunities for patient choice and public involvement and changes to the supply side of the NHS. These included moves towards a quasi-market driven by choice, the creation of Foundation Trusts and greater use of the independent sector in the provision of care. In large part, these initiatives can be interpreted as addressing perceived deficiencies in hospital care provision. In 2005 the expansion of PBR, a mechanism to change the flow of funds in the system, enabling money to follow patients, took place. The quasi-market reforms of the NHS in the 1990s were characterised by block contracts between purchasers and providers of care, with the result that money did not follow patients and patient flows remained largely as they had been prior to the market reforms (Le Grand et al, 1998). However, under PBR, providers receive a fixed price for each case treated and providers are no longer guaranteed income, but have to compete for patients (DH, 2002). Hospitals will lose resources if they fail to treat patients within (p.35) target waiting times or if patients choose to go elsewhere for treatment. PBR can thus be seen as facilitating the processes of modernisation and marketisation. Removing the guarantee of income is intended to make providers more responsive to consumer wishes. Payment based on average cost also rewards low-cost providers who may retain any surplus income over and above the cost of providing care and (in theory) forces ‘inefficient’ (above-average cost) providers to become more efficient and to reduce their costs in the process.
Policies to reform the hospital sector reflect the government’s intention that the substantial increases in NHS resources allocated in recent years (Appleby, 2003) should produce real gains in productivity and responsiveness (Revill, 2002). In 2005 government figures showed a drop in both the number of people on hospital waiting lists in England and the number of people waiting longer than six months for treatment. A combination of unprecedented levels of growth monies and the introduction of quasi-market reforms may, as Edwards suggests, be seen by the government as ‘fixing’ what it perceives to be the problems of hospital care, by improving efficiency and making services more responsive, both in terms of waiting times and services designed around patient preferences. Certainly this is the stated aim of these policies (DH, 2002; HM Treasury, 2004). However, in the context of a shift from management to regulation, they might also be seen as a means of extricating the government from culpability in the event of systems failures. Moving from ‘command and control’ to regulation may also reflect an acknowledgment of the need to hold to account private providers, who are intended to play an increasing role in care provision and whom the government can neither command nor directly control. Whether the government can merely restrict its role to regulation remains to be seen, particularly if and when the required improvements in the system fail to materialise. And there are a number of reasons, many of which concern the potential for demand to outstrip service provision, why improvements may fall short of expectations.
Recent levels of growth funding in the NHS cannot continue indefinitely, yet the increased costs associated with technological development and workforce expansion required to deliver health services in the 21st century show little sign of diminishing. In 2005 an Audit Commission report into the implementation of guidance produced by the National Institute for Clinical Excellence (NICE) found that implementation ‘has not always been timely or comprehensive’ (Audit Commission, 2005, p 23). Eighty-five per cent of NHS senior managers surveyed cited affordability as the main barrier to implementation (p.36) (Audit Commission, 2005). As growth funding levels off after 2008, the situation is likely to be exacerbated. The PBR tariff-based system that pays providers a fixed price for each patient treated is likely to result in increased expenditure on patient care. This is because, unlike the previous system in which NHS providers were obliged to manage increases in hospital activity with little or no additional resources, increased workload results in additional payment and PBR creates incentives to increase workload in order to increase income. Experience of such systems elsewhere suggests that the outcome is usually to increase costs overall. (For a brief summary of the potential adverse consequences of tariff-based funding systems and evidence from other countries, see Fotaki et al, 2005.)
There is disagreement among commentators over the likely impact of an aging population on the demand for health care in the future (Zweifel et al, 1999), although other factors such as government policies to promote choice and empower patients are likely to increase expectations of the system. Taken together, these factors point to the need to manage both expectations and demand within the NHS. Since general practitioners (GPs) have traditionally acted as gatekeepers controlling access to secondary care and thereby containing costs, they play an important role in managing demand, particularly in the context of PBR and the market in health services. Other policies to manage demand for hospital care concern attempts to shift responsibility for health and well-being on to citizens and to redesign the delivery of care so that the reliance on scarce and expensive hospital beds is diminished.
