The NHS will be the biggest management challenge of the 21st century. But whatever solutions are chosen, decisions will have to be made at the level where individual meets carer.
It's easy enough to sketch the outlines of a health service for the 21st century. It is patient-centred, although that's not the right term since it is no longer a sickness service, as at present, but a health service, focusing on prevention of illness rather than cure. Accordingly, the most important institution of third millennium health care is the community health centre, comprising general practice plus a range of services, from chiropody to mental health to anti-smoking to helping with learning difficulties. Most investigations, minor interventions and outpatient treatment take place here. A variety of hospitals and other organisations provide responsive specialist and emergency support for the health centres, with minimal waiting lists. The old district general hospitals have been replaced by smaller, specialised units concentrating on high volumes of a limited range of specialities and complex treatments. They are all linked electronically with their local GPs. Since managing the chronic, degenerative illnesses of old age has become the major burden of health care, there is a greater range of low-tech hospitals, 'patient hotels', rehabilitation, convalescence and hospice care.
Rather than ration specialist treatment by waiting, as now, there is general consensus that the system should confine itself to providing cost-effective treatments of proven clinical worth. This has the surprising effect of reducing the number of operations rather than increasing it. Drugs are recognised as an increasingly important and cost-effective element of treatment. The three components of health-care delivery - primary, hospitals and social care - separate since 1948, have at last been seamlessly integrated. Health promotion and lifestyle matters are taught in school. Since it is by now well understood that an individual's health is primarily determined by genetics, the environment and lifestyle, public health, social and economic policies are closely co-ordinated to help achieve the targets embodied in the Health of the Nation strategy and its successors. This order of priorities will soon be recognised in the disappearance of the Department of Health into the Department of the Environment. Funding is still basically by general taxation, although insurance is increasingly used as a top-up for long-term care.
Yes, reply the cynics, and the pigs are fed and watered and ready to fly. The above prognosis is in most respects uncontroversial, the main argument being non-medical: whether the market or some other mechanism is best equipped to deliver it. So why will it be so hard to achieve? Leaving aside for the moment the sheer unwieldiness of the NHS, it is important to understand a constellation of institutional and cultural factors which will inflect any future attempt to shift the NHS's centre of gravity.
One is the power of history, embodied in the organisational split between the three arms of care: the hospitals, the primary sector (GPs are self-employed) and the social services (which aren't even in the NHS, being in the purview of local authorities). A second, also historical, is the uneasy intertwining of public and private health in the hospital sector, which some observers believe is a contributor to long waiting lists and inequity in health care in general. A third is the long-standing interprofessional pecking order - in the new dispensation, for instance, nurses, traditionally at the interface between medicine and other forms of care, will have to play a much more important, even dominating, role than present rankings might tolerate. A fourth is the 'bio-medical' model of health which assumes that care begins with diagnosis and ends with clinical intervention, effectively 'medicalising' life and dehumanising health by transferring responsibility from the individual to the doctor. This view seems to be as strong among GPs as anywhere in the service.
A more surprising, or alarming, factor is the extraordinary (to a layman) lack of scientific evidence for much medical treatment. In the case of managing long-term illness, outcomes are hard to measure. But in a new book entitled Private Eye, Heart and Hip, Dr John Yates, a former government adviser on cutting NHS waiting lists, notes that less than 15% of health-service intervention has been evaluated and proven to be beneficial. For only two of the 10 commonest operations, he reports - hernia repair and cataract surgery - is there widespread agreement about which patients will benefit and how and when the operation should be done. After a House of Lords committee expressed incredulity that there was no NHS input into medical research, an R&D initiative set up in a new NHS directorate has been greeted with wide approval. 'It's the best thing to come out of the reforms,' says Angela Coulter, director of the King's Fund Centre. It has made a 'promising' start on identifying research priorities, commissioning primary research and disseminating proven best practice. But the ideal of 'evidence-based medicine' is still a long way off ('evidence-based policy,' Coulter adds tartly, 'would be a good idea, too').
