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What will happen to the National Health Service?

Submitted by on 09 Mar 2012 – 15:10

What will happen to the National Health Service?

Philip Sugarman MBChB MSc MBA PhD FRCPsych

Professor Sugarman is Chief Executive of St Andrew’s Healthcare, the UK’s largest charitable provider of NHS services, and honorary Senior Lecturer at King’s College London

Envy of the world

There are good reasons to think that healthcare in the UK is amongst the best in the world, and we are all rightly proud of the NHS. It has some of the world’s leading hospitals, a strong system of community General Practice, and it has improved significantly in recent years. This has been sustained by more than doubling expenditure every ten years, bringing it in line with other countries. Additionally, in recent years, both Government and private sector borrowing has supported the building of many new hospitals and community facilities.

Of course, money is never enough. The value delivered by healthcare systems depends on the quality of treatment, as well as the cost. The US-based Commonwealth Foundation reported in 2010 that despite being the best funded, US healthcare provision ranked last of seven developed countries. The same study scored the UK second overall to the Netherlands, and best for effectiveness and appropriateness of care. However, the UK scored worst on person-centred care, an important measure of value, given occasional but alarming reports of NHS and care home nursing failures. Furthermore, the UK population was second from bottom for length of productive lives. Other studies also question the NHS for major disease outcomes, and whether sufficient benefits have been gained for all the extra cost.

Beyond quality, outcomes and cost, it is on fairness that many feel the NHS is “the envy of the world”, with few financial barriers to equitable healthcare. Research has found the UK top in comparisons of coordination of care for people with complex needs. In contrast, vulnerable people in the US receive worse care than their European counterparts, whilst wealthy American citizens benefit from the best healthcare available. However, there also remain stark and worrying health inequalities in the UK. These exist not only between different areas, but also for vulnerable groups, such as the severely mentally ill, who die up to 20 years early of common, treatable physical diseases. Such disparities show how significant social and educational barriers to health and healthcare remain.

Healthcare reform in the downturn

The challenge to improve western health and social care systems is now compounded by the economic downturn and low birth rates.  The debt crisis is constraining spending, with the ratio of fit younger tax payers to the ill, unemployed and elderly falling fast.  In the UK, healthcare providers are attempting to meet these challenges, but with an increasing number of NHS and private care failures, with vulnerable people the most affected.  Where can we look for some solutions to these problems?

Ways of buying and delivering healthcare vary between countries, and will respond differently in the current climate. The Netherlands serves best the acutely sick, the UK, those with long-term conditions.  The Dutch system enables real choice between health purchasers as well as providers, whilst England continues to pursue market-orientated NHS reforms to strengthen competition. Many are concerned about the risks to vulnerable patients through profiteering, but see the need for greater efficiency.  The challenge is to ensure equitable treatment by getting the best out of all kinds of providers.

Managing the market

A strong system of healthcare market governance is needed. Effective regulation of quality and competition, which encompasses state, commercial and not-for-profit organisations such as charities, is required to protect what is best about the NHS, and secure needed improvements. There are risks of moving too fast or too slow. The Health and Social Care Bill under scrutiny in Westminster may seem radical to some, but in fact a mixed economy has been developing for decades. The NHS has long pursued large-scale outsourcing of care homes and psychiatric hospitals, elective surgery, General Practice, and supply and property services. This has largely gone unnoticed, but we now see tensions between professional groups embedded in NHS careers, and the questionable activities of some private equity groups. The development in the Bill of “Monitor” as competition regulator, twinned with the reforming Care Quality Commission, is a core piece of this jigsaw.

The new competition regulator must manage further market reforms while reducing costly red-tape. A smooth continuity of service and pricing regime is planned to manage clinical and financial risks, but must also attract new commercial investment, and enable the growth of not-for-profit social enterprises. In this more competitive, innovative era, hospitals will focus on acute and specialist care, and reduce beds, while other providers develop high-quality, low-cost community and at-home care. All services will find increasingly informed patients, often more than a match for their doctors, who expect personalised customer service and world-class treatment. At the same time, a needy minority will still require strong support from healthcare professionals.

The recent surge of NHS Trust mergers, and the persistence of buying services en bloc even from a few sub-standard NHS providers, represent a real barrier to achieving the best quality of healthcare. Monitor will have to rehabilitate these monopolistic elements of the old NHS toward a more open, co-operative stance. In particular, charities and commercial providers must be allowed opportunities to provide choice and value for patients, to ensure the NHS continues to be the envy of the world.