Attempts at shifting responsibility from the state to its citizens as part of a process of ‘empowerment’ are not new. While the self-conscious use of labels such as ‘modernisation’ may be intended to differentiate New Labour policies from those of its Conservative predecessors, the process of ‘modernisation’ represents the continuation of a set of policies initiated under previous administrations that seeks to transform the NHS from a rigid and failing bureaucracy to a system of entrepreneurial governance that will ensure its survival. (See Currie and Brown, 2003, for an overview of NHS modernisation and Allsop and Baggott, 2004, for a discussion of specific recent policy initiatives intended to ‘modernise’ the NHS.)
The rhetoric of enterprise, which reflected the shift to the political right in OECD (Organisation for Economic Co-operation and Development) economies towards the end of the 20th century, underpins this approach (Cohen and Musson, 2000), and the discourse of empowerment can be seen as highly consonant with notions of enterprise culture. ‘Enterprise’ not only denotes the preferred model of institutional organisation and provision of goods and services, but also refers to activities (p.37) that are seen as denoting enterprising qualities such as initiative, self-reliance and the ability to accept responsibility for oneself and one’s actions (du Gay et al, 1996). Individuals are encouraged to see themselves as active citizens exercising choice and autonomy (Dean, 1995) at the same time as accepting responsibility for managing their health and well-being. What is new is the publication of various documents in 2005 bringing together specific proposals to redesign the way care is delivered, to reorganise commissioning and to ‘empower’ citizens to make health lifestyle choices and ‘care for themselves if they become ill’ (DH, 2005a, p 14).
Choice and responsibility — shrinking the state?
In June 2004 the Department of Health published the NHS Improvement Plan, which outlined major changes required to move from a centrally directed system to a patient-led system (DH, 2004a). In 2005 proposals to implement the Improvement Plan by redesigning both the way services are delivered (DH, 2005a) and commissioned (DH, 2005b) were published. These proposals, contained in Creating a Patient-led NHS and Commissioning a Patient-led NHS, respectively (DH, 2005a, 2005b), place heavy emphasis on the pursuit of both choice and voice in healthcare. In 2004 it was announced that the much-heralded Commission for Patient and Public Involvement in Health, established in January 2003 to oversee the new system of patient and public involvement in the NHS, was to be abolished as part of a review of the Department of Health’s arm’s-length bodies (Gershon, 2004). Despite this, there are mechanisms intended to ensure that patients and the public are involved in the planning and development of health services. For example, NHS Trusts, Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs) have a statutory duty to make arrangements to involve and consult patients and the public in service planning and operation, and in the development of proposals for change. In addition, local authority councillors have the power to review and scrutinise the planning, provision and operation of local health services.
However, arrangements for collective voice may clash with those providing for individual choice. These tensions are likely to be exacerbated in a PBR system where treatment is funded according to individual patient choice and where hospital departments or hospitals may be forced into extinction if sufficient numbers of patients choose to be treated elsewhere. While PCTs have an obligation to consult the public on hospital closures, the logic of the quasi-market reforms is that providers that are not financially viable will be forced to close despite any collective opposition (p.38) voiced by the local community or its representatives. This suggests that individual choice is to take precedence over collective voice.
Despite government pronouncements on the virtues of expanding individual choice, such developments can be interpreted as attempting to shift what have traditionally been seen as responsibilities of the state on to other agencies and on to citizens themselves through partnerships and community ‘empowerment’ initiatives, and increasingly on to ‘responsible’ citizens as individuals (Newman et al, 2004). One example of this process is the Expert Patient Programme (EPP) (see www.expertpatients.nhs.uk/what.shtml), which is intended to ‘empower’ patients with chronic diseases (DH, 2001) and which forms part of a move to promote self-care for the management of long-term conditions (DH, 2005c, 2005d). The EPP entails participants undertaking a structured training course, which offers the potential for people ‘to take more control over their health by understanding and managing their conditions, leading to an improved quality of life’ (www.expertpatients.nhs.uk/what.shtml). By offering an alternative, active patient identity, to which participants are encouraged to aspire, the programme can be seen less as a means of empowerment than a mechanism for shifting responsibility from the state to the patient.