The final and most important factor in the NHS's future, however, is a cultural divide as sharp as if cloven with a surgeon's scalpel. 'There are two NHSs, not one,' Ken Jarrold, NHS director of human resources, acknowledged in a recent speech. 'Everywhere I go, the senior people - chairs, non-executives, senior managers and even the clinicians most involved in management - tell me of progress, of better working methods and value for money, of objectives achieved and of change delivered.' But, he added, 'Everywhere I go I also glimpse another world, one inhabited apparently by everyone else - a world of daily crisis and concern, of staff under pressure and services struggling to deliver.' Both worlds, he accepted, were real, supported by objective evidence and believed in sincerely. Even those most enthusiastic about the 1991 reforms accept that they have singularly failed to win the hearts and minds of both the lower echelons and the public for the new-look NHS. More than in any other enterprise this is critical, since no health service, however well-founded in theory, can work without the practical commitment of both patients and staff.
Is it possible to gain it? One view gaining ground is that a viable health-care system can be based on either public-service or commercial values - but not both at once. The merits of the market versus planned solutions can of course be debated for ever. The Labour Party has pledged to scrap the internal market and emphasise the integrity of the NHS as a unified public service. At the other extreme the Adam Smith Institute is in favour of radical measures to bust the 'medical monopoly', giving individuals charge of their own medical fund to spend as they choose on minor treatments, the State taking over for major interventions.
In the end, the differences between such systems may be less significant than the discrepancies within them. This would explain why the commercial discourse of the 'internal market' stirs up such implacable resentment in the public-service adherents of the 'old' NHS. The planners of the 1991 reforms massively underestimated this reaction, and as their full implications loom clearer - for instance, the heart-stopping consequences of the nurses abandoning Florence Nightingale-values in favour of a wholehearted market focus - more pragmatic managers and ministers have hastily adopted more moderate language. Whatever the solutions chosen, one thing is not in doubt. If the NHS is to remain free at the point of delivery, the 'reification of the NHS as institutions and buildings rather than the service itself' - in the words of Greg Parston, chief executive of the Office for Public Management (OPM), a public service consultancy - will have to give way to a more pragmatic line. It's the concept - a service available to all on the basis of clinical need, not ability to pay - which is important, not whether it is delivered in a public or private setting: a profoundly unhelpful obsession, believes Peter Griffiths, deputy chief executive of the King's Fund. In the same way, it's not a question of managerialism or the NHS ethos, stresses Brian Edwards, director of the West Midlands Regional Health Authority: the only way of keeping the latter is to exploit the former. 'The UK is one of the few countries left in the world providing a free, comprehensive health service. I think we can sustain that for at least another generation by using the money we've got to better effect.'
Fortunately, along with problems already outlined, it is universally accepted that the reforms have also stirred up a ferment of more positive initiative and experiment. Some of them, like John the Baptist, may not be the light itself but the precursor of the light. But many believe that the movement itself is important, freeing up the seized joints of the old system and incidentally explaining some of the paradox of 'getting better but feeling worse,' as Edwards puts it. Since (to alter the metaphor) the changes are more like chemistry than engineering, the results, he concedes, are unpredictable.
Much of the initial innovation took place in the trust sector, as a combined result of political pressures, managerial liberation and measures taken to respond to the Patient's Charter. To bring down waiting lists for high-priority treatment, health authorities bought a substantial number of operations from the private sector. At the same time, with the same end adventurous trust managers began adopting management techniques that have had a profound effect on private-sector manufacturing. These days any high-level conference on advanced management techniques will have its share of curious trust attendees. Some of this curiosity has been brought to bear on the capital side, too. There remain doubts about the Private Finance Initiative in the NHS, partly because of long-winded authorisation procedures, partly on principle. A Labour government would draw the line at privately-run hospitals within the NHS. But within the trusts many believe that selling services to the private sector can substantially benefit the NHS.
In the longer term, developments in primary care may be at least as important. At the moment, comments Coulter, morale among GPs is poor, even though they are now supposed to be driving the system instead of being its second-class citizens. In fact, it may well be because of the extra responsibility that they are feeling so put upon. Many doctors, says Dr Paul Julian, member of a non-fundholding practice in East London, were unprepared for the stress of having to undertake the rationing which was previously carried out by the system.