Derek Wanless’s (2002) report, Securing Our Future Health: Taking a Long-Term View, has been influential in encouraging the government’s pursuit of the ‘fully engaged’ scenario. As the phrase ‘fully engaged’ suggests, this involves high levels of engagement by citizens in relation to their health. The report estimated the levels of future state funding required for the NHS and identified the extent to which members of the public actively engage in relation to their health as a key cost driver. Full engagement is estimated to produce dramatically improved health status and increased efficiency in resource use. A subsequent Wanless Report dealing with prevention and the wider determinants of health appeared in February 2004. The notion of full engagement, as outlined in the Wanless Reports (2002, 2004), goes beyond self-management for patients with chronic disease. Indeed, the dramatically improved health status assumed to occur under full engagement relies heavily on all citizens, as opposed to the state, taking responsibility for their own health.
Since the most recent Wanless Report was to focus on ‘prevention and the wider determinants of health’ (2004, p 3), policies arising from the review had the potential to make a huge contribution to reducing inequalities in health in the UK in line with the government’s declared aim of improving the health of the poorest fastest (Wanless, 2004). However, a rather narrow definition of ‘wider determinants’ was used, with the result that factors such as poverty and deprivation were largely ignored. (p.39) This reluctance to recognise the influence of the state on population health is reflected in the 2004 Wanless Report, which states that ‘[i]ndividuals are ultimately responsible for their own and their children’s health and it is the aggregate actions of individuals, which will ultimately be responsible for whether or not such an optimistic scenario as “fully engaged” unfolds’ (2004, p 4).
The state’s role, as outlined by Wanless, is one of ‘shifting social norms’ to achieve behaviour change in its citizenry, and assisting in the provision of advice about the adverse health consequences of undesirable behaviours in order to facilitate the individual in making informed lifestyle choices. Regulation will be required from time to time, but such state regulation consists of sending signals to the market (increasing alcohol taxation, for example) rather than interfering with the initial endowments of wealth of consumers. Occasionally, when citizens cannot be trusted to police their own health behaviours (Wanless cites the wearing of seatbelts as one such example), then the state might have a legitimate role in intervening. While the EPP represents an attempt at getting patients with chronic disease to police their behaviour and thereby to reduce their dependence (and hence resource requirements) on the state, the implications of Wanless are that this self-surveillance should be extended to cover the whole population.
Events in 2005 suggest that choosing the issues for which direct state intervention is appropriate is not straightforward. On the subject of restricting smoking in public places in England, for example, the decision taken in October 2005 to exempt private members’ clubs and pubs that do not serve food from the proposed smoking ban was at odds with the advice of Health Secretary Patricia Hewitt, whose aides had previously described the proposal as unworkable. The much-publicised Cabinet split on the subject suggests that on this issue at least not everybody in government is willing to accept a shift from state as nanny to mentor.
The idea that ‘approved’ government involvement consists of ensuring that information is available to enable individuals to make better informed choices about their lifestyles and levying taxes to influence potentially unhealthy consumption decisions underpins Choosing Health? A Consultation on Action to Improve People’s Health (DH, 2004b), Choosing Health? Making Healthy Choices Easier (DH, 2004c) and The Chief Medical Officer’s ‘Ten Tips for Better Health’ (Donaldson, 2004). All of these understate or neglect entirely the role of wider societal inequalities on health status (McDonald and Scott-Samuel, 2004). The questions on which the public were consulted largely concerned lifestyle choices (hence the title Choosing Health?) and the role of government in supporting the exercise of healthier (p.40) choices by individual citizens. Rather than tackling poverty and income inequalities, Choosing Health? focuses on ‘[R]edressing inequalities in access to information to tackle disadvantage’ (DH, 2004c, p 27). Lest citizens should be in any doubt about the government’s role in the process, under the section ‘Defining roles and responsibilities’, the remarks by the Secretary of State for Health that ‘the prime responsibility for improving the health of the public does not rest with the NHS nor with government, but with the public themselves’ (p 7) are featured prominently. The health consumer in these policy documents is one whose actions appear to be informed less by choice or empowerment than an obligation to behave in ways that reduce demand on the health system. More recently the government launched ‘Your health, your care, your say’, a consultation on community health and social care services, which asks people three main questions ‘how can we help you take care of yourself? how, when and where do you want to get help when you need you need it? what do you need to help you manage your care and make decisions?’ (DH, 2005e, p 1). The consultation is framed in rather narrow terms and the online survey that members of the public are invited to complete starts with the statement that ‘We are committed to do more to help people take care of their own health’. While the survey does ask about extending access to primary care services, potentially enabling greater choice, the emphasis on self-care suggests that the choice for individuals to decide whether or not they want to be ‘empowered’ to take greater responsibility for their own health is not one that is on offer.
Reforming primary care
The consultation exercise has implications for the reform of primary care, since the results are intended to inform policy on care outside of hospitals. In 2004 a new contract was introduced for general practice, placing much greater emphasis on the use of direct financial incentives, which reward practices for meeting performance targets (Roland, 2004). In 2005 the first year’s contract performance data were published, with practices achieving 91% of the points available to them. While publicly government ministers praised the performance, anecdotal evidence suggests concern among ministers that the high levels of performance, which were well in excess of budgeted allocations, may reflect targets that were insufficiently demanding. Despite these high levels of performance, the proposals contained in Creating a Patient-led NHS suggest other changes to the provision of care. While the White Paper published in January 2006, Our Health, Our Care, Our Say: A New Direction for Community (p.41) Services (DH, 2006), contains more detailed proposals, Creating a Patient-led NHS describes a system characterised by the blurring of professional boundaries and in which a much larger volume of services is delivered in primary care settings. This new system will also ‘involve freeing up the entrepreneurialism within primary care and developing new types of provider organisations’ (DH, 2005a, p 15).
British primary care has been described as being the envy of the world, with its ability to provide relatively low-cost and accessible care while at the same time acting as gatekeeper to more expensive hospital treatments (de Maeseneer et al, 2000). Furthermore, patients tend to be highly satisfied with the services provided by their practices. However, this satisfaction does not always extend to access to primary care. In April 2005, just days before the General Election, Prime Minister Tony Blair appeared baffled when confronted by a member of the audience on the TV programme Question Time, who described the unintended consequences of government targets to guarantee access to a GP within 48 hours. Blair’s comments that ‘I would be absolutely astonished if you are saying to your GP “I don’t need to see you for four days” and he’s insisting he sees you in two’ (Blair, 2005) may have given the impression of a Prime Minister out of touch with the everyday concerns of ordinary people. The fact that Department of Health officials had publicly acknowledged the problem at least a month earlier did nothing to dispel this impression. Concerns about access to GPs were a recurrent theme in subsequent public consultation exercises (Healthcare Commission, 2005) and in November 2005 Patricia Hewitt declared it no longer acceptable for GP surgeries to be closed in the evenings and at weekends, hinting that if GPs were unwilling to mend their ways, alternative providers would be commissioned to provide patient-friendly care (Carvel, 2005a). The extension of prescribing powers to nurses and pharmacists from spring 2006, announced the same week amid cheers from the nursing and pharmacy community and jeers from the British Medical Association, further reduces the reliance on GPs and creates opportunities for alternative models of care in line with the aims of Creating a Patient-Led NHS.
Although many GPs in England are salaried employees, the majority are still independent contractors. Creating a Patient-led NHS acknowledges that GPs remain one of the most highly regarded groups in the NHS (DH, 2005a, p 15), yet the government plans major reform intended to change the way GPs and other primary care professionals deliver care. The new contract provides the government with some element of control in terms of incentivising the delivery of key aspects of care. However, the government is increasingly reliant on the cooperation of GPs to deliver (p.42) its reform programme. Creating a Patient-led NHS outlines the potential for 15 million outpatient attendances to be delivered in primary care (the figure currently stands at one million), and emphasises the important role primary care professionals can play by intervening early in the course of a patient’s illness (DH, 2005a, p 15). The thrust of redesign is to deliver as much care as possible as close to the patient as possible. Since an increasing emphasis is being placed on individuals taking responsibility for their own health, primary care professionals are likely to be increasingly engaged in facilitating this process and supporting self-care.