Optimists claim that the GP feel-bad factor is a matter of timing. By their nature, initiatives in primary care take longer to bear fruit. 'The move (to primary care) is difficult to understand in the abstract,' admits NHS chief executive Alan Langlands. 'People need to see tangible results on the ground.' He points to hundreds of initiatives taking shape in London and Birmingham. The King's Fund's Griffiths likens primary care to the early days of the trusts, with good ideas spreading out from small beginnings. The issue, he suggests, is how GPs can tool up to deliver the new goals, 'which are mind-blowingly different from those of the old-style village GP'. He adds: 'In terms of being able to deliver, primary health care is probably five years behind the rest of the system.'
Some places are finding ways of staying abreast or even ahead of the game, however. In East London, Julian's practice is joining with others to form cross-disciplinary care teams to cover the district. A much-praised unit in Dorset has combined two non-fundholding practices in a non-profit limited company to manage the entire healthcare budget for 8,000 people. Employing a social worker, health visitors, psychiatric nurses and counsellors, the unit prides itself on unifying the traditionally divided arms of care and providing a single point of access for the complete spectrum of health and social care, from specialist hospital treatment at one end to terminal care with round-the-clock home nursing at the other.
Bromsgrove in Worcestershire is the site of a larger pilot test of total GP purchasing based on four established fundholding practices. Up till now, GP fundholding budgets have covered only around one-fifth of treatments, excluding accidents and much else. Some units, including Bromsgrove, are now testing whether the scheme can improve delivery of more 'difficult' areas of care, such as mental health, care of the elderly in the community, learning difficulties and child development. Dr Richard Wilkinson, one of the leading GPs at Bromsgrove, claims some progress already, but warns that the full impact of GP purchasing for these more complicated areas will need time to take effect. The main bugbear, he complains, is still the separation of social services and health authorities - the disciplines of capital joint purchasing are 'very slow to develop in some areas'.
In general, Wilkinson believes that the GP's role as unbiased broker at the heart of the NHS has been enhanced by the reforms, and even if they have had to learn budgetary control and policy very quickly, their introduction into the world of health-care purchasing has been positive. 'Many of us believe that there are not enough high-quality managers to continue to manage the service, and we expect more and more to fall as a responsibility on GPs who will increasingly be encouraged to influence purchasing,' he says. 'GPs in the UK are now beginning to realise that health-care costs must be controlled and money aimed at the most needy.'
Purchasing at health-authority level, too - the third component of the 1991 reforms - is beginning to produce interesting results, even if, as the OPM's Parston observes, they were unanticipated and unintended at the start. 'The biggest organisational change was getting the districts to focus on health gain in their area,' he maintains. In effect, he points out, the reforms have turned districts into local monopoly health insurers, managing funds on behalf of citizen-subscribers and buying services where they can get best value for money. In a recent report on primary care, the Institute for Public Policy Research noted a number of useful initiatives on the part of the purchasing authorities. More particularly, it added that despite their demonisation, the much criticised health-service managers were an important force for strategic change. 'Many of them appear in real life to carry a vision of health policy directed at empowerment and health gain, not merely at effectiveness and efficiency. Many are frustrated by the difficulties of realising this vision. They are often trained clinicians who have moved into management. As a group they are probably less likely than doctors or nurses to harbour traditional and conservative attitudes.'
At the micro and intermediate level, therefore, all is by no means doom and gloom. And, although this has too often been forgotten as arguments have raged about the institutional forms over the past four years, it is at this level, the interface between individuals and carers, that the future of the NHS will be played out. The service, as Langlands points out, is just too big to be controlled centrally. So whichever party wins the next election will need to ensure that any further institutional changes go with the grain of the best patient-centred innovations rather than stopping them in their tracks. The next phase of health is bottom-up, not top down. The shape of the NHS in the 21st century needs to go on evolving at the level where individuals and their doctors meet.
Simon Caulkin edits the management page of the Observer.