Support for self-care is aimed at reducing demand on hospital services. However, the impact of this is uncertain and likely only to be manifest in the medium to long term. Moving services closer to patients is likely to be popular with patients and the provision of clinics in community settings providing access to specialist care might be construed as providing symbolic reassurance to members of the community. In a context where polls suggest that public perceptions of the NHS remain largely immune to reductions in waiting lists, attempts to create visible symbols of a dependable and ‘patient-centred’ NHS are understandable. However, evidence suggests that moving care closer to patients largely has the effect of increasing demand (see Roland et al, 2005, for a review of the evidence). Given the financial pressures likely to arise from the introduction of PBR, a more immediate means of restricting demand is needed if budgetary limits and waiting list targets are not to be infringed. Practice-Based Commissioning (PBC), or giving general practices financial responsibility for the cost of care provided to their patients, is one means by which GPs may be incentivised to restrict access to secondary care to within allocated budgets. The NHS Improvement Plan’s announcement that ‘from April 2005, GP practices that wish to do so will be given indicative commissioning budgets’ (DH, 2004a, p 69) received a lukewarm reception, with few practices rushing to sign up for the scheme. Creating a Patient-led NHS acknowledges the importance of PBC in managing the risk of ‘supply-induced demand’ and suggests that ‘PCTs will need to think about how to engage all of their practices to take an active part in commissioning by 2008’ (p 22). Although it appears that policy makers were not inclined to leave the thinking to PCTs, as in July 2005, the Department of Health published Commissioning a Patient-led NHS, outlining plans to develop commissioning throughout the whole NHS system, bringing forward the deadline for universal coverage of PBC to December 2006.
These plans are also likely to result in a large-scale reconfiguration of PCTs to more closely reflect local authority boundaries, with a consequent (p.43) reduction in the number of PCTs. PCT reconfigurations are to be completed by October 2006 with SHA changes completed by 2007. In addition, the document outlines changes in function for PCTs and SHAs to create a ‘step-change in the way services are commissioned by front-line staff to reflect patient choice’ (DH, 2005b, p 1). In its 2005 manifesto, the Labour Party promised to release £250 million a year from ‘streamlining measures’ and Commissioning a Patient-led NHS makes clear that reconfiguration is not merely intended to deliver change, but also savings. SHAs were asked to work with their local health communities (that is, the NHS organisations including GP practices, and voluntary and independent sector bodies involved in the commissioning, development and provision of health services within the SHA boundary) to submit plans for streamlined commissioning arrangements in October 2005 to be assessed against the following criteria:
• secure high-quality, safe services;
• improve health and reduce inequalities;
• improve the engagement of GPs and the roll-out of PBC with demonstrable practice support;
• improve public involvement;
• improve commissioning and effective use of resources;
• manage financial balance and risk;
• improve coordination with social services through greater congruence of PCT and local government boundaries;
• deliver at least 15% reduction in management and administrative costs (DH, 2005b, p 3).
If accepted, the proposals would result in a reduction in the number of SHAs (from 28 to 11) and PCTs. Although the number of PCTs in London (currently 31) remains undecided, the 271 PCTs outside London are likely to form about 100 new PCTs. Heavy emphasis is placed on engaging front-line primary care clinicians and rolling out PBC in order to align local clinical and financial responsibilities. PBC also entails the involvement of practices in the redesign of patient pathways ‘to create community based services that are more convenient for patients’ (DH, 2005b, p 6). The inclusion of inequalities in the assessment criteria is understandable given the relatively poor performance in this area reported in 2005 (a continuing widening of inequalities as measured by infant mortality and life expectancy at birth) (DH, 2005f). However, attempts to tackle inequalities via improved working with local authorities may be diminished by moving services closer to patients and shifting (p.44) responsibility for making healthy lifestyle choices on to ‘consumers’, in the context of managing the financial risk associated with PBR and the implementation of NICE guidance. Experience of providing services closer to patients during the 1990s suggests that the results are often increased costs, due in part to the loss of economies of scale associated with hospital-based provision, a reduction in the severity of disease treated, rather than reaching patients in greatest need, and an increase in patient demand for those services (Roland et al, 2005).
Commissioning a Patient-led NHS made clear the intention for PCTs to become focused on promoting health and commissioning services, with their role in provision to be reduced to a minimum. This, together with references to contestability in the provision of community services, implies that these services will be subject to greater provider competition, and was interpreted in some quarters as signalling the extensive privatisation of health services outside of hospitals. Plans by Thames Valley SHA to contract out the commissioning of primary and community care services in Oxfordshire (Relph, 2005) did nothing to allay these fears. However, in October 2005 Patricia Hewitt announced that district nurses, health visitors and other staff delivering clinical services would continue to be employed by their PCT unless and until the PCT decided otherwise. The following month Hewitt apologised for the anxiety caused in a speech to NHS staff. ‘I know that many of you were very unhappy about what we said at the end of July about the future of services that you currently provide through PCTs, and I am very sorry that you have been caused such anxiety. We have listened very carefully to what you and others have said. Clearly we were too prescriptive in Commissioning a Patient-led NHS and we have changed that’ (Hewitt, 2005). In a subsequent briefing to journalists, Hewitt implied that the White Paper might introduce a competitive market in ‘under-doctored’ areas, but nowhere else (Carvel, 2005b). One interpretation of this volte face is that it reflects the government’s desire to allow local discretion in line with its move towards regulation and away from hands-on management. (It is not clear whether Thames Valley SHA’s decision to postpone plans for contracting out is a result of local discretion or direct intervention from above.) An alternative explanation might be that in the aftermath of its first defeat in eight years (on its proposals to give police powers to detain terrorist suspects for up to 90 days), New Labour might be forced to dilute its plans for major reform rather than risk increasing party dissent.
In The NHS Plan the government announced its intentions to ‘give the people of Britain a health service fit for the 21st century: a health service designed around the patient’ (DH, 2000, p 10). The period covered by this review has seen the government consolidating its attempts at reform by attending to the processes and structures by which care is commissioned and provided. In addition to proposals for reconfiguring PCTs, 2005 saw developments aimed at shifting responsibility for care onto individuals as part of proposals to deliver a ‘patient-led NHS’. Redesigning services to move care closer to patients can be interpreted as part of this process. In response to public concerns about the service, it may also reflect a desire to provide highly visible and locally responsive models of care, regardless of their impact on health outcomes and equity (Roland et al, 2005).
Writing in Social Policy Review 17, Klein (2005) described the government’s stance towards the NHS as shifting from management to regulation, as evidenced by falling numbers of civil servants at the Department of Health and a reduction in the number of centrally imposed targets. Despite the declared intention to allow ‘scope for local determination of what works best’ (DH, 2004d, p 3), the extent to which central government is serious in this intent is uncertain. While the recent intervention of the Health Secretary in the decision by a PCT to deny Herceptin, an expensive anti-cancer drug to patients, is an isolated instance (Meikle, 2005), it does raise questions about the extent to which Department of Health directives leave room for local discretion. Similarly, the extent to which NHS managers feel themselves to be ‘empowered’ to manage in this new environment of regulation, which (in theory) leaves them free to get on with the job of managing, depends in large part on the nature of the evolving regulatory regime. For example, labelling the implementation of NICE guidance a ‘standard’ as opposed to a ‘target’ may do little to help managers exercise local discretion, since such core standards, like targets, are required to be met. Recent events, such as the backtracking on PCT reform, suggest that the government is prepared to allow room for local discretion in some areas. Whether this is an isolated case, or part of a wider trend, only time will tell.
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